Following the behaviour change presentation by Prof. Michie at the 2013 GRIP Summit, discussions surrounding behaviour and what factors are required to change behaviour in URTI management commenced. The COM-B model, along with other considerations of key behaviour change, and the review of existing materials, were used as a foundation for a meeting discussion and workshop.
The aims of the discussion were to agree on a refined messaging plan for GRIP’s HCP communications, review the best approaches for GRIP communications directly to patients and the public, and consider the challenges with antibiotic prescribing in children and while communicating with parents. It was agreed that there should be different key messages for professionals, patients (adult) and parents and children. These are outlined below:
Antibiotics are not effective for most RTIs—As the majority of URTIs and lower RTIs are caused by viral infections, and antibiotics only affect bacteria, antibiotics are unsuitable for most patients.13,14 A sub-message was considered, stating that antibiotics do not provide symptomatic relief for most RTIs, however, it was agreed that a simple efficacy message was the priority communication.
Reserve antibiotics for high-risk patients—This describes the exclusion vs. inclusion concept where the majority of patients should be automatically excluded from a prescription for antibiotics, and antibiotics considered only when certain ‘inclusion’ criteria are met, such as older patients, pre-existing comorbidities, patients with immunosuppression, or patients who appear systemically very unwell.15 For the majority of cases that are not high risk, communication should be addressed in a positive language such as ‘your throat is red, but does not appear swollen and there is no pus—a lozenge or analgesic will make your throat feel much better’.
Symptomatic relief is available and effective—A wide range of symptomatic relief products are available in different strengths, formulations, active ingredients and combinations. Dr Duerden mentioned that knowledge and advice on the full range and diversity of OTC symptomatic relief products is important knowledge for HCPs. It was agreed that discussing options or making specific recommendations for symptomatic relief is an effective way to treat patients with URTIs, in addition to providing a personalised approach. GRIP agreed that increasing access to information on symptomatic relief products, to improve HCP trust in the efficacy of these medicines would be of value.
The three messages above help support the appropriate use of antibiotics and HCP antibiotic stewardship measures. Other supporting messages considered in the discussion, specifically for sore throat, included reminding HCPs of the access to point of care diagnostics (POCD), identifying red flags/high risk patients and reinforcing the use of Centor criteria when identifying group A beta-hemolytic streptococcal (GABHS) infection.
GRIP discussed that POCD were not available in many countries and hence concluded this was not an appropriate key message for a global audience. The Centor criteria are embedded into the practice and guidelines of sore throat management in many countries and the group felt it was important not to discount their value as a consultation tool, despite information showing similarity between physical findings in viral and bacterial sore throats. The importance of reassuring patients that their condition had been taken seriously and fully examined was also agreed.
On selection of the three core messages it was noted that information explaining the cause or implications of antibiotic resistance and/or the imperative of antibiotic stewardship was absent. Following discussion, a consensus was reached that GRIP’s information will always be framed by the background information on antibiotic resistance/for antibiotic stewardship, to provide a ‘Why?’ in each communication ensuring alignment to their declaration. Information will include latest resistance rates, national and global initiatives to address the global threat, research into new antimicrobials and possible consequences for future clinical practice.
GRIP agreed that patient messages are best delivered in a positive manner. For example, instead of using ‘your infection is not severe enough to require antibiotics’, use ‘you will feel better with the appropriate symptomatic relief’. GRIP has committed itself to a more-focused approach towards patient messaging in order to improve recall.
Antibiotics are not effective for most coughs and cold symptoms and symptomatic relief is available and effective—These messages to HCPs also apply to patient communications. The group commented on existing campaigns and messages that focus on distinguishing between viral and bacterial infections. It was agreed that due to a similarity in symptoms and the complexities of explaining this to patients, this was not the most effective way to communicate this message. Instead a simplified message (as above) was agreed to.
Your immune system is very capable of dealing with most coughs and cold symptoms—The majority of RTIs are self-limiting and should resolve within 1–3 weeks.15-18 Primary infections are extremely common and healthy patients not at risk of complications only require products to relieve symptoms. Communicating the realistic duration of symptoms was agreed to be of value and an important aspect of GRIP’s communication to date. As rates of complications vary by country and region, GRIP noted the importance of local adaptation of GRIP’s messages to ensure higher risk situations are given due cognisance.
How can these messages be delivered effectively to patients?
GRIP plans to use motivational language and clear, concise information via digital media to engage with and mobilise the general public.
Parents and children
There is a need for reassuring messages when treating a child with a URTI, as infections can be worrying for parents; so education is required to explain when antibiotics are appropriate for this patient group. The group felt different advice is required in this setting compared to adult consultations.
The group discussed messages for both parents and children and felt GRIP’s initial messaging should be targeted at children aged 9 and older, using language that children can relate to. Educating children at a young age can help shape and eventually change behaviours. If children are made aware at home and at school (e.g. ‘e-bug’, a European initiative in schools to educate children about antibiotic awareness, accessible here), the message would spread into the wider community.
The group developed reassuring messages to address this need in parent and child consultations. Dr Duerden referred to a parent information leaflet developed at Cardiff University and endorsed by the UK RCGP entitled ‘When should I worry’ (accessible here). It was agreed that this was an appropriate sentiment for GRIP information to parents. The selected messages for parents are:
- when your child is ill, it is natural to worry—your healthcare professionals can reassure you and help you identify more serious symptoms
- antibiotics should only be used for severe infections as they may not be beneficial for your child in all cases
- symptomatic relief will make your child feel better.
Aside from reassurance, the group discussed the communication between the HCP and the child. Children may find it difficult to articulate their symptoms and severity. This can make consultations difficult for HCPs. GRIP identified supporting the HCP and child dialogue—about the illness and treatment options—as a potential area for GRIP guidance.
For all audiences, GRIP agreed that messages should be carefully formulated and accurately communicated. To achieve this, an understanding of the levels of health literacy in the general public should be considered along with the type of language that will most effectively deliver the key antibiotic conservation messages. Improving the consultation skills of HCPs in various settings was believed by the group to be an important aspect of message delivery.