Between June and October 2016, 29 women were interviewed across four focus groups in three areas of England: London (n = 14), Birmingham (n = 8), and Leeds (n = 7). Women varied in age, ethnicity, and the number of UTIs they experienced in the past year (Table 1). Twenty individual GP interviews took place over the phone. Over half of GPs were salaried GPs (n = 12) with no specific interest in research. Further GP demographics can also be seen in Table 1.
Meta-themes
Data analysis identified key domains from the TDF that influenced GP and patient behaviour associated with the management of urinary symptoms (Supplementary Table S1). In comparing the patient and GP responses based on the TDF, five meta-themes were identified (Table 2) that highlight differing views between the GP and patient regarding the consultation process and treatment of UTIs.
Table 2. Overarching meta-themes identified from GP and patient interviews
Patient knowledge of UTIs
GPs reported that they believed women were quite knowledgeable about UTIs, either because women talk to each other about their UTI or because they have had previous personal experience of a UTI:
‘UTIs are very, generally a very quick consultation, women seem to know a lot about them.’
(GP2)
This study found a large variation in patient knowledge around UTIs. Many women felt that a UTI was something that happened to them that they could not control. Many felt it to be a private matter and some expressed that this [the focus group] was the first time they had spoken openly about their UTI to other women. Interviews highlighted a lack of knowledge in the following areas.
First, UTI experience: many women discussed not knowing what was happening to them when they had their first UTI and what to do about it. They described not going to see their GP until either the pain got ‘too bad’ or until their second episode:
‘My first time I were diagnosing myself, like, oh, it’s kidney stones or it’s this or my gall, it, I was blowing it out of proportion kind of thing …’
(FG [focus group] 4)
Second, prevalence: some women expressed shock at learning how prevalent UTIs were. Older women wrongly assumed that it was age related, expressing surprise at seeing younger women in attendance:
‘It’s obviously far, far, far more prevalent than I realised. I thought for example it was older … I thought I was just very young to be getting these things.’
(FG1)
Third, types of UTI and causes of urinary symptoms: there was a lack of knowledge about the causes of urinary symptoms and the different types of UTI, particularly the difference between cystitis (bladder infection) and other UTIs (for example, kidney infection). The women appeared to associate a UTI with intense pain and did not view cystitis as a painful enough illness to call it a UTI:
‘I’ve had cystitis maybe twice, and that’s a different, but the one I had with the UTI was a completely different situation.’
(FG2)
None of the women appeared to know that urinary symptoms can be caused by inflammation or infection of the urethra post-sexual intercourse, although many associated sexual intercourse with the development of a UTI.
View of the consultation
Although many GP participants reported managing the condition by telephone, they said that they carried out a similar routine when consulting face-to-face. They report being skilled at liaising with the patient and listening to their symptoms, diagnosing a UTI and providing the appropriate treatment:
‘… you just let the patient talk for a minute and see what they say … you might not need to ask them any of the extra questions, to be honest.’
(GP1)
As many of the GPs reported that they considered women were already quite knowledgeable, they saw the UTI consultation as quite a straightforward process. In contrast, women felt that they were not being heard, possibly because they were not asked many questions. Many felt that GPs viewed the consultation as routine, showing lack of empathy or understanding of the patient’s needs, and hurried the consultation to catch up on time:
‘If you have a doctor who is willing to forget about the time he’s got for each patient and sit down and listen to you and let you explain … But when they have this time limit, 10 minutes, they shoo you away.’
(FG2)
Treatment expectations
Most GPs reported that women expected antibiotic therapy for their UTI:
‘People expect antibiotics usually.’
(GP18)
Some stated that their prescribing behaviour is influenced by the patient:
‘Oh I think they always influence what we do … I think it’s unlikely that a GP can say they’ve never been influenced by a patient to prescribe antibiotics because, at the end of the day, there are certain demands on our time and that does happen, and that sometimes may be for lack of back-up, lack of resources.’
(GP10)
Some also expressed concern about how late women present with a UTI and the fear of upper tract infections; as such, GPs reported a low antibiotic prescribing threshold:
‘I think certainly any systemic upset, have a low threshold for obviously treating that because you’re worrying about your upper tract infections and I’m sure most people would say the same.’
(GP20)
Patient’s antibiotic prescribing expectations varied; while women wanted treatment for the pain, they did not necessarily want a quick fix that might not be best for them:
‘… as in here’s a cure, off you go. Maybe how did you get it, why you’ve got it, what you can do to prevent it again.‘
(FG2)
Their needs centred on advice on symptom duration, and pain and discomfort management:
‘There must be something you can put like a cream that’ll make it go cold.’
(FG1)
They wanted validation of their illness; and reassurance that the infection will not ‘move to the kidneys’:
‘ You don’t need a prescription all the time … You just maybe need a bit of reassurance.’
(FG2)
However, those who were prescribed antibiotics said that they would take them out of fear:
‘… getting the antibiotics and taking them might be better than not taking them at all because you don’t know what could develop within that 48 hours.’
(FG1)
There were a few women who expressed a preference for immediate antibiotic therapy. This preference was usually based on their experience of successful past treatment with antibiotics:
‘When I have the antibiotics it gets rid of it.’
(FG4)
‘… was spiking a very high temperature and feeling like I had the flu, I would go to the GP and I would want antibiotics, to be honest with you, because if it gets to that stage it can go to your kidneys, and that’s dangerous.’
(FG1)
Self-care, safety netting, and prevention
GPs stated that they tailored advice to the individual patient; usually gave self-care advice to patients presenting with UTI symptoms for the first time; and provided more detailed information to those with recurring episodes:
‘If she’s only had one or two [episodes] or something like that … I usually say drink lots of fluids. If it’s someone who’s had like more long-term ones, you might talk more about things like: is there an aching after sex or things like that … But it depends often in the individual cases … ’
(GP3)
The majority of GPs stated that they always provided safety-netting advice, mainly because of concern about the infection deteriorating. Few GPs provided self-care or prevention advice citing a lack of supporting evidence:
‘How to help prevent, I probably don’t particularly mention those, because again that’s because there’s not the evidence there, so I don’t bother to go into it.’
(GP5)
In contrast to GP reasoning, it was the women who had less experience of a UTI who were keen to receive self-care and prevention advice:
‘I found that when I went to the doctor’s for the advice … you weren’t getting much information.’
(FG3)
Women who had recurrent UTI had developed their own self-care routine.
Women with only one or two episodes of UTIs were unaware of any preventive measures they could take; however, they were eager to receive such information and were prepared to make behavioural changes as a result:
‘I would like more information about what we can do for ourselves.’
(FG3)
Awareness of AMR
All GPs were very aware that AMR is a huge problem:
‘It’s a really big problem. It’s a problem across the whole board.’
(GP14)
Many reported having to manage antibiotic treatment failure as a result:
Interviewer:‘Have you ever encountered treatment failure because of resistance?
GP13:Oh yeah, definitely, yeah. Have I ever seen treatment failure because of resistance? Oh yes of course …’
Patients also reported being aware of AMR, although some women thought that it was the individual who became resistant to the antibiotics rather than the infecting organism:
‘I’m aware that there’s going to come a time when my body’s going to reject them [the antibiotic].’
(FG4)
Patients were concerned by information provided by the facilitators that effective antibiotics may not be available in the future, and for many this guided their opinions as to whether or not they needed and/or wanted antibiotics for their UTI:
‘… I’ve got a feeling they’re going to stop giving antibiotics.’
(FG3)
Despite being aware of AMR, participants who were previously prescribed antibiotics for their urinary symptoms expressed strong views on the need for antibiotics in every case to treat their UTI:
‘… now I know the first signs and I just know that I need those antibiotics … I just need a dose of antibiotics and then it’s gone.’
(FG1)
One woman stated that the information that antibiotic use increases the risk of resistance may be of benefit to someone who is ‘new to UTIs’:
‘If I was shown this and I read this stuff about antibiotics … maybe I can live with my symptoms for another 24 hours if I have rushed off to the doctor at the first little twinge. Not necessarily in my position but somebody who was new to UTIs.’
(FG1)
Intervention development
Barriers to an effective joint consultation and appropriate prescribing that emerged from the analysis included: lack of GP time; misunderstanding of depth of knowledge between GP and patient; miscommunication between the patient and the GP; nature of the consults (for example, telephone consultations); a history of previous antibiotic therapy; and the lack of a succinct, up-to-date summary of the evidence base with implications for management (Figure 1).
Figure 1. Barriers to effective communication of the UTI consultation and optimal prescribing.
UTI = urinary tract infection.
The UTI leaflet
The authors used interviewee suggestions, and the barriers identified from the data analysis, to co-develop a patient-facing leaflet to be used during consultations with females presenting with a suspected non-complicated UTI. The TARGET Your Infection — Urinary Tract Infection (TYI—UTI) information leaflet for uncomplicated UTIs was designed to be shared during the consultation and taken home by the patient for future reference (Supplementary Figure S1).16 When used in this way the leaflet aims to facilitate dialogue between the GP and patient, covering the areas of misunderstanding found in this study, including the management decisions, safety-netting advice, antibiotic resistance, prevention of a UTI, and shared decisions about management. Six main evidence-based sections each address ≥1 of the aforementioned barriers to effective consultation. All six main evidence-based sections combined provide a succinct, up-to-date summary of the evidence base with implications for management:
Possible urinary symptoms: addresses the knowledge, misunderstanding, and lack of skills barriers. It acts as a checklist for GPs and shows the patient that the GP is considering their symptoms.
Outcomes and recommended care, developed in line with national UTI prescribing guidance: addresses the misunderstanding, lack of skills, and history of prescribing barriers. It outlines the patient care plan options while providing the GP with evidence as to why they do not always need to prescribe antibiotics.
Types of urinary infections using a pictorial guide: addresses the knowledge barrier. Women felt that being able to visualise where and what their UTI was gave them a better understanding of their condition.
Self-care and safety-netting advice: addresses the misunderstanding and lack of skills and time barriers. This facilitates information sharing without using the consultation time.
Preventive advice: addresses the misunderstanding and lack of skills and time barriers. Women felt this information was invaluable for their future health.
Antibiotic resistance: addresses the misunderstanding, lack of skills and time, and history of prescribing barriers. GPs are provided with a reference as to why antibiotics are not always the best treatment option while educating the patient on the dangers of unnecessary antibiotic use.
The fully referenced leaflet provides the GP with the evidence base they felt was previously lacking (Supplementary Figure S1).16