Providing antibiotics to immigrants: a qualitative study of general practitioners' and pharmacists' experiences

Experiences of antibiotic use and healthcare access among migrants to the UK: a qualitative study

BACKGROUND

In recent years, migration to and within Europe has increased. Human mobility has been hypothesised as a contributing factor towards antimicrobial resistance (AMR). However, there is limited evidence to explain how migration contributes towards antibiotic resistance. More qualitative research regarding migrants' perspectives of antibiotic use is needed to understand this complex interaction. The aim of this study was to explore experiences of antibiotic use and healthcare access among migrants in the UK, and how this might influence the risk of AMR.

METHODS

Adult migrants were purposively recruited through community organisations, collaborators, online platforms and snowball sampling representing different migrant statuses, countries of origin and ethnicities. Semi-structured interviews were conducted online, by phone or face-to-face, in participants' preferred languages, between March and July 2022 exploring antibiotic use and healthcare access. Data were analysed thematically and the study was informed by a Project Advisory Committee, with members from Doctors of the World and professionals who were previously refugees or asylum seekers.

RESULTS

Twenty-seven migrants (17 males and 10 females), aged 21-60, from 17 different countries were interviewed. Four main themes were generated: 1) Uncharted territory: navigating a new healthcare system (sub-themes (a) access to care during journey, (b) difficult access to healthcare in the UK and (c) comparison between different healthcare systems); 2) Preserving the sense of agency and decision-making around antibiotic use, 3) Self-perpetuating cycle (sub-themes - (a) co-infections; (b) using alarming symptoms or "red-flags" and (c) taking antibiotics due to previous similar symptoms or persisting symptoms), and 4) The fragile state of the patient-doctor relationship.

CONCLUSIONS

These findings give useful insight into barriers faced by migrants when trying to access healthcare services both en route and after arriving in the UK, as well as their attitudes and behaviours in relation to antibiotics. Results also shed light on the complexity of factors contributing to health-seeking behaviour and antibiotic use, and how these may vary depending on previous experiences. We discuss implications for future research and practice, and how current policies may need to evolve to better support and reduce possible risk factors for AMR in migrant communities.

Antimicrobial Resistance and Migration: Interrelation Between Two Hot Topics in Global Health

Background: Antimicrobial resistance (AMR) and migration are two interlinked issues and both pose an escalating threat to global health. With an increasing trend, there are 281 million migrants globally, while AMR is contributing to over 5 million deaths annually, with a projected rise to 10 million by 2050 if left unaddressed. Both AMR and migration are multifaceted problems that extend beyond human health, involving animals, plants, and the environment-a fact highlighted by the One Health approach. Objective: The aim of this work is: (1) to examine the complex relationship between migration and AMR, drawing on epidemiological data, surveillance strategies, and healthcare access challenges and (2) to address an interventional strategy proposal. Methods: We performed a narrative review of the most updated literature about migration and AMR using three primary databases: PubMed, Scopus, and Embase. Findings: Migrants, particularly from low‑ and middle‑income countries, represent a unique group at increased risk of AMR due to factors such as overcrowded living conditions, limited access to healthcare, uncontrolled use of antibiotics, and high prevalence of AMR in origin countries. Studies reveal higher rates of AMR colonization and infection among migrants compared with native populations, with specific pathogens such as MRSA and multidrug‑resistant gram‑negative bacteria posing significant risks. Migratory conditions, socioeconomic vulnerability, and healthcare barriers contribute to this heightened risk. Conclusion: To address the intersection of migration and AMR, interventions must focus on improving living conditions, enhancing healthcare access, promoting appropriate antibiotic use, and strengthening microbiological surveillance. Multisectoral collaboration is essential to mitigate the spread of AMR and safeguard both migrant and global public health.

Patterns of outpatient antibiotic prescribing in older adults by social determinants of healthcare access: a population-based retrospective cohort study

OBJECTIVES

Strategies to improve antibiotic use may exacerbate health inequities if they do not consider existing barriers to healthcare access. We examined associations between social determinants of healthcare access (SDOH) and antibiotic prescribing and variations in these associations pre- and post-COVID-19 emergence.

METHODS

We conducted a retrospective cohort study of community-dwelling adults aged ≥66 years in Ontario, Canada, between March 2018 and March 2020 (pre-pandemic period) and March 2020 and March 2022 (pandemic period). Multivariable Fine-Gray subdistribution hazard models were used to examine associations between three SDOH variables (neighbourhood-level income and proportion racialized, and individual-level recent immigration) and incident antibiotic prescriptions, accounting for mortality as a competing risk. We assessed for potential effect modification by the pandemic period.

RESULTS

The pre-pandemic (n = 2 567 382) and pandemic (n = 2 744 337) cohorts were similar in average age (75 years). Antibiotic prescribing was slightly higher among residents in the highest income neighbourhoods in pre-pandemic (subdistribution hazard ratio [sHR], 1.03 [95% CI, 1.02-1.04], compared with lowest income) and pandemic (sHR, 1.02 [1.01-1.03]) periods. Prescribing was higher among recent immigrants (vs. long-term residents) in both periods, with a more pronounced difference observed during the pandemic (sHR, 1.21 [1.18-1.25]) than pre-pandemic (sHR, 1.12 [1.09-1.16]) period. Prescribing was lower among residents living in the most diverse neighbourhoods (vs. least diverse) in both periods, with a more pronounced difference during the pandemic (sHR, 0.81 [0.80-0.82]) than pre-pandemic (sHR, 0.92 [0.91-0.93]) period.

DISCUSSION

SDOH variables are associated with antibiotic prescribing patterns over time among older outpatients, and the COVID-19 pandemic further modified some of these associations.

Physicians', pharmacists', and nurses' education of patients about antibiotic use and antimicrobial resistance in primary care settings: a qualitative systematic literature review

Background

Patients' adherence to antibiotic treatment and related prevention of AMR is significant. Understanding healthcare professionals' strategies for advising and educating patients in primary care settings is crucial.

Aim

From the perspectives of professionals and patients, to explore how physicians, pharmacists, and nurses educate patients about antibiotic use and antimicrobial resistance in primary care settings.

Methods

A qualitative systematic literature review was conducted in MEDLINE, EMBASE, CINAHL Complete, Eric, SocINDEX, PsycInfo, Web of Science and Scopus. The study included 102 publications, followed PRISMA recommendations and was registered in PROSPERO (reg.no. CRD4202455761). The studies were screened and selected based on specific inclusion and exclusion criteria using Covidence. Quality appraisal followed the Critical Appraisal Skills Program (CASP) qualitative study checklist. Data were extracted, and the analysis consisted of a descriptive numerical summary analysis and a qualitative thematic analysis.

Results

The analyzed studies spanned multiple countries and settings and included perspectives of primary care physicians, pharmacists, nurses and patients. Two main themes emerged: (1) Relationships between professionals and patients influenced educational strategies, showing that trust and rapport between healthcare professionals and patients played a crucial role in shaping educational strategies around antibiotic use; (2) The organizational structures challenged professionals in guiding and educating patients, highlighting how limited resources, time constraints, and system-level pressures hindered healthcare professionals' ability to provide consistent and effective education. Often, structural challenges led to not educating the patients on the risks of antibiotic misuse and antimicrobial resistance. The use of delayed prescriptions emerged as a strategy for improved AMR stewardship and to meet patients' expectations for antibiotic treatment, though it raised concerns about undermining professional responsibility and authority in ensuring appropriate antibiotic use.

Conclusion

Healthcare professionals' role in educating patients about antibiotic use and AMR in primary care settings was complex, with different challenges faced by nurses, pharmacists and primary care physicians. These challenges extended beyond the clinical level, including relational, social and structural factors. Power dynamics, trust issues, and time pressures often hindered effective education on antibiotic use. Addressing gaps in education on antibiotic use and AMR requires acknowledging these multifaceted challenges, with future efforts focusing on better supporting healthcare professionals in this context.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD4202455761.

Drivers of district-level differences in outpatient antibiotic prescribing in Germany: a qualitative study with prescribers

BACKGROUND

Previous studies have identified substantial regional variations in outpatient antibiotic prescribing in Germany, both in the paediatric and adult population. This indicates inappropriate antibiotic prescribing in some regions, which should be avoided to reduce antimicrobial resistance and potential side effects. The reasons for regional variations in outpatient antibiotic prescribing are not yet completely understood; socioeconomic and health care density differences between regions do not fully explain such differences. Here, we apply a behavioural perspective by adapting the Theoretical Domains Framework (TDF) to examine regional factors deemed relevant for outpatient antibiotic prescriptions by paediatricians and general practitioners.

METHODS

Qualitative study with guideline-based telephone interviews of 40 prescribers (paediatricians and general practitioners) in outpatient settings from regions with high and low rates of antibiotic prescriptions, stratified by urbanity. TDF domains formed the basis of an interview guide to assess region-level resources and barriers to rational antibiotic prescription behaviour. Interviews lasted 30-61 min (M = 45 min). Thematic analysis was used to identify thematic clusters, and relationships between themes were explored through proximity estimation.

RESULTS

Both paediatricians and general practitioners in low-prescribing regions reported supporting contextual factors (in particular good collegial networks, good collaboration with laboratories) and social factors (collegial support and low patient demand for antibiotics) as important resources. In high-prescribing regions, poor coordination between in-patient and ambulatory health services, lack of region-level information on antimicrobial resistance, few professional development opportunities, and regional variations in patient expectations were identified as barriers to rational prescribing behaviour.

CONCLUSIONS

Interventions targeting professional development, better collaboration structures with laboratories and clearer and user-friendly guidelines could potentially support rational antibiotic prescribing behaviour. In addition, better networking and social support among physicians could support lower prescription rates.

Communication training for general practitioners aimed at improving antibiotic prescribing: a controlled before-after study in multicultural Dutch cities

Introduction

Suboptimal doctor-patient communication drives inappropriate prescribing of antibiotics. We evaluated a communication intervention for general practitioners (GPs) in multicultural Dutch cities to improve antibiotic prescribing for respiratory tract infections (RTI).

Methods

This was a non-randomized controlled before-after study. The study period was pre-intervention November 2019 – April 2020 and post-intervention November 2021 – April 2022. The intervention consisted of a live training (organized between September and November 2021), an E-learning, and patient material on antibiotics and antibiotic resistance in multiple languages. The primary outcome was the absolute number of prescribed antibiotic courses indicated for RTIs per GP; the secondary outcome was all prescribed antibiotics per GP. We compared the post-intervention differences in the mean number of prescribed antibiotics between the intervention (N = 25) and the control group (N = 110) by using an analysis of covariance (ANCOVA) test, while adjusting for the pre-intervention number of prescribed antibiotics. Additionally, intervention GPs rated the training and their knowledge and skills before the intervention and 3 months thereafter.

Results

There was no statistically significant difference in the mean number of prescribed antibiotics for RTI between the intervention and the control group, nor for mean number of overall prescribed antibiotics. The intervention GPs rated the usefulness of the training for daily practice a 7.3 (on a scale from 1–10) and there was a statistically significant difference between pre- and post-intervention on four out of nine items related to knowledge and skills.

Discussion

There was no change in GPs prescription behavior between the intervention and control group. However, GPs found the intervention useful and showed some improvement on self-rated knowledge and communication skills.

Migrants' living conditions, perceived health needs and implications for the use of antibiotics and antimicrobial resistance in the United Kingdom: A qualitative study

Background and Aims

Antimicrobial resistance (AMR) is among the top public health concerns around the globe. Migrants, especially forced migrants, could be at higher risk of acquiring and transmitting AMR during their journeys or in host countries. There is limited understanding regarding migrants' living conditions and the wider factors contributing to their risk of acquiring infections, and behaviors around antimicrobial use, and AMR development. In this study, we aimed to explore transit experiences, living conditions, and antibiotic use of migrants living in the United Kingdom.

Methods

We conducted semistructured qualitative interviews with 27 participants and identified five themes regarding migrants' journey and their living conditions during transit and after arriving in the United Kingdom, their access to water, sanitation and hygiene (WASH), and their use of antibiotics.

Results

Migrants, particularly forced migrants, experienced unfavorable living conditions, poor access to WASH, and challenges in accessing healthcare, which further contributed to health conditions like urinary and skin problems. Isolation and difficulty in accessing healthcare played significant roles in migrants' perceived need for storing and using antibiotics as a safety net.

Conclusion

The findings highlight the need for coordinated and multilevel interventions to address these challenges and contribute toward tackling AMR and improving the health of this population group.

Perspectives of Immigrants and Native Dutch on Antibiotic Use: A Qualitative Study

Immigrants constitute large proportions of the population in many high-income countries. Knowledge about their perceptions of antibiotics, in comparison to native populations, is limited. We explored these perceptions by organizing nine homogeneous focus group discussions (FGDs) with first-generation immigrant and native Dutch participants (N = 64) from Rotterdam and Utrecht, who were recruited with the assistance of immigrant (community support) organizations. The FGDs were audio-recorded and transcribed verbatim. Inductive thematic analyses were performed with the qualitative analysis software Atlas.ti, using open and axial coding. We did not find noteworthy differences between immigrants and native Dutch participants; all participants had an overall reluctant attitude towards antibiotics. Within-group differences were larger than between-group differences. In each FGD there were, for instance, participants who adopted an assertive stance in order to receive antibiotics, who had low antibiotic-related knowledge, or who used antibiotics incorrectly. Native Dutch participants expressed similar difficulties as immigrant participants in the communication with their GP, which mainly related to time constraints. Immigrants who encountered language barriers experienced even greater communicational difficulties and reported that they often feel embarrassed and refrain from asking questions. To stimulate more prudent use of antibiotics, more attention is needed for supportive multilingual patient materials. In addition, GPs need to adjust their information, guidance, and communication for the individual’s needs, regardless of the patient’s migration background.