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PLOS One logoLink to PLOS One
. 2021 Feb 4;16(2):e0246506. doi: 10.1371/journal.pone.0246506

Factors determining antibiotic use in the general population: A qualitative study in Spain

Olalla Vazquez-Cancela 1,2, Laura Souto-Lopez 1, Juan M Vazquez-Lago 1,2,3,*, Ana Lopez 4, Adolfo Figueiras 1,3,5
Editor: Vijayaprakash Suppiah6
PMCID: PMC7861377  PMID: 33539449

Abstract

Background

Antibiotic resistance is an important Public Health problem and many studies link it to antibiotic misuse. The population plays a key role in such misuse.

Objective

The aim of this study was thus to explore the factors that might influence antibiotic use and resistance in the general population.

Methods

Qualitative research using the focus group (FG) method. Groups were formed by reference to the following criteria: age (over and under 65 years); place of origin; and educational/professional qualifications. FG sessions were recorded, transcribed and then separately analysed by two researchers working independently. Written informed consent was obtained from all participants.

Results

Eleven FGs were formed with a total of 75 participants. The principal factors identified as possible determinants of antibiotic misuse were: (i) lack of knowledge about antibiotics; (ii) doctor-patient relationship problems; (iii) problems of adherence; and, (iv) use without medical prescription. Antibiotic resistance is a phenomenon unknown to the population and is perceived as an individual problem, with the term “resistance” being confused with “tolerance”. None of the groups reported that information about resistance had been disseminated by the health care sector.

Conclusions

The public is unaware of the important role it plays in the advance of antimicrobial resistance. There is evidence of diverse factors, many of them modifiable, which might account for antibiotic misuse. Better understanding these factors could be useful in drawing up specific strategies aimed at improving antibiotic use.

Introduction

Taken together, antibiotic adverse effects, ineffectiveness and resistance is one of the biggest threats to global health [1], due to the great impact on morbidity, mortality and costs [2]. Over- and misuse of antibiotics contributes significantly to this problem [3]. Indeed, overuse must be assumed to account for the differences in antibiotic use (as much as threefold) among European Union countries [4], due there is no evidence of any difference in the prevalence of infectious diseases [5].

Most antibiotic use (80% to 90%) occurs in the outpatient setting [6, 7]. In terms of antibiotic consumption, Spain not only ranks highest among developed countries (in excess of 40 Define Daily Dose (DDDs) per 1,000 inhabitants per year), but its figures continue to rise [8]. Furthermore, around 30% of all outpatient antimicrobial sales are not identified from reimbursement data, due in large part to the existence of non-prescription sales [9, 10]. While physicians, pharmacists and health authorities are all involved in antibiotic over- and misuse, patients may also play an important role, in that: (i) they are the end-users and can decide whether or not to take antibiotics or to suspend the treatment; (ii) they can demand antibiotics at the pharmacy without medical prescription; and, (iii) they can exert pressure on physicians to prescribe or on pharmacists to dispense these antibiotics [9, 1113].

Despite the key role that the public may play in the advance of resistance, the factors that influence antibiotic misuse in the general population remain unknown [14], something that hinders the design of specific purpose-designed strategies [15]. Accordingly, the aim of this study was to use qualitative methodology to examine factors identified by the public as being responsible for antibiotic use and misuse.

Methods

Study design

The study was undertaken in Galicia, a region in north-west Spain which has a population of 2.7 million [16] and registers high levels of antibiotic use, with a figure of as much as 23 DDD per 1,000 inhabitants per year recorded in 2016 [17].

A qualitative study was conducted, using the focus group (FG) technique as a tool for collecting narrative data. The choice of qualitative methodology was determined by the fact that it allows for in-depth examination of population attitudes to antibiotic use: the FG technique is the best tool for generating interactive discussion and addressing subjective aspects from diverse points of view, something that is difficult to achieve with quantitative methods [18, 19].

Selection, sample and procedure

We sought to ensure a high degree of heterogeneity in the composition of the groups in terms of age (over and under 65 years), urban or rural origin, and educational/professional qualifications, in order to cover the widest range of opinions (Table 1). We made groups following age criteria to explore the differences in knowledge and attitudes between retirees and workers. We decided to made this two groups to better explore the differences in the acces to the heathcare facilities (assuming more time in retirees), and also to explore the differences in the relationship with the doctor between older and yougers. We also took into account the origin criteria due to possible differences in access to the health system. The help of key informants and the snowball method were used [20]. The heads of 50 socio-cultural associations, senior citizen study centres and neighbourhood associations were contacted by e-mail and telephone. At a meeting held with the 16 centres that responded to our invitation, we explained what the study consisted of and its aims. Of the original sixteen centres, three refused to participate, one due to a lack of interest and the other two due to an insufficient number of members. In addition, a further two groups were ruled out because saturation of information had been achieved with 11 FGs. As a result, no new group sessions were convened [21].

Table 1. Focal group characteristics.

FG aged >65 years n M:W Population Professional healthcare qualifications FG aged <65 years n M:W Age participants Population Professional healthcare qualifications
FG1 6 1:5 Rural - FG6 5 0:5 >50 Urban 1 Pharmacist
FG2 5 2:3 Urban - FG7 5 1:4 >50 Rural 1 Biologist
FG3 9 2:7 Urban - FG8 6 3:3 <35 Urban -
FG4 8 0:8 Urban - FG9 5 2:3 >50 Rural 1 Nurse
FG5 8 2:6 Rural - FG10 12 3:9 35–50 Urban -
FG11 6 3:3 <35 Urban 1 Biologist

M: Men

W: Women

We drew up a script so as to conduct the sessions in line with the conclusions of previous studies on general practitioners (GPs) [12, 22] and community pharmacists [23], with the ultimate aim of testing these findings on and with the help of the public. In addition, we conducted a bibliographic review of papers published on the subject to date [14, 2433], requesting the authors for their respective scripts so as to include all relevant topics [28, 3133]. Expert researchers in qualitative methodology (ALD, AFG, JMVL) collaborated in drawing up the script, to ensure open-ended questions and a permissive environment conducive to the free flow of the participants’ discourse and the veracity of the opinions voiced.

The FGs were guided by two researchers (OVC, LSL). At the end of every session, a summary was drawn up detailing the group’s characteristics and first impressions.

A digital audio recorder was used. The sessions had a duration of approximately 45 minutes each, and came to an end when no more new ideas or contributions were forthcoming from the participants. An informal training session on antibiotic use was offered at the end and 4 groups requested this, with the result that their sessions were extended for an extra 40 minutes. One researcher made the literal transcriptions, endeavouring in every case to take no longer than 5 days after the session, and a second observer was responsible for checking and correcting any possible errors on the basis of consensus. Participants were coded by range age and gender ("M" for men, "W" for women), and each group was identified with a serial number (FG1, FG2, FG3, etc.).

Ethical considerations

The study was evaluated and approved by the Santiago-Lugo Research Ethics Committee. After being informed of the purpose of the study and the fact that the sessions were to be recorded and transcribed but kept anonymous, all the participants agreed to take part and gave their written informed consent.

Analysis

The transcriptions were analysed separately by two researchers (LSL, OVC), in the interests of reducing any risk of researcher bias.

A thematic and discourse analysis of the data was performed, and was then discussed by all the authors. Ideas were identified, and the data obtained were organised by topic area and accompanied by literal excerpts, which served as units of analysis. Subsequently, the ideas extracted were associated with pre-established variables using the grounded theory method [34]. Any disagreements as regards interpretation were discussed by the researchers and resolved by consensus. No computer software programme was used for processing the data.

Results

In the period from March to May 2017, eleven FGs, each containing 5 to 12 members, were formed, making a grand total of 75 participants (Table 1).

After analysis of the recordings, the main reasons given by the public to explain antibiotic misuse and abuse (Table 2) were identified as being: (i) lack of knowledge about antibiotics; (ii) problems in the doctor-patient relationship; (iii) problems of adherence; and, (iv) use without prescription. Additionally, the following were also identified, even though they were not cited as reasons per se: (v) lack of perception of the problem; and, (vi) external attribution of responsibility (Table 3).

Table 2. Coding of the results identified in the population.

Lack of knowledge about antibiotics
  • Difficulties in differentiating antibiotics from other medications.

  • Consider that antibiotics are used for any infection.

Problems in the doctor-patient relationship
  • Lack of trust in physician (pressure on physician).

  • Consider that the physician supplies little information about the disease.

  • Consider time of consultation to be insufficient.

Problems of adherence (not finishing the entire treatment)- Reasons
  • Lack of credibility of professional judgement

  • Improvement after initial doses

  • Side effects of antibiotics

  • Abandoning the treatment in order to be able to consume alcohol

  • Oversights, carelessness

Use without prescription
  • Trusted pharmacy

  • Home medicine cabinet/leftover antibiotics

  • Internet

Lack of perception of the problem of development of resistance
  • Do not think that there is any problem at present

  • Excess use of antibiotics is not linked to advance of resistance

  • Not considered to be a Public Health problem

Responsibility
  • Internal: inappropriate use of antibiotics considered responsible for the problem.

  • External (considering other being responsible of the problem): physicians, pharmaceutical industry, food, economic reasons, excess use in the past considered responsible for the problem.

Table 3. Results of the FG sessions.

FG1 FG2 FG3 FG4 FG5 Factor FG6 FG7 FG8 FG9 FG10 FG11
X X X X X Problems of knowledge X X X X X X
X X Doctor-patient relationship problems X X X X X X
X X X X Problems of adherence X X X X X X
X X X X X Use without prescription X X X X X X
X X X X X Lack of perception of the problem of development of resistance X* X* X X* X X*
X X Internal responsibility X
X X X X X External responsibility X X X X X X

*In these groups, one person understood the magnitude of the problem as a result of holding specific healthcare qualifications, as shown in Table 1

Lack of knowledge

In all the over 65 age FGs, at least one participant in each group was unable to differentiate between antibiotics and other types of medication, either asking for clarification or displaying indiscriminate use of the terms while speaking.

While the under 65 age FGs were clear as to the difference, at least one participant in each group was ignorant of the fact that antibiotics were ineffective in the case of viral infections.

Lack of knowledge was considered to be one of the factors of misuse: [“People don’t realise that antibiotics don’t combat viruses, and most infections are viral, but they take antibiotics because they don’t know how to use them”] (>65y, M6, FG1).

This lack of knowledge means that antibiotics are mistakenly regarded as faster-acting and more efficacious medications: [“Don’t give me just any old remedy, give me one that’ll cure me, give me an antibiotic”] (>65y, W2, FG1); [“When I have a cold, of course I’d like to take an antibiotic; I feel really bad and I want an antibiotic, obviously because I think that way I’ll get rid of it more quickly”] (51-65y, W2, FG6).

Fever was reiterated by four over-65 FGs and one under-65 age FG as one of the symptoms that requires antibiotics: [“But if you’ve got a temperature, and you go to the doctor, what’s he going to give you unless it’s an antibiotic?”] (>65y, W1, FG2).

Only two groups saw the medical practitioner as being responsible for taking the decision to prescribe antibiotics, once the necessary check-up and examination had been performed: [“I think it is necessary a severe control in the antibiotics. Doctors are the ones who always have to make the decision (taking or not antibiotics)”] (>65y W6, FG1). Other groups stated that in some illness any person can know that you need an antibiotic, even without a medical examination: [“Here with all the cold we have, you can get an urine infection. A simple urine infeccion, and you don’t have more remedy than take an antibiotic.”] (>65y, W4, FG5).

Poor doctor-patient relationship

Poor doctor-patient relationship was highlighted, especially in the under 65 age group: [“I think that doctors need to learn how to talk to patients. The way they speak to and handle patients, that’s what’s got to improve”] (51-65y, W5, FG6). Participants complained of the lack of information and explanations given by physicians: [“Doctors tend to be pretty evasive and tell you very little …it’s not good to rush things”] (51-65y, M1, FG7).

It was felt that a poor relationship can affect trust, and thus lead to a weakening of medical judgement. This was associated with the pressure which patients put on physicians to prescribe antibiotics: [“People ask for medicine because their GP is the kind of doctor who’s heard it all before, so the patient wants to make sure she’s going to improve, since she believes that it’s only with antibiotics that she’ll be able to get better, because she doesn’t understand, seeing as they don’t tell her what she’s got”] (51-65y, W5, FG6).

Lack of credibility in the health professional translates as a search for alternatives, such as going to the emergency ward or seeking a second opinion from a private physician: [“If your GP doesn’t given you them (antibiotics), well you go to emergencies: if you’re convinced that you really need them, I think you’ll get them in the end”] (18-34y, M2, FG8) [“There are people who go to the GP in the morning and the GP doesn’t give them any (antibiotics)in the afternoon they go to emergencies, so that they’ll give them some. Or you go to a private doctor and they’ll also give them to you”] (51-65y, W2, FG9).

Problems of adherence (not finishing the entire treatment)

In all groups but one (FG4), the participants disclosed problems of adherence. The reasons for abandoning treatment were improvement after initial doses, fear of side effects [“90% of the times in my life that I’ve taken antibiotics for an infection I’ve ended up getting ill from something else… or my stomach or whatever…”] (18-34y, W2, FG11), oversights, and specific abandonment of treatment so as to be able to consume alcohol (FG2, 10).

Loss of credibility and trust in the physician were identified as important reasons for lack of adherence to the prescribed treatment: [“I think that, if we patients more or less followed the doctor’s instructions and those that come with the medicine, I mean to say there’s a lack of trust”] (18-34y, W3, FG8).

Despite the fact that problems of adherence were identified in all groups, doubts about the treatment guideline as prescribed by the physician was not cited as a reason for misuse: [“Sometimes they give you a note and tell you how you have to take it. They put ‘two a day’, or ‘three a day’…”] (>65y, W1, FG3). Two groups pinpointed the pharmacy as the place where doubts were resolved [“Very often, pharmacies are the ones that help you clear things up”] (51-65y, W1, FG9).

Antibiotic use without prescription

There was acknowledged use without prescription, whether by going to trusted pharmacies or by using leftover antibiotics from previous illnesses (home medicine cabinet), associated with people’s belief in their ability to recognise situations in which antibiotics are required: [“I think they self-medicate because they had -or think they had- the same illness, and they still have some drugs left over from last time”] (18-34y, M1, FG8).

Eight groups admitted to having a home medicine cabinet and resorting to it when they thought it was necessary: [“We don’t throw anything anyway; who doesn’t have a medicine cabinet at home?”] (>65y, M5, FG4). In eight groups, the idea of going to a trusted pharmacy to obtain antibiotics was raised [“I go to the pharmacy and I say to him, what’ll you give me? For urinary infections, they always gave it to me () at the pharmacy, provided it’s one you trust, but to be honest, they wouldn’t have given it (the antibiotic) to me, if they hadn’t known me”] (51-65y, W1, FG9). When it came to the difference between resorting to a home medicine cabinet and a trusted pharmacy, the former measure was perceived as negligent, whereas the latter was perceived as an appropriate alternative avenue.

No group reported difficulty of access to the health-care system. However, in six of the groups (4 of which were over 65 years old), people said that they avoided going to the physician and only went as a last resort [“I’m not one for going to the doctor [], I’m not at all keen. If it’s strictly necessary, I’ll go; if it isn’t, I won’t.”] (>65y, W1, FG1).

Lack of perception of the problem of antibiotic resistance

Antimicrobial resistance is regarded as a problem of individual consumption, with no distinction been drawn between resistance and tolerance: [“I have a certain respect for antibiotics, because I don’t want my body to get used to them, and then when I really need them… they don’t work.”] (18-34y, M4, FG11).

Although antibiotic resistance is of concern to the public, its advance is not associated with misuse. Difficulty in finding effective antibiotics is considered a consequence of intensive farming and food, insted of human misuse: [“All the chickens that come from intensive farming, for example, have antibiotics; and the cattlehave them in the meat as well as in the milk…”] (18-34y, M5, FG11).

Only the 4 participants with specific healthcare qualifications (2 biologists FG7 and FG11, 1 nurse FG9, and 1 pharmacist FG2) stated that they understood the magnitude of the problem. In these groups, lack of information was considered the principal problem: [“Resistance is due to a lack of information, the public’s profound lack of information and awareness”] (51-65y, W1, FG9). Groups that displayed worse comprehension of the problem felt that they had sufficient knowledge: [“I don’t think there’s any lack of information, hey! nowadays we’re very well informed”] (>65y, W3, FG4).

Information on antibiotic resistance did not come from health professionals in any of the groups but was instead obtained from the press and other mass media: [“Whenever I go to the doctor, he gives me antibiotics, and that’s all there’s to it. Don’t go telling me, be careful because the bug is getting stronger due to people like you taking antibiotics”] (18-34y, W2, FG11). This information has been disseminated without attaining public health relevance: [“I think it’s the responsibility of each one of us; and what other people do is all the same to me”] (18-34y, M4, FG11).

Physicians, the pharmaceutical industry and food are blamed for the advance of resistance. Yet, public education and awareness raising by the health care sector is nevertheless regarded as essential: [“The health professional has to do a job of awareness-raising, if it not at a personal and human level, then at the level of a publicity campaign; people have to be made aware that taking an antibiotic is no idle matter”] (35-50y, M10, FG10).

Discussion

This is the first qualitative study undertaken in Spain to explore the factors that influence people in terms of their use of antibiotics and its relationship with resistance. Our study shows that the public is unaware of the important role it plays in the advance of antimicrobial resistance. It also highlights the fact that lack of knowledge and doctor-patient relationship problems influence antibiotic use. Knowledge of these factors will enable more specific strategies to be implemented, with the aim of improving antibiotic use and increasing the impact of awareness-raising campaigns [15].

Our study served to detect crucially important gaps in public knowledge, revealing that people: (1) do not understand the difference between viral and bacterial infections; (2) think that symptoms such as fever should be directly treated with antibiotics; (3) believe that excess use of antibiotics is unconnected with the advance of resistance (with industrial livestock farming and food processing being to blame); (4) cannot differentiate between tolerance and resistance; and (5) are unaware of the dimension of the public health risks posed by resistance. These gaps could be accounted for by the fact that previous awareness-raising campaigns have been based on informing the public about excess use and the consequences of not completing a course of treatment [15, 35]. Our study also indicates that the population is extremely receptive to more training in this field, something that could provide a good opportunity for well-designed interventions to be effective.

Our results show that the public demands antibiotics because it does not trust clinical diagnosis and, at the same time, does not complete the course of treatment for fear of side effects. Moreover, there was evidence to show that a poor doctor-patient relationship and communication makes for a loss of credibility in respect of medical advice and worse adherence to treatment [36]. Patients complained that neither the treatment nor the importance of their illness was explained to them [37], and consider more information and communication by health professionals to be necessary. To our study population’s way of thinking, this justifies the pressure that they bring to bear on physicians when it comes to seeking treatments. Previous studies conducted in the same geographical setting found complacency to be one of the main motivations acknowledged by physicians and pharmacists alike, when it came to prescribing and dispensing antibiotics [12, 23]. This is in contrast to the view of patients, who consider that physicians should not succumb to pressure, a finding that is consistent with other previous studies in which physicians were observed to overestimate patients’ expectations [38, 39]. In contrast, dispensing without prescription was perceived in our study as something done as a favour by the pharmacist.

This poor doctor-patient relationship and communication is also associated with a lack of credibility in medical judgement, with the result that patients seek alternative ways of obtaining antibiotics: (1) they admit to making use of the emergency services to get prescriptions for antibiotics in situations where, faced with a refusal on the part of their GP, they nonetheless regard them as necessary. This disparity in criteria between primary and emergency care may weaken the doctor-patient relationship still further. To prevent this, antibiotic optimisation programmes should be extended to the emergency services, using the same criteria as in primary care [3941]. (2) Another alternative is to resort to the use of the home medicine cabinet or their trusted pharmacy to obtain antibiotics without prescription. This might go some way to account for the fact that 30% of antibiotic use takes place outside the health care system [10]. Whereas demand for antibiotics from health professionals is motivated by concern about and problems in the doctor-patient relationship, self-medication, on the other hand, is associated with the belief in the ability to recognise the disease by virtue of having suffered from similar symptoms previously. Our study population insisted that the pharmacies to which they resorted had to be trusted. These results were in contrast to pharmacists’ belief that, if they did not relent, patients would obtain the antibiotics at some other pharmacy [9, 23].

In our study, the public did not report difficulties in access to the health-care system which would justify the search for alternatives to consulting a physician. Even so, they avoid going to the doctor, and when they do go, it is to receive treatment and not medical advice. This goes to show that the existence of a poor doctor-patient relationship is an important gap to be borne in mind.

Strengths and limitations

Limitations

The FG sessions took place in Galicia, an area with a population that has a high use of antibiotics without prescription. Prudence is therefore called for when generalising the findings to other regions of Spain. It is necessary to replicate this workin other parts of Spain. Other natural limitation include the non-random sample, participants were volunteer. We don’t see this as a big limitation because the participants represented a wide range of ages, origin and formation.

Strengths

Eleven FGs were formed, taking into account differences in age, origin (urban or rural) and educational/professional qualifications. The methodology and design used were in line with the quality criteria required by qualitative techniques. The study fulfilled all COREQ scale criteria [42], except for point 23 (Transcripts returned) which did not prove feasible, owing to the characteristics of the population, namely, an elderly age stratum, without any available means for delivery of transcriptions. By way of correction, however, separate transcriptions were drawn up by two researchers, with any points of difference being discussed and settled by common agreement.

Conclusions

Improving antibiotic use is a complex task that calls for a number of complementary approaches. One of the targets must be patients, due to their key role in the correct use of antibiotics. Qualitative population studies and a systematic review have both highlighted the importance of lack of knowledge. Our study goes further still and highlights the importance of the doctor-patient relationship and proper transmission of information to the patient, not only at the level of the individual consultation, but also at the level of public health campaigns. These findings may well be of great utility when it comes to designing more direct, higher-impact campaigns aimed at improving antibiotic use in and by the general population.

Supporting information

S1 Checklist. COREQ (COnsolidated criteria for REporting Qualitative research) Checklist.

(PDF)

S1 File

(DOCX)

Acknowledgments

We should like to thank all the neighbourhood associations and senior citizen study centres that kindly collaborated in this study.

Data Availability

All relevant data are within the manuscript and its Supporting information files.

Funding Statement

This work was supported in part by the Instituto de Salud Carlos III (PI081239, PI09/90609) Spanish State Plan for Scientific and Technical Research and Innovation 2012-2016, The European Regional Development Fund (ERDF). https://www.isciii.es/QueHacemos/Financiacion/Paginas/default.aspx.

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Decision Letter 0

Helena Legido-Quigley

25 Jun 2020

PONE-D-20-05804

Factors determining antibiotic use in the general population: a qualitative study in Spain.

PLOS ONE

Dear Dr. Vazquez-Lago,

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PLOS ONE

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Could you therefore please include the title page into the beginning of your manuscript file itself, listing all authors and affiliations.

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

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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Reviewer #1: Yes

Reviewer #2: Partly

**********

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

Reviewer #1: N/A

Reviewer #2: No

**********

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Reviewer #1: Yes

Reviewer #2: No

**********

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Reviewer #2: No

**********

5. Review Comments to the Author

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Reviewer #1: General comments:

The topic is of great interest where antibiotics abuse and misuse is a serious public health concern.

The authors used adequate and solid methods for qualitative research.

Providing the scripts that the authors used to conduct the sessions as appendices facilitates the replication of the methods.

Manuscript would benefit from a thorough proof read by a native English speaker to improve grammar.

Specific comments:

Line 43: spell out DDD when used for the first time in text

Line 143: Better explain in the methods section the rationale for dividing FGs between over 65 and under 65

Line 163: authors should explain what they mean by M1 (same for lines 168, 171, 183…)

Line 176: authors should explain what they mean by H.1

Lines 356-357: Conclusions are usually free of citations especially if the articles are cited earlier in text; unless they mention a quote or an expert opinion.

Table 1: Providing more details about the baseline characteristics would give more insights to the respondents’ characteristics and would help understand the data better.

Reviewer #2: This is an important topic and authors made a clear important argument on the study purpose. However, there are important parts which require significant revision, also language requires revision and polishing as it is difficult to understand.

1) Introduction:

a)1st para: unclear what author tried to express. Line 35--( delete "it has on"); Line 38-39 please revise and double check the english grammar

b)Line 51 change these drugs to antibiotics

c)Line 57 abuse, can you define "abuse" and add this in the 2nd para

2)Methods

a) Line 72, the references 18,19 did not match in Line 68-72

b) Line 76-79, how the snowball method approved to be high degree of heterogeneity ?

c) Line 85, how did the authors know the "saturation of information had been achieved" without knowing what these two groups' discussion

d) Line 92: what was the response rates for requesting other authors

e) Ethical approval reference No ?

f) It was unclear if the discussion was conducted in Spanish or English ? transcript was translated into english ? how did the author make sure there was a back translation?

3) Results

a)Line 143 and Line 147 over-65? over 65 age, please double check the English grammar

b) add the definition of the summarised 5 main reasons

c) Line 172-176, how many groups stated ? This para seems more related to a communication skills rather than a direct result of poor relationship

d)Line 195 not sure if this is correct, "all groups but one " disclose problem of adherence ?

e) Line 244-248 showed the perception of AMR in farming, however, not sure what author tried to express here

3)Discussion

a)FG natural limitations did not discuss sufficiently

**********

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Reviewer #2: No

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PLoS One. 2021 Feb 4;16(2):e0246506. doi: 10.1371/journal.pone.0246506.r002

Author response to Decision Letter 0


12 Aug 2020

Dear Editor:

Thank you very much for allowing us to review our manuscript so that you appreciate its publication by PLoS One.

In the following lines we try to answer all your questions and comments.

You have been very kind to review our manuscript.

- 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

We have revised the style requirements and believe that the manuscript is now adapted.

- 2. Please include additional information regarding the interview guidelines used in the study and ensure that you have provided sufficient details that others could replicate the analyses.

The script followed for conducting and directing the focus groups is attached, to incorporate the manuscript as supplementary material

- 3. Please ensure that you include a title page within your main document. We do appreciate that you have a title page document uploaded as a separate file, however, as per our author guidelines (http://journals.plos.org/plosone/s/submission-guidelines#loc-title-page) we do require this to be part of the manuscript file itself and not uploaded separately.

A title page has been included at the beginning of the manuscript, as recommended. Thank you very much.

- 4. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information:

It has been revised, We consider that it is now correct. Thank you

Dear Reviewers,

Thank you very much for allowing us to review our manuscript. We consider the topic of abuse and misuse of antibiotic, as you have said, a serius public heath concern. We wanted to make the most of our research. Thanks for appreciating it. We consider your suggestions have contributed positively to our article. Also, we have reviewed the language, thank you.

In its current version, our manuscript has won in quality, waiting now that meets the requirements of your magazine to be revalued and if necessary, be published in the future.

We have tried to respond to each of the contributions and suggestions that have been made to us get.

Thank you.

Reviewer #1: General comments:

The topic is of great interest where antibiotics abuse and misuse is a serious public health concern.The authors used adequate and solid methods for qualitative research.

Providing the scripts that the authors used to conduct the sessions as appendices facilitates the replication of the methods. Manuscript would benefit from a thorough proof read by a native English speaker to improve grammar.

Thank you for your apreciation. We consider the topic of abuse and misuse of antibiotic as you have said a serius public heath concern. We wanted to make the most of our research. Thank you. We have reviewed the language, thank you. We have included de script used to conduct the session in english and in spanish as you have suggest. Thank you.

Specific comments:

Line 43: spell out DDD when used for the first time in text

Thank you for notices this. We have already changed DDD for Define Daily dose. As you can see in the manuscrit: <<Most antibiotic use (80% to 90%) occurs in the outpatient setting, In terms of antibiotic consumption, Spain not only ranks highest among developed countries (in excess of 40 Define Daily Dose (DDDs) per 1,000 inhabitants per year).>>

Line 143: Better explain in the methods section the rationale for dividing FGs between over 65 and under 65.

Thank you for your sugestion. We have rewritten this paragraph in methods section. As you can read in page 3 line 76-89 of the document in highlight: <<We sought to ensure a high degree of heterogeneity in the composition of the groups in terms of age (over and under 65 years), urban or rural origin, and educational/professional qualifications, in order to cover the widest range of opinions (Table 1). We made groups following age criteria to explore the differences in knowledge and attitudes between retirees and workers, we also took into account the origin criteria due to possible differences in access to the health system. >>

Line 163: authors should explain what they mean by M1 (same for lines 168, 171, 183…)

Thank you for notices this. We have made a translate mistake, this is because in spanish the quote "M" is use for <<mujer>> that means woman, and H for <<hombre>> that means male. The quotes were typed incorrectly. Sorry for the misunderstanding, we have already changed this for the correct quotes.

Line 176: authors should explain what they mean by H.1

Thank you for notices this. We have made a translate mistake, this is because in spanish the quote "H" is use for <<Hombre>> that means male, and M for <<Mujer>> that means woman. The quotes were typed incorrectly. Sorry for the misunderstanding, we have already changed this for the correct quotes.

Lines 356-357: Conclusions are usually free of citations especially if the articles are cited earlier in text; unless they mention a quote or an expert opinion.

Thank you for your consideration. We have included this change.

Table 1: Providing more details about the baseline characteristics would give more insights to the respondents’ characteristics and would help understand the data better.

We have to apologize but we did not make that type of questions. In order to help the reader to understand data better we have included in table 1 in groups of <65 years a more specific rage of age being aware of the difference that could exist between participants under 35 years and over 50. We are not able to introduce more details of the baseline respondents characteristics because the only inclusion criteria were being older or younger of 65 age, this would clasificated the participant in one or other group. We have asked their work and fomartion to detect posible variations in the sessions. We also took into account the origin (urban or rural) criteria.

Reviewer #2: This is an important topic and authors made a clear important argument on the study purpose. However, there are important parts which require significant revision, also language requires revision and polishing as it is difficult to understand.

1) Introduction:

a)1st para: unclear what author tried to express. Line 35--(delete "it has on"); Line 38-39 please revise and double check the english grammar

Thank you. We have made the changes you have suggested. Now in the manuscript you can read: <<Taken together, antibiotic adverse effects, ineffectiveness and resistance is one of the biggest threats to global health,i due to the great impact on morbidity, mortality and costs. Over- and misuse of antibiotics contributes significantly to this problem. Indeed, overuse must be assumed to account for the differences in antibiotic use (as much as threefold) among European Union countries, due there is no evidence of any difference in the prevalence of infectious diseases.>>

b)Line 51 change these drugs to antibiotics

Thank you, we have included that change.

c)Line 57 abuse, can you define "abuse" and add this in the 2nd para

Thank you for yor question. After your suggestion we have changed abuse for misuse. Misues is the most used term in scientific researchs and the term that best expresses what we wanted to say. Thank you for your appreciation.

2)Methods

a) Line 72, the references 18,19 did not match in Line 68-72

Thank you for your apreciation. We have changed this.

b) Line 76-79, how the snowball method approved to be high degree of heterogeneity?

Thank you for your question. We have used snowball method using diferent Key informants. We made two categories of groups, taking into account age (over and under 65 years) to detect diferences in the knowledge and attitudes between retired and workers. Also, we asked if they were from the rural or urban due to the possible differences in the acces to the health care system. With this strategy we were able to made heteregeneus categories of groups but with homegeneus participants in each session.

c) Line 85, how did the authors know the "saturation of information had been achieved" without knowing what these two groups' discussion

Thank for your question. After each FG we made a summary with the main ideas that came up during the sesision. Next step was to literaly transcript the sessions. After this, we made an indeep analysis of the trascription to identify the ideas as results by two individual researchers. In order to represent the saturation of the information we made table 3. In this table we have collected all the repeated ideas in each group. We have made 11 FG, when we realiced that no new ideas came up, after the analysis of each session, we stop doing new FG.

d) Line 92: what was the response rates for requesting other authors

Thank you for your question. We have sent an email to all the authors of the published articles of qualitative methodology about this topic. We have send 10 email (concordant with references 24-33) and we reciebed 4 answers (concordant with references 28, 31-33). Also we used the scripts of the articles of general practicioners and pharmacist (concordant with reference 12 and 23 )

e) Ethical approval reference No ?

Thank you. We have included Ethical approval refenrece as you can read in line 114- 119. The study was evaluated and approved by the Santiago-Lugo Research Ethics Committee. After being informed of the purpose of the study and the fact that the sessions were to be recorded and transcribed but kept anonymous, all the participants agreed to take part and gave their written informed consent.

f) It was unclear if the discussion was conducted in Spanish or English transcript was translated into english ? how did the author make sure there was a back translation?

Thank you for your question. The discussion was conducted in Spanish or Galician (all the researchers who did the FG sessions were native speakers in both languages). After the sessions, the researchers (native speakers in both languages) did the literal transcription. Transcript analysis was also performed by native researchers. Finally, the researchers selected the sentences that most represented the results of the investigation, and then those were translated into Spanish (the ones that were in Galician Language). The next step was to send the entire manuscript to a native English speaker. The last step was to carefully read the results to make sure a good quality translation was done.

3) Results

a)Line 143 and Line 147 over-65? over 65 age, please double check the English grammar

Thank you for your suggestion. We have made thouse changes.

b) add the definition of the summarised 5 main reasons

Thank you for your suggestion. We consider that table 2 define the 6 main reasons. As you had appreciated the used terms are not exactly the same in table 2 and main text, we have change this in the table for traing to being more precise. Thank you.

Descriptions of the main reason, as you can see in main text (table 2) are:

(i) Lack of knowledge about antibiotics: Difficulties in differentiating antibiotics from other medications or consider that antibioctics are use for any infection

(ii) Problems in the doctor-patient relationship: Lack of trust in physician (pressure on physician), consider that the physician supplies little information about the disease or consider time of consultation to be insufficient.

(iii) Reason of problems of adherence (not finishing the entire treatment): Lack of credibility of professional judgement, improvement after initial doses, side effects of antibiotics, abandoning the treatment in order to be able to consume alcohol or oversights and carelessness

(iv) Use without prescription (using alternatives): trusted pharmacy, home medicine cabinet/leftover antibiotics or internet.

(v) lack of perception of the problem of development of resistance: Do not think that there is any problem at present, excess use of antibiotics is not linked to advance of resistance or not considered to be a Public Health problem

(vi) Internan Responsibility : inappropriate use of antibiotics considered responsible for the problem. External Responsability: considering other the responsable of the problem such as physicians, pharmaceutical industry, food, economic reasons, excess use in the past considered responsible for the problem.

c) Line 172-176, how many groups stated ? This para seems more related to a communication skills rather than a direct result of poor relationship

We have change the sentence in order to be more exact. We understand that it could lead to misunderstanding. Thank you for your appreciation. In the manuscript now you can read:

<<Only two groups saw the medical practitioner as being responsible for taking the decision to prescribe antibiotics, once the necessary check-up and examination had been performed: [“I think it is necessary a severe control in the antibiotics. Doctors are the ones who always have to make the decision (taking or not antibiotics)”] (W6, FG1). Other groups stated that in some illness any person could be able to know that you need an antibiotic, even without a medical examination: [“Here with all the cold we have, you can get an urine infection. A simple urine infeccion and you don’t have more remedy than take an antibiotic.”] (W4, FG5).>>

d)Line 195 not sure if this is correct, "all groups but one " disclose problem of adherence ?

Thank you for your question. Of the 11 FG made, 10 stated problems in adherence due to lack of credibility of professional judmend, improvement after initial doses, side effects of antibiotics, abandoning the treatment in order to be able to consume alcohol or oversigths or carelessness. Only one group didnt declare any of those reason for stoping antibiotics before ending the treatment.

e) Line 244-248 showed the perception of AMR in farming, however, not sure what author tried to express here

Thank you for your appreciation. We wanted to express that although the preocupaction about antibiotic resistance, general population do not identify the misuse of antibiotic as a main reason. General public point intensive farming as the guilty of the antibiotic resistance. We have changed this paragraph in order to be more clear with or intention. In main text now you can read: Although antibiotic resistance is of concern to the public, its advance is not associated with misuse. Difficulty in finding effective antibiotics is considered a consequence of intensive farming and food, insted of human misuse: [“All the chickens that come from intensive farming, for example, have antibiotics; and the cattle...have them in the meat as well as in the milk…”]

3)Discussion

a)FG natural limitations did not discuss sufficiently

Thank you for your apprecitation. We have included FG natural limitations. Now in the manuscript you can read:

<<The FG sessions took place in Galicia, an area with a population that has a high use of antibiotics without prescription. Prudence is therefore called for when generalising the findings to other regions of Spain. It is necessary to replicate this workin other parts of Spain. Other natural limitation include the non-random sample, participants were volunteer. We don’t see this as a big limitation because the participants represented a wide range of ages, origin and formation.>>

Attachment

Submitted filename: Response to Reviewers.docx

Decision Letter 1

Vijayaprakash Suppiah

8 Oct 2020

PONE-D-20-05804R1

Factors determining antibiotic use in the general population: a qualitative study in Spain.

PLOS ONE

Dear Dr. Vazquez-Lago,

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.

Please submit your revised manuscript by Nov 22 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.

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,

Vijayaprakash Suppiah, PhD

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: All comments have been addressed

Reviewer #2: (No Response)

**********

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: Partly

**********

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

Reviewer #1: N/A

Reviewer #2: Yes

**********

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: No

**********

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: All comments addressed to the extent possible. The manuscript is technically sound, and the data support the conclusions. Recommend to accept manuscript for publication.

Reviewer #2: 1) The most important revision is to get a very careful english proofreading

2) In the abstract, the current conclusion is unclear and is not from the key findings.

3) The reasons why authors chose over and under 65 years old were not explained well.

4) Each quote shall include participant's age. (eg, 45yo W)

5) Add how the transcription and translation were conducted.

**********

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: Elsy Ramia, PharmD, MPH, BCPS

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.

PLoS One. 2021 Feb 4;16(2):e0246506. doi: 10.1371/journal.pone.0246506.r004

Author response to Decision Letter 1


2 Dec 2020

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: All comments have been addressed

Reviewer #2: (No Response)

________________________________________

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: Partly

________________________________________

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

Reviewer #1: N/A

Reviewer #2: Yes

________________________________________

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: No

Thank you for your suggestion. We have submitted the article for review by a native English speaker________________________________________

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: All comments addressed to the extent possible. The manuscript is technically sound, and the data support the conclusions. Recommend to accept manuscript for publication.

Reviewer #2: 1) The most important revision is to get a very careful english proofreading

Thank you for your suggestion. We have submitted the article for review by a native English speaker

2) In the abstract, the current conclusion is unclear and is not from the key findings.

Thank you, We have changed the conclusions of the abstract in order to be more clear

3) The reasons why authors chose over and under 65 years old were not explained well.

Thank you, we have included a new explanation in page 3 line 80-83:

We decided to made this two groups to better explore the differences in the acces to the heathcare facilities (assuming more time in retirees), and also to explore the differences in the relationship with the doctor between older and yougers.

4) Each quote shall include participant's age. (eg, 45yo W)

Thank you for your suggestion

We have to apologize but we dont have this information available. We have the range of age of each group but we dont have the exact age of each participant. We have included the group age in order to make easier the reading.

5) Add how the transcription and translation were conducted.

Thank you for your apreciation. We have included how transcription were conducted in page 4 line 109-112. The transcripts were first analyzed to obtain the results of the study. Subsequently, those that best represented the results were identified and selected. Only these quotes were sent for translation by a native English speaker.

________________________________________

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: Elsy Ramia, PharmD, MPH, BCPS

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.]

Attachment

Submitted filename: Response to reviewer.docx

Decision Letter 2

Vijayaprakash Suppiah

21 Jan 2021

Factors determining antibiotic use in the general population: a qualitative study in Spain.

PONE-D-20-05804R2

Dear Dr. Vazquez-Lago,

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.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Vijayaprakash Suppiah, PhD

Academic Editor

PLOS ONE

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: All comments have been addressed

Reviewer #2: (No Response)

**********

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: Yes

Reviewer #2: Yes

**********

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: No

**********

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: All comments have been addressed, and all findings adequately presented. Manuscript can be accepted for publication.

Reviewer #2: Thanks for addressing the specific comments. A further language polishing or proofreading will be necessary to meet the journal standards.

**********

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: Elsy Ramia, PharmD, MPH, BCPS

Reviewer #2: No

Acceptance letter

Vijayaprakash Suppiah

25 Jan 2021

PONE-D-20-05804R2

Factors determining antibiotic use in the general population: a qualitative study in Spain.

Dear Dr. Vazquez-Lago:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Vijayaprakash Suppiah

Academic Editor

PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 Checklist. COREQ (COnsolidated criteria for REporting Qualitative research) Checklist.

    (PDF)

    S1 File

    (DOCX)

    Attachment

    Submitted filename: Response to Reviewers.docx

    Attachment

    Submitted filename: Response to reviewer.docx

    Data Availability Statement

    All relevant data are within the manuscript and its Supporting information files.


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