Project objectives

The study objectives were to:

• Explore the understandings, beliefs and attitudes of health professionals regarding the use of herbal medicines to treat RTIs
• Explore enablers and barriers to health professionals recommending or prescribing herbal medicines for RTIs.

Changes to project objectives

Original project title:

Investigating the possible role of Andrographis paniculata as a symptomatic intervention for acute respiratory tract infections: a qualitative study exploring the attitudes and beliefs of health professionals around the use of herbal medicines to treat acute respiratory tract infections (RTIs)

Adopted title change suggested by the University of Southampton Faculty of Medicine Ethics committee:

A qualitative study exploring the attitudes and beliefs of health professionals around the use of herbal medicines in the treatment of symptoms of acute respiratory tract infections.

Brief summary

Methods

With the assistance of the NIHR Clinical Research Network, we recruited a purposive sample of Primary Care health professionals following a maximum variation sampling strategy aiming for diversity in terms of years in practice, practice location, practice deprivation score, list size. 

Semi-structured telephone interviews followed an interview guide, which was developed from the research aims and objectives and from a previous systematic review on the use of Andrographis paniculata on the symptoms of respiratory tract infections and from discussions within the supervisory team. The interview guide was subsequently modified slightly in order to collect more rich data. 

Telephone interviews were conducted by ML at Aldermoor Health Centre, Southampton, and ran from August to December 2017. Prior to each interview the researcher provided each participant with information regarding the study, and also the reasons why the data was important, what it would be used for, and how it would be stored. The interviews lasted on average 25 minutes for each participant. The interviews were digitally recorded (Olympus DS-2500), transcribed in full, checked and anonymised using pseudonyms. 

The overall approach in this study was thematic analysis. A hybrid approach (inductive and deductive) was taken with data analysis: in particular using an inductive approach to explore health professionals’ views and experiences of herbal medicines and using a deductive approach to answering specific questions pertinent to the design of the subsequent feasibility study.  

Initially all transcripts were coded on a line-by-line basis by hand while further iterations were made to the coding schedule, in discussion with the supervisory team (AF, MS, MM).  Subsequently, the transcripts were coded using NVivo version 11 to facilitate data handling. The lead researcher (ML) compared codes and developed themes across the whole data set in discussion with the research team (AF, MS, MM).

Findings

22 GPs and 4 Practice Nurses from Southern England were interviewed in this study (12 male, 14 female; length of time in practice 2 to 37 years). These represented staff from 23 practices across Wessex, Peninsular and West of England CRN areas (11 urban, 12 rural; deprivation score 1-10 (median 5.5)).

 Themes emerging from the data include a diversity of experience/opinion around:

• Health professionals views on herbal medicine: familiarity/unfamiliarity of specific products; personal experience, patients’ experience and trial experience
• Health professionals views on the use of herbal medicine: safety, regulation, responsibility for prescribing
• Health professionals perceptions of patient views on herbal medicines; ‘some types of patients’ might be interested in this vs. ‘potentially useful for all’ 

There was a diversity of opinion around the potential use of herbal medicine in primary care in general and around their use in the treatment of respiratory tract infections in particular. However, many felt they would be potentially useful if shown to be effective. Concerns about herbal medicines were widespread, particularly safety, manufacture, quality control, authentication and potential for interactions with other medicines.

Conclusions

Data collection is complete and data analysis is progressing well. The analysis of barriers and facilitators to delivery of a feasibility trial of herbal medicines for respiratory tract in primary care is complete. The inductive analysis of health professionals’ views of the role of herbal medicines in primary care will be completed within the next 4 months then submitted for peer reviewed publication.

Plain English summary

Respiratory tract infections such as cough, sore throat and sinusitis are common, distressing, and costly for individuals, employers and the NHS. Current treatments such as antibiotics and cough medicines have limited benefits.

Widespread use of antibiotics has led to increasing numbers of infections from bacteria that are resistant to antibiotics. A recent government report suggested it is necessary to seek alternative treatments to antibiotics.  Several studies have shown that the herb Andrographis paniculata, when compared with placebo (dummy medicine), helps to reduce the intensity and length of time patients experienced symptoms from respiratory tract infections.

We carried out in-depth interviews with 26 health professionals (22 GPs and 4 Practice Nurses) to find out more about their views around using herbal medicines for respiratory tract infections. It helped us to understand health professionals’ views of safety of herbal medicines, whether they feel they would be an acceptable alternative to antibiotics for respiratory tract infections, and whether or how they see a role for use of herbal medicines in primary care.

The information gathered has helped us design a study, which will evaluate the use of Andrographis paniculata capsules amongst adults who visit their GP with respiratory tract infections.  This will be for people that the GP think have an infection (bacterial or viral) but NOT pneumonia. The doctor will be able to prescribe antibiotics if needed for participants in the study.

The information has also helped us to identify potential barriers to carrying out this study and to develop patient information leaflets. 

Most of the health professionals in this study expressed an interest in the use of herbal medicines for respiratory tract infections, particularly if known to be effective in symptom relief. A common reoccurring theme was concern about the efficacy, safety and manufacture of herbal medicines in the UK.

Dissemination

Published articles

Andrographis paniculata (Chuān Xīn Lián) for symptomatic relief of acute respiratory tract infections in adults and children: A systematic review and meta-analysis. Xiao-Yang Hu , Ruo-Han Wu, Martin Logue, Clara Blondel, Lily Yuen Wan Lai, Beth Stuart, Andrew Flower, Yu-Tong Fei, Michael Moore, Jonathan Shepherd, Jian-Ping Liu, George Lewith.

http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0181780

Public involvement

The study benefited from PPI involvement from conception through design with support from South Central RDS. A PPI representative (MB) who worked on a previous respiratory study (Pelargonium study) was contacted and asked if she would be interested to act as PPI on this qualitative study.  MB reviewed this application and said she was happy with the plain English summary. Some of the issues brought up by GPs and nurses were based on the views of their patients. We will involve MB in refining analysis and disseminating the findings from this study

Impact

The findings from this study are being used to design a forthcoming feasibility study, which is currently progressing through Ethics approval. This is funded through Pukka herbs for the completion of a PhD by Martin Logue, supervised by Andrew Flower, Miriam Santer and Mike Moore.

This research will also be used to further explore the role of herbal medicines in the treatment of respiratory tract infection and their potential for assisting in antibiotics avoidance.

This project was funded by the National Institute for Health Research School for Primary Care Research (project number 371)

Department of Health Disclaimer

The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR School for Primary Care Research, NIHR, NHS or the Department of Health.