Altogether, 29 women participated in the interviews; 26 had been randomised to one of the two devices and three to standard care in the RCT. Participants’ ages ranged from 20–88 years. Other characteristics of the sample are displayed in Table 1. When possible participants were contacted after they had exited the trial, three women declined to take part in the interview study.
Analysis of the interviews revealed three themes reflecting areas where participants with a suspected UTI had information needs. These were awareness around the need to collect a midstream urine sample; awareness around how urine samples can be contaminated; and awareness around the information obtained from urine samples and what this means for antibiotic prescription.
Some of these information needs were expressed by participants themselves, some became evident to the interviewers as participants described their experiences of UTIs and were then further explored within the interview.
Awareness around the need to collect a midstream urine collection
The sample contained women who did know about the need to produce midstream urine samples:
‘I’ve been told that by doctors and the nurses when I’ve had to do samples, I’ve always been told, can you try and do a midstream please … so obviously you pee and then you do a midstream and then you finish off in the toilet.’
(Interview 23, aged 73 years)
One participant was aware because of her work as a healthcare professional (HCP). Others were familiar because of being asked to provide samples during their pregnancies:
‘I suppose it goes back to maternity days, I suppose, which is a long, long time ago.’
(Interview 6, aged 70 years)
‘So I think you get used to that if you’ve had a baby.’
(Interview 28, aged 64 years)
While aware of the need for a midstream sample, some women questioned in practice how easy it was to produce one with a UTI, particularly with regard to the volume of urine necessary:
‘If you haven’t got any and then you can’t do midstream because there is no midstream.’
(Interview 1, aged 66 years)
‘What they call midstream might actually be quite early on because they haven’t got much in them.’
(Interview 19, aged 44 years)
or with a condition such as a prolapse of the womb:
‘About half, yes about halfway through, this is what I was told to do and I mean more often than not I couldn’t do it … you’ve got to be able to stop peeing and if something’s sitting on your bladder you can’t do it.’
(Interview 4, aged 76 years)
For a number of the participants, the information had been received more recently, having been explained to them in the course of taking part in the RCT. Other participants, however, did not mention being asked to produce a midstream sample and, when this was raised with them during the interviews, did not indicate that this was something they had tried to achieve.
One participant indicated that she had always lacked the information needed to produce a sample correctly and recommended more information be given by the HCPs involved:
‘Maybe ... sort of information how to take your sample correctly because I haven’t been really aware of anything I can remember from my childhood like when taking urine samples … maybe just if nurses or just doctors sort of make sure repeat it, how to take the sample correctly, or maybe some information sheet, I don’t know.’
(Interview 21, aged 73 years)
One participant recommended displaying information about collecting urine samples in GP surgeries to help with the issue:
‘I think if it were advertised in the waiting room, as many things are, it would save a lot of women thinking, “How am I going to get that, am I going to use a cup or what am I going to use?” If it was displayed I think women would really value that.’
(Interview 4, aged 76 years)
Awareness around how urine samples can be contaminated
In a similar way, participants’ awareness and understanding about contamination of samples varied considerably.
Knowing that contamination can occur
The majority of participants were unaware of the possibility of contamination of urine samples:
‘I didn’t know, I haven’t been aware of any possible contamination … that might be an issue with urine sample.’
(Interview 21, aged 73 years)
or had been unaware until they participated in the RCT:
‘I wasn’t aware of it beforehand but yeah, she [practice nurse] explained about how, you know, what the idea of the whole study was about, was to try and reduce the amount of samples that are contaminated.’
(Interview 17, aged 22 years)
‘I hadn’t been appreciating the fact about the contamination, I was really surprised about the document [patient information sheet] that I read and the last report that it was contaminated.’
(Interview 29, aged 39 years)
Even participants who were aiming to produce a midstream sample did not necessarily link this to contamination:
‘I’ve been told that by doctors and the nurses when I’ve had to do samples, I’ve always been told, can you try and do a midstream please … No. No, I haven’t, never been aware of that [contamination of samples] at all.’
(Interview 23, aged 57 years)
By contrast, a small number of participants were aware that contamination of samples occurred:
‘Yeah, I’ve read, I think it says on the label to … but it does say to do it midstream and stuff, so I am, I am aware that it can be contaminated.’
(Interview 8, aged 27 years)
Two women attributed their awareness, not to their own experience, but to their professional background — one as a biologist and the other as an HCP:
‘I’m doing a PhD in biology … but not from personal experience.’
(Interview 14, aged 23 years)
‘Yeah, I had been aware, I used to work as a midwife so I knew that happens.’
(Interview 15, aged 42 years)
Other participants knew about contamination because of what they had been told or from their own experience of producing contaminated samples:
‘I think occasionally there’s what they call faecal contamination.’
(Interview 5, aged 74 years)
One participant who had been told she had provided contaminated samples would have also appreciated more information about how contamination occurred and how it could be reduced:
‘I was at the same time a little bit disappointed because then my GP told me that … because of those contaminations she couldn’t told exactly what was going on, which was really disappointing for me … but maybe just if nurses or just doctors sort of make sure repeat it, how to take the sample correctly, or maybe some information sheet, I don’t know.’
(Interview 21, aged 73 years)
Cause of contamination
When the topic of contamination of samples was raised in the interviews, only one participant saw the body as a source of contaminants as the sample was collected and queried whether an anti-bacterial wipe might help:
‘But if it’s your urine, I mean where’s the cross-contamination coming from, is it concern that it’s coming from around the surrounding area or ...? Okay, so it’s nothing to do with the urine itself, it’s just what gets in there from ... but I’m wondering if that would be a way of like doing like an anti-bac wipe or something that’s not going to aggravate the person before you actually pee.’
(Interview 11, aged 57 years)
Other women, who did think more generally about contamination of samples, only envisaged it as being to do with the cleanliness of the container they were using to collect the urine:
‘I always thought, I didn’t like, I do have one, a pot in my cabinet in the bathroom and I always thought, oh well I would never use that because I don’t know if it’s really clean, you know, how can it still be clean?’
(Interview 16, aged 53 years)
‘I did know that [about contamination] but that’s why I use a very clean mug.’
(Interview 18, aged 49 years)
Awareness around the information obtained from urine samples and what this means for antibiotic prescription
A number of participants reported having their urine sample tested immediately using a dipstick. Some were informed that the dip showed infection or that blood was present:
‘… just enough for her to know that there was an infection in there.’
(Interview 9, aged 88 years)
‘… he [the GP] then did the dipstick on that … I had blood … ‘
(Interview 16, aged 53 years)
For one participant, receiving the information that an infection was present was very important as it guided her decision to take antibiotics, which she would otherwise have been very reluctant to do:
‘... she dipped in the whatever it is, into the urine sample, and gave me a result straightaway, and that then meant that I was armed with sufficient information that then persuaded me that actually, for once in my life, I should take the antibiotics and feel much better on it.’
(Interview 19, aged 44 years)
Ambivalence about taking antibiotics also made another participant glad to receive information from the urine samples, which ascertained the need for an antibiotic prescription:
‘I’d rather they do that [check the sample] and then you know that it’s being checked or whatever, rather than just being given antibiotics, you know, and it might not be that … I’m always happy to do a sample and I’d rather do that to be honest with you … I’d rather know that you need them before taking them, you know, I’m, I don’t mind taking tablets but I don’t take them for the sake of it, do you know what I mean?’
(Interview 26, aged 40 years)
Another participant also spoke about receiving information as a result of the urine dip and being prescribed an antibiotic. She also reported how her sample was usually sent away for analysis to check that she was prescribed the ‘right antibiotic’:
‘They test it straightaway to see if you have an infection or what traces of blood or whatever are in and they put the filter paper in I think or do something. And so then they send it off, if there is no trace of anything in it, but there always is when I go in with my sample … yeah, they send it off to get it analysed if there is something but in the meantime they will often give me an antibiotic to control, try and ... hoping they’ve got the right antibiotic.’
(Interview 5, aged 74 years)
For other participants there was also a link between the testing of the urine sample and receiving the best antibiotic for the infection present:
‘I was expecting to get my urine sample tested and to be given with like info, sort of pretty certain that I was, that I had an infection, the correct antibiotic for it.’
(Interview 5, aged 74 years)
Where urine samples had been sent to the laboratory, some women were later told that they had received the right antibiotics or if they needed a different one:
‘I don’t know, I didn’t really think much about it [contamination of urine samples] , you know, I just thought, well she [the GP] usually gives me an antibiotic, and then when I ring down about the results she says, “You were given the right antibiotics,” so and it clears up, so as far as I’m concerned that’s good enough.’
(Interview 22, aged 73 years)
‘And this time too actually, needed different antibiotics. Such a pain … I mean the first lot I wasn’t quite sure when I finished them, so I just took another sample in, and then actually I still had an infection so then just needed stronger antibiotics, different antibiotics.’
(Interview 18, aged 49 years)
Other participants, however, were less certain about what information had been gained from testing their samples or felt conflicted about how the information guided the management of the suspected UTI:
‘And it came back, it did come back and I got the results from the doctor … So he just said he was slightly confused about some of the symptoms and that’s why I went in recently to have a blood test and another urine sample … ‘
(Interview 11, aged 57 years)
‘[the doctor] said, well they’d tested these things, these samples and they hadn’t found a trace … but as she was confident that the urinary tract infection had now cleared I stopped taking it [antibiotics] … The only other thing … was that I found it slightly odd that they were talking about blood in the urine, mostly and not really about what type of bug they’d found and whether the antibiotic would be good for it or not.’
(Interview 1, aged 66 years)
One participant explained that information from the urine dip had ‘ruled out’ a UTI but she remained convinced that this was what she had been experiencing:
‘The only thing I had was that, because it didn’t culture, the nurse practitioner went, no you haven’t got one [UTI] … but the nurse practitioner in the GP surgery was like, no, we’ve had the results from your, the sample, hasn’t shown anything on the dip test, therefore you haven’t got one, so that was interesting … Yeah and the nurse was like, oh this means you haven’t one, and it was kind of like, well that’s not how it may be quite works, but … yeah and I didn’t hear anything afterwards, but they’d give me antibiotics and the symptoms went.’
(Interview 14, aged 23 years)
Similarly for another participant the urine dip hadn’t shown anything and the rest of the sample was sent off for analysis:
‘… she [practice nurse] did the dip test and I asked like was it fine and she said, yeah, it was fine but the nurse that I rang to get that appointment said that they should send it away and do the proper like more lab tests … yeah, when I went in they prescribed me antibiotics then but they did all the other tests and they all came back negative again so I apparently didn’t have a water infection.’
(Interview 20, aged 20 years)
In both cases, antibiotics had still been prescribed. One other participant was unable to find out anything from urine samples taken either at the time of consultation:
‘I mean I don’t think the doctor actually said to me, because he did test, he did test the wee but I don’t think he actually said to me, it was all a bit of a blur … so he didn’t actually say to me “yes, I can see you’ve got something” or “no you haven’t”, he just packed me off with the antibiotics.’
(Interview 26, aged 40 years)
Or later from the laboratory analysis:
‘I think the difficult thing is it’s getting the results back and knowing what come of it, do you know what I mean? You don’t always get that bit of information back … I don’t know what came of it, did they find something or not or, do you know what I mean? I think there’s that kind of it would just be nice to kind of really understand I guess.’
(Interview 26, aged 40 years)