Acceptability
Satisfaction with the ‘When should I worry’ booklet
Positive comments about the booklet were made by the majority of parents, describing it as ‘good’, ‘useful’ and ‘helpful’. However, some parents felt the information was ‘pretty obvious’ or they ‘knew most of the stuff in it’. There was also a high level of consensus amongst clinicians in reporting generally positive impressions of the booklet, describing it as ‘useful’, ‘clear’, ‘patient friendly’, and ‘well designed’.
“…it was nice to have such a friendly, such a patient friendly information booklet to give to parents of young children, I thought that was really useful”
[Clinician 159, below average prescribing practice, higher recruiter]
However, one clinician felt the booklet may be a bit too ‘erudite’ for some patients. Advice about recognising signs of serious illness and the normal duration of symptoms (including the graphical representations) were most frequently mentioned as useful parts of the booklet by both clinicians and parents.
Parental satisfaction with the consultation
When describing their satisfaction with the consultation, most parents talked about the manner of the clinician, and the thoroughness of the examination their child received. Many talked about feeling reassured during consultations;
“I was really pleased she checked [name] over very thoroughly. I thought it wasn’t, you know, listen to me and say ‘ohh yeah, well he’s got a cold you know he’s gonna get over it’. I mean she [the doctor] checked his ears and examined his chest and listened to his chest and was, you know, reassuring”
[Parent 544, no antibiotic, no re-consultation, index consultation with doctor]
Several parents recalled being specifically asked about their concerns, but very few discussed being asked about their expectations. However, parents didn’t typically feel that being asked about their expectations would have been helpful. A small minority of parents were not entirely satisfied with their consultation. For example, a parent described her dissatisfaction in that the clinician dedicated more time to enrolling her child into the study than dealing with the illness. However, after reflecting on the consultation at home she felt less dissatisfied:
“I have to say that when I came out I kind of felt fobbed off … but it wasn’t until I got home I thought well actually I am relieved because he has checked his front and his back, he’s confirmed it’s a cold, so I know he doesn’t need any antibiotics.”
[Parent 556, no antibiotic, no re-consultation, doctor]
Another parent who reported dissatisfaction had strong beliefs about the need for antibiotics, had expected a more thorough physical examination, and felt that she had not been given sufficient information.
Clinicians’ satisfaction with training
Clinician satisfaction with the training was somewhat variable. Several clinicians felt positive about the training, feeling that it was important and provided an opportunity to familiarise themselves with the content of the booklet.
“I thought the training was really excellent - the best bit of sort of introduction to study training that I’ve ever done because it forced you to interact with it”
[Clinician 98, below average prescribing practice, higher recruiter]
A clinician described a positive effect of training on their communication within consultations:
“Having had the training and using the booklet has helped me to consult and to improve my general consulting style in terms of eliciting the patient’s agenda and the patient’s priorities”
[Clinician 53, above average prescribing practice, lower recruiter]
Several clinicians were more neutral about the training, although few explicitly negative comments were made about it. Some clinicians felt that the training contained ‘obvious stuff’, while others remarked that it was useful in refreshing their knowledge within the context of a busy practice. For some clinicians, there was a gap between completing training and recruiting patients, which made it more difficult to recall the content. While a small number of clinicians reported some technical difficulties with the online training (e.g. not having working sound on their computer, difficulty logging on), the majority of clinicians were satisfied with the method of delivery of the training. None of the clinicians stated that they would have preferred face-to-face instead of web-based training.
Implementation
Parent and clinician reports indicated that there was considerable variation in how the booklet had been used during consultations. While some parents reported that the booklet had been discussed with them during the consultation, for others it had not, and some had not received a booklet at all. In line with this, some clinicians reported using the booklet with every participating patient during consultations, while others used the booklet with only some participants or only partially used the booklet as instructed. There was a general consensus for both parents and clinicians that using the booklet interactively during consultations was important;
“I think if you just give it at the end, it wouldn’t carry much weight to be honest.”
[Clinician 98, below average prescribing practice, lower recruiter]
“I think it [being given a booklet] can seem like ‘oh well, here’s a booklet just read about it’, but you know, with sort of being shown the relevant parts it seems like they’re [clinician] taking more notice - they’ve listened to you and they’re trying to reassure you more”
[Parent 544, no antibiotic, no re-consultation, index consultation with doctor]
Many parents reported also reading the booklet at home following the consultation and several had kept the booklet for further reference. A small minority of parents expressed a preference to read through the booklet in their own time and one clinician felt that the information contained in the booklet was more important than the discussion of it.
Nonetheless, interactive use of the booklet during consultations did not appear to be consistently happening in practice. The main barriers to its reported use by clinicians were time, familiarity with use of the booklet during consultations, and discordance between the clinician’s treatment plan/style of consultation and the booklet’s messages. Additional time taken during consultations was a salient theme for clinicians. However, some clinicians considered this a reasonable cost for improving their patients’ understanding and ‘made the consultation more constructive’. Other less frequently reported barriers included feeling that the intervention might lead to use of a paternalistic (rather than shared decision-making) approach, and examples of slightly ’dysfunctional’ consultations where the communication style was perceived to have led to a loss of patient-focus and/or the usual quality of rapport was disrupted.
Mechanisms and context
Clinicians emphasised the challenges involved in managing RTIs, including dealing with parents’ expectations, needs and desires, and the speed with which a child’s condition can change. Knowing how to respond when their child had an RTI was also challenging for parents, particularly in the context of often receiving inconsistent messages about the management of RTIs from healthcare professionals.
Antibiotic prescribing
Clinicians reported an increased understanding of antibiotic prescribing and awareness of parent perspectives as a result of the intervention;
“I’m more aware of the issues of antibiotic overuse and perhaps it’s led to me to think that well parents don’t always want antibiotics, they’re probably more likely to want reassurance in many of these cases.”
[Clinician 266, below average prescribing practice, lower recruiter]
For parents, feeling better informed about the role of antibiotics in managing RTIs and more confident in managing the illness without antibiotics having used the booklet was a salient theme;
“… with the ears. I think I was surprised at, they heal up on their own and you don’t need antibiotics. I just assumed that you need antibiotics every time you’re ill.”
[Parent 612, antibiotics, no re-consultation, index consultation with doctor]
Parents were generally receptive to messages that antibiotics were not always required. However, some parents reported confusion resulting from receiving conflicting messages from clinicians:
“…the doctor was basically saying it might go away on its own anyway, but he felt that an antibiotic might or might not help. That didn’t really make sense….[ ]… I understand what they’re for and I understand the principle of not over-prescribing [antibiotics], but I think it’s a little confusing when they may have the same exactly the same symptoms one time and get them, and get antibiotics, and they feel that they need antibiotics on that occasion, and then the next time you go back and they’ve got identical symptoms you’re not given them.”
[Parent 527, antibiotics, no re-consultation, doctor at index consultation]
Likewise, a number of clinicians talked about the damage done by inconsistent messages given to parents by clinicians, including actions (varying thresholds for prescribing antibiotics) and communication (conflicting advice). Use of the intervention may have encouraged clinicians to prescribe along more evidence-based lines:
“I suppose there were times when you have to try and overcome your own clinical prejudices to either go along with the booklet or not … the booklet was kind of construed, well, that mostly antibiotics are not helpful.”
[Clinician 173, above average prescribing practice, lower recruiter]
A clinician from a higher prescribing practice said that at the end of the study he felt like he ‘explained more and prescribed less’. Other clinicians talked about the booklet backing-up their advice or giving them more authority:
“…it’s not always easy when the expectation or perceived expectation is there for antibiotics, just in case. And it’s much easier to prescribe than not to prescribe. But if you’ve got something like that booklet then it kind of gives more backup or authority to reinforce the advice.”
[Clinician 15, below average prescribing practice, higher recruiter]
Re-consulting
There was considerable ambivalence around consulting the doctor from the parents’ perspective, with parents not wanting to be ‘a pain’, appear ‘paranoid’, ‘feel silly’ or ‘waste time’. Advice about recognising signs of serious illness and information about the usual duration of illness were most frequently mentioned as useful parts of the booklet, which was consistent with the high level of uncertainty parents reported around when they should consult with a doctor for a child’s RTI:
“The one thing that really stuck in my head is that these kind of infections last longer than you think….[]… [The doctor] was right because he said, and your booklet was right …a couple of days later and [name] was a different child… ”
[Parent 550, no antibiotic, no re-consultation, index consultation with doctor]
One parent reported that use of the booklet helped her obtain a timely consultation for a child with signs suggestive of serious illness;
“… it’s the fear of being a complete hypochondriac, and I thought ‘oh, let’s have a look at this booklet and see what it says’. And I read on a section you know, you should take back to your doctor if the child has very cold limbs and you know his hot body, and what have you, you should contact the doctor. So I did this and … she said come I’ll see him. And [the nurse] said you know, it just wasn’t the child she’d seen the day before. And his sats were low, his sats were 89”.
[Parent 594, antibiotic, re-consulted, index consultation with nurse]
For clinicians, similar themes of increased understanding of the natural history of RTIs and recognition of signs of serious illness emerged;
“Understanding the duration of symptoms a bit better than I did at the outset … you know, that mild symptoms can go on longer.”
[Clinician 173, above average prescribing practice, lower recruiter]
“I think I can more usually describe the signs of possible serious illness.”
[Clinician 184, below average prescribing practice, higher recruiter]
Some parents reported re-consulting primarily because they had been asked to by their clinician. Clinicians’ views also indicated that anxiety about not prescribing antibiotics may have increased re-consultations in some cases. For example, a clinician who had decreased his antibiotic prescribing reported that he tended to ask patients to return for follow-up more frequently to reassure himself they were recovering. Conversely, some parents felt that doctors could be quite dismissive;
“Doctors do tend to sort of brush it off with it being a paranoid mother, which I can understand where they are coming from, but at the same time, you know, obviously she’s my daughter and I don’t see every other child with the same symptoms as well.”
[Parent 518, no antibiotics, no re-consultation, index consultation with nurse]
One parent described feeling that they were being discouraged from seeing the doctor ‘in a nice way’ by the interactive booklet but also reported feeling more confident about differentiating between ’normal symptoms’ and signs of more serious illness. Parents often discussed the need for a thorough examination and reassurance from a health professional when their child was unwell, rather than a desire for specific treatment;
“There’s just times when you know you need a bit of reassurance and a bit of peace of mind rather than actually going for a solution, you know”
[Parent 555, no antibiotics, no re-consultation, index consultation with doctor]