Four major themes emerged, and these were relevant to GPs from all five countries. We specifically chose to report only two of the four themes in this paper as they contain instances where GPs’ views indicated differences based on country-specific context. The two themes which are not discussed here cover aspects related to practical aspects of the web-based format of the INTRO intervention. Theme 3, “Ease of use of the intervention format” included GPs’ comments about the attractiveness of the website and how easy it was to navigate. In response to these comments we made changes to the website such as adding a progress bar so GPs were aware of how much of the training programme they had worked through at any one point. Theme 4, “Clarity of the intervention content”, included GPs’ comments on points in the website where there was confusion. These included cross-country examples such as a graph being difficult to understand or web pages containing text which was “too scientific”. It also included country specific examples. GPs from countries outside the UK disliked having to read subtitles when videos had been filmed in English. GPs from Belgium, Spain and Poland also initially misunderstood CRP test results because they were used to working with different measurements (mg/dl rather than mg/l). Comments within these two themes were fed back to assist the development of the final version of INTRO. Major changes to the website included simplifying the main menu and adding pages to indicate when GPs had completed one of the training sessions. Other changes included adding measurements (mg/dl) to the CRP materials alongside mg/l figures for materials to be used in Spain, Poland and Belgium and also removing self-care advice regarding Echinacea, Vitamin C and cough medicines from the Dutch patient booklets as the information was not in line with national guidelines.
All four themes are listed in Table
, with the themes that are discussed here highlighted in bold.
Relevance of the intervention: Awareness of the problem of antibiotic prescribing
GPs in each country agreed with the importance of the intervention’s aim to promote prudent antibiotic use. In addition, they identified with the experience of having difficulties in prudent prescribing for LRTI in their own practice.
"“It is useful to do this study because it just reminds you why you should continue doing what you are doing, because I think after a while GPs forget about antibiotic resistance and how dangerous it is to the patient.” (British, GP2)."
GPs from Poland appeared to particularly like the intervention as they reported having little prior education on this topic.
"“I think that the topic is very interesting. The training is completely new for us. I think that we over-prescribe in Poland. This is a completely new approach for me and I find it very interesting.” (Polish, GP1)."
In contrast, GPs from the Netherlands and the UK felt they were already familiar with the content of the introduction section of intervention, which gave background to the problem of over-prescribing, and were initially less enthusiastic.
"“Some of the stuff I think is quite basic and I think it is more just using it as a teaching aid for medical students or GP registrars or even triage nurses. But normal GPs should hopefully have a lot of that basic skill already.” (British, GP1)."
However GPs often found later components, such as those describing techniques to help change their prescribing, were new to them or helped to reinforce their knowledge.
"“When I look at the communication training it makes me think… actually I already know these things, however I think that… a number of things… in particular drawing out the [patient] expectations and doing a good physical examination, which often I am tempted to just do quickly under the clothes to check their lungs, but doing it properly will reassure people. Yes, I think this is quite good… to do this again… to cross the T’s.” (Dutch, GP4)."
"“I think that’s quite a good illustration about how to specifically, just a revision, about how to specifically address patients concerns, because they… so often, it’s so important… it’s quite a good way of thinking about you know, a way to reinforce how you need to ask about those symptoms.” (British, GP4)."
Attractiveness and feasibility of the content of the interventions
GPs across all countries felt it was crucial that the training, whilst being relevant, should also provide specific benefit for them in their daily clinical practice. Whilst some felt that offering new knowledge was enough, most wanted to see clear advantages that would be obtained by following the intervention. Many GPs liked the idea of being provided with additional equipment in the form of the CRP test and the patient booklet and felt that receiving these would help them to decrease their inappropriate prescribing.
"“The purpose is going to be good but you’ve got to capture people who get 50 emails a day minimum and have to fit lots of education in, so GPs have to see straight away what they are getting out of the intervention for their daily practice.” (British, GP3)."
"“Indeed a CRP test could be reassuring with a borderline case… normally you would do on a Friday what you would never do on a Thursday. Then you prefer certainty over uncertainty which is a shame. Research shows that on Fridays more antibiotics are prescribed. However, I am also guilty of that and I know it… And this would surely help, so you can say no since the CRP is only 15. If it doesn’t get better, you can come back on Monday. This gives you the confidence to [make the decision]. I see this as very valuable.” (Dutch, GP1)."
As well as providing benefit to themselves, GPs sought reassurance that the training offered by the intervention could prevent harm to their patients whilst providing alternative management strategies that still maintained patient satisfaction. Again GPs felt that the additional equipment provided in the intervention would be acceptable for their patients. The CRP test was thought to be particularly helpful as it would give patients “evidence” on the seriousness of their condition; regardless of whether or not the test indicated a need for antibiotics.
"“I think that the act of carrying out a test and being able to give them a quantitative result is very much liked by patients. Patient satisfaction is generally higher if you can give them something that demonstrates that it is a viral infection and supports not having to use antibiotics.” (Spanish, GP2)."
"“I wonder if [the CRP test] would be a good tool to persuade patients who insist on antibiotics, who do not need antibiotics, and you go ‘look, you’ve had your blood test’. It’s like someone having an x-ray right in front of you, you can say ‘look your bone is not broken, go home’.” (British, GP5)."
Whilst all GPs felt that the intervention topic was relevant to their practice and felt the training would be beneficial for them to follow, some anticipated specific barriers in implementing the intervention which reflected the contexts in which they worked.
Some GPs reported that the consultation style and length portrayed in the communication training videos did not match their typical consultations in practice. One example of this was a GP from Poland who felt there were cultural differences in how patients and GPs communicated with one another in consultations between countries.
"“I think it is a copy of a British programme and a local specification should be taken into account. By local specification I mean both the length of time devoted to a patient and the way in which the doctor and the patient communicate with each other. I generally have no experience of such inquisitive patients…This is a wrong assumption that you can talk with every patient in this way. Most Polish patients expect the doctor to make a decision. They don’t expect to make a decision themselves or to be educated during a consultation. It is more about the doctor who has to pass information on to a patient. It is the doctor’s role to tell a patient why he is not going to prescribe an antibiotic.” (Polish, GP1)."
GPs in the Netherlands and Belgium also reported that they would feel they were patronizing patients if they asked them to sum up what they had learned at the end of the consultation.
"“I don’t think that in Belgium it is customary to ask the patient to summarise their account. I think many patients will find that strange (…) I think that we normally say ‘Is everything clear? Are there any questions?’ but not asking something like ‘what have we learnt today?’” (Belgian, GP2)."
GPs from Spain and Poland reported that they experienced problems when patients had already obtained antibiotics over the counter prior to a consultation, which they reported as a common concern for them.
"“I don’t know about other countries but patients come to get antibiotics which they have already bought in the pharmacy, so you’re under pressure to prescribe that antibiotic that they have been using… maybe we should have more information [on this]…” (Spanish, GP2)."
Belgian GPs highlighted the fact that reducing antibiotic prescriptions would lead to fewer consultations, which would result in less income for a practice in their fee for service system.
"“It is of course uncertain whether in Belgium one will be positive about this, that there will be fewer consultations. This is a system where people are paid on performance and [fewer consultations] is not something we are looking forward to.” (Belgian, GP4)."
Lastly, GPs from Belgium and Poland felt that information contained in the intervention about certain patient behaviours was incorrect for their patients. They felt their patients consulted more quickly than suggested in the intervention because of the need for a “sick note” to take time off work. GPs in these countries reported that patients would usually consult after having symptoms for one or two days rather than illnesses of over a week.
"“I think that our reality is a little bit different, because it says that patients consult a doctor seven to ten days after the initial symptoms start and I think that they do it a bit earlier. I think that they come to us on the third day…they don’t wait the whole week or a week and a half, because it is too long for them.” (Polish, GP2)."
Whilst the issue of context was mainly related to implementation, GPs also mentioned the relevance of context when looking at the evidence base of the intervention. Although GPs agreed that evidence was crucial to support guidance and interventions, many stressed that they would prefer evidence to be based on research in their own countries or to be provided with familiar sources, for example national guidelines for their country.
"“[Reading from INTRO webpage] ‘…a study in the US.’ Here we need to be cautious and make sure it can be extrapolated to our system. It also needs to be checked, whether there have been any studies done in Belgium, France or the Netherlands, i.e. that there are no European equivalent studies.” (Belgian, GP1)."
"“Unfortunately these studies are foreign. It is needless to say that our Polish market is different from the western one. I am not sure if the research that is conducted in general practice in Great Britain will have any meaning for Polish doctors.” (Polish, GP1)."