Knowledge and attitude factors influencing primary care clinicians’ diagnosis, treatment, and management of urinary tract infections in England: A qualitative ‘think-aloud’ study

Problem

Antimicrobial resistance is a global problem, and inappropriate prescribing is a major contributing factor. Urinary tract infections are one of the most common conditions for which antibiotics are prescribed. While antibiotics are effective in treating urinary tract infections, suboptimal prescribing of antibiotics occurs, which contributes to antimicrobial resistance. The present study is the first to use a ‘think-aloud’ approach to describe the knowledge and attitude factors influencing clinician decision-making when diagnosing, treating, and managing UTIs.

Approach

Semi-structured qualitative interviews were conducted with primary care clinicians in England over Microsoft Teams. Interviews were transcribed and coded in two ways. First, clinicians’ responses for each scenario were coded as either following (optimal) or not following (suboptimal) evidence-based national guidelines. Second, the knowledge and attitude factors that influenced decision-making were coded according to an empirically-informed umbrella framework. Clinicians external to the study team reviewed the findings to promote their trustworthiness and utility.

Findings

Ten clinicians (6 female) took part. Despite clinicians’ expressing high awareness of relevant evidence-based guidelines (a knowledge factor) and high confidence (an attitude factor), more than half of their decisions were suboptimal in some way. Our framework analysis suggests that knowledge could impede adherence, e.g., where local guidelines conflicted with national guidelines.

Consequences

Suboptimal prescribing decisions could result from a combination of different knowledge and attitude factors. Most clinicians relied on their experiential knowledge rather than using evidence-based guidelines. To optimise antibiotic prescribing, policy-level interventions could increase concordance across local and national guidelines, or more tailored individual-level interventions could help clinicians recognize where their experiential knowledge causes deviations from evidence-based guidelines when diagnosing, treating, and managing urinary tract infections