Hungarian general practice paediatricians' antibiotic prescribing behaviour for suspected respiratory tract infections: a qualitative study.

OBJECTIVES: Inappropriate antibiotic prescribing is a major cause of antimicrobial resistance (AMR). The aim of this study was to explore paediatric general practitioners' (GP Peds) antibiotic prescription practice in suspected respiratory tract infections (RTIs), using the capability-opportunity-motivation-behaviour framework. DESIGN: The design is a qualitative study based on individual, semistructured telephone or virtual interviews. SETTING: Paediatric general practice in Hungary. We applied stratified maximum variation sampling to cover the categories of age, sex and geographical location of participants. PARTICIPANTS: We interviewed 22 GP Peds. Nine were male and 13 were female: 2 of them were less than 40 years old, 14 were between 40 and 60 years, and 6 were above 60 years. 10 worked in low-antibiotic prescription areas, 5 in areas with medium levels of antibiotic prescription, 3 in high-antibiotic prescription areas, and 4 in and around the capital city. RESULTS: Study participants had varying antibiotic prescription preferences. Personal experience and physical examination play a central role in GP Peds' diagnostic and treatment practice. Participants emphasised the need to treat children in their entirety, taking their personal medical record, social background and sometimes parents' preferences into account, besides the acute clinical manifestation of RTI. Most respondents were confident they apply the most effective therapy even if, in some cases, this meant prescribing medicines with a higher chance of contributing to the development of AMR. Some participants felt antibiotic prescription frequency has decreased in recent years. CONCLUSIONS: Our findings suggest that a more prudent attitude toward antibiotic prescribing may have become more common but also highlight relevant gaps in both physicians' and public knowledge of antibiotics and AMR. To reinforce awareness and close remaining gaps, Hungary should adopt its national AMR National Action Plan and further increase its efforts towards active professional communication and feedback for primary care physicians.

Formative Research on HPV Vaccine Acceptance among Health Workers, Teachers, Parents, and Social Influencers in Uzbekistan.

Human papillomavirus (HPV) vaccines effectively prevent cervical cancer, most of which results from undetected long-term HPV infection. HPV vaccine introduction is particularly sensitive and complicated given widespread misinformation and vaccination of young girls before their sexual debut. Research has examined HPV vaccine introduction in lower- and middle-income countries (LMICs), but almost no studies attend to HPV vaccine attitudes in central Asian countries. This article describes the results of a qualitative formative research study to develop an HPV vaccine introduction communication plan in Uzbekistan. Data collection and analysis were designed using the Capability, Opportunity, and Motivation for Behaviour change (COM-B) mode for understanding health behaviours. This research was carried out with health workers, parents, grandparents, teachers, and other social influencers in urban, semi-urban, and rural sites. Information was collected using focus group discussions (FGDs) and semi-structured in-depth interviews (IDIs), and data in the form of participants' words, statements, and ideas were thematically analysed to identify COM-B barriers and drivers for each target group's HPV vaccine-related behaviour. Represented through exemplary quotations, findings were used to inform the development of the HPV vaccine introduction communication plan. Capability findings indicated that participants understood cervical cancer was a national health issue, but HPV and HPV vaccine knowledge was limited among non-health professionals, some nurses, and rural health workers. Results on an opportunity for accepting the HPV vaccine showed most participants would do so if they had access to credible information on vaccine safety and evidence. Regarding motivation, all participant groups voiced concern about the potential effects on young girls' future fertility. Echoing global research, the study results highlighted that trust in health workers and the government as health-related information sources and collaboration among schools, municipalities, and polyclinics could support potential vaccine acceptance and uptake. Resource constraints precluded including vaccine target-aged girls in research and additional field sites. Participants represented diverse social and economic backgrounds reflective of the country context, and the communication plan developed using research insights contributed to the Ministry of Health (MoH) of the Republic of Uzbekistan HPV vaccine introduction efforts that saw high first dose uptake.

Health worker and patient views on implementation of smoking cessation in routine tuberculosis care.

Smoking worsens tuberculosis (TB) outcomes. Persons with TB who smoke can benefit from smoking cessation. We report findings of a multi-country qualitative process evaluation assessing barriers and facilitators to implementation of smoking cessation behaviour support in TB clinics in Bangladesh and Pakistan. We conducted semi-structured qualitative interviews at five case study clinics with 35 patients and 8 health workers over a period of 11 months (2017-2018) at different time points during the intervention implementation phase. Interviews were conducted by trained researchers in the native languages, audio-recorded, transcribed into English and analysed using a combined deductive-inductive approach guided by the Consolidated Framework for Implementation Research and Theoretical Domains Framework. All patients report willingness to quit smoking and recent quit attempts. Individuals' main motivations to quit are their health and the need to financially provide for a family. Behavioural regulation such as avoiding exposure to cigarettes and social influences from friends, family and colleagues are main themes of the interviews. Most male patients do not feel shy admitting to smoking, for the sole female patient interviewee stigma was an issue. Health workers report structural characteristics such as high workload and limited time per patient as primary barriers to offering behavioural support. Self-efficacy to discuss tobacco use with women varies by health worker. Systemic barriers to implementation such as staff workload and socio-cultural barriers to cessation like gender relations, stigma or social influences should be dealt with creatively to optimize the behaviour support for sustainability and scale-up.

Using behaviour change theory to train health workers on tobacco cessation support for tuberculosis patients: a mixed-methods study in Bangladesh, Nepal and Pakistan.

BACKGROUND: Low- and middle-income countries (LMICs) are disproportionately impacted by interacting epidemics of tuberculosis (TB) and tobacco consumption. Research indicates behavioural support delivered by health workers effectively promotes tobacco cessation. There is, however, a paucity of training to support LMIC health workers deliver effective tobacco cessation behavioural support. The TB and Tobacco Consortium undertook research in South Asia to understand factors affecting TB health workers' delivery of tobacco cessation behavioural support, and subsequently developed a training package for LMICs. METHODS: Using the "capability, opportunity, and motivation as determinants of behaviour" (COM-B) framework to understand any issues facing health worker delivery of behaviour support, we analysed 25 semi-structured interviews and one focus group discussion with TB health workers, facility in-charges, and national tuberculosis control programme (NTP) staff members in each country. Results were integrated with findings of an adapted COM-B questionnaire on health worker confidence in tobacco cessation support delivery, administered to 36 TB health workers. Based on findings, we designed a guide and training programme on tobacco cessation support for health workers. RESULTS: Qualitative results highlighted gaps in the majority of health workers' knowledge on tobacco cessation and TB and tobacco interaction, inadequate training on patient communication, insufficient resources and staff support, and NTPs' non-prioritization of tobacco cessation in all three countries. Questionnaire results reiterated the knowledge deficits and low confidence in patient communication. Participants suggested strengthening knowledge, skills, and competence through training and professional incentives. Based on findings, we developed an interactive two-day training and TB health worker guide adaptable for LMICs, focusing on evidence of best practice on TB and tobacco cessation support, communication, and rapport building with patients. CONCLUSIONS: TB health workers are essential in addressing the dual burden of TB and tobacco faced by many LMICs. Factors affecting their delivery of tobacco cessation support can be identified using the COM-B framework, and include issues such as individuals' knowledge and skills, as well as structural barriers like professional support through monitoring and supervision. While structural changes are needed to tackle the latter, we have developed an adaptable and engaging health worker training package to address the former that can be delivered in routine TB care. TRIAL REGISTRATION: ISRCTN43811467 .