Mixed method evaluation of a learning from excellence programme for community health workers in Neno, Malawi.

BACKGROUND: Community Health Workers (CHWs) play an essential role in linking communities to facility-based healthcare. However, CHW programmes have often been hampered by low levels of staff motivation, and new tools aimed at improving staff motivation and work environment are needed. One such intervention is the "Learning from Excellence" (LfE) programme. We aimed to assess feasibility, outputs, and impact of a co-designed LfE programme on CHW motivation, in Neno District. METHODS: We conducted a convergent mixed-method evaluation of the LfE programme. Co-design of the programme and forms took place between October 2019 and January 2020. LfE forms submitted between September and November 2020 were analysed using descriptive statistics and memos summarising answers to the open-ended question. To investigate experiences with LfE we conducted in-depth semi-structured interviews with key stakeholders, CHWs, and site supervisors, which were analysed thematically. A pre-post intervention questionnaire was developed to assess the impact of the co-designed LfE intervention on CHW motivation and perceived supervision. Outcomes were triangulated into a logic model. RESULTS: In total 555 LfE forms were submitted, with 34.4% of CHWs in Neno District submitting at least one LfE report. Four themes were identified in the interviews: LfE implementation processes, experience, consequences, and recommendations. A total of 50 CHWs participated in the questionnaire in January 2020 and 46 of them completed the questionnaire in December 2020. No statistically significant differences were identified between pre-and post-LfE measurements for both motivation (Site F: p = 0.86; Site G: p = 0.31) and perceived supervision (Site F: p = 0.95; Site G: p = 0.45). A logic model, explaining how the LfE programme could impact CHWs was developed. CONCLUSIONS: Many CHWs participated in the LfE intervention between September 2020 and November 2020. LfE was welcomed by CHWs and stakeholders as it allowed them to appreciate excellent work in absence of other opportunities to do so. However, no statistically significant differences in CHW motivation and perceived supervision were identified. While the intervention was feasible in Neno District, we identified several barriers and facilitators for implementation. We developed a logic model to explain contextual factors, and mechanisms that could lead to LfE outcomes for CHWs in Neno District. The developed logic model can be used by those designing and implementing interventions like LfE for health workers.

Utility of large language models for creating clinical assessment items.

PURPOSE: To compare student performance, examiner perceptions and cost of GPT-assisted (generative pretrained transformer-assisted) clinical and professional skills assessment (CPSAs) items against items created using standard methods. METHODS: We conducted a prospective, controlled, double-blinded comparison of CPSA items developed using GPT-assistance with those created through standard methods. Two sets of six practical cases were developed for a formative assessment sat by final year medical students. One clinical case in each set was created with GPT-assistance. Students were assigned to one of the two sets. RESULTS: The results of 239 participants were analysed in the study. There was no statistically significant difference in item difficulty, or discriminative ability between GPT-assisted and standard items. One hundred percent (n = 15) of respondents to an examiner feedback questionnaire felt GPT-assisted cases were appropriately difficult and realistic. GPT-assistance resulted in significant labour cost savings, with a mean reduction of 57% (880 GBP) in labour cost per case when compared to standard case drafting methods. CONCLUSIONS: GPT-assistance can create CPSA items of comparable quality with significantly less cost when compared to standard methods. Future studies could evaluate GPT's ability to create CPSA material in other areas of clinical practice, aiming to validate the generalisability of these findings.

The influence of candidates' race on examiners' ratings in standardised assessments of clinical practice.

PURPOSE: Delivering fair and reliable summative assessments in medical education assumes examiner decision making is devoid of bias. We investigated whether candidate racial appearances influenced examiner ratings in undergraduate clinical exams. METHODS: We used an internet-based design. Examiners watched a randomised set of six videos of three different white candidates and three different non-white (Asian, black and Chinese) candidates taking a clinical history at either fail, borderline or pass grades. We compared the median and interquartile range (IQR) of the paired difference between scores for the white and non-white candidates at each performance grade and tested for statistical significance. RESULTS: 160 Examiners participated. At the fail grade, the black and Chinese candidates scored lower than the white candidate, with median paired differences of -2.5 and -1 respectively (both p < 0.001). At the borderline grade, the black and Chinese candidates scored higher than the white candidate, with median paired differences of +2 and +3, respectively (both p < 0.001). At the passing grade, the Asian candidate scored lower than the white candidate (median paired difference -1, p < 0.001). CONCLUSION: The racial appearance of candidates appeared to influence the scores awarded by examiners, but not in a uniform manner.

Chemokine signaling via the CXCR2 receptor reinforces senescence.

Cells enter senescence, a state of stable proliferative arrest, in response to a variety of cellular stresses, including telomere erosion, DNA damage, and oncogenic signaling, which acts as a barrier against malignant transformation in vivo. To identify genes controlling senescence, we conducted an unbiased screen for small hairpin RNAs that extend the life span of primary human fibroblasts. Here, we report that knocking down the chemokine receptor CXCR2 (IL8RB) alleviates both replicative and oncogene-induced senescence (OIS) and diminishes the DNA-damage response. Conversely, ectopic expression of CXCR2 results in premature senescence via a p53-dependent mechanism. Cells undergoing OIS secrete multiple CXCR2-binding chemokines in a program that is regulated by the NF-kappaB and C/EBPbeta transcription factors and coordinately induce CXCR2 expression. CXCR2 upregulation is also observed in preneoplastic lesions in vivo. These results suggest that senescent cells activate a self-amplifying secretory network in which CXCR2-binding chemokines reinforce growth arrest.

The impact of patient skin colour on diagnostic ability and confidence of medical students.

Previous literature has explored unconscious racial biases in clinical education and medicine, finding that people with darker skin tones can be underrepresented in learning resources and managed differently in a clinical setting. This study aimed to examine whether patient skin colour can affect the diagnostic ability and confidence of medical students, and their cognitive reasoning processes. We presented students with 12 different clinical presentations on both white skin (WS) and non-white skin (NWS). A think aloud (TA) study was conducted to explore students' cognitive reasoning processes (n = 8). An online quiz was also conducted where students submitted a diagnosis and confidence level for each clinical presentation (n = 185). In the TA interviews, students used similar levels of information gathering and analytical reasoning for each skin type but appeared to display increased uncertainty and reduced non-analytical reasoning methods for the NWS images compared to the WS images. In the online quiz, students were significantly more likely to accurately diagnose five of the 12 clinical presentations (shingles, cellulitis, Lyme disease, eczema and meningococcal disease) on WS compared to NWS (p < 0.01). With regards to students' confidence, they were significantly more confident diagnosing eight of the 12 clinical presentations (shingles, cellulitis, Lyme disease, eczema, meningococcal disease, urticaria, chickenpox and Kawasaki disease) on WS when compared to NWS (p < 0.01). These findings highlight the need to improve teaching resources to include a greater diversity of skin colours exhibiting clinical signs, to improve students' knowledge and confidence, and ultimately, to avoid patients being misdiagnosed due to the colour of their skin.

Twelve tips for introducing very short answer questions (VSAQs) into your medical curriculum.

Most undergraduate written examinations use multiple-choice questions, such as single best answer questions (SBAQs) to assess medical knowledge. In recent years, a strong evidence base has emerged for the use of very short answer questions (VSAQs). VSAQs have been shown to be an acceptable, reliable, discriminatory, and cost-effective assessment tool in both formative and summative undergraduate assessments. VSAQs address many of the concerns raised by educators using SBAQs including inauthentic clinical scenarios, cueing and test-taking behaviours by students, as well as the limited feedback SBAQs provide for both students and teachers. The widespread use of VSAQs in medical assessment has yet to be adopted, possibly due to lack of familiarity and experience with this assessment method. The following twelve tips have been constructed using our own practical experience of VSAQs alongside supporting evidence from the literature to help medical educators successfully plan, construct and implement VSAQs within medical curricula.

Assessing the predictive validity of the UCAT-A systematic review and narrative synthesis.

BACKGROUND: The University Clinical Aptitude Test (UCAT) is an admissions assessment used by a consortium of universities across the UK, Australia, and New Zealand, to aid the selection of applicants to medical and dental degree programmes. The UCAT aims to measure the mental aptitude and professional behaviours required to become successful doctors and dentists. We conducted a systematic review to establish the predictive value of the UCAT across measures of performance at undergraduate and post-graduate levels. METHODS: A literature search was conducted in April 2020 using eight electronic databases: MEDLINE, APA PsycInfo, SCOPUS, Web of Science, EThOS, OpenGrey, PROSPERO, and the UCAT website. Data were extracted from selected studies and tabulated as results matrices. A narrative synthesis was performed. RESULTS: Twenty-four studies satisfied our inclusion criteria, 23 of which were deemed to be of good quality (using the Newcastle-Ottawa Scale). For over 70% of univariate data points, the UCAT exerted no statistically significant predictive validity; for the remainder, predictive power was weak. The cognitive total and verbal reasoning subtests had the largest evidence base as weakly positive predictors of academic performance. The SJT subtest was a weak predictor of professional behaviour during medical school. Studies specific to dental schools demonstrated variable findings across the five studies. Only 1 study looked at post-graduate outcome measures and demonstrated that the UCAT was not a predictor of health- or conduct-related fitness to practice declarations at GMC registration. CONCLUSIONS: These data provide some support for the use of cognitive total and verbal reasoning subtests as part of medical school selection. Further research is needed to investigate outcomes beyond professional registration and for dental students.

Is the assumption of equal distances between global assessment categories used in borderline regression valid?

BACKGROUND: Standard setting for clinical examinations typically uses the borderline regression method to set the pass mark. An assumption made in using this method is that there are equal intervals between global ratings (GR) (e.g. Fail, Borderline Pass, Clear Pass, Good and Excellent). However, this assumption has never been tested in the medical literature to the best of our knowledge. We examine if the assumption of equal intervals between GR is met, and the potential implications for student outcomes. METHODS: Clinical finals examiners were recruited across two institutions to place the typical 'Borderline Pass', 'Clear Pass' and 'Good' candidate on a continuous slider scale between a typical 'Fail' candidate at point 0 and a typical 'Excellent' candidate at point 1. Results were analysed using one-sample t-testing of each interval to an equal interval size of 0.25. Secondary data analysis was performed on summative assessment scores for 94 clinical stations and 1191 medical student examination outcomes in the final 2 years of study at a single centre. RESULTS: On a scale from 0.00 (Fail) to 1.00 (Excellent), mean examiner GRs for 'Borderline Pass', 'Clear Pass' and 'Good' were 0.33, 0.55 and 0.77 respectively. All of the four intervals between GRs (Fail-Borderline Pass, Borderline Pass-Clear Pass, Clear Pass-Good, Good-Excellent) were statistically significantly different to the expected value of 0.25 (all p-values < 0.0125). An ordinal linear regression using mean examiner GRs was performed for each of the 94 stations, to determine pass marks out of 24. This increased pass marks for all 94 stations compared with the original GR locations (mean increase 0.21), and caused one additional fail by overall exam pass mark (out of 1191 students) and 92 additional station fails (out of 11,346 stations). CONCLUSIONS: Although the current assumption of equal intervals between GRs across the performance spectrum is not met, and an adjusted regression equation causes an increase in station pass marks, the effect on overall exam pass/fail outcomes is modest.

Standard setting Very Short Answer Questions (VSAQs) relative to Single Best Answer Questions (SBAQs): does having access to the answers make a difference?

BACKGROUND: We investigated whether question format and access to the correct answers affect the pass mark set by standard-setters on written examinations. METHODS: Trained educators used the Angoff method to standard set two 50-item tests with identical vignettes, one in a single best answer question (SBAQ) format (with five answer options) and the other in a very short answer question (VSAQ) format (requiring free text responses). Half the participants had access to the correct answers and half did not. The data for each group were analysed to determine if the question format or having access to the answers affected the pass mark set. RESULTS: A lower pass mark was set for the VSAQ test than the SBAQ test by the standard setters who had access to the answers (median difference of 13.85 percentage points, Z = -2.82, p = 0.002). Comparable pass marks were set for the SBAQ test by standard setters with and without access to the correct answers (60.65% and 60.90% respectively). A lower pass mark was set for the VSAQ test when participants had access to the correct answers (difference in medians -13.75 percentage points, Z = 2.46, p = 0.014). CONCLUSIONS: When given access to the potential correct answers, standard setters appear to appreciate the increased difficulty of VSAQs compared to SBAQs.

Outcomes, mechanisms and contextual factors of positive psychology interventions for health workers: a systematic review of global evidence.

BACKGROUND: Interventions using positive psychology (PP), which build on positive qualities of healthcare personnel and institutions, could potentially enhance organisational performance in healthcare. The aim of this systematic review was to identify if PP interventions have an impact on organisational performance of healthcare personnel, and if so, how this impact can be achieved. We developed a logic model to explain the impact of PP interventions on organisational performance. METHODS: We searched Web of Science, Medline, Psychinfo, Embase, Scopus and CINAHL (from inception until March 2019) and references of included articles to identify studies that evaluated the impact of a PP intervention for health personnel. Study quality was assessed using the SQUIRE checklist for quality improvement studies. Data were extracted about study details, setting, participants, intervention, method of evaluation and results. Outcomes, mechanisms and contexts were coded in nVivo. Data synthesis was guided by Lewis' theory of the impact of PP interventions on organisational performance and Kneale et al.'s method for logic model development. Collected data were integrated into a logic model explaining initial inputs, processes, and intermediate outcomes of PP interventions that lead to improved organisational performance in healthcare settings. RESULTS: We retrieved 4638 articles and identified five through references of included articles of which 29 studies (31 articles) met our inclusion criteria. Most articles were of low quality (n = 19) and outcome measures varied widely. We identified 54 different outcomes of PP interventions, including 'improved well-being' and 'improved interaction and support'. Forty-nine mechanisms were identified including 'recognising and reframing negative interpretations'. Twenty four contextual factors were identified of which seven acted as barriers. 'Managerial support' was a facilitator mentioned in eight studies. All identified outcomes, mechanisms and contextual factors were integrated into a logic model explaining how interventions using PP can impact organisational performance in healthcare. CONCLUSION: Few identified outcomes were statistically significant, however, trends in both quantitative and qualitative outcomes show that PP interventions can increase well-being and interaction and support and thus improve organisational performance in healthcare. The developed logic model can be used in the implementation and evaluation of interventions using PP for health personnel.

Thinking differently - Students' cognitive processes when answering two different formats of written question.

BACKGROUND: Single-best answer questions (SBAQs) are common but are susceptible to cueing. Very short answer questions (VSAQs) could be an alternative, and we sought to determine if students' cognitive processes varied across question types and whether students with different performance levels used different methods for answering questions. METHODS: We undertook a 'think aloud' study, interviewing 21 final year medical students at five UK medical schools. Each student described their thought processes and methods used for eight questions of each type. Responses were coded and quantified to determine the relative frequency with which each method was used, denominated on the number of times a method could have been used. RESULTS: Students were more likely to use analytical reasoning methods (specifically identifying key features) when answering VSAQs. The use of test-taking behaviours was more common for SBAQs; students frequently used the answer options to help them reach an answer. Students acknowledged uncertainty more frequently when answering VSAQs. Analytical reasoning was more commonly used by high-performing students compared with low-performing students. CONCLUSIONS: Our results suggest that VSAQs encourage more authentic clinical reasoning strategies. Differences in cognitive approaches used highlight the need for focused approaches to teaching clinical reasoning and dealing with uncertainty.

National inter-rater agreement of standardised simulated-patient-based assessments.

PURPOSE: The forthcoming UK Medical Licensing Assessment will require all medical schools in the UK to ensure that their students pass an appropriately designed Clinical and Professional Skills Assessment (CPSA) prior to graduation and registration with a licence to practice medicine. The requirements for the CPSA will be set by the General Medical Council, but individual medical schools will be responsible for implementing their own assessments. It is therefore important that assessors from different medical schools across the UK agree on what standard of performance constitutes a fail, pass or good grade. METHODS: We used an experimental video-based, single-blinded, randomised, internet-based design. We created videos of simulated student performances of a clinical examination at four scripted standards: clear fail (CF), borderline (BD), clear pass (CPX) and good (GD). Assessors from ten regions across the UK were randomly assigned to watch five videos in 12 different combinations and asked to give competence domain scores and an overall global grade for each simulated candidate. The inter-rater agreement as measured by the intraclass correlation coefficient (ICC) based on a two-way random-effects model for absolute agreement was calculated for the total domain scores. RESULTS: 120 assessors enrolled in the study, with 98 eligible for analysis. The ICC was 0.93 (95% CI 0.81-0.99). The mean percentage agreement with the scripted global grade was 74.4% (range 40.8-96.9%). CONCLUSIONS: The inter-rater agreement amongst assessors across the UK when rating simulated candidates performing at scripted levels is excellent. The level of agreement for the overall global performance level for simulated candidates is also high. These findings suggest that assessors from across the UK viewing the same simulated performances show high levels of agreement of the standards expected of students at a 'clear fail,' 'borderline,' 'clear pass' and 'good' level.

Factors affecting recruitment into General Practice: a double binary choice approach.

Recruitment to General Practice (GP) is currently low in many countries. Here we focus on two binary choices for junior doctors: first, whether to apply to GP; second, whether to accept a GP training place if offered. Previous attitudinal studies have indicated factors claimed to affect recruitment. The current study goes further by quantifying the relative impact of different factors on the propensity of candidates to apply to GP and accept a training place. An online questionnaire was sent to candidates applying to United Kingdom (UK) specialty training in 2015. Descriptive statistics and a path analysis evaluated the importance of various factors on GP applications. Our results were synthesised with an analysis of data from the online applications portal. With 3838 candidates responding to the survey, the path analysis showed that personality and previous GP experiences were strongly associated with the decision to apply. There was some evidence that it was easier to enter GP than other specialties; in terms of deciding whether to accept, the evidence suggests GP was a backup plan for around 9% of candidates who accepted a GP post. Our results indicate that recruitment initiatives should focus on candidates who apply to GP but not as first choice or consider GP but do not apply, particularly by providing substantial experience of GP and accentuating the positives of the specialty such as work-life balance and the intellectual challenge of working with patients in primary care. Acceptance of a GP place may also depend on competition for places in other specialties.

Reflection in practice: How can patient experience feedback trigger staff reflection in hospital acute care settings?

BACKGROUND: Patient and staff experiences provide important insights into care quality, but health systems have difficulty using these data to improve care. Little attention has been paid to understanding how patient experience feedback can act as a prompt to reflection in practice in the clinical setting. OBJECTIVE: We aimed to identify the ways in which different types of patient experience feedback act as a trigger or prompt for engagement in reflection in clinical practice in acute hospital settings and identify important considerations for enhancing the value of patient experience data for reflective learning. METHODS: We conducted an ethnographic study in eight acute care units in three NHS hospital trusts in England, including 140 hours of observations and 45 semi-structured interviews with nursing, medical and managerial staff working in acute medical units and intensive care units. The data were analysed thematically. FINDINGS: We distinguished between formal patient experience data sources: data purposively collected and collated to capture the patient experience of care, generally at organizational level, including surveys, complaints and comments; and informal sources of feedback on the patient experience recognized by staff alongside the formal data. We also identified patient narratives as an 'in between' source of data. The impact of different types of patient feedback in triggering reflection primarily depended on the extent to which the feedback was experienced as personally relevant, meaningful and emotionally salient. DISCUSSION: Patient experience feedback is multi-faceted, but our study suggests that all types of feedback could be harnessed more effectively to prompt reflection.

The Primary-Secondary Care Partnership to Improve Outcomes in Chronic Kidney Disease (PSP-CKD) Study: A Cluster Randomized Trial in Primary Care.

BACKGROUND: Most patients with CKD are managed in the community. Whether nurse-led CKD management programs improve outcomes in patients with CKD in primary care is unclear. METHODS: To assess the effect of such a program on the rate of renal function decline in patients with CKD (stages 3-5) in primary care in the United Kingdom, we conducted a cluster randomized trial, the Primary-Secondary Care Partnership to Improve Outcomes in Chronic Kidney Disease study. A software program designed for the study created a data file of patients with CKD in participating practices. In 23 intervention practices (11,651 patients), a CKD nurse practitioner worked with nominated practice leads to interpret the data file and implement guideline-based patient-level CKD management interventions. The 23 control practices (11,706 patients) received a data file but otherwise, continued usual CKD care. The primary outcome was defined at the cluster (practice) level as the change from baseline of the mean eGFR of the patients with CKD at 6-month intervals up to 42 months. Secondary outcomes included numbers of patients coded for CKD, mean BP, numbers of patients achieving National Institute for Health and Care Excellence BP targets for CKD, and proteinuria measurement. RESULTS: After 42 months, eGFR did not differ significantly between control and intervention groups. CKD- and proteinuria-related coding improved significantly along with the number of patients achieving BP targets in the intervention group versus usual care. CONCLUSIONS: CKD management programs in primary care may not slow progression of CKD, but they may significantly improve processes of care and potentially decrease the cardiovascular disease burden in CKD and related costs.

Case study of a method of development of a selection process for community health workers in sub-Saharan Africa.

BACKGROUND: Choosing who should be recruited as a community health worker (CHW) is an important task, for their future performance partly depends on their ability to learn the required knowledge and skills, and their personal attributes. Developing a fair and effective selection process for CHWs is a challenging task, and reports of attempts to do so are rare. This paper describes a five-stage process of development and initial testing of a CHW selection process in two CHW programmes, one in Malawi and one in Ghana, highlighting the lessons learned at each stage and offering recommendations to other CHW programme providers seeking to develop their own selection processes. CASE PRESENTATION: The five stages of selection process development were as follows: (1) review an existing selection process, (2) conduct a job analysis, (3) elicit stakeholder opinions, (4) co-design the selection process and (5) test the selection process. Good practice in selection process development from the human resource literature and the principles of co-design were considered throughout. Validity, reliability, fairness, acceptability and feasibility-the determinants of selection process utility-were considered as appropriate during stages 1 to 4 and used to guide the testing in stage 5. The selection methods used by each local team were a written test and a short interview. CONCLUSIONS: Working with stakeholders, including CHWs, helped to ensure the acceptability of the selection processes developed. Expectations of intensiveness-in particular the number of interviewers-needed to be managed as resources for selection are limited, and CHWs reported that any form of interview may be stressful. Testing highlighted the importance of piloting with CHWs to ensure clarity of wording of questions, interviewer training to maximise inter-rater reliability and the provision of guidance to applicants in advance of any selection events. Trade-offs between the different components of selection process utility are also likely to be required. Further refinements and evaluation of predictive validity (i.e. a sixth stage of development) would be recommended before roll-out.

Using recruitment and selection to build a primary care workforce for the future.

Recruitment and selection are critical components of human resource management. They influence both the quantity and quality of the healthcare workforce. In this article, we use two different examples of primary care workers, General Practitioners in the UK and Community Health Workers in low- and middle- income countries, to illustrate how recruitment and selection are, and could be, used to enhance the primary care workforce in each setting. Both recruitment and selection can be costly, so when funding is limited, decisions on how to spend the human resources budget must be made. It could be argued that human resource management should focus on recruitment in a seller's market (an insufficient supply of applicants) and on selection in a buyer's market (sufficient applicants but concerns about their quality). We use this article to examine recruitment and selection in each type of market and highlight the interactions between these two human resource management decisions. Recruitment and selection, we argue, must be considered in both types of market; particularly in sectors where workers' labour impacts upon population health. We note the paucity of high-quality research in recruitment and selection for primary care and the need for rigorous study designs such as randomised trials.

Health care professionals' knowledge and attitudes towards antibiotic prescribing for the treatment of urinary tract infections: A systematic review.

PURPOSE: Previous models identify knowledge and attitudes that influence prescribing behaviour. The present study focuses on antibiotic prescribing for urinary tract infections (UTIs) to describe levels of health care professionals' knowledge and attitude factors in this area and how those levels are assessed. METHODS: A systematic search was conducted to identify studies assessing the identified knowledge or attitude factors influencing health care professionals' antibiotic prescribing for urinary tract infections up to September 2022. Study quality was assessed using the Newcastle-Ottawa scale. Data were extracted about the types of factors assessed, the levels indicated and how those levels were assessed. Data were synthesized using counts, and levels were categorized as 'poor', 'moderate', 'high' or 'very high'. RESULTS: Seven studies were identified, six of which relied entirely on closed-ended items. Levels of knowledge factors assessed were poor, for example, their 'knowledge of condition' and 'knowledge of task environment' were poor. Levels of the attitude factors assessed varied, for example, while health care professionals expressed moderate confidence in providing optimal patient care and appropriate attitude of fear towards the problem of antibiotic resistance, they expressed a poor attitude of complacency by giving into patient pressure to prescribe an antibiotic. CONCLUSIONS: Present evidence suggests that clinicians have poor levels of knowledge and varying levels of attitudes about antibiotic prescribing for UTIs. However, few studies were identified, and assessments were largely limited to closed-ended types of questions. Future studies that assess more factors and employ open-ended question types could better inform future interventions to optimize antibiotic prescribing.