Abstract
Antimicrobial resistance represents one of the most pressing global health challenges of the twenty-first century, with inappropriate antibiotic prescribing in primary care constituting a significant contributing factor. This dissertation synthesises current evidence examining how primary care clinicians navigate the complex interplay between patient expectations, time pressures, and antimicrobial stewardship responsibilities when making prescribing decisions. Through a comprehensive literature review methodology, this study identifies that overprescribing frequently reflects systemic tensions rather than clinician ignorance, with perceived patient demand, diagnostic uncertainty, and consultation time constraints emerging as principal drivers. Critically, evidence demonstrates that clinicians systematically overestimate patient expectations for antibiotics, with many patients primarily seeking explanation and reassurance rather than medication. The review identifies several stewardship-supporting interventions demonstrating efficacy, including delayed prescribing strategies, enhanced communication training, shared decision-making tools, and multifaceted antimicrobial stewardship programmes. This synthesis concludes that effective stewardship requires systemic approaches addressing the relational and contextual nature of prescribing decisions, enabling clinicians to decline or defer antibiotic prescriptions in ways that remain feasible, efficient, and safe for both patients and practitioners.
Introduction
Antimicrobial resistance (AMR) has emerged as a defining public health crisis of the contemporary era, threatening to undermine decades of medical advancement and render previously treatable infections fatal (World Health Organization, 2021). The inappropriate and excessive use of antibiotics accelerates the development and spread of resistant organisms, with primary care settings representing a critical intervention point given that approximately 80-90% of all antibiotic prescriptions originate from community healthcare providers (Dolk et al., 2018). Understanding the factors that influence prescribing behaviour in these settings is therefore essential for developing effective antimicrobial stewardship (AMS) strategies.
Primary care clinicians occupy a uniquely challenging position within the healthcare system. They must make rapid clinical decisions under conditions of diagnostic uncertainty, often without access to laboratory confirmation of bacterial infection. Simultaneously, they navigate complex interpersonal dynamics with patients who may arrive with preconceived expectations regarding treatment, whilst operating within time-constrained consultation frameworks that limit opportunities for extended explanation or shared decision-making. These pressures exist in tension with professional and public health imperatives to prescribe antibiotics judiciously and only when clinically indicated.
The consequences of this tension are substantial. Research consistently demonstrates that a significant proportion of antibiotic prescriptions in primary care are clinically unnecessary, particularly for acute respiratory tract infections where viral aetiology predominates (O’Connor et al., 2018). Such prescribing patterns contribute directly to the selection pressure driving antimicrobial resistance, whilst simultaneously exposing patients to unnecessary risks of adverse drug reactions, Clostridioides difficile infection, and disruption of beneficial microbiota.
This topic carries profound academic, social, and practical significance. Academically, it illuminates the complex behavioural and systemic factors underlying clinical decision-making, contributing to theories of professional practice and health behaviour. Socially, addressing inappropriate prescribing protects community health by preserving antibiotic efficacy for future generations. Practically, understanding the barriers and facilitators to appropriate prescribing enables the development of targeted interventions that support clinicians in balancing competing demands whilst maintaining therapeutic relationships with patients.
Recent years have witnessed growing recognition that simplistic approaches emphasising clinician education alone are insufficient to address inappropriate prescribing. The evidence increasingly points toward the need for multifaceted interventions that acknowledge the relational, contextual, and systemic nature of prescribing decisions. This dissertation therefore synthesises current evidence to examine how primary care clinicians balance patient expectations, time pressures, and stewardship responsibilities, identifying both the barriers to appropriate prescribing and the strategies that support better outcomes.
Aim and objectives
Aim
This dissertation aims to critically examine how primary care clinicians balance patient expectations, time pressures, and antimicrobial stewardship responsibilities when making antibiotic prescribing decisions, and to identify evidence-based strategies that support appropriate prescribing behaviour.
Objectives
To achieve this aim, the following specific objectives have been established:
1. To explore the influence of perceived patient expectations on antibiotic prescribing behaviour in primary care settings, including the accuracy of clinician perceptions regarding patient demands.
2. To examine how time constraints and workload pressures affect prescribing decisions and the feasibility of implementing shared decision-making approaches.
3. To analyse the role of diagnostic uncertainty and risk aversion in driving defensive prescribing practices.
4. To identify and evaluate strategies and interventions that support clinicians in balancing stewardship responsibilities with patient care demands.
5. To synthesise findings to inform recommendations for policy, practice, and future research in primary care antimicrobial stewardship.
Methodology
This dissertation employs a literature synthesis methodology to examine the complex factors influencing antibiotic prescribing decisions in primary care settings. Literature synthesis represents an established approach for integrating findings across multiple studies to develop comprehensive understanding of multifaceted phenomena, particularly where the evidence base encompasses diverse methodological approaches including qualitative, quantitative, and mixed-methods research.
Search strategy and source identification
The synthesis draws upon peer-reviewed literature identified through systematic searching of academic databases, supplemented by grey literature from authoritative governmental and international health organisations. Primary sources were identified through the Consensus research platform, which employs artificial intelligence to aggregate and analyse peer-reviewed publications. This approach enabled identification of contemporary, high-quality evidence directly relevant to the research questions.
The search strategy prioritised studies published within the past decade to ensure currency of findings, whilst including seminal earlier works where these provided essential conceptual foundations. Search terms encompassed variations of key concepts including antimicrobial stewardship, antibiotic prescribing, primary care, general practice, patient expectations, time pressure, shared decision-making, and diagnostic uncertainty.
Inclusion and quality criteria
Sources were included if they addressed antibiotic prescribing behaviour in primary care or community settings, examined factors influencing prescribing decisions, or evaluated interventions designed to support appropriate prescribing. Eligible publication types included peer-reviewed journal articles, systematic reviews, meta-analyses, and authoritative reports from governmental or international health bodies.
Quality assessment considered methodological rigour, relevance to the research questions, and credibility of publication venues. Priority was given to studies published in established journals and reports from recognised authorities such as the World Health Organization, Public Health England, and the Centers for Disease Control and Prevention.
Analytical approach
The synthesis employed a narrative analytical approach, enabling integration of diverse evidence types whilst acknowledging the contextual and qualitative nature of much relevant research. Findings were organised thematically according to the research objectives, with particular attention to identifying patterns, tensions, and relationships across studies. This approach facilitated development of a coherent understanding of the multiple interacting factors shaping prescribing behaviour, whilst preserving attention to contextual nuances that quantitative synthesis might obscure.
Limitations
The methodology carries inherent limitations common to literature synthesis approaches. The reliance upon published literature introduces potential publication bias, as studies demonstrating significant effects are more likely to reach publication. Additionally, the narrative synthesis approach involves interpretive judgements that may differ across researchers. These limitations are mitigated through transparent reporting of the analytical approach and critical engagement with the strength and consistency of evidence across sources.
Literature review
The global context of antimicrobial resistance
Antimicrobial resistance represents a global health emergency of unprecedented scale. The World Health Organization has identified AMR among the top ten threats to global health, projecting that without effective intervention, resistant infections could cause 10 million annual deaths by 2050, surpassing cancer as a cause of mortality (World Health Organization, 2021). The economic consequences are equally severe, with estimates suggesting AMR could reduce global gross domestic product by 2-3.5% by 2050, representing cumulative losses of approximately $100 trillion (O’Neill, 2016).
Primary care settings occupy a critical position within strategies to address AMR. Community prescribing accounts for the majority of human antibiotic consumption, with respiratory tract infections representing the single largest indication despite predominantly viral aetiology. Charani and Holmes (2019) observe that after twenty years of antimicrobial stewardship development, primary care remains a challenging environment for implementing effective interventions, reflecting the unique pressures and constraints operating in community healthcare.
Perceived patient expectations and prescribing behaviour
Clinician perceptions of patient expectations emerge consistently as a powerful influence on prescribing decisions. Research demonstrates that clinicians frequently cite patient or parent pressure as a major driver of unnecessary prescribing, with concerns regarding dissatisfaction, negative reviews, and loss of income particularly salient in urgent care and walk-in settings (Kohut et al., 2019; Amin et al., 2022; Zetts et al., 2020).
The concept of the “inconvincible patient” has been identified as particularly influential in shaping prescribing behaviour. Kohut et al. (2019) found that many clinicians believe certain patients cannot be satisfied without receiving an antibiotic prescription, making refusal appear futile and a waste of limited consultation time. This perception creates powerful incentives toward prescribing even when clinical indications are absent, as the perceived relational cost of declining antibiotics outweighs the abstract future harm of contributing to resistance.
However, the evidence reveals a significant discrepancy between perceived and actual patient expectations. Multiple studies demonstrate that clinicians systematically overestimate patient demand for antibiotics, with many patients primarily seeking explanation, reassurance, and confidence that their concerns have been taken seriously (Amin et al., 2022; O’Connor et al., 2018; Yau et al., 2021). This finding carries profound implications, suggesting that interventions addressing clinician perceptions and communication skills may substantially reduce unnecessary prescribing without adversely affecting patient satisfaction.
The dynamics of patient expectations are further complicated by the consultation context. Patients arriving in urgent care settings may present with heightened anxiety and expectations for immediate action, creating pressure for tangible intervention. Zetts et al. (2020) found that primary care physicians perceived significant external pressure toward prescribing, viewing antibiotic stewardship as swimming against a cultural current that equates medication provision with quality care.
Time constraints and their impact on prescribing decisions
Time pressure emerges as a second major determinant of prescribing behaviour. High workload, short consultation durations, and peak demand periods push clinicians toward antibiotic prescriptions as a rapid means of concluding consultations, particularly when the alternative requires time-intensive explanation and negotiation (Kasse et al., 2024; Balea et al., 2025; Dorairajan et al., 2025).
The relationship between time pressure and prescribing operates through several mechanisms. First, comprehensive clinical assessment enabling confident exclusion of bacterial infection requires time that may not be available within standard consultation frameworks. Second, shared decision-making—widely advocated as a means of engaging patients in treatment decisions—requires explanation of options, elicitation of preferences, and collaborative deliberation that busy clinicians may perceive as impractical (Balea et al., 2025; Kasse et al., 2025). Third, managing patient expectations without prescribing demands communication skills and emotional labour that depleted practitioners may lack capacity to expend.
Kasse et al. (2024) conducted a systematic review identifying consultation duration as a significant factor contributing to variation in antibiotic prescribing among primary health care physicians. They found that clinicians facing time constraints were more likely to prescribe antibiotics as a pragmatic strategy for managing workload, even when clinical indications were uncertain. This finding illustrates how individual prescribing decisions are shaped by system-level factors beyond the immediate clinical encounter.
The challenge is compounded in resource-poor settings where clinician-to-patient ratios are unfavourable and infrastructure limitations restrict access to diagnostic support. Yau et al. (2021) examined antimicrobial stewardship in rural and remote primary health care, finding that geographical isolation, limited specialist support, and workforce pressures created distinctive challenges for implementing stewardship approaches developed in urban or well-resourced settings.
Diagnostic uncertainty and defensive prescribing
Diagnostic uncertainty constitutes a third major influence on prescribing behaviour. The difficulty of distinguishing viral from bacterial infections on clinical grounds alone, combined with limited access to rapid diagnostics, creates conditions favouring precautionary prescribing. Fear of complications, deterioration, and potential litigation promotes defensive approaches where antibiotics function as insurance against adverse outcomes (Datta et al., 2024; Amin et al., 2022; Charani and Holmes, 2019; Yau et al., 2021).
Datta et al. (2024) examined diagnostic uncertainty in home-based primary care, finding that the absence of immediate access to investigations heightened uncertainty and promoted antibiotic prescribing as a risk management strategy. Clinicians described prescribing antibiotics to avoid potential hospitalisation and to ensure that “something tangible is done” for patients presenting with concerning symptoms. The desire to be seen as taking action, combined with asymmetric consequences of under-treatment versus over-treatment, created systematic bias toward prescribing.
Christensen et al. (2025) explored decision-making processes in general practice for acute rhinosinusitis, illustrating how clinicians navigate uncertainty in a condition where bacterial infection is present in a minority of cases but complications, though rare, can be serious. The study revealed that clinicians employed various heuristics and risk assessments in determining whether to prescribe, with individual factors including experience, risk tolerance, and beliefs about patient resilience influencing decisions alongside clinical features.
The challenge of diagnostic uncertainty is particularly acute in populations with limited health literacy or communication barriers, where history-taking may yield less reliable information, and in vulnerable populations where consequences of missed bacterial infection are more severe. Paediatric populations, elderly patients, and those with immunocompromising conditions present particular challenges where the threshold for precautionary prescribing may appropriately differ from that applied to healthy adults.
Strategies supporting appropriate prescribing
The evidence identifies several strategies that support clinicians in balancing stewardship responsibilities with patient care demands. These approaches address different aspects of the prescribing decision and operate through distinct mechanisms.
Delayed prescribing and safety-net advice
Delayed prescribing strategies, wherein patients receive a prescription with instructions to fill it only if symptoms persist or worsen, have emerged as an effective compromise between immediate prescribing and outright refusal. This approach reduces immediate antibiotic use whilst meeting patient expectations for validation and providing reassurance that treatment remains available if needed (Jordan et al., 2025; Balea et al., 2025; O’Connor et al., 2018; McIsaac et al., 2021; Yau et al., 2021).
The effectiveness of delayed prescribing reflects its capacity to address multiple influences simultaneously. For patients, it provides concrete evidence that their concerns are taken seriously and that a safety net exists. For clinicians, it offers a middle path that acknowledges uncertainty without requiring confident exclusion of bacterial infection. Research suggests that a substantial proportion of delayed prescriptions are never filled, representing antibiotic use avoided without requiring patients to return for additional consultations.
Safety-net advice—clear guidance on symptoms warranting return consultation or prescription use—complements delayed prescribing by providing patients with criteria for recognising deterioration. This approach addresses clinician concerns about missed bacterial infection by establishing structured pathways for escalation whilst avoiding routine antibiotic provision for self-limiting conditions.
Communication skills and patient education
Communication training for clinicians emerges as a powerful intervention for reducing inappropriate prescribing. Evidence demonstrates that enhanced communication skills enable clinicians to explore patient expectations, provide effective reassurance, and negotiate treatment decisions in ways that maintain satisfaction without unnecessary prescribing (Amin et al., 2022; O’Connor et al., 2018; Yau et al., 2021).
The evidence that clinicians systematically overestimate patient expectations suggests that communication interventions may work partly by correcting these misperceptions. Techniques including open questioning about patient concerns and expectations, explicit acknowledgement of symptom impact, and clear explanation of treatment rationale enable clinicians to address underlying needs that may not require antibiotic provision.
Patient education complements clinician training by addressing knowledge gaps and expectations at population level. Public awareness campaigns regarding the limitations of antibiotics for viral infections, the risks of antimicrobial resistance, and appropriate self-care strategies may reduce pressure on clinicians by reshaping the expectations patients bring to consultations (Balea et al., 2025).
Shared decision-making tools
Shared decision-making (SDM) represents a patient-centred approach wherein clinicians and patients collaborate in treatment decisions, integrating clinical evidence with patient preferences and values. Decision aids supporting SDM have demonstrated effectiveness in reducing antibiotic prescribing for conditions where appropriateness is uncertain (Jordan et al., 2025; Balea et al., 2025; Kasse et al., 2025).
However, implementation of SDM in primary care faces significant challenges. The time demands of comprehensive SDM processes may be incompatible with short consultation durations typical of busy general practice. Additionally, SDM tools developed in well-resourced settings may require adaptation for contexts characterised by lower health literacy, language barriers, or limited technological infrastructure.
Kasse et al. (2025) systematically reviewed factors influencing adoption of shared decision-making for antibiotic treatments in developing countries, finding that while both physicians and patients generally viewed SDM positively, practical barriers including time constraints, communication challenges, and resource limitations impeded implementation. These findings underscore the need for context-sensitive approaches that adapt SDM principles to local circumstances.
Multifaceted antimicrobial stewardship programmes
The evidence consistently supports multifaceted interventions combining multiple components including education, audit and feedback, decision support, and system-level changes. McIsaac et al. (2021) conducted a pragmatic randomised trial of a primary care antimicrobial stewardship intervention in Ontario, Canada, demonstrating that combined approaches produced meaningful reductions in prescribing whilst maintaining patient safety.
Xiao et al. (2025) examined routine data systems for informing continuous optimisation of antimicrobial stewardship in primary care settings, illustrating the potential for embedding stewardship within ongoing quality improvement processes. This approach enables identification of prescribing patterns, targeted feedback to practitioners, and iterative refinement of interventions based on local evidence.
Amin et al. (2022) reviewed practical antibiotic stewardship approaches in outpatient settings in the United States, emphasising that successful programmes focus on supporting clinicians rather than simply restricting prescribing. By providing tools, training, and system supports that make appropriate prescribing easier, such programmes address the underlying tensions that drive overprescribing rather than merely imposing additional demands on already-pressured practitioners.
Summary of key tensions and responses
The literature reveals consistent patterns in the tensions clinicians experience and the strategies that support resolution toward appropriate prescribing. When patients seek tangible evidence of care whilst antimicrobial resistance demands restraint, effective responses include strong communication, reassurance, safety-netting, and delayed prescribing. When short consultations conflict with shared decision-making requirements, brief decision aids, patient leaflets, and pre-visit education offer practical adaptations. When diagnostic uncertainty conflicts with safety imperatives, point-of-care testing, structured watch-and-wait approaches, and clear follow-up pathways enable confident management without routine prescribing.
Discussion
This synthesis illuminates the complex, relational, and context-bound nature of antibiotic prescribing decisions in primary care. The evidence demonstrates that overprescribing frequently reflects systemic tensions rather than clinician ignorance or indifference to antimicrobial resistance concerns. Understanding prescribing behaviour requires attention to the multiple competing demands clinicians navigate, including clinical uncertainty, patient expectations (perceived and actual), time constraints, risk aversion, and professional obligations to both individual patients and population health.
Addressing the first objective: perceived patient expectations
The evidence strongly supports the influence of perceived patient expectations on prescribing behaviour, with clinicians frequently citing patient pressure as a driver of unnecessary prescribing. However, the finding that these expectations are systematically overestimated carries significant implications. Many patients primarily seek explanation, reassurance, and confidence that their concerns have been addressed rather than specific medication provision.
This discrepancy between perceived and actual expectations suggests that prescribing decisions are shaped as much by clinician assumptions as by explicit patient demands. Interventions addressing these assumptions—through communication training, feedback on patient preferences, or direct exploration of expectations within consultations—may substantially reduce unnecessary prescribing without adversely affecting patient satisfaction or therapeutic relationships.
The concept of the “inconvincible patient” warrants particular attention. While some patients may indeed insist upon antibiotics regardless of clinical explanation, the evidence suggests these cases represent a minority. By categorising larger proportions of patients as inconvincible, clinicians may inadvertently avoid conversations that could successfully resolve concerns without prescribing. Training that builds confidence in managing these conversations, combined with system supports that make such engagement feasible within time constraints, offers promising directions for intervention.
Addressing the second objective: time pressure and shared decision-making
The relationship between time pressure and prescribing behaviour reflects the practical reality of primary care practice. Shared decision-making, while theoretically appealing and ethically appropriate, demands time that may not be available within standard consultation frameworks. This creates tension between evidence-based recommendations for patient engagement and the operational constraints of healthcare delivery.
However, the evidence also identifies adaptations that make SDM more feasible under time pressure. Brief decision aids, patient-facing educational materials, and pre-consultation preparation can reduce the within-consultation time required for meaningful engagement. Digital tools enabling patients to review information before appointments may similarly reduce clinician burden whilst enhancing patient preparedness for shared decisions.
These findings highlight the importance of system-level interventions that create conditions enabling appropriate prescribing. Advocating for longer consultation times, protected time for complex cases, or alternative service models that reduce peak-period pressure may prove more effective than exhorting individual clinicians to implement time-intensive approaches within inadequate frameworks.
Addressing the third objective: diagnostic uncertainty and risk aversion
Diagnostic uncertainty emerges as a fundamental challenge in primary care prescribing. The inability to confidently distinguish bacterial from viral infection on clinical grounds alone creates conditions favouring precautionary prescribing, particularly given the asymmetric consequences of under-treatment versus over-treatment from the individual patient perspective.
Point-of-care testing offers a potential solution by providing rapid diagnostic information that could reduce uncertainty and enable more confident decisions to withhold antibiotics. However, the evidence regarding such testing is nuanced. Tests must be sufficiently sensitive and specific to usefully inform decisions, results must be available within consultation timeframes, and clinicians must be confident in acting upon negative results. Additionally, the cost-effectiveness of routine testing for self-limiting conditions requires careful evaluation.
Alternative approaches including structured watch-and-wait strategies, delayed prescribing with clear criteria for use, and robust safety-netting address uncertainty through different mechanisms. Rather than seeking to eliminate uncertainty through diagnostic technology, these approaches acknowledge uncertainty whilst creating frameworks for managing risk. The evidence supports their effectiveness in reducing antibiotic use without adversely affecting outcomes for patients with bacterial infections.
Addressing the fourth objective: supporting strategies and interventions
The synthesis identifies a portfolio of evidence-based strategies supporting appropriate prescribing. Critically, effective interventions tend to address multiple influences simultaneously rather than targeting single factors in isolation. Multifaceted programmes combining education, feedback, decision support, and system changes demonstrate greater effectiveness than single-component interventions.
Delayed prescribing emerges as a particularly valuable strategy that addresses multiple tensions simultaneously. By providing a prescription whilst deferring its use, clinicians acknowledge uncertainty, validate patient concerns, provide a safety net, and reduce immediate antibiotic exposure. The approach requires minimal additional consultation time whilst enabling clinicians to avoid the perceived relational costs of outright refusal.
Communication training and patient education operate through complementary mechanisms. Clinician training builds skills and confidence for managing expectations, corrects misperceptions regarding patient demands, and provides language and techniques for explaining decisions not to prescribe. Patient education shapes expectations before consultations occur, potentially reducing pressure on individual encounters.
Addressing the fifth objective: implications for policy and practice
The synthesis carries implications across policy, practice, and research domains. For policy, the findings underscore the need for approaches that address system-level factors rather than placing responsibility solely upon individual clinicians. Adequate consultation times, appropriate staffing levels, accessible diagnostic support, and protection from perverse incentives that reward prescribing over quality care represent structural enablers of stewardship.
For practice, the evidence supports investment in communication training, implementation of delayed prescribing as routine practice, and adoption of multifaceted stewardship programmes. Professional development should address not only clinical knowledge but also skills for managing patient expectations and communicating decisions effectively.
For research, priorities include further investigation of context-adapted SDM approaches, evaluation of point-of-care testing in primary care settings, and development of interventions addressing the distinctive challenges of resource-limited, rural, and remote contexts. Longitudinal research examining the sustainability of interventions and their effects on antimicrobial resistance patterns would strengthen the evidence base.
Limitations and considerations
Several limitations warrant acknowledgement. The literature synthesised derives predominantly from high-income country contexts, limiting generalisability to settings with fundamentally different healthcare systems, cultural expectations, and resource constraints. The reliance upon published literature introduces potential publication bias, and the heterogeneity of included studies limits direct comparison across contexts.
Additionally, the evidence regarding patient expectations relies substantially upon clinician perceptions and self-report, with less direct evidence from patient perspectives. While studies suggest patient expectations are overestimated, more research directly examining patient views would strengthen these conclusions.
Conclusions
This dissertation has examined how primary care clinicians balance patient expectations, time pressures, and antimicrobial stewardship responsibilities when making antibiotic prescribing decisions. The synthesis demonstrates that prescribing decisions are relational and context-bound, shaped by perceived demand, time pressure, and uncertainty as much as by clinical evidence or pharmacological knowledge.
Regarding the first objective, the evidence confirms that perceived patient expectations strongly influence prescribing behaviour, with clinicians frequently citing patient pressure as a driver of unnecessary prescribing. However, these expectations are systematically overestimated, with many patients primarily seeking explanation and reassurance rather than antibiotic provision.
Regarding the second objective, time constraints emerge as a significant barrier to implementing recommended approaches including shared decision-making. High workload and short consultation durations push clinicians toward prescribing as an efficient means of concluding consultations. Effective responses include adapted SDM tools, brief decision aids, and system-level changes that create conditions enabling appropriate prescribing.
Regarding the third objective, diagnostic uncertainty promotes defensive prescribing, with clinicians prescribing antibiotics to manage risk of missed bacterial infection. Strategies including point-of-care testing, structured watch-and-wait approaches, delayed prescribing, and clear safety-netting address this uncertainty through complementary mechanisms.
Regarding the fourth objective, evidence supports several strategies for supporting appropriate prescribing, including delayed prescribing with safety-net advice, communication skills training, shared decision-making tools adapted for time-constrained contexts, and multifaceted antimicrobial stewardship programmes combining education, audit and feedback, and decision support.
Regarding the fifth objective, the findings inform recommendations emphasising system-level enablers of stewardship, investment in clinician communication skills, routine implementation of delayed prescribing strategies, and continued research into context-sensitive interventions.
The significance of these findings lies in their reframing of inappropriate prescribing from a problem of individual clinician behaviour to a systemic challenge requiring multifaceted responses. Effective stewardship supports clinicians with communication tools, diagnostic aids, and system-level changes so that saying “no” or “not yet” to antibiotics becomes feasible, fast, and safe for both patients and prescribers. Future research should prioritise development and evaluation of interventions adapted for resource-limited and underserved settings, longitudinal assessment of intervention sustainability, and direct investigation of patient perspectives on antibiotic prescribing decisions.
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