Journal of General Internal Medicine

, Volume 30, Issue 4, pp 408–416 | Cite as

Clinicians’ Views and Experiences of Interventions to Enhance the Quality of Antibiotic Prescribing for Acute Respiratory Tract Infections

  • Sibyl AnthierensEmail author
  • Sarah Tonkin-Crine
  • Jochen W. Cals
  • Samuel Coenen
  • Lucy Yardley
  • Lucy Brookes-Howell
  • Patricia Fernandez-Vandellos
  • Jaroslaw Krawczyk
  • Maciek Godycki-Cwirko
  • Carl Llor
  • Christopher C. Butler
  • Theo Verheij
  • Herman Goossens
  • Paul Little
  • Nick A. Francis
  • on behalf of the GRACE/CHAMP INTRO team
Original Research



Evidence shows a high rate of unnecessary antibiotic prescriptions in primary care in Europe and the United States. Given the costs of widespread use and associated antibiotic resistance, reducing inappropriate use is a public health priority.


We aimed to explore clinicians’ experiences of training in communication skills and use of a patient booklet and/or a C-reactive protein (CRP) point-of-care test to reduce antibiotic prescribing for acute respiratory tract infections (RTIs).


We used a qualitative research approach, interviewing clinicians who participated in a randomised controlled trial (RCT) testing two contrasting interventions.


General practice clinicians in Belgium, England, The Netherlands, Poland, Spain and Wales participated in the study.


Sixty-six semi-structured interviews were transcribed verbatim, translated into English where necessary, and analysed using thematic and framework analysis.


Clinicians from all countries attributed benefits for themselves and their patients to using both interventions. Clinicians reported that the communication skills training and use of the patient booklet gave them greater confidence in addressing patient expectations for an antibiotic by providing answers to common questions and supporting the clinician’s own explanations. Clinicians felt the booklet could be used for a variety of patients and for different types of infections. The CRP test was viewed as a tool to decrease diagnostic uncertainty, to support non-prescription decisions, and to reassure patients, but was only necessary when clinicians were uncertain about the need for antibiotics.


Providing clinicians with training and support tools for use in practice was received positively and was valued by clinicians across countries. Interventions seemed to have influenced behaviour by increasing clinician knowledge about illness severity and prescribing, increasing confidence in making non-prescribing decisions when antibiotics were unnecessary, and enabling clinicians to anticipate positive outcomes when making such decisions. Addressing such determinants of behaviour change enabled interventions to be relevant for clinicians working across different contexts.


qualitative research decision making antibiotic prescribing communication training point-of-care testing primary care 



We thank all participants, clinicians and patients, who took part in the GRACE INTRO trial. We especially thank all the clinicians who consented to be involved in this qualitative study. We also thank all members of the GRACE INTRO consortium whose hard work made the trial and this study possible.

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Author Contribution

All authors participated in study concept and design and preparation of the manuscript. SA and STC participated in moderation of interviews, transcript analysis and interpretation, and they take responsibility for the manuscript as a whole. JWC and NAF participated in interpretation of the analysis. PFV, JK, CL, LBH participated in moderation of interviews, checking interpretation and preparation of analysis. All authors read and commented on different versions of the manuscript.


This GRACE/CHAMP study was supported by the European Commission Framework 6 Programme (grant 518226). The work in the UK was also supported by the National Institute for Health Research and the Research Foundation Flanders (grant G.027408N). The work reported on in this publication has been financially supported through the European Science Foundation (ESF), in the framework of the Research Networking Programme TRACE (

Prior Presentations

Presented at the General Respiratory Infections Network (GRIN) Annual meeting 2012, Bristol, UK; the South West Society of Academic Primary Care (SW SAPC) conference 2012, Torquay, UK and the 41st Annual Scientific Meeting of the Society of Academic Primary Care (SAPC) 2012, Glasgow, UK. Presentation entitled: “Exploring clinicians’ views across six countries of a near patient test and/or communication skills training as techniques to decrease inappropriate antibiotic prescribing for acute cough”.


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Copyright information

© Society of General Internal Medicine 2014

Authors and Affiliations

  • Sibyl Anthierens
    • 1
    Email author
  • Sarah Tonkin-Crine
    • 2
  • Jochen W. Cals
    • 3
  • Samuel Coenen
    • 1
    • 4
  • Lucy Yardley
    • 5
  • Lucy Brookes-Howell
    • 6
  • Patricia Fernandez-Vandellos
    • 7
  • Jaroslaw Krawczyk
    • 8
  • Maciek Godycki-Cwirko
    • 8
  • Carl Llor
    • 9
  • Christopher C. Butler
    • 6
  • Theo Verheij
    • 10
  • Herman Goossens
    • 4
  • Paul Little
    • 2
  • Nick A. Francis
    • 6
  • on behalf of the GRACE/CHAMP INTRO team
  1. 1.Department of Primary Care and Interdisciplinary CareUniversity of AntwerpWilrijkBelgium
  2. 2.Primary Care and Population Sciences, Faculty of MedicineUniversity of SouthamptonSouthamptonUK
  3. 3.Department of General Practice, CAPHRI School for Public Health and Primary CareMaastricht UniversityMaastrichtThe Netherlands
  4. 4.Vaccine & Infectious Disease Institute (VAXINFECTIO), Laboratory of MicrobiologyUniversity of AntwerpAntwerpenBelgium
  5. 5.Academic Unit of Psychology, Faculty of Social and Human SciencesUniversity of SouthamptonSouthamptonUK
  6. 6.Cochrane Institute of Primary Care and Public Health, School of MedicineCardiff UniversityCardiffUK
  7. 7.Applied Research in Respiratory DiseasesHospital Clinic of BarcelonaBarcelonaSpain
  8. 8.Department of Family and Community MedicineMedical University of LodzLodzPoland
  9. 9.Primary Care Centre Jaume IUniversity Rovira i VirgiliTarragonaSpain
  10. 10.Julius Centre for Health Sciences and Primary CareUniversity Medical Center UtrechtUtrechtThe Netherlands

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