PONE-D-20-11324

General practitioners’ understanding of antibiotic use and resistance, and perceived barriers and facilitators to prudent antibiotic prescribing: a qualitative study

PLOS ONE

Dear Dr. Saliba-Gustafsson,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

The two reviewers raised a couple of concerns that you should consider in a revised version (see end of mail). By the way, you will find most of the comments of Reviewer 2 in an additional file.

I also have some concerns and additional suggestions you which you will find also at the end of this mail.

Please submit your revised manuscript by Oct 24 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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We look forward to receiving your revised manuscript.

Kind regards,

Wolfgang Himmel

Academic Editor

PLOS ONE

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[I have read the journal's policy and the authors of this manuscript have the following competing interests: At the time of the study, SRK was employed at Karolinska Institutet, Sweden. She is currently employed by the European Centre for Disease Prevention and Control (ECDC). The views and opinions expressed herein are the authors’ own and do not necessarily state or reflect those of ECDC. ECDC is not responsible for the data and information collation and analysis and cannot be held liable for conclusions or opinions drawn. EASG, AN, MAB and CSL have no competing interests to declare.].

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Additional Editor Comments:

A real strength of your paper is the ecological model, or say, the parallel consideration of the many influences on a personal, professional, organizational level and so on. And exactly this makes the paper attractive not only for GPs in Malta but also in other countries, even in those with a lower use of antibiotics. Therefore, I would recommend that you make clearer than to date that the method of the paper and its results could also be of interest for readers worldwide.

Similar to Reviewer 2, I would also recommend that you start with the ecological model directly at the beginning of the Results section so that readers get a good overview of what they can expect on the following pages and how you organized your analysis and presentation of results.

Like Reviewer 1, I recommend a significant shortening of the manuscript. Even if PlosOne is an online journal, we should consider the readers interest to read concise manuscripts (“to the point”). Medical journals, even those with a qualitative focus (such as Family Practice) have usually word limits around 3,000 to 4,000 words. As far as I see, your manuscript has more than 10,000 words (!) and I ask you to limit it by a maximum of 6,000 words (fewer words would be even better!). You will see some suggestions later in my comments that may help to reach this limit.

The title of the manuscript, although rather long, misses and important term: “respiratory tract infections”. A shorter version, including this term could be:

Barriers and facilitators to prudent antibiotic prescribing in respiratory tract infections – a qualitative interview study with general practitioners in Malta (or “acute resp. …,” as often used)

I’m sure you find alternatives if you don’t agree with my suggestion.

Although I like the ecological model that guided, or helped to organize, your analysis, I have some concerns with the definitions and contents of your sub-themes and categories. Of course, I don’t want to interfere in the analysis of your working group, but perhaps you may find some other definitions in one or another case or re-work some of the categories:

See, for example, the first sub-theme. This is more or less the title of the paper or what you want to study but not a precise sub-theme. Do you find a more appropriate one?

Another example is a strong overlapping of category 1 and category 3 of the first sub-theme. Especially here, you could cancel a lot of text and concentrate on those aspects that are really outstanding and significant.

Also, sub-theme 1 and parts of sub-theme 2 are overlapping, especially as far as patient behavior is the issue. Again, here is room for strengthening the manuscript.

For me, the title of sub-theme 3 is too ‘positive’, if we have in mind, for example, drug reps. A better alternative may simply be: “The role of other professionals”.

One last example is category 9 of sub-theme 4. I feel parts of this category have nothing to do with ‘organization’ and so on but more or less with ‘attitudes’ of GPs towards testing and would then go well with sub-theme 1 (and could, again, be shortened!).

The Discussion is much too long and addresses too many issues, many of them already extensively discussed in the relevant literature. Please concentrate on the most important results from your research and the consequences for GPs and the international state of the art. Perhaps you can/may structure the discussion under 2 main issues: “GPs’ conceptions and misconceptions” and “external factors”. Just an idea.

For the Conclusion, I would recommend to restrict yourselves to 2 paragraphs: one with a stronger focus on the Malta GPs, one on the international discussion and future research.

As Reviewer 1, I also recommend to be precise when talking about patients and their behavior. Mostly, it’s not ‘patients’ but ‘patients and their behavior as perceived by the interviewees’. That is especially important in the case of ‘patient demand’, most often a matter overestimated by doctors but then ‘real in their consequences’. I think you know the rather old, but still excellent work of Paul Little and colleagues (https://www.bmj.com/content/bmj/328/7437/444.full.pdf) where we learn: “… after controlling for patient preference, medical need, and clustering by doctor, doctors' perceptions of patient pressure were strongly associated with prescribing … In all cases, doctors' perception of patient pressure was a stronger predictor than patients' preferences.”

Two minor remarks:

At several places in your paper, you talk about a ‘wait and see’ approach in such a way that one may think this is in some contrast to a ‘delayed prescription’ approach. Reading this interview with Geoffrey Spurling (https://medicalxpress.com/news/2017-09-dose-wait-and-see-unnecessary-antibiotic.html, I see no difference, also when reading his original paper (https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004417.pub5/full?cookiesEnabled). By the way, you may cite the paper.

Maybe this paper, too, is worth to be referenced as an update of the Gulliford paper you cited:

https://pubmed.ncbi.nlm.nih.gov/30755451/

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: N/A

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The methods section could still use some additional information regarding sampling technique and also regarding the use of the socio ecological model.

Interview data is normally not made publically available as there is no consent for that given by the participants I assume

for further comments see attached document

Reviewer #2: The paper focuses on an important and timely health care issue. We read it with great interest. It is well structured and well written. Some aspects have already been described, but there are also new and interesting connections.

- line 118: „A target of 20 GPs was deemed necessary to ensure data saturation.“ – Is this a preliminary consideration? What does it result from? From my point of view, this is an unnecessary sentence, possibly delete it.

- line 160: EASG – that this is the author is not self-explanatory, I was thinking of a software. Please write e.g. „by autor EASG“ at the first time.

- It is written about RTI. This is very broad. Does it mean ARTI? Or can it be narrowed down if necessary?

- The results are very lengthy, maybe not everything has to be presented in every detail, please always concentrate on essentials. It is normal, that the categories can frequently not be separated accurately. Please avoid repeating yourself!

- The whole manuscript should be shortened, especially the results section. Here are some suggestions:

o Try to avoid overlapping passages: e.g. uncertainty of the GPs in line: 204 ff., 299-301 etc., 333-337) please in one section

o citation line 323-327 please delete (no new information)

o second citation line 403-406 please delete

o Category V, line 417-456: please cut, normal prescription behavior does not need to be described in every detail

o citation line 536-538 please delete

o citation line 566-570 please delete too

o line 583-589 please cut, e.g. „GPs often felt that they cannot afford to wait too long to treat patients as they can develop complications. Consequently they felt that they have no choice but to prescribe antibiotics without knowing whether they are truly warranted.“ could be deleted

o citation line 624-628 please delete, line 640-643, too

o line: 657 – 662 please cut (no new information)

o line 666-670: could be deleted

- The results regarding the GPs view on patients should be presented as such, that means: Please write about GPs perception of patients and not of patients as such. Your results are based on the way GPs experience and perceive their patients and are not based on patient views and reports themselves. This should be clear for the reader, e.g. “GPs perceive their patients to expect something…/ GPs have the feeling that their patients …. etc”.

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Reviewer #1: No

Reviewer #2: No

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Attachments

Attachment

Submitted filename: Review PLOS one 2020.docx

PONE-D-20-11324R1

Barriers and facilitators to prudent antibiotic prescribing for acute respiratory tract infections: a qualitative study with general practitioners in Malta

PLOS ONE

Dear Dr. Saliba-Gustafsson,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

While Reviewer 2 accepted the manuscript as it is, Reviewer 1 has still some minor concerns (see below) which I ask to consider for the final version. 

I have also some minor concerns and a major concern which you hopefully may address for the final version:

I would recommend to move the last sentence of the Findings section in the Abstract (“Findings were collated … prescribing.”) to the end of the Methods section. And you should present 2 or 3 more results in the Findings section of the Abstract. I think you have room enough there and it makes the Abstract more interesting and this may stimulate readers to read the whole paper.

You talk about a “formative” study at the beginning of the Methods. I’m afraid this is an unusual description of your study type and/or irritating for readers since they typically know this expression form educational research (summative – formative assessment). Is “qualitative” not sufficient – what do you think?

A better heading of Category III may be: “Why GPs use or do not use diagnostic tests”. I think it’s not so much “attitudes” that matter but structure (e. g., access to facilities, lack of resources and so on). Of course, your decision!

Perhaps “GPs’ experience in patient education” is a better heading for Category V (instead of “role”).

Following Reviewer 1, my major concern refers to the structure of your Discussion section. Your socioecological model is really interesting but I was disappointed that you did not use this innovative approach to structure your discussion. Instead, you discuss several of your results, sometimes with a subheading, sometimes without (e.g., when discussing the role of pharmacists). For the reader, this selection of issues and the structure of how you present them must appear arbitrary. I strongly recommend to try the following: Take the subheadings of your socioecological model as subheadings of your Discussion and discuss (as short as possible!) how the interviews with the GPs inform this model or to put it the other way how the barriers and facilitators to prudent prescribing cannot be understood if we only look at GPs and their education/knowledge. The model helps us to consider the many other factors that influence antibiotic prescribing. I know that the first three areas or levels of the model are far better represented in your interview material than “community” and “public policy”, but, for example, guidelines and insurance do play a role in “public policy” for GPs, as you found out.

So, please try to structure the discussion this way and get back to me if it is impossible. If it is possible (and I do hope so!) you should report one important “limitation” of your study or study design. Even if the model helps to better understand antibiotic prescribing, your study only captures the model as seen/perceived by the GPs. Further research should examine the 5 areas of the model not alone from the GP perspective but as ‘realities’ of their own. Questions, for example, could be: Did information campaigns take place and did they change antibiotic prescriptions ad so on. I think your paper could show how the future of research in drug prescribing could be and what elements are needed. Take the chance!

I’m sure this revision will not take so much time as the last revision and I look forward to your final version.

Please submit your revised manuscript by Jan 24 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Wolfgang Himmel

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: N/A

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: dear authors,

well done on addressing comments adequately apart from comment 5 about the data been collected in 2014, so still valuable but it might already be a bit dated, so you need to address this in the strenght and limitation section.

The discussion still needs a bit of work I think, as you have used the socio ecological model I would expect to find some findings and implications related to those different levels (intrapersonal, interpersonal, organisation and community and policy level)

word count is still a lot, I personally find an article of more then 5000 words too lenghty and people might not read it. It is worth trying to get the essence said in under 5000 words

Reviewer #2: (No Response)

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: prof dr Sibyl Anthierens

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Barriers and facilitators to prudent antibiotic prescribing for acute respiratory tract infections: a qualitative study with general practitioners in Malta

PONE-D-20-11324R2

Dear Dr. Saliba-Gustafsson,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

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Kind regards,

Wolfgang Himmel

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Dear authors,

I would like to add that it was a pleasure to read both revisions and to see how the paper improved during the revisions so that is now a clearly written paper and will add to our knowledge. I do hope that you share my view although it was a lot of work for you (I appreciate it!).

By the way, when you submit the final version, you may consider to change the heading of the subchapter 'Organisational and public policy-level factors: addressing diagnostic uncertainty' simply into 'Addressing organisational, community and public policy factors'. Thus, you could include the 'community' level so that all levels of the Figure are addressed in the Discussion. And perhaps you may add a sentence somewhere in this section, such as: "Educational activities and information campaigns in the community could help to support the adequate prescription and use of antibiotics" (sorry for my English). Indeed, I think this is one message of the Figure and it is important not only to call on doctors but to include the community when implementing a prudent drug strategy.

But, of course, it is your decision whether or not you follow my suggestion.

Thanks, Wolfgang Himmel

Reviewers' comments: