Determinants of antibiotic prescribing in primary care in Vietnam: a qualitative study using the Theoretical Domains Framework

Abstract Background: To formulate effective strategies for antimicrobial stewardship (AMS) in primary care, it is crucial to gain a thorough understanding of factors influencing prescribers' behavior within the context. This qualitative study utilizes the Theoretical Domain Framework (TDF) to uncover these influential factors. Methods: We conducted a qualitative study using in-depth interviews and focus group discussions with primary care workers in two provinces in rural Vietnam. Data analysis employed a combined inductive and deductive approach, with the deductive aspect grounded in the TDF. Results: Thirty-eight doctors, doctor associates, and pharmacists participated in twenty-two interviews and two focus group discussions. We identified sixteen themes, directly mapping onto seven TDF domains: knowledge, skills, behavioral regulation, environmental context and resources, social influences, social/professional role and identity, and optimism. Factors driving unnecessary prescription of antibiotics include low awareness of antimicrobial resistance (AMR) as a health threat, diagnostic uncertainty, prescription-based reimbursement policy, inadequate supply of symptom relief medications, patients’ perception of Commune Health Centers (CHC) medication as “free” benefits, and maintaining doctor-patient relationships. Potential factors facilitating AMS activities include time availability for in-person patient consultation, experience in health communication, and willingness to take action against antimicrobial resistance. Conclusion: Utilizing the TDF to systematically analyze and present behavioral determinants offers a structured foundation for designing impactful antimicrobial stewardship interventions in primary care. The findings underscore the importance of not only enhancing knowledge and skills but also implementing environmental restructuring, regulation, and enablement measures to effectively tackle unnecessary antibiotic prescribing in this context.