Revisiting patient expectations and experiences of antibiotics in an era of antimicrobial resistance: Qualitative study

Abstract Objective To investigate contemporary patient expectations and experiences of antibiotic prescribing in England. Background Primary care providers’ compliance with patient influences has been identified as a motivation for antibiotic‐prescribing behaviour. Since 2013, there have been concerted efforts to publicize and address the growing threat of antimicrobial resistance. A fresh qualitative insight into patient expectations and experiences is needed. Design Qualitative study using semi‐structured interviews. Setting and participants Two English regions, one an urban metropolitan area and the other a town in rural England. Patients who recently consulted for infections were recruited. The information power approach was used to determine the number of participants, yielding a sample of 31 participants. Main measures Thematic analysis was carried out to analyse the interview data. Results Five themes were identified: beliefs, expectations, experiences of taking antibiotic, experience of antimicrobial resistance and side‐effects, and experiences of consultations. The accounts reflected improved public knowledge: antibiotics were perceived to be much‐needed medicines that should be prescribed when appropriate. The data showed that patients formed expectations of expectations, trying to read the prescribers’ intentions and reflect on the dependency between what prescribers and patients wanted. Patient experiences featured as nuanced and detailed with knowledge of AMR and side‐effects of antibiotics in the context of positive consultation experiences. Conclusions The study highlighted complex interplays between adherence to antibiotics and consuming antibiotics in reflexive, informed ways. Ensuring that present and future patients are informed about potential benefits and harms of antibiotic use will contribute to future antimicrobial stewardship.


| BACKG ROU N D
Public awareness of antibiotic resistance and the need for more judicious use of antibiotics is increasing, but inappropriate use of antibiotics remains widespread. 1,2 Older studies have ascribed a prominent role to patient influences on antibiotic prescribing, with many studies stressing the view that prescribers may be responsive to patient expectations for antibiotic treatment. 3 This 'patient influence' factor has been identified in most systematic reviews 3 Estimates from patient surveys suggest that patients' positive expectations for antibiotics are substantial but have varied between studies. [4][5][6][7][8][9][10] Family physicians may assume that patients consulting for infections want antibiotics 11 but primary care clinicians can overestimate the extent to which patients are seeking and expecting antibiotic prescriptions, 11,12 especially for parents of young children. 13 There is consistent evidence that GPs are more likely to prescribe antibiotics when their patients are perceived to be expecting them. 8,[14][15][16] A systematic review found a generally positive association between physician perceptions of patient expectation and antibiotic prescription, 17 but some studies find evidence of a negative association between expectation and prescription 4 with evidence of inconsistency between physicians' perceptions and patients' desire for antibiotics. It is also well established that prescribing antibiotics increases the likelihood that patients will consult in future illness episodes, 18 raising the possibility that expectations are a consequence not a cause of antibiotic prescribing.
Relationships between patients and primary care providers play a major part in antibiotic-seeking and antibiotic-prescribing behaviours. A qualitative study in the UK found that doctors prescribed antibiotics in order to maintain good relationships with patients, with potential patient benefits outweighing the less tangible community risks from antimicrobial resistance. 15 However, patient expectations are seldom made explicit during consultations. While a high proportion of patients may want antibiotics and expect to be given a prescription, only a minority ask directly for antibiotics. 14 Some studies confirm that meeting patient expectations is associated with greater patient satisfaction, but other research suggests a more nuanced interpretation. A mixed method study in Australia demonstrated that even though parents consulting with their children wanted antibiotics, satisfaction with their GP visit was not dependent on solely receiving antibiotics. 10 In a qualitative study of parents consulting GPs in four European countries, parents' accounts revealed that a trusting and open relationship with the clinician, in which parents felt comfortable to ask questions, challenge and discuss decisions, led them to feel generally satisfied with consultations and accept clinicians' decisions whether to prescribe antibiotics or not. 19 In recent years, there have been concerted efforts from scientists, clinicians and policy-makers to publicize and address the growing threat of antimicrobial resistance both in the UK and worldwide. [20][21][22] In this context, it is timely to revisit patient beliefs, expectations and experiences of antibiotics and of antimicrobial resistance. Recent systematic reviews have included studies which may antedate current increased concerns for antimicrobial resistance. 14,15 This study aims to address a need for additional qualitative investigation to understand contemporary patient perspectives on antibiotic prescribing in this era of antimicrobial resistance.

| Research design
The aim of the current study was to examine contemporary patient expectations and experiences of antibiotic prescribing in England. Semi-structured interviews were conducted with patients who consulted general practice for infection in two English regions, one an urban metropolitan area and the other a town in a rural part of England with a high demand for primary care services. The two regions represented diverse contexts for general medical practice. The participants were invited to be interviewed if they had recently consulted and been diagnosed by a GP as having a bacterial infection.
The bacterial infections were identified using Read codes for the relevant conditions including respiratory tract infections, urinary tract infections and skin infections as the major indications for antibiotic prescribing. An interview guide was developed to reflect expectational structures associated with antibiotics as well as the experiences of illness and experiences of consultations. The items were informed by a review of the literature and included past and current experience of being prescribed antibiotics, knowledge, beliefs and attitudes towards taking antibiotics and interactions with medical practitioners. The questions were discussed among the research team and piloted with a small number of patients before refining.
The items in the topic guide were organized under six main headings (Table 1). All interviews were conducted by the first author (OB) to ensure consistent quality. The interviewer has a PhD in medical sociology and is an experienced qualitative researcher. Interviews were conducted in the period February-December 2019. Interviews lasted between 13 minutes and 42 minutes.

| Recruitment of participants and data collection
Metropolitan practices were invited to the study by the local Clinical Research Network who generated the expression of interest; a practice in a town in a rural area of England was recruited through informal Clinical Research Network contact. The researcher's invitations to take part generated expressions of interests from the general practices that agreed to purposively select patients who visited a primary care professional for infection in the last 6 months. Patient lists were approved by a general practitioner acting as research gatekeeper in each practice and initially 927 patients were sent invitations to study via the Docmail postal system. The invitations contained a letter from the practice inviting patients to take part and information sheet. Patients who agreed to take part either returned reply slips or contacted the researcher using the contact details provided. The researcher then communicated via email or text message to establish the contact followed by sending the consent form and confirmation of the interview meeting.
In total, 33 patients agreed to participate. The interviews with two patients were discarded: one involving a parent interview and in another where the patient did not consult for an infection. Out of 31 patients (Table 2) who comprised the final sample, 26 patients were interviewed face-to-face in patients' homes and five patients were interviewed via phone (see Table 2). The sample size was determined using the pragmatic concept of 'information power', 24 which proposes that the size of a sample with sufficient information power depends on (a) the aim of the study, (b) sample specificity, (c) use of established theory, (d) quality of dialogue and (e) analysis strategy.
While our aim was (a) broad and (b) specificity is biased towards one group (almost half of the interviewees were older female patients consulted for urinary tract infection), we followed (c) a theoretical model to explain the findings and (d) the quality of the interviews is relatively high. Since we aimed for (e) a cross-case analysis, we decided to continue recruitment until the sample size reached thirty-one eligible patients.

| Analysis
The interviews were digitally recorded, transcribed verbatim by a professional transcriber, imported to an NVivo-12 project and coded through an iterative six phased process described in thematic analysis. 25 Data analysis occurred iteratively and involved familiarization, coding, theme searching, theme reviewing, theme defining and naming, producing the report. Repeated patterns in the data formed the basis for the codes, identified by the first author, and one single code for every different concept/idea was generated. To ensure that codes were applied consistently, a co-author (initials) independently coded a random sample of four interview transcripts. Coding was refined after discussion. Data identified by the same code were collated together, and all different codes were sorted into potential subthemes and themes using NVivo options of tree building. Then, the potential themes were re-assessed and re-organized to reflect major narratives and themes in the coded data. Finally, the authors refined and named the five main themes and subthemes. Participants' feedback on the transcripts or the summarized final findings was not sought.
This research was part of a larger project concerning the safety of reduced antibiotic prescribing. The research is supported by a patient and public involvement group, including eight members of diverse ages and ethnic origins. The process of developing subthemes and themes was discussed at a patient and public involvement meeting, and feedback received was included in the interpretation.

| RE SULTS
We summarize the results under the headings of five main themes that were identified in the thematic analysis. Analysis did not identify systematic differences according to metropolitan or rural location nor according to mode of interview completion.

| Beliefs about antibiotics and antimicrobial resistance
Antibiotics emerged as trusted medicines that had widespread use; the descriptors used by the interviewed patients ranged from 'magic answer' to 'sledgehammer' treatment. Those who referred to antibiotics as a magic pill were often older females with recurrent urinary tract infections with expectations for apparently appropriate prescribing. On a whole, the most common belief among the interviewees was that antibiotics should be prescribed and taken when

| Experience of taking antibiotics
The interviewees had different exposure to antibiotics: some of them were prone to recurrent infections and were prescribed antibiotic more than once in recent months, others received an occasional prescription for antibiotic. Most of them described days and weeks of experiencing illness before they consulted a clinician. Apart from one case, there had been a sense of welcoming antibiotic treatment,

| Main findings and comparison with the literature
Participants perceived antibiotics to be much-needed medicines that should be prescribed when appropriate. Expectations for antibiotic treatment were often conditioned on previous experiences.
However, past experiences were not restricted to successful treatment of infections but also included experience of antibiotic resistant infections, antibiotic drug side-effects and inappropriate prescribing. Patients' views were also informed by genuine concern about antimicrobial resistance. These lay accounts appeared to reflect the contemporary medical ideas of 'precision' or 'personalized' medicine, which are represented in the slogan of the 'right drug for the right patient at the right time'. 26 Consistent with other studies, 9 participants' knowledge about side-effects was not associated with their expectations of antibiotics. The concern about and experience of antimicrobial resistance found in our sample contradicts evidence from a review of general public attitudes which reported low awareness of AMR. 27 We found that around a quarter of the sample experienced AMR in one form or another and these participants were more sceptical about antibiotics. The accounts of those who experienced AMR were full of frustration and confusion because either antibiotics had not worked or the first-line treatment had not worked. Likewise, in the qualitative arm of their study, 8  The recent research demonstrated that patients were unwilling to follow the prescriber's recommendations blindly and wanted to know about appropriateness of prescribing 12 and our study of expectations and experiences lent support to this. Patients seemed to have been more prepared to openly deliberate on prescribing decisions and their expectations were more explicit than previously, even though trust in clinician still had a major role to play. 12,19,33 Those participants who emerged as informed patients rejected a blind compliance. Indeed, patient expectations were due to disclo-

| Strengths and limitations
We Future studies should also aim to include patients with infections who were not prescribed antibiotics to evaluate their experiences of illness and consultation.

| CON CLUS IONS
While compliant with antibiotic treatment, participants in our study raised important questions concerning the right antibiotics being

ACK N OWLED G EM ENTS
We would like to thank all participants in this study and PPI group members. The SafeABStudy Group also includes Vasa Curcin and James Shearer, Judith Charlton, Emma Rezel-Potts, Joanne R.

CO N FLI C T O F I NTE R E S T
The authors have no conflicts of interest.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.