Background: Self-medication with antibiotics, which comes in different forms [e.g., leftover or over-the-counter (OTC) use], contributes to antimicrobial resistance as it often happens in a non-prudent manner. In order to tackle this persistent public health problem, its drivers need to be known. The aim of this study was therefore to identify determinants of self-medication with antibiotics via a systematic literature review.Methods: A comprehensive search on determinants of self-medication with antibiotics in the ambulatory care was conducted in PubMed, Scopus, and Embase for studies published between January 2000 and March 2017. There was no limit on the language nor on the type of study. The search was restricted to European and Anglo-Saxon countries. Pairs of reviewers independently screened the abstracts and full texts and performed a quality assessment.Results: From the initial 664 abstracts, 54 publications that included 44 countries were retrieved of which most identified patient related determinants. Important determinants include storing antibiotics at home, poor access to healthcare, and having the intention to self-medicate. Healthcare professionals contribute to the practice of self-medication when catering for demanding and socially vulnerable patients. Healthcare system related determinants include dispensing antibiotics in whole packages and the lack of enforcement of medicine regulations. For some determinants (e.g., patients' age) contradictory results were found.Conclusion: Self-medication with antibiotics is driven by a variety of determinants on the patient, healthcare professional, and system levels. Policy makers should recognise the complexity of self-medication in order to develop multifaceted interventions that target healthcare professionals and patients simultaneously.

Background Elderly residents in long-term care facilities (LTCFs) are vulnerable to healthcare-associated infections. Although hand hygiene is a leading measure for preventing infection, the compliance of healthcare workers is low. The aim of this study is to identify determinants that influence hand hygiene compliance of nursing staff in LTCFs. This information on determinants can eventually be used to develop a tailored implementation strategy for LTCFs. Methods This is an explorative, descriptive study using qualitative methods. We performed semi-structured focus group discussions with 31 nurses and nurse assistants from five Dutch LTCFs. Our focus group discussions continued until no new information could be identified from the data. We used Flottorps’ comprehensive checklist for identifying determinants of practice (the TICD checklist) to guide data collection and analysis. The audiotapes were transcribed verbatim and two authors independently analysed the transcripts with Atlas.ti software. Results LTCFs for the elderly have setting specific determinants that are decisive in explaining hand hygiene compliance. Most of these determinants are related to the residents with whom nurses build close relationships and for whom they want to create a homelike atmosphere. Residents can complicate the provision of care with unpredictable behaviour, being unwilling to receive care or use shared facilities. Our study also discovered setting-transcending determinants related to knowledge, professional interactions, guidelines, and incentives/resources. Conclusions Nurses in LTCFs are constantly pursuing a balance between working hygienically, responding adequately to acute care needs, and maintaining a homelike environment for their residents. As a result, setting-specific determinants affect hand hygiene compliance, as do the known determinants that are important in other care settings. To improve compliance in LTCFs, interventions should be selected on a theoretical base while linking these determinants to change interventions. Trial registration Registration number 50-53000-98-113, Compliance With Hand Hygiene in Nursing Homes: Go for a Sustainable Effect (CHANGE) on ClinicalTrials.gov. Date of registration 28-6-2016.

Background If healthcare professionals perceive that patients strongly expect to be prescribed antibiotics, inappropriate prescriptions may result. As it is unknown whether this happens more often with certain patient groups, we explored whether general practitioners (GPs) and pharmacists perceived such expectations when they provided antibiotics to immigrant patients. Methods Ten GPs and five pharmacists from Rotterdam, the Netherlands, were interviewed on the basis of a semi-structured topic guide. Atlas.ti software was then used to conduct a thematic analysis. Results GPs felt that immigrant patients, especially those who had arrived recently, were more likely to expect to receive antibiotics than native Dutch patients. However, these expectations had decreased over the last years and did not always lead immigrants to exert pressure on them. Except for language barriers, the factors reported by GPs to influence their antibiotic prescribing behaviour were unrelated to patients’ immigrant background. If there was a language barrier, GPs experienced greater diagnostic uncertainty and needed additional time to obtain and communicate correct information. To overcome language barriers, they often used point-of-care testing to convince patients that antibiotics were unnecessary. Although pharmacists rarely experienced problems dispensing antibiotics to immigrants, they and GPs both struggled to find effective ways of overcoming language barriers, and stressed the need for multi-language support materials. Conclusion While pharmacists rarely experience any problems providing antibiotics to immigrants, GPs regularly face language barriers with immigrant patients, which complicate the diagnostic process and communicating information in the limited available time. This sometimes leads antibiotics to be prescribed inappropriately.