An opportunity to confront uncertainty? Holly Jenkins, Public Health England North West 20 October 2015 Dr Holly Jenkins, Dr Andy Liu , Dr Nicola Schinaia, Mr Darryl Quantz, Mr Sam Rowell, Mrs Lea Madgwick, Dr Alberto Mateo, Dr Sarah Blagden, Caroline Holtom, Dr Rebecca Wagstaff We welcome this recent review by Touboul-Lundgren et al. to identify cultural determinants of antibiotic use in Europe. Given that inappropriate use and overuse of antibiotics is a major driver of antimicrobial resistance , a better understanding of the determinants of antibiotic use is a key public health priority. The review identified a total of 13 papers meeting the eligibility and clearly validated quality assessment criteria . Whilst cultural determinants have previously been reported as a separate category in narrative literature reviews, they found, in fact, that different determinants described as ‘cultural’ permeate numerous stages of the disease process. The authors highlight the lack of exclusively qualitative studies. Concerning this, we have several comments and suggestions regarding the search strategy. First, as only free-access databases were searched, many studies in non-medical databases rich in qualitative studies may have been excluded. Second, in light of the cross-border, European approach of the study, restricting results to only English and French publications could limit the data and thus conclusions. Third, the inclusion criteria stipulated only studies that made cross-country comparisons. However, in-depth qualitative research exploring individual and behavioural norms are often limited within single countries – often due to ethical or resource restrictions. Fourth, no justification is given for the time limit of the review’s results. 1997-2015 spans a period in which the internet begins to influence medical practice and public demand  and there is a growth in policies surrounding the issue. Finally, it would be good to know the range of MeSH terms used to define ‘culture’; this would allow other researchers, particularly sociologists who are more practised in qualitative research, to review these and provide comment. Perhaps the most interesting finding for public health practice arises from the authors’ identification and description of the influence of Hofstede’s  cultural dimensions on antibiotic prescribing. The review highlighted that ‘Uncertainty Avoidance’ was the most influential dimension. Brookes-Howell et al.  European qualitative study suggests that currently, clinicians develop ways to handle uncertainty through their own ritual of clinical processes and practice. The suggestion that GPs use prescribing to replace ‘uncertainty management’ in which they have not been trained  is most interesting and offers an opportunity to complement existing public health interventions. Indeed, current training on antimicrobial prescribing has mainly focused on awareness and the importance of the AMR problem, with mixed results; perhaps there is an argument instead for training generic skills – such as in risk or uncertainty management. We would therefore welcome further discussion from the scientific, behavioural and medical education community on the approaches that GPs and prescribers could use to manage this uncertainty. Competing interests All authors declare that they have no conflicts of interest.