Education and Enablement Towards the Recommended Self-Management of Uncomplicated UTI Symptoms: Making Evidence-Based Recommendations for Women in the Maltese Context
Authors:   , Cutajar Elaine 
Published: March 2024

The resistance of bacteria to antibiotic drugs (Antibiotic Resistance [ABR]) has advanced to the point that it considerably jeopardizes the advancements made in healthcare over many years, and is thus perceived as a leading global public health concern. As is the case with various other health isues, the emergence and spread of ABR are largely influenced by human behaviour including unnecessary use of antibiotics, particularly in self-limiting infections (SLI) such as Urinary Tract Infection (UTI) that may not necessarily need antibiotics. Therefore, behaviour change initiatives informed by the behavioural and social sciences have been highlighted as worthwhile options to consider when attempting to address the spread of ABR. This thesis begins with a scoping review which established a situational analysis of research around public knowledge, attitudes and practices (KAPs) related to antibiotic use and resistance in SLI. To fill an identified lacuna illustrated by the results and discussion of the scoping review, the current doctoral research aimed to explore experiences of the management of uncomplicated UTI symptoms by women in the Maltese context, with a view to derive highly specific recommendations for behaviour change. An exploratory in-depth interview study was conducted with twenty-two women recruited online and from pharmacies and places of public congregation on the Maltese archipelago, who have experienced symptoms of UTI. Guided inductive Thematic Analysis (TA) (Braun & Clarke, 2006) was conducted to expose and explore key beliefs and experiences around the subject. Building from this, a post-hoc deductive application of the Theoretical Domains Framework (TDF), the Behaviour Change Wheel (BCW) and the Behaviour Change Technique Taxonomy (BCTT) (Version 1) was conducted, following a set of guidelines. Inductive TA resulted in six overarching themes that represented the overall responses of women in the Maltese context to symptoms of UTI, and provided insights into motives, decisions, and beliefs underlining self-management behaviours. Post-hoc analyses and reference to literature suggested that from the overall behavioural system of UTI symptom management in the Maltese context, it would be most beneficial to encourage the ‘recommended self-management of UTI symptoms for at least 48 hours after symptom recognition’. This, when compared with evidence-based guidelines, was then further specified into a group of target sub-behaviours that were also considered within the analyses. Behavioural analysis found that women’s decisions and behaviours were complex and impacted by numerous barriers and facilitators at the individual, interpersonal, and overall community or environmental level. Intrinsic barriers or facilitators influencing behaviours included knowledge and awareness, previous experience, perceptions of symptom severity, emotional responses to symptoms, and barriers related to memory or forgetfulness. However, external factors also featured in participant narratives including the accessibility or availability of antibiotics or conflicting information from family, friends, or healthcare professionals (HCPs). Specific ways of optimizing the suggested interventions were also described in relation to potentially useful Behaviour Change Techniques (BCTs) for a public-facing, credibly sourced, informational resource that also includes advice for behavioural regulation, self-monitoring, and environmental changes and an opportunity to make a commitment towards the recommended self-management of UTI symptoms for at least 48 hours after symptom recognition. While the body of evidence supporting public-facing interventions to slow the spread of ABR is expanding swiftly, there is still much to be learned about how research and intervention based on social and behavioural theory might lead to better outcomes. The current study provided a systematic approach towards detailed behavioural analysis and the use of the TDF and BCW approach to develop highly specific, evidence-based, and theoretically informed proposals for intervention design and optimization.