The world is facing the hidden healthcare crisis of antimicrobial resistance (AMR) driven mostly by misuse of antibiotics in the outpatient sector, and leading to major consequences such as worsening health, longer hospital stays and increasing healthcare costs [1, 2]. Over the next two decades AMR could result in a sharp increase in mortality rates, potentially causing up to 10 million deaths per year, with associated costs rising proportionally [3]. The alarming rise in fatalities would primarily be driven by the growing ineffectiveness of antibiotics and other antimicrobial agents against bacteria that were once easily treatable, leading to more severe and prolonged infections [3]. The phenomenon is evolving on a global scale due to the continued emergence of strains of resistant bacteria and the interconnectedness of our world [4,5,6,7].

The issue of AMR is deeply rooted in the primary care sector, which is estimated to account for 80–90% of prescriptions for antibiotics [2, 8]. Various elements in family practice contribute to the misuse and overprescription of antibiotics. The main driving factors are diagnostic uncertainty, time constraints combined with the high numbers of patients presenting each day, and doctors’ cautious attitude toward taking risks with patients’ health. Rezal et al.’s systematic review [9] also discussed several factors that influence doctors’ prescribing behavior, including patients’ expectations, severity, and duration of infections, uncertainty over diagnosis, and doctors’ concern about potentially losing patients. Another leading factor is the pressure exerted by patients, who expect to receive antibiotics and directly request prescriptions [2]. A systematic review [10] also reports, among other factors, economic aspects (e.g., incentives) driving doctors’ intention to prescribe an antibiotic. Another study [11] underscores the role of doctors’ fear of losing their patients and consequently their income. Other studies [12, 13] have a focus on the legal aspects and the lack of regulations or homogeneous and stricter rules on antibiotic usage.

The role of patient-provider interactions

As reported by the Economic and Social Research Council (ESRC) in a brief compiled in 2016 [14], antibiotic prescribing practices are deeply intertwined with the dynamics of the doctor-patient relationship. Trust, open communication, and continuity of care are central to this dynamic. A recent systematic review [15] demonstrated that in the discussion about antibiotic overprescription, communication and patient-provider behavior hold a central position. Other studies emphasize the contributing role of patients’ requests to the emergence of AMR along with more practical issues, such as scarcity of time and lack of resources for doctors to communicate effectively with their patients [16,17,18].

A qualitative study [19] found that patients’ willingness to seek antibiotics is shaped by their perceived symptom burden and beliefs about antibiotic effectiveness.

As for the consequences, patient demand has been consistently linked to higher chances of receiving a prescription, a pattern documented in several studies and systematic reviews [9, 20,21,22,23,24]. This correlation between patient demand and antibiotic prescription highlights a significant challenge in managing appropriate antibiotic use in healthcare.

Other studies [23,24,25,26,27,28,29] underscored the importance of the interpersonal dimension in the context of antibiotic prescription, indicating that general practitioners frequently encounter pressure from patients’ in the form of requests and expectations, even when such requests are not deemed appropriate or essential to the healing process. That is especially the case when confronted with respiratory tract infections (RTI), even though antibiotics are proven to have a limited impact against them [19, 20].

The importance of trust in the healthcare context

Patient-physician trust plays a stabilizing role in shaping the dynamics and quality of the healthcare experience [30,31,32,33]. Moreover, the doctor-patient relationship is often characterized by an inherent imbalance, as patients are typically the most vulnerable party [34] due to several key factors: an information asymmetry, in which physicians possess specialized knowledge that patients lack; the authoritative role of the physician; and the emotional and physical vulnerability of patients who typically seek care during illness or distress [31, 32].

Trust is crucial in the patient-physician relationship, influencing various aspects of healthcare delivery, from communication and shared decision-making to patient adherence and satisfaction [35, 36]. Multiple studies reported on the positive outcomes of high trust, such as the formation of positive attitudes towards treatment and adherence, reduced pain perception, greater openness to sharing sensitive information and lower inclination to seek second opinions [37,38,39,40,41]. Patients with low trust in their physicians often feel less satisfied with their care, are less likely to follow medical advice and tend to report fewer improvements in their symptoms [40, 42].

Although trust in physicians is typically associated with greater adherence to medical advice and thus a lower likelihood of antibiotic misuse, trust may also shape patients’ expectations for antibiotic treatment. It is important to distinguish between these two constructs: misuse generally occurs after a prescription has been given, while expectations or intentions to request antibiotics arise before or during the consultation. In this light, trust may play a dual role. On one hand, it can reduce misuse by encouraging adherence to prescribed treatment. On the other hand, it may increase demand for antibiotics by fostering greater openness and willingness to communicate with the doctor, potentially leading to more direct requests, whether or not these requests are ultimately fulfilled. Relatively few studies have explored how trust shapes patients’ expectations for drugs. For example, one study [42] found that patients with higher levels of trust were more likely to request new medications in general, suggesting that a strong patient-provider relationship fosters openness and a greater willingness to express treatment preferences. Thorpe et al. [25] investigated how trust in physicians interacts with the information provided during consultations to shape patients’ expectations for antibiotics. Their findings suggest that trust can have a twofold influence. When patients highly trust their doctor but receive limited information about why antibiotics are unnecessary, they are more likely to hold inappropriate expectations for antibiotic treatment. In contrast, when clear and detailed explanations are given, trust contributes to lowering those expectations. Results of this study suggest that the relationship between patients’ trust and their expectation of receiving antibiotics might be moderated by other factors, highlighting a dynamic worthy of further investigation.

Physicians’ trust in patients may also shape how patients communicate their treatment preferences, including requests for unnecessary medications. Although physicians’ trust and patients’ behavior pertain to two different individuals, the relational dynamics of the clinical encounter suggest that they are closely intertwined. Patients are highly sensitive to how they are perceived by their doctors, and subtle cues of trust or mistrust can influence their attitudes and choices during the consultation. This mechanism works through an interpretation of affective cues, which is informed by prior experiences, expectations, and the evolving dynamics of the clinical interaction [43]. As in any interpersonal exchange, the emotional atmosphere is co-constructed and plays a key role in shaping mutual perceptions and behaviors. Patients may interpret a physician’s trust not only through explicit verbal statements, but also through non-verbal communication such as tone of voice, body language, attentiveness, and expressions of empathy. These cues contribute to an overall emotional climate that patients interpret as either validating or distancing [44]. When patients perceive a lack of trust, they may feel compelled to assert themselves more forcefully, for instance, by insisting on specific treatments like antibiotics. In contrast, feeling trusted and respected can encourage patients to adopt a more collaborative attitude and rely more on the physician’s clinical judgment.

A dyadic approach to consider doctor-patient relationships

Given the intricate nature of doctor-patient relationships, a dyadic framework provides a more comprehensive understanding of how trust and behavior are mutually shaped, yet relatively few studies have employed a dyadic approach to communication and trust in healthcare.

In a study on doctor-patient communication [44, 45], it was explained that doctors and their patients have very different perspectives of doctors’ communication skills during routine clinical encounters. Another study [46] analysed doctor-patient trust, discovering a reciprocal effect of trust. Both studies applied a dyadic analysis approach called “One With Many”, where the physician acted as a focal person and common element across all participants. Such methodologies, which are designed to accommodate the hierarchical structure of the data, enhance the reliability of the findings by accurately reflecting the interdependencies inherent in the patient-physician dynamic [47].

No research applied a dyadic approach to the study of antibiotic requests from patients, stressing another gap in knowledge, especially from the analytical methodologies employed. Classic statistical analysis does not adequately address the clustering of patients under individual physicians, resulting in a critical oversight. By assuming the independence of the collected data, these analyses position physicians as passive recipients of influence from their patients, thereby failing to capture the complexities of the dynamic, and misrepresenting the influences that shape both patient and physician behaviors.

Some advancements toward this perspective have been made through the adoption of analytical methods such as Generalized Estimating Equations and mixed logit models, which account for the clustering of patients under different physicians [48, 49]. This evolution in analytical approaches indicates a shift in conceptualization towards a more interpersonal understanding of the dynamics at play. Therefore, this study specifically applies a dyadic conceptual level of analysis, considering both patients’ and doctors’ views and applying a corresponding dyadic level of analysis to account for the interdependence of the data.

The aims of the study

The aim of the study is to investigate the factors influencing patient’s intention to request antibiotics by adopting an interpersonal approach and introducing in the analysis the reciprocal ratings of trust from both doctors and patients.

As a first step we analyzed the relational construct of patients’ trust in physicians and its role regarding their intention to ask for antibiotics. As underscored in the introduction, studies performed on patients’ trust generated mixed results which prevented us from formulating a specific hypothesis, but rather generates the following research question:

RQ1

How does patient’s trust in the doctor influences the intention to ask for antibiotics?

Secondly, we moved from the individual patient-level to consider the interdependence of the patient-provider relationship. To bridge the gaps in research for what concerns the role of doctors’ trust, we investigated how doctors’ trust in their patients influences patients’ requests for antibiotics in a hypothetical scenario. The lack of prior research on this topic prevents us again from the formulation of a specific hypothesis, leading instead to a second research question:

RQ2

How does the doctors’ trust in patients influences patients’ intention to ask for antibiotics?

Consequently, we tested the interactions between the two ratings to gain more knowledge on how both perspectives can influence patients’ willingness to request antibiotics in a hypothetical scenario. This is also an innovative aspect of our research for which previous studies are lacking, some dyadic studies [41] performed on different contexts allow us to hypothesize that the interactions between patient and physicians’ trust ratings will have a significant effect, but the lack of specific research on the topic leads us to formulate a third research question:

RQ3

How does the interaction between patient’s and doctors’ trust affect patients’ intention to ask for antibiotics?

The abovementioned relationships have been controlled for several patients’ characteristics, such as socio-demographic variables, and susceptibility to illness, perceived severity of symptoms, concern related to health problems, these constructs have been derived from the Health Belief Model (HBM) [50]. Moreover, these same constructs have been considered in a moderation analysis of the relationship between trust and intention to request antibiotics.

A visualization of the conceptual framework is presented in Fig. 1.

Fig. 1

Visualization of the conceptual framework of the study