Patient Preference and Adherence Dovepress open access to scientific and medical research Open Access Full Text Article ORIGINAL RESEARCH A Co-Design Process to Elaborate Educational Materials to Promote Appropriate Use of Antibiotics for Acute Lower Respiratory Tract Infections in Primary Healthcare in Catalonia (Spain) This article was published in the following Dove Press journal: Patient Preference and Adherence Laura Medina-Perucha 1 Purpose: Co-design processes with patients allow developing health education materials, that are Pablo Gálvez-Hernández2,3 adapted to the population’s knowledge and use of language, to reduce inappropriate antibiotic use. Ana García-Sangenís 1,4 Patients and Methods: This study presents a co-design process of educational material Ana Moragas 5 Josep María Cots6 with patients (over 18 years old) with a previous diagnosis of acute lower respiratory tract Anna Lanau-Roig6 Alícia Borrás2,7 infection. The co-design was framed within a qualitative study (Phase I, interviews; Phase II, Isabel Amo2 Nieves Barragán8 focus group) conducted in Barcelona between April and September 2019. Ramon Monfá1,4 Carl Llor1,9 Results: Twenty-nine semi-structured interviews were conducted. Six people participated in Anna Berenguera 1,4,10 the focus group. Based on participants’ narratives, educational materials can be useful to 1 Fundació Institut Universitari per a la recerca support healthcare consultations. Materials should be designed to be accessible in terms of a l’Atenció Primària de Salut Jordi Gol i Gurina the content and language used. (IDIAPJGol), Barcelona, Spain; 2Institut Conclusion: The co-design of educational materials is essential for health promotion. This Universitari de Pacients (Patients’ University Institut), Universitat Internacional de Catalunya, study presents an example of how materials can be co-developed with patients. The material Barcelona, Spain; 3University of Toronto, elaborated in this study is being used for the ISAAC-CAT project and may be useful for IHPME-BFON Collaborative PhD Specialization Program in Health Services and Policy Research, future research, practice in health services and health policy. Ontario, Canada; 4Universitat Autònoma de Keywords: health education, co-design, acute respiratory infections, antimicrobial Barcelona, Bellaterra (Cerdanyola del Vallès), Spain; 5Universitat Rovira i Virgili, Jaume resistance, primary healthcare I Health Centre, Institut Català de la Salut, Tarragona, Spain; 6La Marina Health Centre, Institut Català de la Salut, Associació d’Infermeria Familiar i Comunitària de Catalunya, Barcelona, Spain; 7Escola Plain Language Summary Universitària d’Infermeria, Escoles This study is an example of how educational materials can be designed with patient collaboration. Universitàries Gimbernat, Universitat Autònoma de Barcelona, Sant Cugat del Vallès, The study is focused on encouraging people to use antibiotics correctly to avoid developing Spain; 8Societat Catalana de Medicina Familiar antibiotic resistance. The researchers interviewed 29 patients that had had a respiratory infection i Comunitària (Camfic), Grupo Programa Comunicación y Salud semFYC. CAP Vallcarca in Catalonia (Spain). Six of the patients that were interviewed also participated in a group session Health Centre, Barcelona, Spain; 9Via Roma where they collaborated with the researchers, on how to design educational material to improve Health Centre, Institut Català de la Salut, antibiotic use. The materials needed to be easy to understand for the general population, so the Barcelona, Spain; 10Departament d’Infermeria, Universitat de Girona, Girona, Spain language had to be clear and plain. There were also some ideas on how to make the content and formatting of the educational material better. The material that was elaborated will be used in a larger study called ISAAC-CAT. The researchers hope that this study will help in future research and aid healthcare professionals to create public policies. Correspondence: Laura Medina-Perucha Gran via de les Corts Catalanes, 587, Introduction Attic, Barcelona, 08007, Spain An increase in morbidity and mortality due to antimicrobial resistance is one of the Tel +34 93 482 4253 ext. 4761 Email lmedina@idiapjgol.info main public health challenges worldwide.1,2 This is the reason why public health submit your manuscript | www.dovepress.com Patient Preference and Adherence 2021:15 543–548 543 DovePress © 2021 Medina-Perucha et al. This work is published and licensed by Dove Medical Press Limited. 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Medina-Perucha et al Dovepress programs have been developed around the globe, to design based on the following characteristics: sex, age, ethnicity, strategies that reduce inappropriate use of antibiotics.3–6 date of last ALRTI, number of ALRTIs in the last year and The first aim of the policies planned by the World Health treatments received.15 Thus, participant characteristics Organization is currently to “increase consciousness and were considered throughout recruitment to ensure infor­ knowledge around antimicrobial resistance through effec­ mants’ variability in their profiles and discourses. tive communication, education and training”.1 High- Interviewed participants were recruited from four primary quality and effective health communication has become healthcare centers, three in Barcelona and one in even more crucial in the context of the COVID-19 Tarragona (Catalonia, Spain). The focus group participants pandemic.7 were selected from among those who had taken part in the The design of materials for health education is one of interviews. Then, all interview participants were contacted the key priorities. These materials help to convey precise and invited to take part in the focus group. Six participants health information and can be accessed through healthcare agreed and participated in the focus group. A topic guide services. Thus, they complement the information that was used to conduct the interviews, which included other patients receive during a healthcare consultation. Given topics including the development and use of educational the importance of adapting educational materials to the materials (see Supplementary Material 1). Another topic population to ensure a full understanding of the informa­ guide was developed for the focus group, using data from tion, involving patients in the co-design of materials is the interviews and different manuals to design health edu­ essential.8,9 However, the population is rarely included as cation materials (see Supplementary Material 2).16–18 All an active agent for co-design research and practice.10 This interviews and the focus group were audio-recorded with is a crucial element to promote patient-centered healthcare participants’ consent. Data were analyzed using thematic systems.11,12 content analysis.15 This paper presents a co-design process of educational As for the co-design process, first, interview data were materials to promote an appropriate use of antibiotics for analyzed to design a draft of educational material (Phase I). acute lower respiratory tract infections (ALRTIs) in pri­ In the focus group (Phase II), preliminary results were mary healthcare in Spain. This study is part of the ISAAC- presented to participants, for feedback and co- CAT project,13 a randomized controlled trial that aims to interpretation of the data. Discussing interview findings compare three interventions to reduce antibiotic prescrip­ with the focus group participants was also useful to design tion for ALRTIs in Catalonia (Spain). and develop the educational material. Then, participants worked on the co-design of the material. Each participant Patients and Methods was given the educational material draft that had been This paper presents a co-design process, using qualitative prepared based on the interviews. Participants discussed research methods, to develop health educational materials their views on the drafted material and suggested changes to promote appropriate antibiotic use in Catalonia (Spain). for improvement throughout the session. The study took place in two phases. In Phase I, twenty- The final educational material was based both on the nine patients participated in semi-structured individual analysis of the interviews and the focus group. This mate­ interviews that took place between April and July 2019. rial was finalized with the contributions of the members of The interviews lasted between 21 and 84 minutes and were the research team and a graphic designer (NG). The conducted by the authors LMP (N=24) and ABe (N=5). designed material cannot be presented in this publication The interviews covered other relevant topics, such as the to prevent any interference in the development of the design and use of educational materials. Other interview randomized controlled trial of the ISAAC-CAT project findings are published elsewhere.14.In Phase II, a focus where the educational material will be used.13 Instead, group (N=6) was selected and a discussion took place at examples of changes led by the participants in the material the [research center] on September 26th 2019, lasting 90 content will be provided. minutes and chaired by LMP and ABe. Participants were adult patients (over 18 years old) Results with a diagnosis of at least one ALRTI in the last 12 Interview participants were 29 patients (16 women and 13 months. Sampling was selective and purposive. men). The average age was 57 (range from 25–89). Almost Participants were selected to attain discursive diversity all participants were White (N=28), while one was Latino. 544 submit your manuscript | www.dovepress.com Patient Preference and Adherence 2021:15 DovePress Dovepress Medina-Perucha et al Most had been born in Spain (N=26). Some were working information had to be available in print, as most people full time (N=12). Six interview participants took part in the preferred this format (especially the elderly). However, focus group (five men and one woman), the average age was there should also be the option of having this information 67. Findings are presented separately for the interviews (co- online so that healthcare professionals could send it via design phase I) and the focus group (co-design phase II). email to those who may prefer it. Better on paper [. . .] Yes, you can read and re-read and Phase I: Interviews highlighted and even re-read [. . .] Yes, you are used to Based on participants’ narratives, having access to written paper because you retain it and re-read 40 times. And the materials on ARLTIs could be useful to care for their laziness of scrolling 40 pages on the phone . . . and also another thing, the phone screens that are used, they do not health. The current access to information was seen as go well. (P28, man, 89 years old; interview) a problem as it is not regulated. For instance, anyone could access a great amount of information on the Online would be ideal [. . .]. What could be done is to send Internet but there was no control over the quality of the it always online and the doctor could ask ‘do you want information and how it is portrayed. According to partici­ information?’ and then print the leaflet. If you say you pants, written information should never replace the infor­ don’t want to, then you don’t want to. (P26, woman, 25 years old; interview) mation given by healthcare professionals. A few participants mentioned that, even if they thought having written information available was useful, they Phase II: Focus Group would most probably not read. Another few explained Participants discussed the content’s coherence and suitabil­ that they considered having enough information already. ity. Changes were suggested on how the material content Yes, it would be interesting that they could also give it was organized. Participants agreed on the fact that educa­ [written information] to you . . . well, that there was infor­ tional materials should be based on the patient’s needs and mation, a leaflet or something . . . [. . .]. Well, everything is objectives. The importance of appropriate antibiotic use on the Internet now, also . . . well, you also need to filter should be highlighted. what you find in the Internet, because it could be that you Participants identified and suggested eliminating con­ are already dead for having pneumonia, you know?. (P11, tradictions in the material, such as promoting the use of woman, 35 years old) over-the-counter medication, at the same time that anti­ Participants thought that written information should biotic use was encouraged to be responsible and based on mainly include treatment guidelines (including non- a prescription. Some participants also mentioned the pharmacological) and preventive measures (including risk importance of not using a symptom (eg, cough) as a synonym for a health condition (eg, ARLTI), as this factors and transmission routes). Some participants also can be misleading. They suggested that language should mentioned the utility of including the etiology of ARLTIs, be accessible and technical terms should be avoided. guidelines to follow when there are comorbidities, drug´ However, the language had to be formal enough to com­ side effects, contraindications and mechanisms of action. municate respect and formality. Some concepts (eg, what Well so I suppose that related to what each person has, so a virus is) should be explained to facilitate understanding. what is the disease itself, the medication that needs to take, Besides, some of the terms used were perceived as being especially warning that it is always the doctor who need to too subjective (eg, continuously or profusely). Participants say . . . but well, normally the medication usually available, suggested replacing them with clearer descriptions or and well, these kind of things, and the guidelines to take terms. Participants also pointed out that the reasons for this medication, because more or less the medication some health recommendations (eg, avoid covering your guidelines are always the same, right?. (P18, man, 60 mouth with your hands when coughing) should be years old) explained. Participants considered that the materials should be avail­ The images available in the educational material’s draft able both in Catalan and Spanish (the two official languages were not sensitive or representative to the gender, age and in Catalonia), and use an inclusive and non-judgmental ethnical diversity in the participant’s context, as most language. Most participants explained that written images were originally of White men only. Images for submit your manuscript | www.dovepress.com Patient Preference and Adherence 2021:15 545 DovePress Medina-Perucha et al Dovepress the materials should be carefully selected so that they are subjects.14,22,23 This is the reason why the co- inclusive of gender, age and ethnical diversity. Other for­ development of educational materials with patients is matting elements, such as font and institutional logos’ size key, not only to achieve their function effectively, but to were mentioned. Font-size should be bigger than in the accompany people in a long-term learning process. draft, around 14–18 points. Institutional logos should be Health literacy should also be considered when devel­ small to be perceptible without taking too much space. oping educational materials. This concept is understood as Participants preferred the material in an A4 sheet to the ability for people to critically evaluate information and a leaflet. make health-related decisions accordingly.24,25 It is an Examples of initial suggestions (on the educational essential element for co-development processes as health material draft) and changes made based on participants’ literacy has an impact on how people use the healthcare suggestions can be found in Table 1. system, communicate and relate with healthcare profes­ sionals and practice self-care.24,26 Educational materials Discussion and Conclusions for appropriate antibiotic use should ensure health literacy Communication is an essential element for health among users. The population’s diversity in education promotion.19–21 One of the reasons for its importance is should be considered and people with different character­ that it promotes the population’s knowledge of their own istics (eg, educational and socioeconomic status levels) body and health. Then, communication can become a tool should be included in co-development sessions.27,28 to allow patients to abandon an inherently passive model In this study, findings suggest that educational materi­ of patients so that they actively promote and protect their als could be useful to support healthcare consultations. own health.14 This approach means to break with the These materials should be accessible, in terms of the con­ traditional biomedical model of health, in which the tent and language used. The educational material will be means of healthcare is exclusively owned by healthcare used for the randomized controlled trial of the ISAAC- professionals, who represent authorities inside a system CAT project.13 We expect this material to be useful for that understands and treats people as passive future research, clinical practice and health policies. And, Table 1 Examples of Initial Suggestions and Changes Based on Participants’ Suggestions Areas of Initial Suggestion (Draft) Changes Based on Participants’ Suggestions Improvement Content What is a cough? What is a cough? What causes a cough? Causes How long does a cough last? To prevent infection Are antibiotics useful? Remedies What can be done? Need for antibiotics How to prevent transmission? When to ask for help Over-the-counter medication When to ask for help Format Leaflet A4 sheet Images lack of gender, age and ethnical diversity Change images to ensure gender, age and ethnical diversity Small font size (point 9) Increase Font size (point 14–18) Institutional logos are too big Reduce size institutional logos Language There is no difference made between “dry cough” and “wet Explain the differences between dry and wet cough cough” Use of the term “transmission” Use the term “infect” Use of the term “airways spasm” Use of the term “breathing difficulties” 546 submit your manuscript | www.dovepress.com Patient Preference and Adherence 2021:15 DovePress Dovepress Medina-Perucha et al ultimately, we expect it to contribute to tackling antimi­ critically reviewed this manuscript. ABe supervised the crobial resistance. development of the qualitative study. She participated in the design of the study, data collection, data analysis and Data Sharing Statement interpretation. She also contributed to the design of the Data will be made available upon reasonable request to the educational materials and reviewed this manuscript. All authors, contacting Dr Anna Berenguera at aberenguer­ authors made substantial contributions to conception and a@idiapjgol.org. All data will be anonymized to ensure design, acquisition of data, or analysis and interpretation participants’ confidentiality and anonymity. of data; took part in drafting the article or revising it critically for important intellectual content; agreed to sub­ Ethics Approval and Informed mit to the current journal; gave final approval of the version to be published; and agree to be accountable for Consent all aspects of the work. Ethical approval was granted by the Ethics Committee of the Institut de Recerca en Atenció Primària Jordi Gol i Gurina (IDIAPJGol) (REC P18/227) on 19th of Funding This study is part of the ISAA-CAT Project, funded by the December 2018. All participants were informed about the Fundació La Marató de TV3 (Ref. 201820): https://www. purpose of the study and gave their verbal and written ccma.cat/tv3/marato/fundacio/. The funder has not influ­ consent to take part in the study prior to their participation. enced the development of this study. This study has been conducted in accordance with the Declaration of Helsinki. Disclosure The authors report no conflicts of interest in this work. Consent for Publication All participants gave their consent for their anonymized data to be published. References 1. World Health Organization. Global Action Plan on Antimicrobial Resistance. Geneva:World Health Organization; 2015. Acknowledgments 2. Gajdács M. The concept of an ideal antibiotic: implications for drug We would like to thank all participants that have taken part design. Molecules. 2019;24(5):892. doi:10.3390/molecules24050892 3. Aslam A, Gajdács M, Zin CS, et al. Evidence of the practice of in this study. 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This journal has open access journal that focusing on the growing importance of been accepted for indexing on PubMed Central. The manuscript patient preference and adherence throughout the therapeutic conti­ management system is completely online and includes a very quick nuum. Patient satisfaction, acceptability, quality of life, compliance, and fair peer-review system, which is all easy to use. Visit http:// persistence and their role in developing new therapeutic modalities www.dovepress.com/testimonials.php to read real quotes from pub­ and compounds to optimize clinical outcomes for existing disease lished authors. Submit your manuscript here: https://www.dovepress.com/patient-preference-and-adherence-journal 548 submit your manuscript | www.dovepress.com Patient Preference and Adherence 2021:15 DovePress