Research

Identifying and addressing UTI prevention barriers in primary care: a qualitative study

Merel EP Wilmsen, Laurens C van Gestel, Martijn Sijbom, Ashty Koucher, Marjan J Aantjes, Leti van Bodegom-Vos, Rimke C Vos, Tobias N Bonten, Marieke A Adriaanse, Suzanne E Geerlings, Leo G Visser and Merel MC Lambregts
BJGP Open 17 August 2026; BJGPO.2025.0230. DOI: https://doi.org/10.3399/BJGPO.2025.0230

Abstract

Background Urinary tract infection (UTI) recurrence rates are high for certain patient groups, affecting physical and mental health, and leading to repeated antibiotic usage. Behavioural measures and non-antibiotic products can prevent recurrences, reducing the need for antibiotics. However, these preventive strategies are often not addressed, despite being advocated in UTI guidelines.

Aim To identify barriers to and facilitators of discussing UTI prevention in primary care and to identify strategies to overcome these barriers.

Design & setting Qualitative study in a primary care setting.

Method Semi-structured interviews were performed with GPs, doctor’s assistants, and patients with a history of UTI to identify barriers to and facilitators of discussing UTI prevention. Deductive content analysis was employed, using the Theoretical Domains Framework to structure the interview guide and analyse the data. Subsequent focus groups were performed to identify strategies to overcome the barriers.

Results Main barriers for all stakeholders included incomplete knowledge, prioritisation of treatment over prevention, and time pressure at the general practice. Additionally, general practices lacked protocols on when, which, and by whom preventive measures should be discussed. Healthcare professionals also assumed patients already held preventive knowledge and solely sought care to obtain antibiotics. The main facilitator was patient-initiated conversations about UTI. Strategies included enhancing knowledge, inviting patients to initiate conversations about UTI, and optimising the timing of preventive information dissemination.

Conclusion Barriers exist across behavioural, interpersonal, and organisational domains, but provide clear starting points for tailored interventions. The strategies offer promising directions for improving UTI prevention and reducing antimicrobial consumption.

How this fits in

To date, implementation of non-antibiotic urinary tract infection (UTI) prevention in primary care has received little attention. In this qualitative study, we identified behavioural, interpersonal, and organisational barriers that explain why preventive counselling is often omitted or incompletely provided in daily practice. Tackling these barriers has the potential to improve overall UTI management, and reduce the number of UTI recurrences, antibiotic use, and primary care visits.

Introduction

UTIs negatively impact the quality of life of patients and pose a significant burden on health care.1,2 UTI is one of the most diagnosed infectious diseases in primary care with over 100 cases per 1000 patients annually.3,4 One-year recurrence rates are high, particularly among post-menopausal women and women with a history of UTI.5,6

UTI recurrences decrease physical functioning, increase emotional distress,7 and drive antimicrobial resistance.8,9 Antibiotic resistance delays effective treatment, prolonging illness.10 Therefore, preventing UTI recurrences is essential to reducing both the disease burden and antibiotic needs.

Non-antibiotic preventive measures can be effective in reducing the frequency of recurrences. Available evidence shows beneficial effects of increased fluid intake,11 complete voiding,12 cranberry products,13,14 and vaginal oestrogens on preventing UTI.15 Evidence of wiping patterns, douching, post-coital voiding, and use of contraception without spermicide remains limited, as fewer and lower-quality studies have been conducted on these measures.16,17 Guidelines on UTI, for example, from the European Association of Urology and Dutch College of General Practitioners, recommend discussing preventive measures with patients based on the available evidence18–20 (see Supplementary Table S1).

However, research shows that non-antibiotic UTI prevention is not always addressed in the primary care setting.21,22 Previous studies on UTI management in primary care have mainly focused on optimising antibiotic use and understanding barriers to guideline-adherent care, while only briefly covering non-antibiotic prevention.23,24 To build on these insights and support the integration of UTI prevention in primary care, our study aimed to provide a comprehensive understanding of the underlying reasons — barriers and facilitators — of discussing non-antibiotic UTI prevention in primary, and to identify potential strategies to overcome the barriers.

Method

This study included semi-structured interviews to identify barriers to and facilitators of discussing preventive measures, and focus groups to identify strategies to overcome the barriers.

Study design and setting

The study was conducted in the Netherlands, within the Leiden–the Hague area. For the interview study, semi-structured interviews were used. The Theoretical Domains Framework (TDF), containing fourteen domains that describe the underlying reasons of behaviour, was applied to structure the interview guide and analyse the data. We chose a deductive approach based on existing knowledge on barriers to antibiotic-sparing treatment options in UTI, and applied the TDF to systematically identify behavioural determinants.25 Interviews were conducted from June to November 2024 with GPs, doctor’s assistants (DAs), and patients with a history of cystitis in the past 2 years (see Supplementary Tables S2–S4). In the Netherlands, DAs are the primary point of contact in general practice, handling triage and basic clinical tasks. Due to GPs and DAs having a shared responsibility in UTI management in the Netherlands, both stakeholders were included. Focus groups were conducted in February 2025 with the same type of stakeholders as the interviews, but with different participants (see Supplementary Table S5), to ensure that the strategies meet patient needs but minimise workload in general practice.

This study was conducted and reported according to the Consolidated Criteria for Reporting Qualitative Research check-list.26

Participant selection and recruitment

Interview and focus group participants were recruited from the regional network of GP centres. To achieve heterogeneity in both samples, we focused on variation in age, gender, patient history of UTI, and work experience of GPs and DAs. Participants were approached via e-mail with an explanation of the study. In case of interest, the information and consent forms were sent either by e-mail or post, depending on a participant’s ability to sign digitally, and returned. The informed consent process was completed prior to the interviews and focus groups. Details of invitations and final participation are shown in Supplementary Table S6. All participants received a €25 voucher for an online department store as compensation.

Interview participants were recruited until data saturation. Each focus group had a maximum of eight participants, so that all attendees could actively contribute to the discussion. We ensured a patient-majority to minimise the risk of patients being overshadowed due to power dynamics. Two focus groups were held, as most insights generally arise from the first session and decline thereafter.27

Development of the interview guide and the focus group topic list

The interview guide was based on the TDF, which was used to pre-determine questions to maintain the interviews within the lines of the framework, while simultaneously allowing for questions to emerge during the interviews.28 The interview guide was co-created (by AK, MMCL, and LCvG), adapted to the stakeholders (Supplementary Tables S7 and S8), and pilot-tested with three healthcare professionals and one patient with a history of UTI to assess completeness, clarity, terminology, and question sequencing.

For the focus groups, a topic list was drafted (by MEPW and MMCL) based on the identified barriers in the interview phase. Each barrier was presented using a PowerPoint presentation and explained to the group to initiate a discussion per barrier. Through these discussions, potential strategies were generated to overcome the barriers.

Data collection and analysis

Interviews were conducted in Dutch (by MEPW, AK, and MJA), either online (via Microsoft Teams) or in person. In-person interviews took place at the participant’s home, their work office, or the Leiden University Medical Centre. Each interview was conducted with one interviewer and one participant. The interviewers had no relationship with the participants. Interviews took between 30 and 45 minutes and were audiorecorded. Audiorecordings of the interviews were uploaded in Microsoft Word to automatically generate transcripts of the recordings, which were checked manually. Data from the interviews were analysed deductively through content analysis.29 The interviews were coded according to the domains of the TDF (major themes) using ATLAS.ti (version 24). Similarities between quotes were identified and grouped into barriers and facilitators (minor themes) per TDF domain in Microsoft Excel. Two researchers (MEPW and AK) independently performed the coding. In case of disagreements, a third researcher (MMCL) was involved. Researcher triangulation was applied by frequently discussing the results with members of the research team,30 which consisted of scientists with different backgrounds (see Supplementary Table S9). Data were considered saturated when three consecutive interviews yielded no new barriers or facilitators. The absence of new information was assessed by two researchers (MEPW and MMCL).

The focus groups were conducted in person at two sites of Leiden University. They were guided by a process moderator (MMCL) and a content moderator (MEPW), and took 90 minutes. Sessions were audiorecorded. The recordings were reviewed, and any mention of a potential strategy was documented (by MEPW). The list of strategies was systematically reviewed to identify overlap or similarity in meaning (MEPW and MMCL). Strategies with overlapping content were consolidated and rephrased into a clearly-defined, single strategy. When strategies related to >1 barrier they were linked to the best-fitting barrier. In case multiple barriers shared most strategies, the barriers were combined in the same table row (MEPW and MMCL). Matching the strategies and linking them to the barriers resulted in Table 1.

View this table:
Table 1. Identified strategies addressing the barriers

Results

Participant characteristics

We included 31 interview participants; 10 GPs, 10 DAs, and 11 patients (two men and nine women) with a history of UTI. Median work experience of the GPs and DAs was 8 (interquartile range [IQR] 5–19) and 5 years (IQR 3–25), respectively. The patients had a median age of 69 years (IQR 52–73) and experienced a median of three UTIs in the past 2 years (IQR 2–12). An overview of the individual demographics is presented in Supplementary Tables S2–S4.

The first focus group included four patients, two GPs, and one DA. The second included four patients and two GPs. All patients had a history of UTI in the past 2 years (see Supplementary Table S5).

Barriers and facilitators

Barriers and facilitators were primarily identified across 10 TDF domains. Table 2 specifies which minor themes applied to whom.

View this table:
Table 2. Overview of the barriers and facilitators within each TDF domain, along with the stakeholders to whom they apply, and illustrative example quotes

Knowledge

All stakeholders held knowledge of the existence of some preventive measures, particularly of sufficient hydration, complete bladder emptying, and cranberry supplements. One DA acknowledged not being familiar with the mechanisms of action, discouraging her to provide preventive counselling. Knowledge of vaginal oestrogen therapy was lowest; patients generally never heard of it, whereas GPs and DAs mentioned its use for indications, such as vaginal atrophy, but its role in UTI prevention was relatively unknown to them.

A few DAs also noted that they were not aware of the impact UTIs can have on the quality of life of patients. Low awareness affected whether or not patients were referred to external resources, such as the GP-at-home website.

Memory, attention, and decision processes

Some DAs acknowledged that certain preventive measures were forgotten over time, resulting in only a limited selection being shared with patients. This was mainly due to the infrequent use of memory aids, such as the triage guide or the national guideline, during UTI management:

‘… UTIs are encountered so often that you don’t check that [the GP-at-home website] anymore. But, now I see and think “oh yes, there were even more preventive measures available”.’ (DA5)

Behavioural regulation

For DAs, UTI management is a routine action, which was also noticed by the GPs. For two DAs, this routine included prevention, whereas for the others, it did not. As a result, DAs acknowledged not discussing prevention during UTI consultations, despite having the knowledge:

‘I do think we know it [the preventive measures], but we’re just unaware of them, but we definitely know it.’ (DA1)

Social and/or professional role and identity

Both GPs and DAs felt responsible for sharing preventive measures with patients. However, the sense of responsibility was dependent on the patient’s context. Some GPs felt that their responsibility was limited to specific cases, such as to patients with frequent recurrences, but most GPs did consider it their responsibility to train the DAs to be able to accurately convey preventive information. The DAs stated it was their responsibility to discuss the preventive measures, mainly because they serve as the primary point of contact. In line with the GPs, the DAs felt the responsibility shifted to the GP in case of frequent recurrences.

Most patients indicated that they listen to and trust the information provided by their healthcare provider (HCP). However, preferences varied regarding who should provide information on preventive measures. Four patients explicitly stated that they did not want to receive this information from the DA, whereas three other patients greatly appreciated the advice from the DA in the past.

Beliefs about capabilities

Both the patients and the HCPs felt confident enough to initiate a conversation about preventive measures. However, a GP and some DAs acknowledged situations where they found discussing preventive measures more difficult, related to characteristics of the patient population and type of advice:

‘Some Muslim women, for example, bring their child … and then you’re going to ask, “do you have regular sex?’” … Perhaps you hold back on that when there’re children present … ’ (GP6)

‘Sometimes that’s difficult [discussing urination post-coitus] when someone is very old … While everyone can have sex, even those elderly women, but you just tend to hold back.’ (DA7)

Among the patients, it was noted that they felt more comfortable discussing preventive measures with a younger GP, a female GP, and a long-standing GP with whom they had an established relationship.

Beliefs about consequences

Uncertainty about patients’ acceptance of preventive information influenced GPs and DAs in their decision to initiate conversations about preventive measures. Less educated and older patients were generally perceived as less receptive to accept advice than highly educated and younger patients. For patients with occasional UTIs it was anticipated that they might not feel the need to receive the advice, while for those with recurrences, it was feared by some DAs that patients would already know the preventive measures and would be frustrated by receiving it again:

‘Of course, when people are familiar with this [preventive measures], it could cause irritation when telling them the same story over and over … ’ (DA6)

Additionally, some GPs and DAs questioned whether patients would actually follow the advice, even when provided. Others believed that patients experiencing a high disease burden would be motivated to engage in preventive measures.

It was also noted that the high frequency of UTIs in general practice, with several cases seen daily, contributed to a sense of normalisation of UTIs and perceiving these infections as minor health issues. This reduced the delivery of information on preventive measures.

Additionally, there existed some slight scepticism towards the efficacy of preventive measures among all stakeholders. Nevertheless, the patients remained motivated to engage in preventive measures, mostly due to fear of antimicrobial resistance and the possibility of untreatable UTIs in the future. Generally, the preventive measures were perceived as having few downsides by the patients. A notable exception was vaginal oestrogen therapy, due to concerns about risks of hormonal use.

Goals

Most GPs and DAs indicated that the focus during consultations was primarily on treating the current UTI, rather than on preventing future episodes. When patients contact the GP practice, the urgency of the acute infection often takes precedence, leaving little room for preventive counselling. This was also acknowledged by three patients, who prioritised treatment of their current symptoms over prevention.

‘You would just prescribe antibiotics and be done with it, the patients didn’t even need to bring in urine. Do you recognise symptoms? Then it’s like “here you go, here’s your prescription!”.’ (DA1)

Discussing preventive measures was not prioritised by HCPs due to the overall low priority of UTI management in general practices. Although nearly all HCPs acknowledged the importance of discussing preventive measures, in most general practices it is overshadowed by other health issues. GPs and DAs stated that prevention gains priority when patients present with recurrences or severe complaints:

‘I can say I do [believe it’s important to discuss preventive measures], but apparently not, otherwise I would’ve done it. That’s the reality.’ (GP4)

For most patients it was high priority to prevent future UTI episodes, due to the significant impact UTIs had on their daily lives.

Reinforcement

Two GPs noted the absence of follow-up after giving preventive advice. As a result, they were often unaware whether discussing preventive measures had any beneficial effect, which discouraged them from raising the topic in future consultations. Receiving positive feedback from patients was seen as a motivator to discuss preventive measures more often, as it would reinforce the value of such conversations:

‘We’re also quite happy when we’re prescribing a weekly oestrogen ovule and we receive feedback, such as, “that really is a solution, now that I no longer have to deal with it [UTIs].”’ (GP1)

Environmental context and resources

Both GPs and DAs stated not to have on-site agreements on when, which, and by whom preventive measures should be discussed. GPs also did not know whether preventive advice was part of on-site protocols. As a result, they were unaware of the information DAs shared with patients, and DAs did not know the work procedures of the GPs. DAs stated that the GPs likely expected them to provide patients with preventive information, although this expectation was never explicitly communicated. According to DAs, there was also considerable heterogeneity in the preventive advice provided within general practices:

‘Some [DAs] do it very consistently [discussing preventive measures], you hear them say it every time. Others only mention it sporadically. There’s no uniformity.’ (DA3)

For a few patients and DAs, lack of privacy at the front desk was another barrier to discussing preventive measures. Patients were uncomfortable knowing others could overhear the conversation. For DAs, discussing sex-related measures, such as urinating post-coitus, in an open space felt uncomfortable for both themselves and their patients.

Most GPs stated that they discussed preventive measures primarily during personal contact, such as scheduled consultations; however, such contact is mostly limited to patients with recurrences or complications. Most UTI cases are managed by DAs without direct GP involvement, limiting opportunities for GPs to provide preventive counselling.

Lack of time was commonly mentioned across stakeholders, though experiences varied. Long wait times on the telephone discouraged further contact for patients. Time constraints during short consultations and a high workload were mentioned as reasons for omitting preventive advice by both GPs and DAs. Other HCPs felt time shortage should not be an excuse, as discussing preventive measures would not have to take long.

Language barriers hindered DAs from verbally transferring preventive information to patients. As a result, these patients were believed to receive less information. Physical information forms offer little help, as these are not available in multiple languages:

‘So, there’re a number of patients who absolutely don’t understand a thing and you try using gestures instead. But the reality is, they receive less information because of the language barrier.’ (DA7)

Social influences

Assuming patients are already familiar with the preventive measures was frequently mentioned by the GPs and DAs as a reason for not discussing them. These assumptions were rarely verified with patients. Reasons for these assumptions were being a (young) female, experiencing frequent recurrences, the patient making a ‘hygienic’ impression, and finding the preventive measures recorded in the patient files:

‘Maybe it’s not entirely fair, but if someone doesn’t look clean on the outside, you don’t really expect things to be clean underneath either … you might bring it up more easily with them than with a neatly dressed lady … ’ (DA7)

Another barrier for GPs and DAs was patients reacting dismissively towards preventive advice. They were often interrupted with comments, such as ‘I already know that’ and ‘just give me antibiotics’, which discouraged further preventive counselling. In other cases, preventive measures were not brought up at all because it was assumed that patients were only interested in receiving antibiotics. However, patient-initiated questions about UTIs, for example, regarding possible causes, were seen as a facilitator by most DAs to introduce preventive measures into the conversation.

For DAs, it was sometimes difficult to provide patients with additional information, as they felt that patients did not always want to accept information from them. For some DAs, this was reason to have the GPs take over the management of these patients:

‘Once they’ve provided a urine sample, they find it hard to accept what an assistant has to say, because you’re not a doctor. That’s something you often hear. That’s also a reason why we often let the GP handle this [discussing preventive measures].’ (DA1)

For some patients, it could be a barrier to visit the GP during a UTI episode, as they felt reluctant to occupy the GP’s time with something ‘simple’. Two patients mentioned to have experienced feelings of dismissiveness towards the impact of their UTIs:

‘I didn’t have the feeling that I was really able to convey how big the impact was — how much my complaints affected my daily functioning. To me, yeah, it was a very big deal.’ (Patient 9)

Strategies

The focus groups generated diverse strategies, which addressed multiple barriers, both within and across domains (Table 1). The strategies, considered feasible and relevant by all stakeholders, targeted both patient- and HCP-related barriers. Proposed strategies included improving patient knowledge (for example, via leaflets or posters), enhancing HCP knowledge and awareness (through training), and inviting patients with a history of UTIs to reach out to their HCP. Organisational strategies comprised clarifying the delineation of responsibilities between GPs and DAs, and optimising the timing of preventive information dissemination, both within the general practice (through consultations at fixed timepoints) and for patients (by receiving information outside acute episodes).

Discussion

Summary

Discussing UTI prevention in primary care is challenged by several barriers, spanning behavioural, interpersonal, and organisational domains. The most frequently mentioned obstacles included incomplete knowledge of preventive measures and the impact of recurrent UTI, a predominant focus on treatment rather than prevention among both patients and HCPs, lack of local agreements, and assumptions about patients’ knowledge and preferences.

Strengths and limitations

The main strength of this study is the engagement of all stakeholders involved in UTI management. The perspectives of both HCPs and patients with a history of UTIs with varying UTI frequencies, including those with recurrent UTI, offer a complete view of the barriers and facilitators. Additionally, involving scientists from diverse backgrounds (see Supplementary Table S9) reduces researcher bias and enhances both credibility and confirmability of the findings. Finally, the strategies identified in this study were co-created with all stakeholders, ensuring their relevance to clinical practice and likely acceptance. These strategies provide concrete directions for improving UTI prevention in primary care.

We may have introduced selection bias, as the patients and HCPs who agreed to participate are likely more receptive towards UTI prevention, possibly not reflecting the overall attitudes of stakeholders. Although the perspectives of DAs were well-represented in the interview phase, their representation was limited in the focus groups. Given their central role in UTI management and the barriers they face in daily practice, this may have influenced the breadth of the proposed strategies. Follow-up work should ensure stronger input from DAs. Finally, transferability is limited to healthcare systems similar to the Netherlands.

Comparison with existing literature

Past studies have shown that GPs may omit prevention due to insufficient evidence, unawareness of available guidelines, and restricting detailed advice to those with multiple recurrences.23,24 Our stakeholders also expressed doubts about the effectiveness of preventive strategies, illustrating how uncertainty or lack of familiarity with existing evidence may discourage preventive counselling in daily practice. Nonetheless, adherence to the guidelines remains important, as some patients may still wish to engage in prevention and could benefit from it.

In our study, for both incidental and recurrent UTIs reasons emerged to not discuss prevention. We found that preventive advice was not offered during a patient’s first episode — as it was considered less relevant at that time — but was also omitted in patients with frequent recurrences due to assumptions that it was already known. Guidelines do not specify whether preventive measures should be discussed with all patients presenting with a UTI in primary care. As 30%–44% of females with a UTI episode will experience a recurrence, often within 3 months,31 a significant proportion of patients could already benefit from preventive advice around the time of their first episode. The patients in our focus groups, who were heavily affected by UTI, also suggested to address prevention during a first episode. In practice, this could also prevent negative reactions from patients, as patients inexperienced with UTI may be more receptive towards advice than those with prior experience,23,32 possibly because the latter already tends to engage in self-help.33

We also found similarities between our study and research on barriers to non-antibiotic treatment, such as delayed antibiotic prescribing, including GP assumptions that women expect antibiotics, time constraints, lack of privacy, habitual prescribing behaviour, and limited GP–patient contact.23,34,35 In the context of prevention, it is noteworthy that assumptions about patients’ wish for antibiotics can still act as a barrier, even though this information is meant to complement — not replace — treatment. This finding indicates that the concepts of treatment and prevention tend to become conflated in patient communication. Given the partial overlap between the two, it is important to convey that preventive measures remain valuable beyond the acute episode.

Additionally, this study revealed that knowledge of vaginal oestrogens as a preventive product for UTI was relatively unknown, despite strong evidence for their effectiveness. This suggests that educational efforts of HCPs, which was identified as a solution during the focus groups, should especially focus on this knowledge gap. Although education targeting specific barriers can be successful in reaching behaviour change in general practice, combinations with other interventions, such as reminders of the desired behaviour, will likely have more impact.36,37 More frequent reminders than monthly educational sessions — for example, electronic pop-ups — may help to replace old with new habits.38

Another insight is the importance of agreements on who is responsible for providing preventive advice, and how and when it should be provided. Without them, work routines among HCPs vary and prevention is overlooked due to assumptions that either the GP or DA is responsible. Poor interprofessional communication has been described before as an important factor for inappropriate UTI management in older patients,39 reflecting the importance of clear local agreements among HCPs in providing appropriate UTI care.

Lastly, the general perception that UTIs are minor health issues is a reason why patients avoid the GP practice in case of a UTI. This represents missed opportunities for preventive counselling, as patients who initiate conversations about their UTI are clearly able to facilitate such counselling. Therefore, there is need to increase awareness about the UTI impact — not only through education, but also by hearing it directly from patients. Inviting patients to contact the general practice in case of UTI-related questions, and planning a consultation dedicated to UTI, has — aside from strengthening contact between patient and HCP — potential to increase such awareness. Moreover, patients will likely feel more prioritised and comfortable to reach out,40 reinforcing the patient-initiated facilitator. As we found DAs willing to take responsibility for providing preventive advice, similar to van Horrik et al,35 UTI consultations can initially be conducted by DAs. Consultations dedicated to UTI simultaneously reduce time pressure during busy hours and solve the lack of privacy. This is an example of how the proposed strategies have the potential to tackle barriers across several domains.

Implications for research and practice

Non-antibiotic UTI prevention is an understudied topic, despite the high recurrence rate of UTI. This study contributes to this research gap by showing that patients and HCPs face multifaceted challenges in discussing preventive measures in primary care.

The wide range of barriers identified in this study provide concrete starting points for the development of tailored interventions. Some of the proposed strategies can be considered ‘low-hanging fruit’, as they require minimal resources and can be readily integrated into existing workflows; for example, providing promotional and educational material, such as posters, flyers, and leaflets. Other strategies, such as introducing GP-signed letters, structuring prevention-focused consultations, or incorporating reminders and documentation fields into electronic patient records, may require more organisational support. Recognising the complexity of achieving behaviour change in health care, the next step is to refine and support the implementation of the proposed strategies in real-world primary care settings, followed by evaluation of implementation outcomes, such as feasibility, acceptability, and sustainability of the strategies in daily practice. In conclusion, this study identifies the barriers that hinder discussing UTI prevention in primary care and offers promising directions for tackling these barriers. To reduce the burden of recurrent UTI and the associated antimicrobial consumption, the proposed strategies need to be translated into practical tools for easy integration into daily routine.

Notes

Funding

This study was funded by Antimicrobial Resistance Network Holland West.

Ethical approval

As the Medical Research Involving Human Subjects Act (Dutch abbreviation: WMO) does not apply to this study, the non-WMO advisory committee of Leiden University Medical Center (on behalf of the Medical Ethics Committee Leiden The Hague Delft) approved this study (reference number: nWMODIV2_2024023).

Provenance

Freely submitted; externally peer reviewed.

Acknowledgements

We would like to thank all the participants of the interviews and focus groups for making this study possible.

Competing interests

The authors declare that no competing interests exist.

  • Received October 17, 2025.
  • Accepted November 11, 2025.

This article is Open Access: CC BY license (https://creativecommons.org/licenses/by/4.0/)

References

  1. 1.↵
    1. Vallejo-Torres L,
    2. Pujol M,
    3. Shaw E,
    4. et al.
    (2018) Cost of hospitalised patients due to complicated urinary tract infections: a retrospective observational study in countries with high prevalence of multidrug-resistant gram-negative bacteria: the COMBACTE-MAGNET, RESCUING study. BMJ Open 8(4), doi:10.1136/bmjopen-2017-020251, pmid:29654026. e020251.
    OpenUrlAbstract/FREE Full Text
  2. 2.↵
    1. Wagenlehner F,
    2. Wullt B,
    3. Ballarini S,
    4. et al.
    (2018) Social and economic burden of recurrent urinary tract infections and quality of life: a patient web-based study (GESPRIT). Expert Rev Pharmacoecon Outcomes Res 18(1):107–117, doi:10.1080/14737167.2017.1359543, pmid:28737469.
    OpenUrlCrossRefPubMed
  3. 3.↵
    1. Ahmed H,
    2. Farewell D,
    3. Jones HM,
    4. et al.
    (2018) Incidence and antibiotic prescribing for clinically diagnosed urinary tract infection in older adults in UK primary care, 2004-2014. PLoS One 13(1), doi:10.1371/journal.pone.0190521, pmid:29304056. e0190521.
    OpenUrlCrossRefPubMed
  4. 4.↵
    1. Bes J,
    2. Heins M,
    3. Weesie Y,
    4. et al.
    (2024) [General practice care. Nivel Primary Care Database: 2023 annual figures and trend data 2019-2023]. [Article in Dutch], accessed. https://www.nivel.nl/nl/publicatie/zorg-door-de-huisarts-nivel-zorgregistraties-eerste-lijn-jaarcijfers-2023-en. 17 Jul 2026.
  5. 5.↵
    1. Ikäheimo R,
    2. Siitonen A,
    3. Heiskanen T,
    4. et al.
    (1996) Recurrence of urinary tract infection in a primary care setting: analysis of a 1-year follow-up of 179 women. Clin Infect Dis 22(1):91–99, doi:10.1093/clinids/22.1.91, pmid:8824972.
    OpenUrlCrossRefPubMed
  6. 6.↵
    1. Suskind AM,
    2. Saigal CS,
    3. Hanley JM,
    4. et al.
    (2016) Incidence and management of uncomplicated recurrent urinary tract infections in a national sample of women in the United States. Urology 90:50–55, doi:10.1016/j.urology.2015.11.051, pmid:26825489.
    OpenUrlCrossRefPubMed
  7. 7.↵
    1. Renard J,
    2. Ballarini S,
    3. Mascarenhas T,
    4. et al.
    (2014) Recurrent lower urinary tract infections have a detrimental effect on patient quality of life: a prospective, observational study. Infect Dis Ther 4(1):125–135, doi:10.1007/s40121-014-0054-6, pmid:25519161.
    OpenUrlCrossRefPubMed
  8. 8.↵
    1. Ku JH,
    2. Tartof SY,
    3. Contreras R,
    4. et al.
    (2024) Antibiotic resistance of urinary tract infection recurrences in a large integrated US healthcare system. J Infect Dis 230(6):e1344–e1354, doi:10.1093/infdis/jiae233, pmid:38743691.
    OpenUrlCrossRefPubMed
  9. 9.↵
    1. Lob SH,
    2. Nicolle LE,
    3. Hoban DJ,
    4. et al.
    (2016) Susceptibility patterns and ESBL rates of escherichia coli from urinary tract infections in Canada and the United States, SMART 2010-2014. Diagn Microbiol Infect Dis 85(4):459–465, doi:10.1016/j.diagmicrobio.2016.04.022, pmid:27306116.
    OpenUrlCrossRefPubMed
  10. 10.↵
    1. Butler CC,
    2. Hillier S,
    3. Roberts Z,
    4. et al.
    (2006) Antibiotic-resistant infections in primary care are symptomatic for longer and increase workload: outcomes for patients with E. coli UTIs. Br J Gen Pract 56(530):686–692, pmid:16954001.
    OpenUrlAbstract/FREE Full Text
  11. 11.↵
    1. Scott AM,
    2. Clark J,
    3. Mar CD,
    4. Glasziou P
    (2020) Increased fluid intake to prevent urinary tract infections: systematic review and meta-analysis. Br J Gen Pract 70(692):e200–e207, doi:10.3399/bjgp20X708125, pmid:31988085.
    OpenUrlAbstract/FREE Full Text
  12. 12.↵
    1. Minardi D,
    2. d’Anzeo G,
    3. Parri G,
    4. et al.
    (2010) The role of uroflowmetry biofeedback and biofeedback training of the pelvic floor muscles in the treatment of recurrent urinary tract infections in women with dysfunctional voiding: a randomized controlled prospective study. Urology 75(6):1299–1304, doi:10.1016/j.urology.2009.11.019, pmid:20303577.
    OpenUrlCrossRefPubMed
  13. 13.↵
    1. Williams G,
    2. Hahn D,
    3. Stephens JH,
    4. et al.
    (2023) Cranberries for preventing urinary tract infections. Cochrane Database Syst Rev 4(4), doi:10.1002/14651858.CD001321.pub6, pmid:37068952. CD001321.
    OpenUrlCrossRefPubMed
  14. 14.↵
    1. Moro C,
    2. Phelps C,
    3. Veer V,
    4. et al.
    (2024) Cranberry juice, cranberry tablets, or liquid therapies for urinary tract infection: a systematic review and network meta-analysis. Eur Urol Focus 10(6):947–957, doi:10.1016/j.euf.2024.07.002, pmid:39030132.
    OpenUrlCrossRefPubMed
  15. 15.↵
    1. Chen Y-Y,
    2. Su T-H,
    3. Lau H-H
    (2021) Estrogen for the prevention of recurrent urinary tract infections in postmenopausal women: a meta-analysis of randomized controlled trials. Int Urogynecol J 32(1):17–25, doi:10.1007/s00192-020-04397-z, pmid:32564121.
    OpenUrlCrossRefPubMed
  16. 16.↵
    1. Amiri FN,
    2. Rooshan MH,
    3. Ahmady MH,
    4. Soliamani MJ
    (2009) Hygiene practices and sexual activity associated with urinary tract infection in pregnant women. East Mediterr Health J 15(1):104–110, pmid:19469432.
    OpenUrlPubMed
  17. 17.↵
    1. Hooton TM,
    2. Scholes D,
    3. Hughes JP,
    4. et al.
    (1996) A prospective study of risk factors for symptomatic urinary tract infection in young women. N Engl J Med 335(7):468–474, doi:10.1056/NEJM199608153350703, pmid:8672152.
    OpenUrlCrossRefPubMed
  18. 18.↵
    1. Bonkat G,
    2. Kranz J,
    3. Cai T,
    4. et al.
    (2026) EAU Guidelines on Urological Infections. accessed. https://d56bochluxqnz.cloudfront.net/documents/full-guideline/EAU-Guidelines-on-Urological-Infections-2026_2026-05-18-101552_yupb.pdf. 13 Jul 2026.
  19. 19.
    1. Klinkhamer S,
    2. Geerlings SE,
    3. Knottnerus BJ,
    4. et al.
    (2026) [NHG-standard urinary tract infections]. [Article in Dutch]. accessed. https://richtlijnen.nhg.org/standaarden/urineweginfecties. 13 Jul 2026.
  20. 20.↵
    1. Ackerman AL,
    2. Bradley M,
    3. D’Anci KE,
    4. et al.
    (2026) Updates to recurrent uncomplicated urinary tract infections in women: AUA/CUA/SUFU guideline (2025). J Urol 215(1):3–12, doi:10.1097/JU.0000000000004723, pmid:40905426.
    OpenUrlCrossRefPubMed
  21. 21.↵
    1. Lelie-van der Zande R,
    2. Koster ES,
    3. Teichert M,
    4. Bouvy ML
    (2021) Womens’ self-management skills for prevention and treatment of recurring urinary tract infection. Int J Clin Pract 75(8), doi:10.1111/ijcp.14289, pmid:33928723. e14289.
    OpenUrlCrossRefPubMed
  22. 22.↵
    1. Leverenz A,
    2. Hernandez RA
    (2023) Uncertainty management strategies in communication about urinary tract infections. Qual Health Res 33(4):321–333, doi:10.1177/10497323231156370, pmid:36760161.
    OpenUrlCrossRefPubMed
  23. 23.↵
    1. Lecky DM,
    2. Howdle J,
    3. Butler CC,
    4. McNulty CA
    (2020) Optimising management of UTIs in primary care: a qualitative study of patient and GP perspectives to inform the development of an evidence-based, shared decision-making resource. Br J Gen Pract 70(694):e330–e338, doi:10.3399/bjgp20X708173, pmid:32041765.
    OpenUrlAbstract/FREE Full Text
  24. 24.↵
    1. Park J,
    2. Torosis M,
    3. Kim J-H,
    4. Ackerman AL
    (2024) U.S. primary care physician perceptions on barriers to providing guideline-driven care for UTI and recurrent UTI: a qualitative study. BMC Prim Care 25(1), doi:10.1186/s12875-024-02477-3, pmid:38951826. 234.
    OpenUrlCrossRefPubMed
  25. 25.↵
    1. Atkins L,
    2. Francis J,
    3. Islam R,
    4. et al.
    (2017) A guide to using the theoretical domains framework of behaviour change to investigate implementation problems. Implement Sci 12(1), doi:10.1186/s13012-017-0605-9, pmid:28637486. 77.
    OpenUrlCrossRefPubMed
  26. 26.↵
    1. Tong A,
    2. Sainsbury P,
    3. Craig J
    (2007) Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care 19(6):349–357, doi:10.1093/intqhc/mzm042, pmid:17872937.
    OpenUrlCrossRefPubMed
  27. 27.↵
    1. Hennink MM,
    2. Kaiser BN,
    3. Weber MB
    (2019) What influences saturation? Estimating sample sizes in focus group research. Qual Health Res 29(10):1483–1496, doi:10.1177/1049732318821692, pmid:30628545.
    OpenUrlCrossRefPubMed
  28. 28.↵
    1. Dicicco-Bloom B,
    2. Crabtree BF
    (2006) The qualitative research interview. Med Educ 40(4):314–321, doi:10.1111/j.1365-2929.2006.02418.x, pmid:16573666.
    OpenUrlCrossRefPubMed
  29. 29.↵
    1. Elo S,
    2. Kyngäs H
    (2008) The qualitative content analysis process. J Adv Nurs 62(1):107–115, doi:10.1111/j.1365-2648.2007.04569.x, pmid:18352969.
    OpenUrlCrossRefPubMed
  30. 30.↵
    1. Mortelmans D
    (2020) [Quality criteria in qualitative research. In: Handbook of Qualitative Research Methods]. [Book in Dutch] (Acco, Den Haag), pp 465–485.
  31. 31.↵
    1. Gupta K,
    2. Trautner BW
    (2013) Diagnosis and management of recurrent urinary tract infections in non-pregnant women. BMJ 346, doi:10.1136/bmj.f3140, pmid:23719637. f3140.
    OpenUrlFREE Full Text
  32. 32.↵
    1. Cox S,
    2. Vleeming M,
    3. Giorgi W,
    4. et al.
    (2023) Patients’ experiences, expectations, motivations, and perspectives around urinary tract infection care in general practice: a qualitative interview study. Antibiotics 12(2), doi:10.3390/antibiotics12020241, pmid:36830152. 241.
    OpenUrlCrossRefPubMed
  33. 33.↵
    1. Sanyaolu LN,
    2. Hayes CV,
    3. Lecky DM,
    4. et al.
    (2023) Patients’ and healthcare professionals’ experiences and views of recurrent urinary tract infections in women: qualitative evidence synthesis and meta-ethnography. Antibiotics 12(3), doi:10.3390/antibiotics12030434, pmid:36978301. 434.
    OpenUrlCrossRefPubMed
  34. 34.↵
    1. van Horrik TMZXK,
    2. Laan BJ,
    3. van Seben R,
    4. et al.
    (2022) Shared decision making for women with uncomplicated cystitis in primary care in the Netherlands: a qualitative interview study. BMC Prim Care 23(1), doi:10.1186/s12875-022-01867-9, pmid:36199037. 259.
    OpenUrlCrossRefPubMed
  35. 35.↵
    1. van Horrik TM,
    2. Colliers A,
    3. Blanker MH,
    4. et al.
    (2024) Qualitative study on shared decision making in cystitis management in general practice. BJGP Open 8(3), doi:10.3399/BJGPO.2023.0179, pmid:38580388. BJGPO.2023.0179.
    OpenUrlCrossRefPubMed
  36. 36.↵
    1. Chauhan BF,
    2. Jeyaraman MM,
    3. Mann AS,
    4. et al.
    (2017) Erratum to: behavior change interventions and policies influencing primary healthcare professionals’ practice — an overview of reviews. Implementation Sci 12(1):38, doi:10.1186/s13012-017-0568-x.
    OpenUrlCrossRef
  37. 37.↵
    1. Mostofian F,
    2. Ruban C,
    3. Simunovic N,
    4. Bhandari M
    (2015) Changing physician behavior: what works? Am J Manag Care 21(1):75–84, pmid:25880152.
    OpenUrlPubMed
  38. 38.↵
    1. Potthoff S,
    2. Kwasnicka D,
    3. Avery L,
    4. et al.
    (2022) Changing healthcare professionals’ non-reflective processes to improve the quality of care. Soc Sci Med 298:114840, doi:10.1016/j.socscimed.2022.114840, pmid:35287065.
    OpenUrlCrossRefPubMed
  39. 39.↵
    1. Hartman EAR,
    2. Groen WG,
    3. Heltveit-Olsen SR,
    4. et al.
    (2022) Decisions on antibiotic prescribing for suspected urinary tract infections in frail older adults: a qualitative study in four European countries. Age Ageing 51(6), doi:10.1093/ageing/afac134, pmid:35697352. afac134.
    OpenUrlCrossRefPubMed
  40. 40.↵
    1. Duane S,
    2. Domegan C,
    3. Callan A,
    4. et al.
    (2016) Using qualitative insights to change practice: exploring the culture of antibiotic prescribing and consumption for urinary tract infections. BMJ Open 6(1), doi:10.1136/bmjopen-2015-008894, pmid:26754175. e008894.
    OpenUrlAbstract/FREE Full Text
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Identifying and addressing UTI prevention barriers in primary care: a qualitative study
Merel EP Wilmsen, Laurens C van Gestel, Martijn Sijbom, Ashty Koucher, Marjan J Aantjes, Leti van Bodegom-Vos, Rimke C Vos, Tobias N Bonten, Marieke A Adriaanse, Suzanne E Geerlings, Leo G Visser, Merel MC Lambregts
BJGP Open 17 August 2026; BJGPO.2025.0230. DOI: 10.3399/BJGPO.2025.0230
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British Journal of General Practice