154 Chapter 6 Determinants Regarding socioeconomic determinants with a significant impact on appropriateness of antimicrobial prescribing, migration background emerged as an important factor. While patients with a Moroccan migration background received more appropriate antimicrobial prescriptions compared to Dutch patients without a migration background, GPs were found to relatively more often inappropriately prescribe antimicrobials for patients with Turkish, Surinamese and Dutch Caribbean backgrounds. A prospective cross-sectional Dutch study including 1,939 patients reported that first generation migrants were more likely to be prescribed antimicrobial medication compared to second generation immigrants or patients with a non-immigrant Dutch background (30). By contrast, another Dutch study based on health insurance data from 21,617 patients did not find any differences in antimicrobial prescription across 6 migration backgrounds (including Turkish, Moroccan, Surinamese) (31)), although appropriateness was not examined as an outcome in that study. A possible explanation for most of these results is that GPs presume that patients with an infectious disease want antimicrobial therapy, but fail to actually verify this tacit assumption during shared decision making with the patient (19, 32-34). In fact, when asked, patients are usually more worried about the seriousness of their symptoms than eager to be treated (35). Nevertheless, results from a focus group study suggested that the expectation of being prescribed an antibiotic by the GP may be higher among patients with a non-Dutch migration background (36). Furthermore, as these groups tend to visit their GP more often than people with a non-immigrant Dutch background (37), a higher frequency of GP visits may increase the risk of being prescribed more antimicrobial prescriptions and consequently more inappropriate antimicrobial prescriptions. It is not completely clear to what extent knowledge and attitudes to antimicrobials amongst the various migration groups influence antimicrobial prescribing. A qualitative study from The Netherlands on this topic found no difference in attitudes towards antimicrobials amongst groups with different migration backgrounds compared to the overall Dutch population (38). However, several different migration backgrounds (Turkish, Moroccan, Surinamese, Syrian and Cape Verdean) were included in this study as one group. Another Dutch study reported that people from a non-Dutch migration background were less knowledgeable about antimicrobials compared to people with a Dutch background (31). When and how antimicrobials are used in the country of migration background may affect attitudes. For example, in Turkey antimicrobials are used not only for infections but for a broad variety of other diseases and symptoms (39), a pattern that might continue in The Netherlands for patients familiar with both cultures. The higher level of appropriate antimicrobial prescription amongst people
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