Prescription of Antibiotics in pRimary CAre

Although antibiotic use and antimicrobial resistance in the Netherlands is relatively low, inappropriate prescription of antibiotics is substantial. First generation non-western immigrants in the Netherlands are shown to be prescribed more antibiotics than native Dutch. However, they have been largely ignored in research and programs into antibiotic stewardship. General practitioners (GPs) experience pressure to prescribe antibiotics for immigrants, and they have difficulty to communicate in a cultural-sensitive way. Multifaceted interventions that include communication skills training for GPs are shown to be most effective in reducing antibiotic prescribing. Therefore, our study aims to develop and evaluate a tailored intervention for GPs and their immigrant patients.

GPs who have learned to communicate in a cultural-sensitive way during the PARCA-intervention, prescribe less antibiotics than GPs who did not received the PARCA-intervention.

We will use data for the primary and secondary outcome from the following 6-month periods: November 2019 to April 2020 (baseline option 1); November 2020 to April 2021 (baseline option 2), and November 2021 to April 2022 (follow-up). Due to COVID-19 we include two options for the baseline period. In the first year after the emergence of COVID-19, it was shown that the number of antibiotic prescriptions in the Netherlands decreased significantly (van der Pol, 2021). We do not know whether the effect of the COVID-19 pandemic will continue in the coming years. Therefore, we have two baseline options. Because the control arm will not receive the intervention, it reflects the ‘normal’ situation regarding the number of dispensed antibiotics. If the primary outcome measure in the control arm during the follow up is closer to baseline option 1, we will use this as baseline for the trial; if it is closer to baseline option 2, we will use this as baseline for the trial.

We will collect data about individual background characteristics (e.g. gender, age, years of practice) via a registration questionnaire which the GPs receive at the intake of the study.

The E-learning for the GPs in the intervention arm will take place in Autumn 2021. One to two weeks after the E-learning, the GPs receive the evening training. The GPs in the control arm will receive the E-learning and the training session in Spring 2022, after the observation period for the trial.

In addition to our RCT we will perform a process evaluation, in which we obtain insight into the opinion of GPs regarding the improvement of their communication skills, the relevance of the training, and the applicability of the developed patient materials in practice. Also, we will ask them to rate their own cultural-sensitive communication skills, skills to assess patient expectations, and skills to explain non-prescription of antibiotics to immigrant patients, before and after the intervention. We will measure this using two online questionnaires. The first questionnaire will be filled in before the training and the second questionnaire three months afterwards.

The intervention for the GPs will consist of three different components:
- An E-learning focused on intercultural skills with 4 lessons of 10-15 minutes each;
- An evening training session (3.5 hours) in which GPs will be taught intercultural skills, discuss video-taped consultations with intercultural doctor-patient interactions, and practice the newly learned skills during role plays with a training actor;
- Use of patient materials (written information and an animation movie that will be presented on the website Thuisarts.nl) for immigrant patients in their own language, to be used during consultation.