- Explore the acceptability and feasibility of using the leaflet.
- Understand the perceived value of the leaflet.
- Identify barriers and facilitators to using the leaflet.
- Understand how the leaflet interacts with UTI diagnostic tools and other resources.
- Inform further developments to the leaflet.
- Explore potential indications of behaviour change.
2.1. Key Findings
2.1.1. The Acceptability and Feasibility of Leaflet Use in Primary Care and Care Home Settings
2.1.2. Value of the Leaflet
- Written information reinforces their advice to older adults (clinicians and care staff),
- It is an educational guide for care staff (care staff) and friends and family (older adults), and
- It has flexibility for use in other infection prevention and control (IPC) areas (commissioners), with other age groups (clinicians and older adults).
2.1.3. Barriers and Facilitators
2.1.4. Comments on the Leaflet
2.1.5. Leaflet Interaction with UTI Diagnostic Tools and Other Resources
2.1.6. Indications of Behaviour Change Following Use or Implementation of the Leaflet
2.1.7. Key Findings and the Theoretical Domains Framework
3.2. Comparison with Existing Literature
3.3. Strengths and Limitations
4. Materials and Methods
4.1. Participant Selection and Eligibility
4.2. Data Collection
4.3. Interview Schedules
4.4. Data Analysis
4.5. Researcher Context
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
- Genao, L.; Buhr, G.T. Urinary tract infections in older adults residing in long-term care facilities. Ann. Longterm Care 2012, 20, 33–38. [Google Scholar] [PubMed]
- Public Health England, Annual Epidemiological Commentary: Gram-Negative, MRSA and MSSA Bacteraemia and C. Difficile Infection Data, Up to and Including Financial Year April 2018 to March 2019. 2019. Available online: https://www.gov.uk/government/statistics/mrsa-mssa-and-e-coli-bacteraemia-and-c-difficile-infection-annual-epidemiological-commentary (accessed on 15 January 2021).
- Public Health England, Health Protection Report; Infection Report, 17 June 2016. 2016. Available online: https://www.gov.uk/government/publications/health-protection-report-volume-10-2016 (accessed on 15 January 2021).
- Abernethy, J.; Guy, R.; Sheridan, E.A.; Hopkins, S.; Kiernan, M.; Wilcox, M.H.; Johnson, A.P.; Hope, R. Epidemiology of Escherichia coli bacteraemia in England: Results of an enhanced sentinel surveillance programme. J. Hosp. Infect. 2017, 95, 365–375. [Google Scholar] [CrossRef] [PubMed]
- Nicolle, L.E. Asymptomatic bacteriuria in older adults. Curr. Geriatr. Rep. 2016, 5, 1–8. [Google Scholar] [CrossRef]
- Jones, L.F.; Cooper, E.; Joseph, A.; Allison, R.; Gold, N.; Donald, I.; CAM, M. Development of an information leaflet and diagnostic flow chart to improve the management of urinary tract infections in older adults; A qualitative study using the theoretical domains framework. BJGP Open 2020. [Google Scholar] [CrossRef]
- Flokas, M.E.; Andreatos, N.; Alevizakos, M.; Kalbasi, A.; Onur, P.; Mylonakis, E. Inappropriate management of asymptomatic patients with positive urine cultures: A systematic review and meta-analysis. Open Forum Infect. Dis. 2017, 4, 207. [Google Scholar] [CrossRef]
- NHS Nottingham. To dip or not to dip—A patient centred approach to improve the management of UTI in the Care Home environment. In Proceedings of the 2017 Federation of Infection Societies Conference, Birmingham, UK, 30 November–2 December 2017. [Google Scholar]
- Macfarlane, J.; Holmes, W.; Gard, P.; Thornhill, D.; Macfarlane, R.; Hubbard, R. Reducing antibiotic use for acute bronchitis in primary care: Blinded, randomised controlled trial of patient information leaflet. Br. Med. J. 2002, 324, 91–94. [Google Scholar] [CrossRef]
- Moerenhout, T.; Borgermans, L.; Schol, S.; Vansintejan, J.; Van De Vijver, E.; Devroey, D. Patient health information materials in waiting rooms of family physicians: Do patients care? Patient Prefer. Adher. 2013, 7, 489–497. [Google Scholar]
- Humphris, G.M.; Field, E.A. The immediate effect on knowledge, attitudes and intentions in primary care attenders of a patient information leaflet: A randomized control trial replication and extension. Br. Dent. J. 2003, 194, 683–688. [Google Scholar] [CrossRef]
- Public Health England. UTI Resources Suite. Available online: http://www.rcgp.org.uk/targetantibiotics (accessed on 1 October 2018).
- Cane, J.; O’Connor, D.; Michie, S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement. Sci. 2012, 7. [Google Scholar] [CrossRef]
- Atkins, L.; Francis, J.; Islam, R.; O’Connor, D.; Patey, A.; Ivers, N.; Foy, R.; Duncan, E.M.; Colquhoun, H.; Grimshaw, J.M.; et al. A guide to using the theoretical domains framework of behaviour change to investigate implementation problems. Implement. Sci. 2017, 12, 77. [Google Scholar] [CrossRef]
- De Bont, E.G.; Alink, M.; Falkenberg, F.C.; Dinant, G.J.; Cals, J.W. Patient information leaflets to reduce antibiotic use and reconsultation rates in general practice: A systematic review. BMJ Open 2015, 5. [Google Scholar] [CrossRef] [PubMed]
- Sustersic, M.; Gauchet, A.; Foote, A.; Bosson, J.L. How best to use and evaluate Patient Information Leaflets given during a consultation: A systematic review of literature reviews. Health Expect. 2017, 20, 531–542. [Google Scholar] [CrossRef] [PubMed]
- Francis, N.A.; Phillips, R.; Wood, F.; Hood, K.; Simpson, S.; Butler, C.C. Parents’ and clinicians’ views of an interactive booklet about respiratory tract infections in children: A qualitative process evaluation of the EQUIP randomised controlled trial. BMC Fam. Pract. 2013, 14, 1. [Google Scholar] [CrossRef] [PubMed]
- Mikesell, L. Medicinal relationships: Caring conversation. Med. Educ. 2013, 47, 443–452. [Google Scholar] [CrossRef] [PubMed]
- Poplas-Susič, T.; Klemenc-Ketis, Z.; Kersnik, J. Usefulness of the patient information leaflet (PIL) and information on medicines from professionals: A patients’ view. a qualitative study. Zdr. Vestn. 2014, 83, 368–375. [Google Scholar]
- Jones, L.F.; Cooper, E.; McNulty, C. Urinary tract infections (UTIs); a leaflet for older adults, and carers: The development of a UTI leaflet for older adults and their carers. Br. J. Gen. Pract. 2018, 68. [Google Scholar] [CrossRef]
- Fleming, A.; Bradley, C.; Cullinan, S.; Byrne, S. Antibiotic prescribing in long-term care facilities: A qualitative, multidisciplinary investigation. BMJ Open 2014, 4, e006442. [Google Scholar] [CrossRef]
- Nicolle, L. Symptomatic urinary tract infection or asymptomatic bacteriuria? Improving care for the elderly. Clin. Microbiol. Infect. 2019, 25, 779–781. [Google Scholar] [CrossRef]
- Nicolle, L.E. Asymptomatic bacteriuria in institutionalized elderly people: Evidence and practice. Can. Med. Assoc. J. 2000, 163, 285. [Google Scholar]
- Nicolle, L.E. Asymptomatic bacteriuria. Curr. Opin. Infect. Dis. 2014, 27, 90–96. [Google Scholar] [CrossRef]
- Guest, G.; Namey, E.E.; Mitchell, M.L. Chapter 2: Sampling in qualitative research. In Collecting Qualitative Data: A Field Manual for Applied Research; SAGE Publications: New York, NY, USA, 2013. [Google Scholar]
- Rogers, E.M. Diffusion of Innovations; Simon and Schuster: New York, NY, USA, 2010. [Google Scholar]
- Bauer, M.; Gaskell, G. Individual and group interviewing. In Qualitative Researching with Text, Image and Sound; Sage Publications: New York, NY, USA, 2000; pp. 39–56. [Google Scholar]
- Public Health England. Diagnosis of Urinary Tract Infections Quick Reference Tool for Primary Care: For Consultation and Local Adaptation; Public Health England: London, UK, 2018.
- National Institute for Health and Care Excellence. Urinary Tract Infection (Lower): Antimicrobial Prescribing; Public Health England: London, UK, 2018.
- Health Education England. Antimicrobial Resistance and Infections. Available online: https://www.e-lfh.org.uk/programmes/antimicrobial-resistance-and-infections/ (accessed on 24 November 2020).
- Lecky, D.M.; Howdle, J.; Butler, C.; McNulty, C.A.M. Women’s and general practitionersx experiences and expectations of the consultation for symptoms of uncomplicated urinary tract infection—A qualitative study informing the development of an evidence based, shared decision-making resource. Br. J. Gen. Pract. 2020. [Google Scholar] [CrossRef]
- Public Health England. Public Health Profiles. Available online: http://fingertips.phe.org.uk/ (accessed on 24 November 2020).
- UCL Institute of Health Equity. Local Action on Health Inequalities; Improving Health Literacy to Reduce Health Inequalities; Public Health England: London, UK, 2015.
- ENRICH—Enabling Research in Care Homes Practical Advice. Available online: http://enrich.nihr.ac.uk/page/practical-advice (accessed on 31 May 2017).
- QSR International Pty Ltd. NVivo Qualitative Data Analysis Software. 2012. Available online: https://www.qsrinternational.com/nvivo-qualitative-data-analysis-software/home (accessed on 24 November 2020).
|Use and Implementation of the UTI Leaflet||Identifying/Diagnosing a UTI||Managing and/or Treating a UTI|
Most older adults did not like the title ‘older adults’ as they do not associate themselves with the label. “the only thing I didn’t like about it was the wording at the top which says it’s a leaflet for older adults and carers.” Older adult 2 (Professional role and identity)
Stakeholders stated that because the leaflet links with hydration they can link it to many areas of infection prevention such as respiratory infections and AMR. “I think at a time when people are feeling the pinch, they’re very happy for messages that crossed over several goals, really.” Stakeholder 6 (Reinforcement)
CCG stakeholders reported that high turnover of care staff makes implementation difficult. “It was a two day course and it’s like painting the Forth Bridge, due to the turnover. Somebody said to me, what about the rest of (location) and I said, that’s a full time job.” Stakeholder 3 (Environmental context and resources)
All CCG stakeholders stated that they did not have enough resource to provide education to all care homes and GP practices. “we’ve got so many care homes I haven’t got enough time in the day, as well as 70 odd GP practices.” Stakeholder 4 (Environmental context and resources)
Most general practice staff did not believe it is their role to cascade information to care homes. “if you go to the care homes and you do in care homes one by one it will work very well…Rather than you doing with the GP practice and then you think GP practice will influence the care homes.” General practice staff 2 (Professional role and identity)
One stakeholder suggested that difficulties in implementation in OOH is due to transient staff. “The people who run out of hours say to me, anything that’s implemented nationally or best practice, in out of hours is probably 12, 18 months later. Because they work with a bit of a more transient locum population” Stakeholder 3 (Social influence)
All GP staff expressed the intention to implement or use the leaflet. “I will print it off and I will give, …I definitely will because I do like giving people information …so yeah, that is definitely something I will use.” Nurse practitioner 1 (Intentions)
All CCG stakeholders intended to continue their implementation work of the leaflet and wider complimentary resources. “next year…we’re planning to run a day to really train people in how to improve their practice…that’s how I really hope to roll it out.” Stakeholder 2 (Intentions)
Commissioner stakeholders stated that they have no way of monitoring leaflet use. “I’ve got no way of knowing whether they used those leaflets.” Stakeholder 3 (Behavioural regulation)
The general practice staff using the leaflet tended to also use PHE’s national diagnostic and treatment guidelines, or their own adapted version of the guideline as a complementary resource. “We’ve all got, the flowcharts we’ve got them all in colour, they’re laminated, they’re in all the rooms.” Nurse practitioner 2 (Environmental context and resources)
One practitioner would not use the leaflet with the over 85s as they feel it could be too much for some. “it’s knowing your patient well enough to think, is this going to add to my consultation or actually are we just better off talking very, very simply and having that as a conversation…rather than saying here’s some information which backs up what we’ve talked about. I would spend more time with that older patient so that they feel more comfortable in knowing that information.” Nurse practitioner 3 (Memory, attention and decision processes)
Two older adults passed the leaflet on to friends and family. “What I’ve done is, I’ve photocopied yours…just to give to my daughters because this sort of information is invaluable.” Older adult 1 (Intentions)
All older adults believed the leaflet would help with the identification and management of UTIs better. “I read the leaflet and yes, it’s very helpful…when I looked at the worsening signs of urine infection I’ve had all those when it’s been at its worst and I think people should know what it is and what to expect.” Older adult 3 (Beliefs about consequences)
Most older adults felt that the leaflet would benefit younger adults too. “it’s not just for older people, is it? I mean it’s for, a lot of young people get it as well. So why is it targeted to older people?” Older adult 2 (Beliefs about consequences)
One stakeholder believed that the leaflet would reduce the demand for antibiotics.
“one thing that I kept hearing was about GPs feeling pressured by patients for antibiotics. So, what I think …. it will really impact on how health professionals manage and therefore then that will have a knock on.” Stakeholder 1 (Beliefs about consequences)
Some general practice staff reported that their overall goal was quality improvement. “the thing is quality improvement…there’s no point in doing stuff if you’re not actually making a difference or it’s going to be useful to you.” General practice staff 1 (Goals)
A few general practice staff wanted to use the leaflet to educate those bringing in urine samples to reception. “to have at reception actually…for the people that don’t get as far as the waiting room and they drop in a sample or want to drop in a sample.” General practice staff 3 (Intentions)
As detailed in ‘beliefs about consequences’, all older adults were optimistic that the leaflet could have a positive effect on UTI management, but care staff were pessimistic about the utility of the leaflet with many older adults. (Optimism)
One stakeholder reported optimism that their work around UTIs, implementing the leaflet and decreasing dipstick use in their region had reduced the amount of urines being bought in to general practice. “receptionist love me because I stop that wave of urine that used to come in every morning, and the nurses said it was taking hours of their time.” Stakeholder 8 (Optimism)
All general practice staff reported that they have had issues with patients bringing in urine samples to reception for dipping. “lots of patients just dropping in samples that we never knew what they were for or whether to send it off, so we’ve tightened up on that.” General practice staff 3 (Social influence)
Care staff decided to use urine dipsticks as a result of noticing other symptoms. “we usually notice something else which has caused us to do that test anyway…so we’re not just relying on that.” Care home staff 2
Care home staff felt pressured by GP staff to use and report dipstick results for suspected UTIs. “they’ll ask if you’ve done a urine dip, you’ll say, yeah, you’ll have to tell them what it’s showing.” Care home staff 4 (Social influence)
Some clinicians feel pressured by care homes to prescribe antibiotics based on a urine dipstick result. “Sometimes we get a call from the care homes, they dip the urine and if it is positive and then they want antibiotic.” General practice staff 2 (Social influence)
Some care homes intended to keep using urine dipsticks to identify UTIs. “Because it’s worked for us. It seems to have worked, I think that’s the hard thing, because it always has seemed to work that way.” Care home staff 1 (Intentions)
Some care homes intended to stop using urine dipsticks moving forwards. “We feel that if it’s not required then it’s one less thing that you have to try and get from people.” Care home staff 3 (Intentions)
Some care staff identified that other conditions can present like a UTI. “Some of them will present as if it’s a UTI but it’s actually constipation.” Care home staff 3 (Knowledge)
Many care home staff expressed that residents will not or are unable to tell them about their symptoms. “A lot of them either don’t recognise the symptoms or if you ask them they’re going to say yes anyway.” Care home staff 7 (Social influence)
General practice staff stated that care staff sometimes provide vague information. “they say the patient looks a little bit more confused today or a little bit more agitated, it’s not unusual, some of the behaviour, but again, that’s again vague.” General practice staff 2 (Social influence)
One GP stated that they were mindful that atrophic vaginitis can cause urinary symptoms and present like a UTI. “they’ve had tummy pain, dysuria, frequency and it’s cloudy and they haven’t got any itching, then I would treat it as a UTI but…especially in older women, I’m always thinking about have they got atrophic vaginitis, especially if it’s a recurrent thing.” GP 2 (Memory, attention and decision processes)
A few GPs used urine culture results as a diagnostic tool. “I’m not going to start antibiotics until I have obvious MSU showing there is an infection or not.” General practice staff 2 (Knowledge)
All care staff were confident in their ability to identify early signs of illness. “We’re fairly observant of the symptoms and quite good at noticing changes in people and when they might be unwell.” Care home staff 2 (Beliefs about capabilities)
All care homes actively encouraged residents to keep hydrated. “I would say actually physically passing the drink to them, so you would encourage them to drink and usually they say, oh you know, I’ve had a lot today. We say, oh well just a little bit more and try and just sort of encourage them.” Care home staff 3 (Skills)
All general practice staff encouraged hydration as a preventative and self-care method. “Hydration is what I focus on.” GP 1 (Skills)
Some care homes would decide to encourage drinking before concluding that the resident has a UTI. “as harsh as it sounds we give them a drink and see if that perks them up and we see how far the confusion goes, we don’t automatically think UTI, it could be dehydration.” Care home staff 4 (Memory, attention and decision processes)
One resident described drinking less in order to avoid urinating at night. “because I keep going at night. Which isn’t right…I’m not drinking more. I hopefully am drinking less.” Care home resident 2 (Goals)
Care staff believed that residents do not want to drink to avoid visiting the toilet regularly. “they get worried about drinking too much because they don’t want to keep going to the toilet.” Care home staff 7 (Social influence)
A few general practice staff reported prescribing antibiotics for UTI as a result of demanding patients. “there is always still that pressure to prescribe. I came here because I’ve got a urine infection and you are going to prescribe me antibiotics no matter what you think.” Nurse practitioner 3 (Social influence)
Older adults do not mind taking antibiotics as long as it makes them well. “I just want to feel well, and I don’t care what I take to feel like me you know.” Care home residents 1 (Goals)
Older adults aware of D-mannose were receptive to trying it as an antibiotic alternative. “I went in and she immediately said I’ve been looking something up for you and she’d found them, they’re expensive but if it’s going to work then I’ll pay the money.” Older adult 3 (Social influence)
A few general practice staff expressed interest in conducting a UTI antibiotic audit. “Auditing the antibiotic use would be really interesting to do, if we could do that that would be good.” General practice staff 1 (Intentions)
One general practice mentioned auditing their UTI antibiotics. “We’ve re-audited the antibiotic prescribing…it’s kind of improved…my trimethoprim prescribing’s halved.” General practice staff 3 (Behavioural regulation)
All care staff reported changing soiled incontinence pads immediately, even if the resident has a limited pad allowance. “So, the residents are restricted on how many day or night pads that they’re assessed or allocated but if we find a resident that is soiled or their pad is wet we automatically change it.” Care home staff 5 (Environmental context and resources)
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.
© 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).