Exploring the social ecology for appropriate antibiotic prescribing and stewardship in primary care: presenting the VALUE driven model of practice derived from qualitative analysis of public and private care settings in Singapore

Background: Singapore’s healthcare system allows both antibiotic prescribing and dispensing across public and private primary care settings, presenting an ideal context to learn from systems where dispensing is closely tied to diverse operational models and funding mechanisms. Aim: To explore processes underpinning decision-making for antibiotic prescribing by primary care doctors in Singapore, by examining doctors’ experiences in different primary care settings. Methods: : Thirty semi-structured interviews were conducted with 17 doctors working in publicly funded primary care clinics (polyclinics) and 13 doctors working in private general practitioner (GP) clinics (solo, small group and large group practices). Interviews were audio-recorded and transcribed verbatim. Data were analysed using applied thematic analysis. Results: : Given the lack of National Guidelines for antibiotic prescribing in the Singapore context, this practice is currently non-standardised in both private and publicly funded primary care settings. Themes contributing to best practice narratives relate to having independent funding sources and control over drug formulary orders, and valuing reduction in antimicrobial resistance (AMR). The existence of trusting patient-doctor relationships, and reasonable patient loads were observed to allow joint participatory and informed decision-making that further enabled appropriate prescribing. The importance of monitoring and application of data/evaluations to inform practice was a minority theme, nevertheless underpinning all levels of optimal care delivery. Conclusions: : A model for appropriate antibiotic prescribing-related interventions needs to prioritise addressing and shaping organisational and personal V aluing of AMR reduction. These values have to also A lign with wider systemic constraints experienced in publicly funded institutions, operational management of private clinics and interactions with patients at the interpersonal level. The overcoming of such constraints and allowing time for patient L iaison and trust building will crystalise these earlier initiatives. U se of data to monitor and E valuate antibiotic prescribing, informing optimal delivery systems should be routinely shared for transparency and to improve prescribing practices . These dimensions are summarised in the VALUE model for appropriate antibiotic prescribing and stewardship in primary care, which is recommended as transferable to diverse contexts.