Socio-demographic characteristics
In the survey study sample, GPs were predominantly male (58% IG; 64% CG), with a mean age of 53 years and 25 years of professional experience. MAs had a mean age of 41 years and almost exclusively were female (100% IG; 98% CG). Across groups, MAs had been working for more than 15 years for the respective practice. 68% of participating GPs in the intervention group and 82% in the control group stated to have implemented changes in their practice in the last two years. GPs of the intervention group further stated to have visited a mean of 8.6 professional medical education workshops in the last six months. Table 2 gives an overview of socio-demographic characteristics of the quantitative study sample.
Table 2: Socio-demographics of survey participants (T1 n=185; T2 n=127)
|
Intervention Group
|
Control Group
|
T1
|
GP (n=41)
|
MA (n=50)
|
GP (n=39)
|
MA (n=55)
|
Age in years, mean (SD)
|
53 (9)
|
41 (12)
|
53 (10)
|
42 (12)
|
Sex f (%)
|
17 (42)
|
50 (100)
|
14 (36)
|
54 (98)
|
Experience years mean (SD)
|
25 (10)
|
17 (11)
|
23 (9)
|
17 (11)
|
Changes implemented in last 2 years yes (%)
|
28 (68)
|
34 (75)
|
34 (82)
|
38 (70)
|
T2
|
GP (n=32)
|
MA (n=32)
|
GP (n=31)
|
MA (n=32)
|
Age mean (SD)
|
54 (10)
|
41 (12)
|
57 (9)
|
41 (11)
|
Sex f (%)
|
13 (41)
|
32 (100)
|
9 (29)
|
32 (100)
|
Experience years in current role mean (SD)
|
25 (10)
|
17 (12)
|
27 (9)
|
16 (9)
|
Medical education workshops in the last six months mean (SD)
|
9 (6)
|
N/A
|
N/A
|
N/A
|
In total, 47 interviews were conducted between January and November 2019. Interviewed GPs (n=16) had a mean age of 53 years, 24 years of professional experience and a nearly equal distribution of gender (region MV n=10). Interviewed MAs (n=7) had a mean age of 48 years, had worked with their employer for 16.7 years and were exclusively female (region MV n=4). Patients (n=16) had a mean age of 36 years and had been consulting the respective GP for eight years on average (region MV n=11). To support anonymity of the small sample of OVs (n=5) and GPs (n=3) who participated in an in-depth interview regarding outreach visits, the only characteristic collected was related to gender. Table 3 summarizes the socio-demographic characteristics of the qualitative study sample.
Table 3: Socio-demographic characteristics of interview participants (n=47)
Characteristics
|
GPs (n = 16)
|
MAs (n = 7)
|
Patients (n = 16)
|
OVs (n=5) + VGPs* (n=3)
|
Age in years mean (SD)
|
53 (±8.29)
|
48 (±11.8)
|
36 (±12.2)
|
N/A
|
Sex f (%)
|
9 (56)
|
7 (100)
|
10 (62.5)
|
5 (62.5)
|
Expert years (mean SD)
|
24 (±8.2)
|
22 (±11.8)
|
N/A
|
N/A
|
Years with current employer mean (SD)
|
N/A
|
16.7 (±6.1)
|
N/A
|
N/A
|
Consulting this GP for years mean (SD)
|
N/A
|
N/A
|
8 (±8)
|
N/A
|
*VGPS=GPs who had received an outreach visit
Survey study
Survey waves were April to July (T1) and March to April 2020 (T2). A total of 109 practices (BW n=54, MV n=55) with 132 GPs were invited to participate in the survey. In T1, 185 participants responded of which 41 GPs (response rate 64%) and 50 MAs belonged to the intervention group. In the control group, 39 GPs (response rate 57.3%) and 55 MAs responded. Of these participants, 127 also answered the T2 survey questionnaire which represents a response rate of 69% across both participant groups. Here 32 GPs and 32 MAs in the intervention group and 31 GPs and 32 MAs in the control group returned the questionnaire until the set due date in April 2020. Five questionnaires were returned after the due date and could not be included for analysis. Overall, 312 survey questionnaires were included for analysis (response rate 58.3%).
Table 4 describes the uptake of all intervention components offered to the intervention group and the control group. Across time points, groups and occupational profession, the uptake of the website was between 40 and 50%. Here, uptake is defined by using the website as a counseling tool in order to strengthen patients’ health literacy competencies, however, it was also intended to strengthen healthcare professionals’ competencies. All paper-based material was provided to the practices in the intervention group. Control group practices received the mailing and could order their choice of material via the study-specific website. Initial uptake of the paper-based educational material was high. While the utilization of these components remained stable in the control group, it dropped in the intervention group over time. In the intervention group, adoption of the non-digital components by the participating MAs dropped from 86% in T1 to 41% inT2.
Table 4: Uptake of study components across study groups for T1 and T2
|
Intervention Group
|
Control Group
|
T1
|
GP (n=41)
|
MA (n=50)
|
GP (n=39)
|
MA (n=55)
|
Mail n (%)
|
33 (81)
|
45 (90)
|
31 (80)
|
42 (76)
|
Website n (%)
|
20 (49)
|
22 (44)
|
19 (49)
|
23 (42)
|
Information material n (%)
|
34 (83)
|
43 (86)
|
25 (64)
|
44 (80)
|
First feedback report n (%)
|
36 (88)
|
35 (70)
|
N/A
|
N/A
|
Outreach Visit n (%)
|
24 (59)
|
20 (40)
|
N/A
|
N/A
|
E-learning for teams n (%)
|
8 (20)
|
11 (22)
|
N/A
|
N/A
|
Tablet n (%)
|
18 (44)
|
29 (58)
|
N/A
|
N/A
|
|
T2
|
GP (n=32)
|
MA (n=32)
|
GP (n=31)
|
MA (n=32)
|
Mail n (%)
|
20 (63)
|
26 (81)
|
29 (93)
|
25 (78)
|
Website n (%)
|
14 (44)
|
13 (41)
|
N/A
|
13 (41)
|
Information material n (%)
|
16 (50)
|
13 (41)
|
23 (74)
|
24 (75)
|
Second feedback report n (%)
|
20 (63)
|
18 (56)
|
N/A
|
N/A
|
Outreach Visit n (%)
|
18 (57)
|
22 (69)
|
N/A
|
N/A
|
E-learning for teams n (%)
|
10 (31)
|
2 (6)
|
N/A
|
N/A
|
Tablet n (%)
|
15 (47)
|
20 (63)
|
N/A
|
N/A
|
The uptake of the intervention component feedback report dropped over the period of time. In T1, 88% of GPs used the first feedback report and considered it to be helpful in evaluating the performance of their practice. This number decreased to 56% in T2 for the second report. GPs and MAs rated the outreach visit to be beneficial in T1 and T2. The e-learning platform had the lowest rate of adoption compared to all intervention components. In total, only 10 GPs and 11 MAs reported using this format which could be reached via personalized access. Approximately half of respondents offered the tablet devices to patients. Noticeably, the uptake dropped over time whereby MAs appeared to have a higher rate of adoption compared to GPs.
In addition to the general uptake of study components, Table 5 illustrates the extent of the comprehensive uptake of GPs and MAs working in one facility. This overlap is shown for the intervention group only since particular interest was on intervention components. In general, the overlap of the digital intervention components (tablet; e-learning platform) was considerably high. In T1, 83% of responding practices were consistent in the uptake of tablet devices in their practice team. In T2, this consistency slightly decreased to 65%. Considering absolute numbers, the consistency in the perception of outreach visits stayed stable over time. In comparison, the perception of feedback reports providing helpful information for performance evaluation of the practice dropped from 76% to 65%.
Table 5: Overlap of self-reported component uptake within practices
Device
|
T1 (practices n= 41)
|
T2 (practices n = 31*)
|
Mailing n (%)
|
30 (73.2)
|
25 (80.6)
|
Website n (%)
|
25 (61)
|
20 (64.5)
|
Feedback n (%)
|
31 (75.6)
|
20 (64.5)
|
Outreach visit n (%)
|
23 (56.1)
|
21 (67.7)
|
E-learning n (%)
|
34 (82.9)
|
25 (80.6)
|
Tablet n (%)
|
34 (82.9)
|
20 (64.5)
|
Flyer
|
N/A
|
27 (87.1)
|
Coloring book
|
N/A
|
17 (54.8)
|
Plush Toy**
|
N/A
|
17 (54.8)
|
COLD magazine**
|
N/A
|
26 (83.9)
|
Comic**
|
N/A
|
19 (61.3)
|
Printed and online information for professionals
|
N/A
|
18 (58.1)
|
* questionnaires returned by GPs and MAs from 31 practices
**Only offered in second half of the intervention period
Interview study
Between January and April 2019, semi-structured guide-based telephone interviews were carried out with a sample of intervention group GPs (n=16), MAs (n=7), and patients (n=16) from the intervention group and the control group with a mean duration of 22.1 minutes. In addition, semi-structured guide-based interviews were conducted in October and November 2019 with 4 outreach visitors, 1 expert and three GPs who had received an outreach visit to broaden obtained findings regarding the visits. Here, the mean duration was 27.5 minutes.
All interviews added in-depth understanding of the educational intervention components, context factors impacting the uptake of the intervention and the significance and role of the implemented set of measures to practice teams and patients. Findings are reported in relation to three TDF constructs that emerged as main categories from the analysis: Environmental context and resources; Social/professional role and identity; Beliefs about consequences. Other TDF constructs such as Emotion, Skills and Optimism were less prevalent. Since a utilization gap between digital and paper-based study components was identified post hoc, these component groups as well as the outreach visits are reflected. Included quotes have been translated into English with due diligence and are cited with transcript position.
Environmental context and resources
Outreach visits
A total of 44 on-site outreach visits and 4 telephone visits were conducted. In general, on-site visits were attended by GPs and MAs, in some cases by the GP only. The telephone visits were conducted on individual request with the respective GP. Due to refusal or drop-out, 9 visits could not take place. OVs reported that they were met with reluctance and had to overcome difficulties in scheduling of the visits already. Efforts to reach practices in rural areas were considered too high and premises often inadequate. In general, OVs were made aware of the scarcely available resource of time in practices which was repeated when they arrived for the outreach visit: “now in fast forward, we don’t have time” (OV3, 01:53). On practice site, the re-occurring issue of sub-optimal premises restricted the options for a set-up in a quiet location to deliver the prepared presentation and materials and to discuss the feedback report. In some cases, this meant to deliver the intervention component during lunch hours and in break rooms “between the garbage bin and the coffee maker” (VExp; 23:18). OVs felt that the visits and they themselves were seen as disruptive for routine processes. Moreover, they experienced GPs to play down the relevance of visits since elements referring to participatory communication were not seen as crucial and available data presented in feedback reports was not seen as significant: “Not all of them thought it was interesting, there were critical voices, too, data too old, nothing in it, we don’t prescribe antibiotics at all“ (OV01, 08:47). In contrast to OVs’ statements, interviewed GPs saw benefits in visits. They felt motivated by the comparison of prescription rates between practices. OVs mentioned that this benchmarking supported them in conveying improvement potential in prescribing patterns, particularly if GPs initially perceived their prescription rates as flawless. According to the OVs, the outreach visits could not be delivered as planned and according to the developed concept they were made familiar with since diverse contextual factors required a certain extent of flexibility, tailoring and deviation from the implementation plan.
“You have to deliver [the intervention] in a way people can accept it” (OV02, 03:21).
“In other words, the intervention never was delivered in a standardized way. … practice did not expect a presentation, …, suitable room not available, improvised in the consulting room, contents of the feedback report not known, but interested in topic.” (OV4; 03:08 -04:53)
„comparing to other practices was very helpful, I had the impression that this combination - create awareness and provide information - … actually a good thing, because it opens doors“. (OV02, 04:43)
Non-digital intervention components
When the interviews were conducted, rolled out non-digital intervention components were still limited to paper-based flyers and posters containing educational relevant information. Consistent with survey findings, the uptake of these two components was reported to be high. Especially MAs saw benefits in providing patients with information material which was perceived to be appealing. Flyers in particular had a high rate of adoption which was explained by a suitable integration into practice routines. “Well, I have to say the flyers, they yield a lot, because people actually engage with them” (M4; 10:24). GPs used flyer in counselling situations and considered them fitting to give to patients instead of a prescription for antibiotics. “People want to hold something in their hands when they leave the practice, if not a prescription for antibiotics then a recommendation how to inhale and drink different tees” (GP10; 12:23).
Digital intervention components
The public campaign which included a website met challenges in reaching the target group. Patients could not clearly differentiate the campaign from other sources of information. One patient even wrongly attributed a televised spot to the campaign. Nevertheless, patients hypothesized that a reliable and trustworthy web-based source of information would be helpful in creating thematic awareness and increasing health literacy and considered the GP practice to be a suitable location to learn about such a website.
While no interviewed MAs had used the e-learning module, two interviewed GPs stated to have done so and considered it helpful for handling patients’ expectations. In particular, they expected benefits for situations in which patients actively requested antibiotics and thought that communicative elements conveyed by the module could help them to promote alternative treatment approaches: “Yes, very artificial scene, but I thought it was good to create awareness [for patient expectations]” (GP6; 06:58). GPs who had not used the e-learning module reported they had not been aware of its existence.
During the period of conducting interviews, tablet devices had only been available to the practices for a short time. In a few practices, the tablet had not been available yet or was refused completely. Opinions about using tablet devices for information provision in GP practices were heterogenous. Critics argued that only one person at a time could use a tablet. Additionally, hygiene issues were discussed as major concerns and grounds for potential refusal. Additional stress and burden for the team was anticipated regarding dispensing and monitoring whereabouts of the tablets. Supporters of tablet devices saw opportunities to extend application areas: In order to avoid uncomfortable situations with GPs, they could help to address sensitive topics. Due to prioritizing consultation topics in advance, this would also lead to an intensified utilization of consultation time. The interviewed patients were not aware of the tablet devices, but reflected on a potential use. Waiting room TVs were proposed as a proper alternative for digital information provision. GPs, MAs and patients shared concerns regarding the uptake of tablet devices and also voiced a general fear of theft. From their perspective, a standardized procedure would be required to define when and how to let patients use the tablet and to take a deposit of some sort to ensure it would be returned again.
“I think perhaps you would have to have several [tablets]. Well, I think a screen everybody can look at would be simpler. Or, 15 to 20 tablets would be necessary so everybody [in the waiting area] could use them.” (P10; 18:53)
“Tablets are an option that would be very appealing to me. Then you don’t have to ask the GP again, which could make others [patient] uncomfortable.” (P14: 8:45-9:22)
Social/professional role and identity
Outreach Visits
OVs experienced a diverse integration of MAs in visits. Predominantly, the whole practice team was attending, but in some cases, GPs denied the participation of MAs. Here, OVs presumed that GPs did not want to create an additional burden for MAs since the GPs themselves are responsible for antibiotic prescription rates. In other cases, MAs participated in the visit while the GP refused to do so. One interviewed GP saw the visit as opportunity to foster team building and considered reflection on internal routines more suitable with an external visitor than within the team only. GPs who favored homeopathy and naturopathic medicine conveyed that in their understanding, other medical specialist groups such as pediatricians would be responsible for high antibiotics prescription rates in primary care, not they themselves. With regard to intervention fidelity, OVs felt that practices with background in academic teaching demonstrated stronger adherence to the protocol.
“It was very good [the visit]. I have 4 MAs and it is always beneficial when you are not he only one conveying knowledge, but to have someone external coming in and talk about antibiotic resistances.” (VGP03; 11:30)
“…I visited two or three practices … that we have worked with before and over years. You noticed that everything ran differently there. These are academic teaching practices and they took more time.” (OV1; 18:42)
Non-digital components
Paper-based components appeared to be in line with the perceived social professional role of interviewed GPs and MAs and were considered to be supportive for their daily routines. GPs generally supported the idea to increase health literacy competencies in patients. Thus, poster and flyer were seen as constant reminders for the appropriate use of antibiotics in acute respiratory tract infections. Patients contemplated their willingness to engage with educative health-related information in medical practices. It was assumed that in case of consulting a GP for an acute respiratory infection, they might lack receptivity while sitting in a waiting area and prefer to be educated by the GP directly.
“…I believe, this is the main factor, you actually know it somehow, but often you don’t think of it anymore, right? Such a campaign supports simply thinking of it and being aware.” (GP7; 09:58)
“I don’t know. When I am sick, then I am really sick and when I sit there, then I personally have no interest in […] then I am happy to see the GP quickly and get out again fast.”
(P17; 10:56-11:12)
Digital components
In contrast to paper-based components, the acceptance of tablet devices was mixed. Refusing GPs saw their practice as a place of tranquility and protection. Thus, in days of constant information flooding and availability, they consciously wanted to establish a “safe harbor” for patients. Following this perception of the social professional role of a GP practice, tablet devices were seen as a disruption, neither fitting the needs of patients nor GPs or the team. To some extent, MAs seemed to adopt their employers’ positions.
Interviewed GPs and MAs were not familiar with the study-specific website. At the time of the interviews, less than half of the interviewed professionals had visited the platform, yet they generally supported the idea of providing a site with evidence-based reliable information. GPs who used the e-learning tool appreciated the input of communicative training elements in which they gathered ideas on how to respond to irrational patient demands for antibiotic therapy. Patients saw a general need for trustworthy sources of health-related information, but had not come across the study-specific website.
“I think people already are getting bombarded enough with this stuff. I don't want that in the practice here. We actually also have a ban on mobile phones here. So, of course you can play around on your mobile phone, but you must not talk on the phone [...] I believe that this is also quite good for the patients if they come to rest for a few minutes in the waiting area. In this respect, I don't see a place for it in my practice now.” (GP14; 18:10)
Beliefs about consequences
Outreach Visits
As applied and in retrospect, OVs and the interviewed expert did not consider the visits to be a suitable intervention component for the CHANGE-3 study. GPs argued that feedback reports on their antibiotics prescribing were of minor relevance to them since case numbers appeared to be small and lacked contextual interpretation. To accommodate scheduling issues, OVs conducted a total of 4 visits via telephone which was considered to have worked surprisingly well. To increase GPs’ motivation to participate in visits, OVs suggested offering a higher compensation. Even though experiences of OVs about visits seemed to be connected with defiance, interviewed GPs considered the visits to be beneficial. They acknowledged the included feedback reports which offered rational benchmarking and saw ways to include their staff into sustainable care quality improvement mechanisms.
„ … using [outreach visits] widely would surely be extremely complex and complicated. So, for sure it was good to test it again for such a relevant topic, but I believe it probably cannot be used in routine care, because it is relatively expensive…I am afraid this concept would rather be suitable for other things” (VExp; 17:34)
Non-digital components
The most significant consequence of paper-based components was seen in an increased awareness of an appropriate use of antibiotics. For GPs, the daily confrontation with poster and flyer worked as a constant reminder to question if antibiotics were indicated. For MAs, the material assisted to meet the patients’ needs in providing them information they could rely on and which guided them in handling their infection.
Digital components
Referring to the public campaign, chances were recognized for providing a reliable source of relevant information via a trustworthy website. As awareness of the study-specific website was limited, statements and beliefs were primarily hypothetical considerations.
“Well, that would tie up far too much time at the front desk, if a MA first has to explain what to do with the tablet, then she has to collect a deposit for it and then return it, disinfect it, that would tie up far too much MA working time, so we didn't use it.” (GP04; 06:54)
“Yes, and something has been stolen before, somehow a painting even from the wall, and we just didn't want to induce this stress with this tablet now, [...] we had this conversation in the practice […]” (M01; 12:03)