Better Antibiotic Prescribing Through Action Research

Phase 1: Exploring In the exploratory phase of this research the focus will first be on partnership development and engaging the GPs with this research project. The success of the PAR approach depends on the willingness of the stakeholders to play an active role.

To map the willingness to participation and the need to change, contacts with the GPs of the GPC are planned. Emphasis will be put on the fact that the partnership is non-judgmental, has a reciprocal character, and is based on trustworthiness. Developing a positive partnership with the GPs will be essential. A first contact with the board of the GPC has already taken place, and they expressed their willingness to participate in this project.

Next, narrative research will be undertaken to explore how the different stakeholders experience or make sense of antibiotic prescribing within their setting. By better understanding GPs' behaviour and taking into account the different barriers they experience, we will be able to understand their conduct and to develop interventions with better chances of success and bigger support from the GPs. Individual in-depth interviews will be performed with the relevant identified stakeholders (GPs, manager, etc.). A semi-structured interview guide will be used. Topics consist on the one hand on the specifics on prescribing antibiotics in OOH primary care, the perceived need and the receptiveness to change, local antibiotic prescribing culture and habits etc. and on the other hand on the willingness to participate in PAR, the degree of commitment in being a co-researcher, the perceived viability of the project etc. Purposeful sampling will be performed to obtain a relevant variety in participants that reflects our specific setting (young vs experienced GPs, solo vs group practice during office hours, ethnical background etc.). Scientific rigour is ensured by using triangulation and member checks involving first the participants in the interviews and second all other stakeholders (see Phase 2). The GPs who have contributed to the interviews will receive a formal analysis report with the summary of the findings and will be asked to deliver feedback (member checking, but also reflecting on it) in a focus group. In a second phase this will be made available to all GPs of the GPC. Coding of the first three to five interviews will be done by two researchers independently (AC, a GP and SA, a sociologist). The coding framework will then be developed by consensus of these two researchers. Following the independent coding, the initial thematic framework will be compared, and similarities and differences will be discussed and amended to create a set of themes that represents both analyses. This thematic framework will be used for further analysis and if new themes emerge this will be discussed amongst the research team. The interim analyses will be critically looked at by the other three members of the multidisciplinary research team and will be adapted after their feedback.

To develop a clear view on the why and when antibiotics are prescribed in OOH primary care an ethnographic study will be setup. If consent is given by the GPs we will use video observations to achieve a better understanding of the context, difficulties, clinical issues, patient-doctor interactions etc. during prescribing antibiotics in OOH primary care. It gives the possibility to gain insight in GPs habits in their natural, real-world setting. The videos will be observed solely by the research team. Complete anonymity of the GPs and patients will be guaranteed. Using video-observations can be a sensitive method for GPs in practice, but a review showed that from an ethical and practical point of view recording consultations is generally acceptable to both patients and GPs. The data collected through video observations will be analysed on the one hand for research purposes and on the other hand to guide the intervention development. During the interviews of phase 1 the use of video-observations and possible related barriers will be discussed with the participants. During the interviews we explore the thoughts of the GPs about receiving personal feedback or the possibility to discuss the videos with one of the researchers or with their peers. Another question is asked about the thoughts about using the videos solely as transcripts for research or also for peer education, or even to use them in video-format with peers. Hence, the way we will use the video material will depend on the willingness or preference of the participants in our action research.

Because PAR is setup together with the participants having a voice in the design of the study, alternative data collection methods to gain insight in the daily practice of using antibiotics in OOH primary care can be suggested and subsequently applied. Alternative methods could be a live observation by a member of the research team, a study of the anonymised electronical medical health records, standardised patients, patient interviews, case vignettes, etc..