Is sharing the TARGET respiratory tract infection leaflet feasible in routine general practice to improve patient education and appropriate antibiotic use? A mixed methods study in England with patients and healthcare professionals

Abstract

Background:

Patient education on treatment choices for common respiratory tract infections (RTIs) is important to encourage appropriate antibiotic use. Evidence shows that use of leaflets about RTIs can help reduce antibiotic prescribing. TARGET leaflets facilitate patient–clinician communication in consultations.

Aim:

To explore patient, healthcare professional (HCP) and general practice (GP) staff views on the current Treating Your Infection (TYI)-RTI leaflet and proposed new ‘antibiotic effect’ column aimed at sharing information on the limited effect antibiotics have on the duration of RTIs.

Methods:

Service evaluation underpinned by Com-B behavioural framework, using patient and HCP questionnaires, and GP staff interviews/focus groups.

Results:

Patients completed 83 questionnaires in GP waiting rooms. A lack of patient understanding about usual illness duration influenced their use of antibiotics for some RTIs. Patients provided positive feedback about the leaflet, reporting it increased their capability to self-care, re-consult when necessary and increase understanding of illness duration. Patients indicated they would value information on the difference antibiotics can make to illness duration. In total, 43 HCP questionnaires were completed and 16 GP staff participated in interviews/focus groups. Emerging themes included: barriers and facilitators to leaflet use; modifications; and future dissemination of the leaflet. GP staff stated that the ‘antibiotic effect’ column should not be included in the leaflet.

Conclusion:

Patient education around usual illness duration, side effects of antibiotics and back-up prescriptions gives patients a greater control of their infection management. As GP staff opposed the extra information about benefits of antibiotics on illness duration, this will not be added.

Introduction

Antimicrobial resistance

The UK Department of Health Five Year Antimicrobial Resistance Strategy (Department of Health, 2019) outlines seven key areas for future action, one of which includes educating patients more generally about appropriate antibiotic use and antimicrobial resistance during patient–healthcare worker (HCW) consultations. Four-fifths of all antibiotics are prescribed in the community (Public Health England [PHE], 2019) and it is suggested that at least 20% of these are considered unnecessary or inappropriate (Smieszek et al., 2018). There is public misunderstanding about how long infections usually last, how to use antibiotics correctly and delayed antibiotic prescriptions (McNulty et al., 2007a, 2007b, 2015, 2016). Patient education on the value of antibiotics for common respiratory tract infections (RTIs) and usual course of infection is important to improve appropriate use of antibiotics.

TARGET antibiotics toolkit (Treat Antibiotics Responsibility, Guidance, Education, Tools)

The TARGET antibiotics toolkit (TARGET, 2019) supports the Department of Health strategy on antimicrobial resistance by optimising prescribing practice through supporting antimicrobial stewardship in primary care (Department of Health, 2019) and patient facing leaflets are endorsed by the National Institute for Health and Care Excellence (NICE, 2017). The toolkit resources, including patient leaflets, aims to improve use of antibiotics through behaviour change of primary care staff and their patients and are fully evaluated (Jones et al., 2018; McNulty et al., 2018). Hosted on the Royal College of General Practitioners (RCGP) website, the TARGET toolkit is freely available to all primary care health professionals. A national questionnaire was sent to all 209 Clinical Commissioning Groups (CCGs) in England in 2017 and found that the TARGET toolkit was actively promoted by 99% of CCGs to their Primary Care Networks and General Practices: 94% actively promoted TARGET patient leaflets; 92% The Treating Your Infection (TYI) leaflet; and 40% had integrated the TYI-RTI leaflet into clinical systems (Allison et al., 2018).

TARGET Treating Your Infection leaflet for respiratory tract infections (TYI-RTI)

The TYI-RTI leaflet has been designed to be used with patients who are experiencing self-limiting upper RTIs and supports implementation of recommendations in the NICE guidelines on processes for antimicrobial stewardship, behaviour change for antimicrobial stewardship and antibiotic prescribing for RTIs (NICE, 2017). The leaflet addresses illness management, safety netting and self-care advice. Evidence shows that the use of leaflets in consultations for RTIs, especially sharing information on the natural length of RTIs, can result in reduced re-consultation rates and antibiotic prescribing (Francis et al., 2009; McNulty et al., 2007a, 2007b, 2013). The TYI-RTI leaflet is widely used during patient consultations to facilitate conversation about treatment choice (Bunten et al., 2015). Originally developed using the Theory of Planned Behaviour (Ajzen, 1991), the leaflet aims to give patients the confidence to self-care for their infection at home while reducing unnecessary prescribing (Bunten et al., 2015).

Research determining usual duration of symptoms for common infections and the effect antibiotics has on the duration of RTIs has been well documented (Arroll and Kenealy, 2005; Lemiengre et al., 2012; Little et al., 1997; Smith et al., 2014; Spinks et al., 2013; Venekamp et al., 2015). However, limited research has been conducted on the views and understanding of how this information should be shared with patients. Patients have previously advised that they want to be well informed before making decisions about their health; however, the current TYI-RTI leaflet does not provide specific information on the effect that antibiotics have on the duration of a common RTI as the key message is that antibiotics do not work on viral infections.

The present study underpinned its research using the Com-B framework for behaviour (Michie et al., 2011). Capability, opportunity and motivation are the three constructs of this framework that interact to generate behaviour, which, in turn, also influences these components.

The present study aimed to explore patient, healthcare professional (HCP) and general practice (GP) staff views on the current TARGET TYI-RTI leaflet and also views on a proposed modification of an ‘antibiotic effect’ column sharing information on the effect antibiotics have on the duration of the illness.

Methods

Study design

The study was a service evaluation of the TARGET TYI-RTI patient information leaflet across three general practices and one Infection Prevention Conference in England including questionnaires with HCP, interviews and focus groups with GP staff and patient questionnaires (Figure 1).

Figure 1.

Service evaluation study design and study participants.

Patients, HCPs and GP staff viewed the TARGET TYI-RTI leaflet (version 8 that was currently on the RCGP website at the time of the research, available in the Appendix) followed by a modified version which included an additional ‘antibiotic effect’ column with the title ‘With antibiotics: May only shorten illness by’ (Figure 2).

Figure 2.

TARGET Treating Your Infection – Respiratory Tract Infection leaflet (version 8) and proposed additional column.

Questionnaire and topic guide development

Patient and HCP questionnaires and GP staff topic guides were developed by the lead author and research group, based on other qualitative work in this area (Bunten et al., 2015). The Com-B behavioural framework (Michie et al., 2011) was used to guide the questionnaires and topic guide to understand staff and patient capability, opportunity and motivation to use the TYI-RTI leaflet and manage their illness appropriately. Further open questions outside the Com-B framework were also used to ensure all areas of practice were covered to evaluate the leaflet; this allowed inductive analysis.

The patient questionnaire (Appendix) consisted of three demographics questions, 10 questions with ‘yes’, ‘no’ or ‘not sure’ responses, and three open-ended questions, taking approximately 5–10 min to complete. The patient questionnaire was modified following feedback from patients at the first general practice and included separating the illnesses into different conditions to gain illness-specific views. This general practice was visited a second time as noted previously so all three practices used the modified questionnaire.

The patient questionnaires aimed to explore public understanding about:

• RTI illness durations

• RTI treatment expectations

• How the public interpret information on illness duration and treatment choice to make an informed decision

The HCP questionnaire and interviews/focus groups with GP staff aimed to explore HCP staff views on the TARGET TYI-RTI leaflet, especially about:

• Diagnosis of upper RTIs

• How the TYI-RTI leaflet is used in practice

• Illness durations

• The proposed new column ‘With antibiotics: May only shorten illness by’ (hereby referred to in short as the ‘antibiotic effect’ column)

• Back-up prescriptions

• Patient behaviour

Setting and recruitment

Figure 1 shows the setting and recruitment of study participants between June 2017 and June 2018.

Healthcare staff data collection

A convenience sample of HCPs were recruited at the Infection Prevention Conference in September 2017. TARGET TYI-RTI leaflet and questionnaires were distributed to HCPs who visited the TARGET exhibition stand. All returned questionnaires were entered into a prize draw to win a set of Giant Microbes (Giant Microbes, 2019).

General practice staff data collection

Five general practices that previously expressed interest to take part in PHE research, across the Midlands and South West of England in three CCGs, were invited by email and telephone to take part in the service evaluation; three accepted. Practice managers then invited staff to take part in the research. Two practices declined based on time constraints and other commitments.

GP staff (including general practitioners, nurses, pharmacists and practice managers), from the same practices that consented to patient recruitment, were invited to participate in face-to-face interviews or focus groups through the practice manager and were incentivised with a £20 voucher. GP staff provided verbal and written informed consent to take part. Interviews and focus groups were conducted by an experienced female researcher at PHE trained in qualitative research; no observers were present. Introductory questions on staff demographics, i.e. job role and how long participants had been qualified, were asked to establish baseline characteristics.

Patient data collection

At the same practices whose staff took part in the study, the lead researcher approached patients at random in the general practice waiting room and recruited them to take part in the study. The lead researcher visited three general practices (one practice was visited twice to increase sample size). Recruited patients were asked to look at the RTI-TYI leaflet and complete a questionnaire.

Patient data collection in general practice took place mainly during morning practice clinics to maximise patient enrolment due to high footfall. Patients were randomly approached (every other patient to sit in the waiting room) by a trained researcher (CE) to review the TARGET TYI-RTI leaflet and complete a face-to-face questionnaire in the GP waiting rooms before their appointment with the general practitioner. Patients could either complete the questionnaire independently or complete it with the researcher, giving answers verbally to the researcher who completed the questionnaire; all general practices had a quieter area to conduct verbal questionnaires. No questionnaire translations were required.

Data analysis

Quantitative data analysis

Closed HCP and patient questionnaire data were inputted into Stata13 software and analysed to produce descriptive statistics.

Qualitative data analysis

To ensure correct citation of the conversation, all focus group and staff interviews were recorded and transcribed verbatim and checked for accuracy by a researcher. Notes of major themes were recorded by the researcher immediately after patient questionnaires and staff focus groups. All transcripts and open-ended question responses with patients and HCPs were inputted into NVivo 10 data analysis software used to organise and code the data for thematic analysis. A subset of data (one focus group and 10% of patient data) was independently analysed by a second researcher (CH) to ensure reliability. Researchers discussed the coding and agreed on the main emerging themes. Once the main themes were agreed, an additional data analysis stage was conducted, and the findings were applied to the Com-B behavioural framework. This was then discussed and agreed by the research team.

Ethics

This study did not require National Research Ethics Service (NRES) approval as it was classed as service evaluation (NHS, 2017). The PHE Research Support and Governance Office conducted an internal review and granted approval for this service evaluation. The practice managers provided written approval for the research to be conducted at each general practice.

All participants who completed the surveys were aged > 18 years and provided verbal consent to participate in the research. All questionnaire responses were collected in line with the Data Protection Act 1998 and Caldicott 1999 regulations on handling and distributing sensitive participant information. Interview and focus group participants provided written informed consent for participation in the research, audio recording and the publishing of anonymised quotes.

Results

In total, 83 patients (66% women, 34% men, age range = 18–70 years; Table 1) in the three locations participated in the questionnaire survey. There were no patient refusals to participate. A total of 43 HCP questionnaires and 15 GP staff took part in two focus groups lasting 20–40 min and one GP staff participated in a face-to-face interview.

Table 1.

Characteristics of patient survey participants.

	Bristol (n = 13)	Gloucestershire (n = 55)	South Worcestershire (n = 15)	Total (n = 83)	Percentage (%)
Age (years)
18–29	2	10	3	15	18
30–49	6	19	7	32	39
50–69	5	16	4	25	30
70+	0	10	1	11	13
Gender
Male	7	16	5	28	34
Female	6	39	10	55	66

Patient results

Overall, patients were positive about the TYI-RTI leaflet and reported that the leaflet gave them the understanding that antibiotics are not an appropriate treatment for common RTIs, that self-care is the best treatment for common RTIs, how long common RTIs usually last and the consequences of overuse of antibiotics.

Use of the leaflet

Nearly all (93%, 77/83) the patient questionnaire participants were happy for the GP to discuss the TARGET TYI-RTI leaflet with them in a consultation. Three in four patients (73%, 60/83) indicated they would read the leaflet again when they returned home. Only 14% (12/83) stated they would share the leaflet with a friend/family member and a small number, who were generally men, 11% (9/83) stated they would not use it again.

Four overarching themes emerged from the open-ended patient questionnaire responses, directly related to appropriate behaviour to treat common RTIs: illness durations; antibiotic behaviour for RTIs; consequences of antibiotic overuse; and self-care.

Illness durations

Patients were asked if they knew how long common RTIs usually last. The data showed that patient knowledge varied. Of the patients, 60% from the first general practice were aware of how long general RTIs lasted, based on the information in the leaflet. After the first general practice visit, patients were asked about duration for each of the common infections to see if there was variance of knowledge between different illnesses. Although most patients (76%) knew how long a common cold lasted, less reported knowing how long a sore throat (44%), cough (40%), sinusitis (29%) or middle ear infection (21%) lasted (Figure 3).

Figure 3.

Patients knowledge of the usual illness duration and whether they would want an antibiotic for that condition (n = 43).

Patients reported that before reading the leaflet they had little knowledge of the usual illness duration for common RTIs especially cough, sinusitis and middle ear infections. When patients were introduced to the ‘antibiotic effect’ information that stated in hours or days how much antibiotics usually shortened illness, some patients would still want to or were not sure if they would take antibiotics for common RTIs, particularly for middle ear infections, cough and sinusitis. The open-ended patient answers (Box 1) indicated that most patients clearly understood the information presented in the illness duration column entitled ‘without antibiotics most are better by’.

Box 1.

Illness duration column.

‘How long you can expect illnesses to last’ (Bristol, p9) ‘How long common illnesses can last that are normal and don't really need to be seen by a GP until after that time period’ (Glos, p14) ‘The possible length of illness and how to keep yourself well during the illness’ (Worcs, p7)

Boxes (quotes).

Antibiotic behaviour for common RTIs

Patients were asked whether they would take an antibiotic for each of the common RTIs; 89% responded that they would not take antibiotics for common RTIs in general, in the first general practice visit. Subsequent practice visits separated the different RTIs and patients responded differently dependent on the illness. Of the patients, 8% reported that they would expect an antibiotic for a common cold, sinusitis (15%), cough (33%) or middle ear infection (40%). One-fifth of respondents advised they were unsure about whether they should take antibiotics for sinusitis and middle ear infections; patients had different opinions about different infections. Of the patients, 70% (28/40) stated that most common RTIs get better without antibiotics; however, 43% stated they would want an antibiotic for their child or relative. Of the patients, 65% (26/40) reported that they knew antibiotics can cause side effects.

Qualitative patient findings indicated that generally patients understand that antibiotics are not always an appropriate treatment as antibiotics should not be used for minor ailments, and patients often get better without them (Box 2). Some patients also understood that there were consequences of antibiotic overuse including that antibiotics have side effects, may not be helpful and can cause resistance (Box 3).

Box 2.

Quotes about antibiotics not being an appropriate treatment.

‘Antibiotics shouldn't be our first treatment and possibly not at all’ (Bristol, p13) ‘We should “go without antibiotics where possible with minor infections”’ (Glos, p10) ‘Antibiotics don’t cure everything, and you can often get better as quick without them’ (Worcs, p9)

Box 3.

Overuse of antibiotics.

‘Antibiotics have side effects and can cause resistance’ (Bristol, p5) ‘Antibiotics are not necessarily what you need and may damage your resistance in the long term’ (Glos, p12)

Self-care

Nearly all (93%, 38/41) patients knew the information in the column ‘How to look after yourself and your family’ before reading the leaflet and also reported knowing the self-care information including getting plenty of rest, drink fluids, ask your pharmacist and take paracetamol. Of the patients, 60% (24/40) knew the ‘when to get help’ information, such as if you develop chest pain or fever; 15% (6/40) of patients had heard of a back-up prescription. Most patients (78%, 32/41) thought that the ‘antibiotic effect’ column showing the minimal effect that antibiotics may have to the duration of your illness should be included in the leaflet for patient education and to provide patients with all the information to make an informed choice. Patients also felt that the common RTIs listed on the leaflet can be easily managed at home with appropriate self-care as antibiotics are unnecessary (Box 4).

Box 4.

Self-care.

‘It’s an illness that’ll go away quite quickly with self-care’ (Bristol, p4) ‘Reduce unnecessary use of antibiotics by self-care’ (Glos, p13) ‘These illnesses may be managed at home’ (Worcs, p1)

All emerging themes from the patient findings fitted well into the Com-B framework to help inform how patient capability, opportunity and motivation could influence their management for common RTIs (Figure 4). This theoretical framework could help modify the TYI-RTI leaflet in the future if the leaflet is deficient in one of the determinants.

Figure 4.

Behavioural determinants required for appropriate patient behaviours for treating common RTIs using the COM-B framework.

The theoretical framework (Figure 4) indicates that in order for the patient to conduct the appropriate behaviour for managing common RTIs, patients require: the knowledge about antibiotics, usual illness duration, back-up prescriptions, when to seek help and the skills to self-care at home; the opportunity in terms of the time for common RTIs to get better on their own, facilities to self-care at home and access to self-care advice/pharmacy; and the motivation in terms of having the beliefs about antimicrobial resistance and the consequences, and side effects of antibiotics as well as the intentions to use antibiotics appropriately and to seek help.

Healthcare professionals and general practice staff results

Forty-three HCPs completed the questionnaire and 16 GP staff took part in qualitative interviews/focus groups (Table 2).

Table 2.

Characteristics of health professional questionnaire participants at the Infection Prevention Conference and general practice staff focus group participants.

	Questionnaires	Interviews/Focus groups			Total (n = 59)	Percentage (%)
	IPS Conference	Bristol	Gloucestershire	South Worcestershire
Infection prevention control nurse	32	0	0	0	32	54
General practitioner	0	5	5	0	10	17
Practice nurse	3	1	1	1	6	10
Prescribing pharmacist	0	1	1	0	2	3
Non-medical HCP staff	8	0	1	0	9	15

Four overarching themes emerged from the qualitative responses directly related to facilitators to using the TYI-RTI leaflet, barriers to using the TYI-RTI leaflet, modifications to the TYI-RTI leaflet and future dissemination of the leaflet. Detailed key findings and accompanying quotes are recorded in Table 3.

Table 3.

Main qualitative themes from healthcare professionals and general practice staff on the TYI-RTI leaflet.

Theme	COM-B construct	Examples and quotes
Facilitators to using the TYI-RTI leaflet • Increase patient education around common RTIs and usual illness length • Reduce re-consultation rates • Provide self-care and safety netting advice patients have something to take away with them from the consultation • Facilitate important discussions between GP and patient • Provision of hard copies or computed prompted	Capability	Increase patient education around common RTIs and usual illness length ‘If you’re happy that it’s viral and there are no risks then I would share the patient the leaflet and say, “this is what we would expect, it’s normal for it[cough] to last up to 3 weeks”’ (South Worcs, Nurse, Interview)
	Motivation	Reduce re-consultation rates ‘We know that not prescribing [antibiotics] certainly reduces consultation, so if the leaflet’s been done [given] instead of prescription then it’ll help’ (Bristol, GP, Focus Group)
	Motivation	Self-care ‘The “how to look after yourself” is good for patients because they don’t know this information, they don’t do it and they think it’s wrong to stop when they’re ill. So, telling someone to do that [self-care] and them actually looking at the leaflet might encourage those [self-care] behaviours’ (Glos, GP, Focus Group)
	Capability	Safety netting ‘If you’re safety netting properly, which we should always do, you say “I want you to come back if you’re feeling worse, if you continue to feel feverish, if you’re coughing up blood, if you get chest pain. . .”. And actually, you can say “have a read through this [section of leaflet] and if any of these things happen then get back in touch”. It’s quicker’ (Bristol, GP, Focus Group)
	Opportunity	Side effects ‘I talk about the GI side effects. . . I say, “look there’s not a lot of point in using antibiotics because you’re going to find you’re not going to tolerate them very well. . . you’re going to get diarrhoea with it”’ (Glos, GP, Focus Group)
	Opportunity	Patients have something to take away with them ‘You've got something to take home with you’ (Glos, Nurse, Focus Group)
Barriers to using the TYI-RTI leaflet • Lack of time in a consultation to print out and discuss in detail as GPs only have 10-min appointments • Printing costs • Remembering • Awareness	Opportunity	‘It’s too much hassle. . . They’ve only got 10 minutes’ (Glos, GP, Focus Group) ‘I think we should use the leaflets more. . .but we’ve only got 10 minutes to see everyone. It should happen, but it doesn’t’ (South Worcs, Nurse, Interview)
Modifications needed to improve the TYI-RTI leaflet • Increasing the text size • Remove professional body logos • Remove ‘without antibiotics’ from the column title, just say ‘most get better by’ to not highlight antibiotics • GPs voiced very strongly that the ‘antibiotic effect’ column should not be included in the patient-facing leaflet but would be useful for GPs to know this information but not necessarily share with patients	Motivation	Increase the text size ‘I haven’t actually noticed, “never share antibiotics and always return any unused ones”. . . I didn’t see that’ (Bristol, GP, Focus Group) Remove logos ‘No one’s going to look at the bottom in the logos realistically’ (Bristol, Nurse, Focus Group) Remove ‘without antibiotics’ just say ‘most get better by’ or include ‘ your illness’ ‘You’re talking about mainly viral infections. You should say, most of these are better by this time and we have no treatment that’s going to make any difference to that. That’s the crux of the message’ (Glos, GP, Focus Group) ‘Whether you would want to put in. . . something in about “your illness”’ (Nurse, South Worcs, Interview) ‘Antibiotic effect’ column should not be included in the patient-facing leaflet ‘If you want to play devil’s advocate a common cold is a viral infection. You’re using antibiotics for viral infection and you actually may shorten the illness by 24 hours. That is illogical’ (Glos, GP, Focus Group)
Future dissemination of the TYI-RTI leaflet • Primary care professionals to explain and share the leaflet during consultation to help aid patient understanding of all sections	Capability	‘Think it needs to be backed up by a verbal explanation also as some [patients] may not understand’ (Infection Prevention Nurse, Questionnaire) ‘There is a need for a good explanation of risks of antibiotics to go with it’ (Infection Prevention Nurse, Questionnaire)

Facilitators to using the leaflet

Staff reported that the leaflet can facilitate important discussions between HCPs and patients. GP staff reported that in their experience the TYI-RTI leaflet increases patient education around common RTIs and usual illness length, can reduce re-consultation rates through patient education, and provides self-care and safety netting advice. Staff reported that patients like having something to take away with them and they can share the information with friends and family.

Barriers to using the leaflet

Barriers to using the leaflet expressed by GP staff included a lack of time during the 10-min consultation to both print out the leaflet and discuss it with patients. Costs associated with printing were also highlighted by staff as a barrier, as well as remembering to use the leaflet during busy routine consultations.

Modifications to the leaflet

Modifications to the leaflet were suggested and will be considered when developing the next version of the leaflet. These included: increasing the leaflets text size; removing professional body logos as not important to the patient; and removing ‘without antibiotics’ from the column title so it just says ‘most get better by’. Overwhelmingly, GPs voiced strongly that the ‘antibiotic effect’ column should not be included in the patient-facing leaflet. Staff reported it would be useful for GPs to know this information, but not necessarily to share with patients.

Future dissemination of the leaflet

Views relating to future dissemination of the leaflet highlighted that this leaflet should be used by primary care professionals during consultation to help aid patient understanding. It should not be a parting gift, but as a communication tool.

Discussion

Main findings

Overall, patients were positive about the TYI-RTI leaflet and reported that the leaflet gave them the understanding that antibiotics are not an appropriate treatment for common RTIs, self-care is the best treatment for common RTIs, how long common RTIs usually last and the consequences of overuse of antibiotics. Patients, HCPs and GP staff were positive about the TARGET RTI leaflet reporting it increased patient’s capability to self-care, re-consult when necessary and increased patients understanding of how long infections last; so, reducing early consultations. The findings were aligned to the Com-B framework to help inform how the leaflet can increase patient capability, opportunity and motivation to manage acute uncomplicated RTIs without antibiotics.

Although patients expressed a preference for the ‘antibiotic effect’ column, GP staff and other HCPs were adamant that the proposed new ‘antibiotic effect’ column should not be included in a patient-facing leaflet as they felt that it ‘glorifies’ antibiotics as a ‘Superdrug’ rather than highlighting that self-care is the best treatment for viral infection and may not reduce antibiotic demand by patients for common RTIs and could actually increase demand as some patients would request antibiotics for an 8–24-h reduction in symptoms.

Strengths and limitations

This is the first study exploring patients and staff opinions about adding information about the small benefit of antibiotics to the duration of illness (8–24 h). The study also includes patients and staff from across different areas in England and is larger than previous evaluations (Bunten et al., 2015). The mixed methodology and robust sample allowed questioning of patients and healthcare staff with space for open text comments followed by in-depth qualitative research with GP staff, which brought synergism, snowballing of ideas and stimulation of participants noted by the researcher as conversation flowed and there was discussion between staff rather than with the researcher. The open interview schedule with probing ensured that the interview and focus groups could be thematically analysed. All data collection was conducted by one researcher (CE) to ensure validity. An experienced second researcher double coded a subset of the data to eliminate research bias and data saturation was reached as no new themes were emerging. Patient and GP staff data were gathered from three practices across three CCGs to obtain a range of views of understanding and acceptability of the leaflet from patients across the Midlands and South West of England. The questionnaire survey was undertaken with HCPs from all over the UK. The patient questionnaire data were collected from 83 patients from a routine GP setting where the leaflet will be used. A general patient population from a GP waiting room is applicable, as nearly two-thirds of the general public report having an RTI in the previous six months and 20% visit the GP practice (McNulty et al., 2013). Data collected during routine general practice is more transferable across England than using research practices.

A limitation of the study is that after the first GP visit and patient questionnaire data collection, slight modifications were made to the questionnaire to capture further results. This meant that the questionnaire was not standardised across the total patient population. The first version of the questionnaire leads itself for future research to separate questions on different types of infections as there is a clear variation in patient understanding. It should be noted that recruitment of GP practices could be biased as they expressed interest in taking part in research and therefore may be more favourable towards antimicrobial stewardship projects such as TARGET.

Comparison with existing literature

A large study with > 7000 members of the general public found that 62% of respondents knew that antibiotics do not work against most coughs or colds and there is no simple relationship between increased knowledge and more prudent antibiotic use (McNulty et al., 2007a). Our findings suggest similarities as most patients (70%) self-reported knowing that these common infections get better without antibiotics. However, the present study, outlined by the Com-B framework, adds to the literature by suggesting that patients require the knowledge about antibiotics and usual illness duration to help patients make an informed decision about managing their infection. No other study to date has developed a framework to highlight that patients need the opportunity (facilities to self-care at home, access to self-care advice/pharmacy, be able to reuse the leaflet and share with family) and the motivation (belief about antimicrobial resistance and side effects of antibiotics) in order to have appropriate behaviour to manage common RTIs.

A large survey with > 1700 members of the general public found that 10% of people who experienced an RTI expected an antibiotic (McNulty et al., 2015); our findings support this as 8% of our patient participants expected they would get an antibiotic for a common cold. However, our study adds to this literature by reporting that patient expectation for antibiotics is different depending on the illness (15% sinusitis; 33% cough; 40% middle ear infection).

Bunten et al. (2015) also reported that the information on illness duration gave patients realistic expectations about how long they may experience symptoms. Our findings reported that 60% of patients knew how long infections last; yet, when each common RTI was separated, it was clear there was wide variation in opinion and understanding about how useful antibiotics were for different common infections. The present study suggests that patient education around usual illness duration using the TARGET TYI leaflet is useful, particularly for middle ear infections, sinusitis and coughs. Sharing information on illness durations allows patients to make a more informed decision about managing their infection with self-care, the value of using antibiotics and when they should re-consult.

The present study reported that only 15% of patients had heard of a back-up/delayed prescription, which is similar to the results in a large survey in England with 1625 adults that found that only 17% of the general public fully understood the meaning of delayed antibiotic prescription and strategy use in general practice (McNulty et al., 2015). Our study adds to the literature that there is a lack of public understanding around back-up/delayed antibiotic prescribing, and this should be addressed through future public education, and possibly expanding this section of the TARGET TYI-RTI leaflet.

Implications for future research

The TYI-RTI leaflet is useful to inform patients about the usual length of illness and its use should be promoted. The TARGET team should consider modifications: the extra column about the effect antibiotics can have should not be included; improve titles of heading such as ‘without antibiotics’ to just ‘most are better by’; and removing collaborating logos in order to increase the size of the text on antibiotics (resistance, side effects). The modifications suggested from this research have been implemented. Since this research, the TYI-RTI leaflet was rebranded in line with the PHE Keep Antibiotics Working campaign in October 2018 and disseminated to every general practice in England to reach a wide range of HCPs and the general public.

Patients’ awareness of the information in the antimicrobial resistance section of the leaflet varied; some were able to discuss with the researcher about the importance of this information whereas others had never heard of resistance. While the general public liked being knowledgeable about the limited effect that antibiotics have on the duration of your illness, the extra column will not be included in future versions of the leaflet as HCPs believed that it added confusion to the clear public message that antibiotics do not work on common RTIs (coughs, colds, etc.).

Future work will need to explore why only 14% (12/83) stated they would share the leaflet with a friend/family member and a small number (11%, 9/83) stated they would not use it again. HCPs need to encourage patients to keep the leaflet, use for future use, and share with friends and family. Future research can also consider the service evaluation of the pictorial version of the TYI-RTI leaflet, which was designed and developed in the community setting with adults with learning disabilities.