From this qualitative interview study we found that women with urinary tract infection want to avoid taking antibiotics and are open to alternative management strategies, including a delayed antibiotic prescription. They valued the opportunity to avoid the unwanted side effects associated with antibiotics and to allow “natural” healing of the body. For most, delayed prescribing was reassuring on two levels. Firstly, having a prescription waiting in the general practice reception was reassuring because it meant that they could collect the antibiotic should their symptoms worsen. Secondly, having a prescription available to them validated patients’ experiences of their symptoms. There were a few negative experiences of delay, when being asked to “wait some more” served to undermine the legitimacy of their visit. Finally, our study indicates that women with and without previous experiences of urinary tract infection might not fully understand the causes or might draw on a theory of self blame and negligence, or both. Some women seemed to view antibiotics as necessary because they believed that they expedite the alleviation of symptoms.
Results in context
Urinary tract infections are common and are of concern to generalists (general practitioners, family doctors, urgent care) and specialists (including gynaecologists, urologists, and renal physicians). Little is available, however, on women’s experiences and views of urinary tract infection and its management, especially the particular issue of alternative management strategies.
The strategy of antibiotic delay can be used in the management of sore throat and conjunctivitis16
and has been found to be acceptable to patients.27
The study of Everitt et al also indicated that patients will accept and encourage an alternative management strategy, including antibiotic delay.27
Increased information for and discussion with women attending for urinary tract infection is vital, however, if they are to better understand the rationale that underlies antibiotic delay. A full understanding might help to increase women’s sense of validation and of being taken seriously.
Women might attribute urinary tract infection to issues of poor cleanliness and general “negligence.” Lifestyles have been fully commercialised,28
and it is unsurprising to find that participants spoke in terms that suggested a (moral) duty to “consume a healthy lifestyle.” It is important for general practitioners to be aware of them in the clinical encounter and be mindful of the consequences of such beliefs. For example, the cause of urinary tract infection might come to be construed as indicative of personal weakness.29
Women who tend to use a theory of self blame and negligence might be particularly vulnerable to feelings of not being taken seriously when their doctor proposes a strategy of no antibiotic or delayed antibiotic.
Strengths and limitations
Representation of thematic analysis can result in the de-contextualisation of speakers’ words from the original sequence, which might misrepresent the intended meaning. We took care to analyse the participants’ words in the broader context of the surrounding speech to ensure a fair interpretation of the meaning of the fragments reported here.
Women indicated some discomfort when asked to discuss the cause of urinary tract infection. It is difficult to know whether this reflected “limited knowledge” or whether the context of the interview might have caused or exacerbated this discomfort. The questions might have been viewed as a “test” in which participants could be right or wrong. Indeed, answers were often prefaced or closed with the phrase “I don’t know” or some similar epistemic downgrade. Regardless of these features, interviews suggest a need for improved information about urinary tract infection and greater dialogue between doctors and patients, even when patients have previous experience of the condition.
Regarding sample selection, only a few women declined to take part in the trial22
or the interviews. Allocation to groups was random, and so selecting from one group (that is, delayed antibiotics) should not bias the type of patient selected for interview but did allow us to focus the qualitative work. The randomised controlled trial of different management strategies for urinary tract infection provided an ideal opportunity to explore patients’ views and experiences of different management strategies. These views do not represent anticipated or hypothetical experiences but rather views based on women’s experiences of the actual management strategy proposed, which is important for the care of patients. The women interviewed, having already consented to take part in a trial, might have been more receptive to the concept of delayed treatment. The information about alternative management strategies, however, was presented in a balanced, neutral way (all general practitioners were in equipoise and were coached face to face by the trial coordinator on the aims of the study and how to recruit patients and obtain consent). We are confident that the views expressed by the women relate to their experiences of the particular management strategy they were assigned to. Moreover, our thematic findings resonate strongly with other relevant studies,27
and this increases the face validity and transferability of our findings.
As with all interview studies the kind of data generated is a limitation. Interviews provide useful perspectives on events or experiences but not a window to events as they occur. Qualitative interviews were the optimal method of data collection for this relatively unexplored and personal condition, offering insight into patients’ experience and views. Future work could usefully explore the negotiation of delayed antibiotic prescribing and other options in situ.
Implications for future research or clinical practice
Patients’ expectations do not necessarily revolve around healthcare professionals’ prescription notepads. Rather, expectations are likely to centre on being understood and believed and in being helped to understand the rationale for alternative management strategies, such as antibiotic delay.
Some healthcare professionals might overestimate patients’ demand for antibiotics.30 31
And patients might also overestimate the desire of healthcare professionals to prescribe.
- “We know that viral infections don’t necessarily respond to antibiotics but I do think that there is a general feeling out there that a lot of GPs will just go yeah here’s a course of antibiotics just to get you out of the door and move on to the next one” (patient 2)
Background expectations like these have potential to influence the consultation. If doctors recommend delayed antibiotics, the reasons must be clear. Equally, doctors need to be cautious in assuming that patients expect antibiotics. In our study, it seemed that the option to avoid the side effects of antibiotic treatment could lead to a sense of relief, and the opportunity to try other approaches was viewed positively. The next challenge is to establish whether and how these findings relate to clinical practice outside the context of a trial. A priority for exploration is whether there are advantages to offering an alternative to antibiotics when no antibiotic or a delayed antibiotic is recommended.
Overall, findings suggest that the particular strategy of delay could represent a happy medium for patients whereby they feel validated and reassured by the availability of a prescription, “just in case.” A clear acknowledgement of a woman’s triggers to consult is needed. If women are asked to delay taking antibiotics, the clinician must address the particular worries that women might have and explain the rationale for not prescribing antibiotics immediately.
What is already known on this topic
- Patients’ understanding of the causes of urinary tract infection and their views on and experiences of different management strategies are not well understood
- The potential effectiveness of antibiotics for urinary tract infection needs to be balanced against wider issues such as side effects, antibiotic resistance, and general practitioners’ workload
What this study adds
- Women with urinary tract infection want to avoid taking antibiotic medication and are open to alternative management strategies, including a delayed antibiotic prescription
- Clinicians need to acknowledge women’s experiences before consulting (including attempts to self care), and if women are asked to delay taking antibiotics, the clinician must address the particular worries that women might have, and explain the rationale for not using antibiotics immediately