The development of a theoretically-informed intervention to improve the antibiotic prescribing behaviour of dentists in primary care in Scotland

  • Gillian Forbes

Student thesis: Doctoral ThesisDoctor of Philosophy


Background: Despite the publication of national dental guidance recommending the minimal use of antibiotics, evidence suggests that antibiotics continue to be prescribed when there is no clinical indication.

Aim: The aim of this thesis was to apply the Theoretical Domains Framework (TDF), and the Behaviour Change Technique Taxonomy v1 (BCTTv1) guided by the Behaviour Change Wheel (BCW) to further an understanding of general dental practitioners’ (GDPs) antibiotic prescribing behaviour in Scotland and to inform the development of a proposed intervention (co-produced with GDPs) to reduce the non-clinically determined prescribing of antibiotics.

Methods: Two literature reviews, 4 studies and a workshop with GDPs were completed to inform the content of the intervention. The reviews profiled factors and beliefs influencing prescribing decision making and previous antibiotic prescribing intervention studies. The studies were a semi-structured interview (qualitative) study with 16 GDPs, two independent surveys (quantitative studies) conducted with 402 GDPs and 291 patients and an experimental study of 2 recruitment methods (formal and informal) to increase participation in the patient survey. The identified TDF domains were mapped to behaviour change techniques (BCTs), the active components of an intervention using the BCTTv1. These potential BCTs were discussed at workshop of 8 GDPs who helped to operationalise and further refine the intervention components in terms of their practicality and acceptability in primary dental care.

Results: The literature review identified no previous interventions designed to influence antibiotic prescribing were conceptualised using a theoretical framework, as recommended by the Medical Research Council, which severely limited any understanding of their success or failure. The underlying assumption in this literature appeared to be that knowledge of when to prescribe and which antibiotics to use including the correct dosage, frequency and duration is the primary issue behind inappropriate prescribing as this was the key focus of most interventions.

The GDP interview study (n = 16) identified patient expectation as the factor most likely to influence inappropriate prescribing. Nine specific beliefs, the barriers or enablers of inappropriate prescribing, were mapped on to 4 TDF domains (cognitive, affective, social and environmental factors influencing behaviour). The GDP survey (n = 402) identified the most salient of these beliefs in their decision to prescribe an antibiotic that may not be clinically determined, i.e. coping with negative consequences of the patients who may bully them or not accept dental treatment if an antibiotic was not prescribed.
The patient survey (n = 291) provided evidence that 31% of patients did believe antibiotics would help them get better if they were in pain, expected their GDP to prescribe an antibiotic and expected to get an antibiotic if they had made an emergency appointment. Any intervention will need to take this into account.
The experimental study indicated that significantly more patients participated in the survey if they received a formal style of recruitment compared to an informal style.
Sixteen potential BCTs, the active components of an intervention, may influence GDP and patient beliefs were identified guided by the Behaviour Change Wheel. The results of the workshop included several refinements that involved reception staff and patients more, to increase the importance of not succumbing to patient expectation and to provide more support to GDPs on how to manage these patients.

Based on these findings, a proposed intervention bundle was determined as the most likely approach to reduce non-clinically based antibiotic prescribing. This involved the whole dental team that included triaging instruction at the reception and poster and leaflets in the waiting room, and for the GDPs a persuasive message that included information on how to cope with expectation in the treatment room was proposed.

Conclusions: The findings from this research indicated that dentists are aware that they are prescribing when an antibiotic is not clinically indicated, and they are looking for support to overcome the barriers of managing patient expectation appropriately. This proposed intervention is underpinned by evidence and behaviour change theory that offers evidence of how and why it works and co-designed with end-user it has the potential to be acceptable and implementable in primary dental care in Scotland. Also, it has wider relevance for intervention development as it demonstrates a staged approach design and the application of frameworks underpinned by behaviour change theories.
Date of Award2019
Original languageEnglish
SponsorsThe Health Foundation
SupervisorJanet Clarkson (Supervisor) & Debbie Bonetti (Supervisor)

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