Table 3.

Factors associated with prescribing of antibiotics for acute conditions in primary care setting: short name, descriptor and mapping to the TDF

Factor short name	Descriptor	TDF domain
Access	Access to the right care for the right patient at the right time, including when the practice is shut (e.g. weekends), whilst the patient is on holiday, for patients who live a distance from the practice continuity of care by a single clinician, and if necessary access to specialist care through referral services and laboratory equipment and/or testing.	Environmental context & resources
Accountability	Clinicians held accountable (or feel like they are held accountable) for their antibiotic prescribing patterns.	Beliefs about consequences
Antibiotic awareness	Level of clinician knowledge about the relationship between antibiotic use and resistant infections.	Knowledge
Antibiotic beliefs	Level of personal responsibility towards antibiotics, including blaming others for misuse of antibiotics and/or resistant infections. Belief that antibiotics are low risk: describing use as ‘Better safe than sorry’.	Beliefs about consequences
Clinician characteristics	Clinician age, sex, years in practice, location of primary dental qualification, previous clinical experience.	Does not map to TDF
Competing demands	Availability of sufficient time to treat patient in accordance with guidelines, including ‘sit and wait’ approach to booking urgent patients and other patients waiting.	Environmental context & resources
Conflict	Fear of conflict with patient due to dissatisfaction and subsequent loss of the patient to the practice.	Emotion
Efficacy of options	Beliefs about the efficacy of different treatment options, including, ability of antibiotics versus other approach/procedure to resolve conditions and belief that a procedure may worsen symptoms.	Beliefs about consequences
Fear about outcome	Fear about adverse outcomes, including anxiety about making a mistake and the prospect of serious complications if patients with symptoms go without antibiotics. Described as ‘just-in-case’ or ‘belt-and-braces’.	Emotion
Feelings about decisions	Feeling about the appointment and decisions, including frustration at lack of consent for gold standard treatment or clinician's emotional state at the appointment start.	Emotion
Financial burden	Beliefs about financial burden on patients, including ability to pay for clinical consultation or fees for laboratory tests.	Beliefs about consequences
Fix the problem	Goal for the appointment is to fix the patient's problem: symptomatic relief and/or preventing the problem returning.	Goals
Guidance–practice gap	Gap between guidance and clinical practice, including clinician concerns about the application of the guidelines to specific clinical encounters and belief about whether their clinical practice (such as delayed prescribing in dentistry) adheres to relevant guidance.	Beliefs about consequences
Guidelines & information	Knowledge about relevant guidelines and other sources of information (such as from the internet and pharmaceutical company medical representatives), including appropriate treatment of acute conditions/prescribing.	Knowledge
Habits	Prescribing habits of clinician, including patterns of prescribing and practitioner-level variation.	Memory, attention & decision processes
Healthcare context	Healthcare system context in relation to prescription of antibiotics, including perceived pressure to reduce antibiotic prescribing, ability to reuse a prescription, and availability of antibiotics without a prescription.	Environmental context & resources
Incentives	Incentives for and against antibiotic use, including the impact of a ‘time is money’ business approach on unscheduled/urgent appointments and the financial risk of losing dissatisfied patients.	Reinforcement
Patient/condition characteristics	Characteristics of the patient (age, sex, ethnicity), their presenting condition (signs, symptoms and diagnosis), their medical history/comorbidities and their socioeconomic background (level of education, affluence/deprivation etc.).	Does not map to TDF
Patient influence	Influence of (perceptions about) patients, including: antibiotic-seeking behaviour (expectations/demand); negotiating skills; patient knowledge/attitudes towards antibiotics; fear of adverse outcomes without antibiotics; and willingness/ability to accept operative dental procedure. Also the influence of poor/irregular attenders and the impact of late-running unscheduled appointments making other patients who are waiting for their scheduled appointment angry.	Social influences
Patient management	Skills in patient management, diagnosis, treatment planning and consent, including eliciting concerns, interpreting the patient’s description of their symptoms, managing anxious patients, managing expectations and avoiding confrontation. Negotiation, persuasion, education and hedging. Communication skills.	Skills
Patient satisfaction	Belief about patient satisfaction, including impact of failing to meet patient expectations, impact of repeat visits and failure to relieve symptoms.	Beliefs about consequences
Peers & colleagues	Influence of peers and other colleagues in practice, including: prescribing patterns locally; professional courtesy by avoiding encroaching when treating another clinician's patient; confusion caused by different treatment patterns by different clinicians (patients uncertain what is correct); and utility of peer support when dealing with demanding situations.	Social influences
Planning & consent	Belief about ability to plan treatment and gain consent during urgent appointments, including ‘do nothing’ options and managing anxious/phobic patients.	Beliefs about capabilities
Practice characteristics	Characteristics of the practice, including public/private/insurance provision, geographic location (rural versus urban) and country.	Does not map to TDF
Procedure possible	Belief about whether it is possible to provide treatment due to issues beyond the dentist’s skills during urgent appointments, including the ability to achieve adequate local anaesthesia and/or to provide operative treatment (in accordance with guidelines) to dentally phobic patients without sedation.	Beliefs about capabilities
Professional role	Influence of professional role on managing urgent appointments, including what is the means to care for patients, and feeling ‘morally obliged’ to offer something tangible (to ‘do nothing’ is difficult). The ability to prescribe antibiotics and use own ‘rules of thumb’ are both signs of expertise and power.	Professional/social role & identity
Relationship	Desire to build/maintain a good clinician-patient relationship.	Goals
Risk perception	Beliefs about risks when managing the patient's condition, including worsening of the condition, failure of (or inability to complete) an operative procedure, and pain during or after provision of a procedure or medicolegal complaint.	Beliefs about consequences
Treatment skills	Skills in providing urgent procedures, including placing local anaesthetic by injection in difficult clinical situations or lancing an abscess in the presence of swelling.	Skills
Workload	Belief about impact on workload, including time taken to explain treatment options, gain informed consent, deliver treatment options and/or treat the patient another day on recall.	Beliefs about consequences