Summary

Objective: (1) To explore the upper respiratory tract infection (URTI)-related knowledge, consultation behaviour, self-care practice and the reasons for consultation of patients visiting general out-patient clinic (GOPC) for URTI. (2) To explore determinants of URTI-related knowledge, self-care practice and consultation behaviour.

Design: Questionnaire survey.

Subjects: 443 guardians of paediatric patients and 448 adult patients consulted for URTI in a GOPC within a four-month period.

Main outcome measures: Knowledge score, pattern of consultation behaviour, self-care practices and reasons for consultation related to that episode of URTI.

Results: Only 31.3% of respondents knew that URTI was mainly caused by viruses, 31.3% knew that URTI would resolve on its own, and 48.4% wrongly thought that injection would hasten recovery. Higher education level was predictive of higher knowledge score in both guardian and adult patient groups. One third of respondents did not practice self-care prior to consultation, particularly those who believed that "one must consult a doctor for a common cold". The median duration of symptoms was 3 days. Fever was the only factor that predicted early consultation in both groups. The belief that "one must consult a doctor for a common cold" was the commonest reason for consultation. Confusion between the Chinese terms of "antibiotic" and "anti-inflammatory drug" was found.

Conclusion: A significant portion of respondents had misconceptions, did not practice self-care prior to consultation and consulted early for URTI. Important determinants of low knowledge score, no practice of self-care and early presentation were low education level, belief of "one must consult a doctor for a common cold" and presence of fever, respectively.

Keywords: Upper respiratory tract infection, general out-patient clinic, common cold, antibiotic, questionnaire survey

摘要

目的：（1）探討因患上呼吸道感染到政府門診就診的病人，對上呼吸道感染的有關知識的了解程度，求診行為，自我護理情況以及求診的主因。（2）研究有關於上呼吸道感染的知識、自我護理以及求診行為的決定因素。

設計：問卷調查。

對象：在四個月內到普通科門診求診的448名上呼吸道感染病人和443名監護人。

測量內容：知識分數，求診行為模式，自我護理情況以及求診的原因。

結果：31.3%的回應者知道上呼吸道感染是由病毒引起，31.3%知道上呼吸道感染會自行痊癒，48.4%錯誤地認為注射可加快康復。在監護人和成年病人兩組 中，高教育水平者有關知識分數較高。三份之一的回應者在會診前並未自我療理，尤其是那些認為有感冒一定要看醫生的人。發病就醫的中位數是三天，在兩組中發燒是提早求醫唯一因素。感冒一定要看醫生這個信念是病人就診最常見的原因。抗生素和消炎藥的中文含義常被混淆不清。

結論：較大部份的回應者對上呼吸感染存有誤解，並沒有在就醫前進行自我護理，而且他們認為上呼吸道感染應盡早看醫生。低知識分數，缺乏自我護理和提早看醫生的決定因素包括低教育水平、發燒和抱有「感冒一定要看醫生」的信念。

主要詞彙：上呼吸道感染，普通科門診，感冒，抗生素，問卷調查

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Introduction

Background

Upper respiratory tract infection (URTI) is a self-limiting minor illness, yet it is not "minor" in terms of workload and financial burden imposed on the health care system. It is one of the commonest human infections in the world¹ and is a leading cause of acute morbidity, visit to physicians and industrial and school absenteeism.^2,3 According to the 1994 and 1998 morbidity surveys of general practice in Hong Kong, URTI was the commonest disease for which general practitioners were consulted and accounted for about one third of private general practice and government out-patient clinic consultations.^4,5 In the paediatric age group of 0 to 9 years old, URTI represents 61.9% of all diagnoses.⁵

The vast majority of URTIs are caused by viruses¹ and the management is limited to symptomatic relief.⁶ However, 36% to 50% of adults request antibiotics for their URTI^7,8 even though it contradicts with the current evidence of the ineffectiveness of antibiotics in treating uncomplicated URTI.^1,9-11 On the other hand, many doctors continue to prescribe antibiotics for URTI in an attempt to fulfill the patients' expectation and to keep them satisfied, even though receiving antibiotic does not equal satisfaction.^9,10 The end result is that up to 60% of patients seen in primary care for common cold received a prescription for an antibiotic^11,12 as most doctors overestimated the patients' expectation for a prescription.¹³ Inappropriate antibiotics prescribing will not only reinforce the false belief of its usefulness in URTI,^14,15 but also produce side effects, increase future visits for more antibiotics¹⁶ and promote antibiotic resistance.¹⁷

A local study by Chan (n=1009) in the private sector in 1990 found that 69% of adult patients had the misconception that URTI will not resolve on its own.⁷ While 60% of patients claimed knowledge of self-management of URTI, 50% visit their private doctors within the first two days of their symptom onset. It also showed that only 40% of adults self-medicated prior to the consultation. Another local study by Tan et al concerning children in 1987 found that the average duration of URTI was 6.5 days prior to consultation at general out-patient clinic (GOPC).¹⁸

In contrast, an American study in 1997 found that 85% of patients knew that URTI resolves on its own.⁸ An Australian survey found that URTI was the second commonest problem presented to general practitioners (GP).¹⁹ A Canadian population-based survey in 1998 found that only 14% of adults with URTI in the previous 2 weeks visited a doctor and 76% engaged in self-care.²⁰ A British study in 1987 found that 82% of patients attempted self-medication before consultation and the average duration of symptoms was 6 days; 94% of Asians wanted a prescription for antibiotic, cough mixture or other cold-medication.²¹

It seems that local people lack knowledge about the natural presentation of URTI and get less engaged in self-care. At the time when this study was carried out, GOPCs were run by the Department of Health of the Hong Kong Government. At a running cost of HK$219 per attendance, the general out-patient services were highly subsidized by the government.²² Although GOPCs provide only 15% of primary care services as compared with the private sector,²³ the prescribing cost for URTI is still considerable. Studies found that there are differences between certain beliefs, concerns and attitude of adult patients and guardians of paediatric patients.^6,7 No study comparing adult patients and guardians about URTI in GOPC setting exists.

Objectives

1. To explore the URTI-related knowledge, consultation behaviour, self-care practice and the reasons for consultation at GOPC.
2. To explore determinants of URTI-related knowledge, self-care practice and consultation behaviours.

Methods

Study design

Questionnaire survey.

Subjects

Chinese patients of any age who attended for URTI at a GOPC in the New Territories within a four months period were recruited consecutively by one doctor.

Inclusion and exclusion criteria

URTI was diagnosed according to the International Classification of Primary Care (ICPC-2)²⁴ and the International Classification of Health Problems in Primary Care - Defined (ICHPPC-2)²⁵ criteria. Inclusion criterion was any one symptom of cough, running nose, sneezing, nasal congestion, with or without fever or sore throat; and evidence of acute inflammation of nasal or pharyngeal mucosa. Exclusion criteria included symptoms lasting longer than 14 days, re-attenders who have already filled questionnaire once before, fever 39.5, unaccompanied children, known chronic illnesses such as asthma, chronic obstructive airway disease, and presence of tonsillitis, otitis media, sinusitis, bronchitis or pneumonia.

Sample size

The estimated sample size required were 440 paediatric (aged <18 years) and 440 adult (age 18 years) patients, with power = 0.8 and error level =0.05, using the PASS 2000 (Power Analysis and Sample Size) programme based on a previous study result.⁷ The estimated response rate was 80%.

Data collection

A questionnaire in Chinese containing 18 questions was developed. The adult and paediatric versions of the questionnaire were essentially the same except that some wordings concerning the subject were different and were printed on different colour paper. The face validity was tested during pilot study and proof-read by an experienced high school Chinese language teacher while the content validity was assessed by a group of primary care doctors.

Verbal consent was obtained after consultation. The doctor first filled in the demographic section of the questionnaire. The patient then completed the questionnaire while waiting at the dispensary. The completed questionnaires were collected using a box placed near the dispensary. Guardians (parents or grandparents) were invited to fill in the questionnaire for their children. Illiterate patients were interviewed by the doctor who filled in the questionnaire for them.

Statistical methods

Data was analysed using the Statistics Package for Social Sciences (SPSS) 9.05 for PC. Chi-square test was used for categorical variables while t-test was used for continuous variables to compare the responses between adult patients and guardians. A knowledge score of each respondent was calculated according to the number of correct answers in the knowledge section and then dichotomised into high and low. Next, univariate analysis was performed to test for any association between various socio-demographic factors with the score. Only factors with p<0.25 were tested in the final model of stepwise multiple logistic regression analysis. Similar analysis was used to determine predictors of self-care practice and early consultation.

Results

Participants

There were 443 guardians and 448 adult patients; with 37 males and 382 females in the guardian group, 161 males and 287 females in the adult patient group (Table 1). Respondents' age ranged from 20 to 68 (median 36 years) in the guardian group, and 18 to 72 (median 40 years) in the adult patient group. Among those children included, 227 were boys and 213 were girls with age distribution of 10.4% 1 year old, 37.7% 2-5 years old, 42.2% 6-11 years old, 9% 12-17 years old.

Response rate

Seventy-one patients were excluded from the study based on the exclusion criteria. Common reasons for exclusion were presence of chronic illness (29%), duration longer than 14 days (23%) and unaccompanied children (21%). Among the 1025 eligible patients, there were 43 refusals, 37 missing and 54 incomplete questionnaires; leaving 891 questionnaires for analysis. The commonest reason for refusal was being busy. Incomplete questionnaires were those with more than half of the questions not answered. The response rate was 87% (891/1025).

Knowledge

52.7% of patients thought that URTI is caused by bacteria, only 31.3% knew that it is mainly caused by viruses (Table 2). 52.4% of respondents thought that antibiotic is useful for URTI and they were more likely to think that bacteria rather than viruses are the cause of URTI (p<0.0001).

About half of the respondents (52.5%) knew that URTI usually lasts for about a week. However, many patients had the misconception that injections hasten recovery and URTI will not resolve on its own. Significantly more adult patients thought that injection hastens recovery (53% vs 43.6% of guardians; p<0.001) and antibiotic is useful for treating URTI (60% vs 44.7% of guardians; p<0.0001); while more guardians wrongly thought that URTI in children will not resolve on its own (67.1% vs 50.5% of adult patients; p<0.0001). Those who knew that virus is the cause were more likely to believe that URTI will resolve on its own (p<0.001). Questions about prevention were generally well answered. However, over 60% of respondents did not realize that stress and smoking may predispose to URTI.

Total knowledge scores of both groups follow normal distribution and t-test shows no significant difference in the mean total score between adult patients (5.54) and guardians (5.57) (p=0.866). Knowledge scores range from 0 to 12. Those scored 0-5 (41% of all respondents) were assigned to the low-score group while those scoring 6-12 (59%) were assigned to the high-score group. Stepwise multiple logistic regression was then performed to determine which variables were predictive of higher knowledge score. In the guardian group, "secondary education" is the only factor predictive of higher score. Adult patients with tertiary education, who are housewife, student or GS/DGS/Pen/HAS have higher score.

GS/DGS/Pen/HAS denotes government servant/dependents of government servant/Pensioner/ Hospital Authority staff

Self-care

Respondents generally knew well about methods of self-care of URTI such as increasing fluid intake, taking more rest and over-the-counter (OTC) cold remedies. However, only about 40% felt moderately and very confident in practising self-care. For the current episode of URTI, 67% of respondents had tried at least one type of self-care; with more adult patients than guardians (73.9% = 331/448 vs 60% = 266/443; p<0.001). Common forms of self-care are OTC cold remedies (36.5%), left-over medication (32.7%) and herbal tea (18.4%) (Figure 1). Significantly more adult patients had tried herbal tea (p<0.0001) and body scraping than children (p<0.005).

Among all respondents, those disagreeing with the statement "one must consult doctor for common cold" were more likely to have attempted at least one kind of self-care. Guardians with higher total knowledge score, and adult patients with primary education were more likely to practice self-care.

Consultation behaviour

The mean duration of symptoms prior to consultation was 3.49 days (mode = 2 days, median = 3 days), with 46.1% attending within the first 2 days of onset (Figure 2). No significant difference was found between guardians and adult patients for the mean duration (Mann-Whitney test: p<0.665). The second peak at day 7 (one week) is probably because this number is easier to recall than adjacent numbers. Among those who have not seen any doctor, 54.3% (209/385) presented within the first 2 days of symptom onset; 89.9% (346/385) within 4 days. The commonest reason for choosing GOPC was lower fee (Figure 3). More guardians than adult patients wanted to see a familiar doctor (p<0.018).

Those consulted within first 2 days of symptoms onset (46.1% of all respondents) were compared with those consulted 3 days of onset (53.9%) using logistic regression. Fever is the only factor that predicted early consultation in both guardian (OR=8.12, p<0.01) and adult groups (OR=7.47, p<0.01). Among guardians, those believing that "one must consult doctor for common cold" and perceived "mild" severity consulted earlier. Among adults, aged <50, social class 3N, 3M, 4, not working, and did not consult other doctor were significant predictors of early consultation.

Reasons for consultation

More guardians than adult patients (63.4% vs 48.9%; p<0.0001) held the belief that "one must consult doctor for common cold" (Figure 4), which is significantly associated with the belief that "URTI will not resolve on its own" (chi-square test: p<0.0001). Other reasons were "wish for medication", "want a diagnosis" and "symptoms lasted too long". More guardians than adults worried about complication (32.7% vs 20%; p<0.0001).

24.8% (107/431) of guardians and 30.3% (132/436) of adult patients felt that their URTI had been lasting for too long. However, among these respondents, 52.3% (56/107) of children and 59.1% (78/132) of adult patients actually had symptom duration of 4days. Those believing that antibiotic is useful was significantly associated with an explicit request for antibiotic (p<0.016). Adult patients who wanted injection were more likely to perceive their URTI severity as moderate or severe (chi-square test: p<0.017), but this association is not found in guardian group.

Although the majority of respondents (85%) did not request antibiotic or anti-inflammatory drug explicitly, 23% of them thought that the Chinese terms of "antibiotic" and "anti-inflammatory" drug are the same, while 30% did not know if there are any differences.

Discussion

1. Knowledge

Only about one-third of respondents knew that URTI is caused by viruses, and about half thought that injection can hasten recovery. This was similar to the results of the study by Chan in the private sector in 1990 (the figures are 30% and 48%, respectively).⁷ On the other hand, 52.5% of respondents knew that URTI will usually last 5 - 7 days and 31.3% knew that URTI will resolve on its own, which is better than the results from the previous study (33% and 31% respectively). Over half of respondents have the misconception that antibiotic is useful for URTI. More adults thought that antibiotic and injection are useful probably because of past experience and increased likelihood of doctors to prescribe these to adults than children. More guardians thought that URTI in children will not resolve on its own probably because they believe that children have weaker healing ability than adults. The mean score about facts is only 1.54 out of 5. The questions about prevention were better answered with mean score of 4.58 out of 8. Among respondents, 63.6% and 60.9% did not know that avoidance of stress²⁶ and smoking,²⁷ respectively, can reduce likelihood of getting URTI.

As expected, higher education level is associated with higher knowledge score in both guardian and adult patient groups. The insignificant odds ratio for tertiary education among guardians was probably due to the small size of this subgroup.

These show that a significant portion of respondents have inadequate knowledge about the natural history of URTI and much education is needed to emphasize its self-limiting nature and the average duration of an uncomplicated URTI. Explaining the viral nature may also help correct the false belief that antibiotic is useful for URTI.

2. Self-care practice

Consistent with previous studies results,^1,28 93% and 81.4% of respondents knew that increase fluid intake and rest respectively, can relieve symptoms. However, 36% did not consider OTC drugs helpful. They may not know how to choose medicine, have uncertainty about efficacy, dosage and duration. Physicians may take opportunities to discuss about proper use of OTC medications for symptoms relief. Guardians with higher knowledge score were more likely to attempt self-care prior to consultation; so were guardians and adult patients who disagreed with the statement that "one must consult doctor for common cold". Adult patients with primary education were more likely to have self-care which could be due to less money or less free time to see doctor.

Educating patients on the natural course of URTI with emphasis on the body's own healing power and proper ways of self-care may promote greater patients' responsibility for their own health. Also, reinforcing the message that "URTI may resolve on its own even without consulting a doctor" and education on recognition of symptoms suggesting complications such as earache, sinus pain and breathlessness are equally important.

A Canadian "cold-and-flu" campaign²⁹ in 1994, which aimed at reducing physician visits for cold and flu using self-care pamphlets, was found to be futile because this approach lacked personal explanation of material, no telephone advice line and no physicians support. More importantly, 85% of Canadian adults do not seek medical care for URTI, and therefore even an effective community strategy would have a limited marginal benefit. Local doctors seemed to be supportive as shown in a local study in which 95.2% of family doctors (n=730) agreed that patients should be advised on self-management and 69.7% also considered advising on self-medications for URTI.³⁰

3. Consultation behaviour

52.5% (463/729) of all respondents knew that URTI usually lasts for 5 - 7 days; however, 80.9% (721/891) of them attended within the first 4 days of the onset. This shows an incongruity between belief and behaviour, as there is no significant association between impact on daily activities or perceived past health, and timing of consultation. In fact, most presented within a few days of onset (mean = 3.49 days, median = 3 days, mode = 2 days), which is shorter than the average duration of 6.5 days found in the study by Tan et al in 1987 concerning URTI consultation in children at GOPC.¹⁸ More guardians wanted to see familiar doctor probably because the attending doctor is friendly and for continuity of care. When this study was carried out, the usual fee for a GP consultation for URTI was around HK$150-200 which was 4 - 6 times of HK$37 at GOPC; no wonder why "cheaper fee" was the commonest reason for choosing GOPC instead of GP.

Fever is the only factor predictive of early consultation in both groups, hence education about management of fever may be useful. Unexpectedly, knowledge score has no effect on timing of presentation. Self-care also has no effect on the presentation time, which may be due to inappropriate or inadequate self-care as the "had self-care" variable did not take into account the actual methods used and adequacy of self-care. Further studies of the quality and quantity of self-care and expectation from self-care are needed.

Marsh et al found that trained nurses could diagnose and treat a large proportion of patients currently consulting GP about minor illness provided that the nurse has immediate access to a doctor.³¹ Evidence found that nurses manage acute illness in primary care safely,^32,33 can reduce antibiotic prescription³⁴ and improve people's ability to care for themselves.³⁵ Local studies are needed to assess the feasibility, safety and acceptability of this option.

4. Reasons for consultation

Most respondents (70%) knew that they had a common cold prior to consultation, over half thought that "one must consult doctor for common cold", about half wanted medications and less than one third worried about complications. These could be explained by the belief "URTI will not resolve on its own" and people's underestimation of their own bodies' healing power. More guardians thought that "one must consult doctor for common cold" because they may think that URTIs in children are more difficult to recover. About half (48.4%) of the respondents thought that injection hastens recovery but only 3% wanted it, which may be explained by that they did not think their URTI was severe enough to warrant injection or fear of pain.

Confusion between the Chinese terms of "antibiotic" and "anti-inflammatory drug" may be caused by indiscriminant use of the terms. Doctors may perceive a request of "anti-inflammatory drug" for an "inflammed throat" as a request for "antibiotic". This study shows that this perception may not be true in over half of the cases.

Ibuprofen is a non-steroidal anti-inflammatory drug (NSAID) which has safety profile similar to paracetamol in treating URTI.³⁶ Naprosyn is another NSAID which was shown to be effective for symptomatic relief of sore throat, headache, myalgia, malaise, fever and even cough.³⁷ Lysozyme is an anti-inflammatory enzyme which may help relieving sore throat in URTI.³⁸ Further research is needed to study the effectiveness and safety of these agents before more definite recommendation can be made. Butler et al found that patients generally do not accept the microbiological explanation for why antibiotic is not needed for URTI or sore throat; instead, explaining the lack of responsiveness of sorethroat to antibiotics may be more useful.³⁹ A study in Iceland found that by withdrawing subsidies for antibiotics and educating the public on the danger of antibiotic resistance, the sale of antibiotics and incidence of penicillin-resistant pneumococci had been reduced.⁴⁰

Limitations

Since this study was carried out in one GOPC only, the result may not be generalized to other primary care settings in the public sector. Similar studies may be performed in other clinics so that the whole picture about the public primary care sector can be revealed. Male guardians are under-represented in this study and this may affect the generalizability of the result to this subgroup.

Conclusions

Misconceptions about URTI existed among respondents, one third of respondents did not practice any self-care prior to consultation and the majority consulted early in the course of this minor self-limiting illness. "One must consult doctor for common cold" is an important belief which is not only the commonest reason for consultation but also associated with reduced likelihood of having self-care in both groups and early consultation in children. Consistent determinants of low knowledge score and early consultation are low education level and presence of fever, respectively. Confusion between the Chinese terms of "antibiotic" and "anti-inflammatory drug" was found. There is room for educating people about the correct information of URTI, especially for those with lower education level. Practical advice on proper self-care, fever management and when to consult may be of particular importance. Patient education may be provided opportunistically or through a community-based campaign. Research is needed to study the potentials of these educational activities, with or without raising consultation fee, in delaying or even reducing unnecessary consultations for URTI in the public sector. On the other hand, doctors should not perceive a request for "anti-inflammatory drug" as request of "antibiotic" indifferently and prescribe antibiotic unnecessarily.

Key messages

1. Misconception about upper respiratory tract infection (URTI) exists among participants who attended for URTI at a general out-patient clinic (GOPC) in the public sector.
2. A significant portion of respondents did not try self-management before consulting for URTI.
3. The commonest reason for choosing GOPC instead of private doctor for URTI was lower fee.
4. Presence of fever was an important determinant of early consultation in both adult and paediatric group.
5. Confusion between the Chinese words of "anti-inflammatory drug" and "antibiotic" was noted.

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References