Main findings of study and comparison with previous literature
This study explored individuals’ perceptions and beliefs about URTIs and the way they managed them. Although the participants had different beliefs about the causes of URTIs, they generally knew how to manage their symptoms and prevent the infections from occurring. For the most part, individuals applied the same perceptions and coping strategies whether they themselves or their children were ill. Yet, they mentioned that they would be more concerned when it came it to their children.
Almost all participants mentioned that they would not routinely go to the doctor because of URTIs; instead, they tried to manage the symptoms by using home remedies and OTC medications which is consistent with findings from studies in the USA and UK [32, 33]. However, visiting the doctor was often reported as the first choice for many patients with URTIs in studies from South Korea, Malaysia and Qatar [34,35,36]. This may be in part due to lack of public knowledge about self-management of URTIs [34]. Also, cultural beliefs in some parts of the world, such as belief in the effectiveness of treatments that are received from doctors, could explain these results [36].
Almost all participants mentioned that they would only go to the doctor if there was a serious problem (e.g. breathing or swallowing difficulties, high fever, long-lasting cough). Findings from a study in the Netherlands also reported that the small number of patients, who decided to visit doctors, often had good reasons (e.g. serious symptoms, suffering for more than two weeks, respiratory comorbidity) [37].
When visiting a doctor, participants mostly wished to be examined and to gain an explanation for their symptoms. Consistent with our results, thorough examination, explanation and reassurance were expected by patients with URTIs in USA, UK, South Korea, Germany, Qatar, Denmark and Netherlands [9, 24, 32, 35, 37,38,39]. Interestingly, some participants reported that their reason for visiting the doctors was to get a refill for inhaler/puffer. URTIs can trigger long-lasting coughs in those who have a history of asthma, or other reactive airway diseases. Those patients would require inhalers because of the cough caused by URTIs.
Our results showed that participants did not usually visit the doctor to ask for antibiotics, which is consistent with other studies [34, 35, 39, 40]. Specifically, a study investigating patients in six European countries with respiratory tract infections revealed that only 2% of these patients explicitly requested antibiotics [40]. Similar findings were reported from other parts of the world (UK, South Korea, Australia, China, Qatar, Denmark, Germany, USA) [24, 34, 35, 38, 39, 41,42,43,44]. A study from USA reported that patients put a lot of pressure on doctors for the prescription of antibiotics for URTIs by the way they presented their symptoms. However, they observed that only 6% of cases made direct requests for antibiotics [7]. Another study from USA argued that doctors felt a pressure to prescribe antibiotics from the patients who suggested a candidate diagnosis, but the authors noted that an overt demand for antibiotics was unusual [44]. Conversely Dosh et al. from USA reported that 60% of patients expected antibiotics [6], but their study included respiratory infections for which the antibiotics were sometimes necessary. In addition, these three studies are older compared to other studies and this may in part explain the difference in results. This is consistent with the results of a recent systematic review that showed that the trend of patient expectation for receiving antibiotics for respiratory tract infections is declining over time on a global level [45]. Public knowledge and beliefs may have changed in recent years because of easy access to different sources of information through internet or media.
Most participants believed that there was no need for prescription medication or antibiotics and the symptoms would go away by themselves after a few days. Some participants also mentioned their concerns about time or money as reasons for not visiting their doctors. In Ontario, visiting the primary care provider is covered and people do not pay for consultations out of pocket. However, they may need to pay for their prescriptions. Furthermore, visiting a doctor may require paying for transport/parking, taking day off from work, paying for a babysitter to look after the kids while they are visiting their doctors. Even if the illness is serious and needs to be seen by a doctor, the patients may end up waiting for hours in their doctors’ offices or walk-in clinics. So, some participants preferred to mange their symptoms themselves, instead of spending time waiting in doctors’ offices.
Participants’ strategies for managing URTIs were based on their previous experiences of these infections, common sense and things that they had learnt from their parents in childhood. They mostly relied on family members, Internet and pharmacists as sources of information.
Implications for research and practice
Our results showed that individuals with URTIs did not necessary ask for antibiotics, instead they expected a thorough examination and an explanation for their symptoms. Although we did not interview the healthcare providers in our setting, the literature review from different settings suggest that some doctors perceive pressure from patients to prescribe antibiotics [6,7,8, 12, 46,47,48,49]. This suggests that there may be a miscommunication between patients and healthcare providers. We believe that better communication with patients could help doctors to elicit patients’ expectations and potentially reduce unnecessary prescriptions while increasing patients’ satisfaction with being heard by their healthcare professionals. Choosing Wisely Canada (CWC) in recent years has tried to promote the conversations between doctors and patients about treatment expectations. As part of their framework, they have encouraged patients to be more engaged in clinical encounters and ask questions about the necessity of treatments or procedures. CWC has also persuaded doctors to change their practice styles and to be more explicit about their clinical decisions with patients [50]. They have just recently published a toolkit for ‘Using antibiotics wisely’ for the management of URTIs in primary care, in which they discuss different ways to change current practice [51]. Furthermore, some useful resources have been developed in other parts of the world, which can be adapted to Canada settings. A good example of these open access resources is TARGET learning series, in which one webinar discussed managing patient expectations among other topics [52].
Individuals in our study had different perceptions about the causes of URTIs. Providing information (by healthcare providers or mass media) that viruses are the main cause of most URTIs may help patients feel more comfortable about not visiting doctors or taking antibiotics for these infections. Furthermore, there were misconceptions among some patients that changes in symptoms might require antibiotics (e.g. if the color of sputum changes to green, antibiotic is needed). However, there is evidence that these changes do not imply the need for antibiotics [53, 54]. When patients are visiting their doctors because they are concerned that due to their symptoms, they need antibiotics, the doctors could use those opportunities during patient visits to clarify the reasons for patients’ concerns, as well as addressing those concerns with evidence-based information.
Our results were based on English speaking individuals’ beliefs and perceptions in a single practice. However, Canada consists of individuals from different ethnicities and cultural backgrounds. Studying individuals from different locations or ethnicities may identify new concepts that are specific to those groups.
Strengths and limitations of the study
Our study has identified a number of factors that could be addressed by interventions to reduce antibiotic use. Some of our findings confirm those of previous studies, but this study allowed us to better understand this issue in our context and explore how our context differs from other settings.
Except for a few studies that have used grounded theory model [32], Theory of Planned Behaviour [33] and Andersen’s behavioural model [34], most studies have not used any theoretical models in their investigations to elicit patients’ perceptions of URTIs [e.g. 24, 35, 36, 41, 42, 43]. To our knowledge, this is the first qualitative descriptive study to apply a theory-based approach to study this topic in the Canadian context. Regardless of the results, we believe that using a theory can help in guiding the research process and reducing researchers’ possible biases in interpreting and analysing the findings. Also, its pre-defined constructs, facilitate the design of possible interventions, by identifying behavioural strategies that specifically target the constructs identified as contributing factors to requesting antibiotics, to be implemented in an intervention.
Although the CS-SRM is rarely used for studying acute diseases, it showed to be very useful in demonstrating individuals’ perceptions (illness representatives) of URTIs. This is of great importance with regards to designing future interventions to reduce unnecessary use of antibiotics for URTIs. Because this allows us to focus our interventions on those specific illness representatives which may not be based on scientific evidence, and by changing individuals’ illness representatives over time, we can expect to change their behaviours.
While our study presented a novel perspective on determinants of patients’ behaviors, it had a few limitations. By confining our sample to English speaking individuals, we may have missed varying perceptions from other patients. In addition, we used convenience sampling and approached the individuals who were available in the clinic and willing to participate. Although most individuals who were approached at the clinic agreed to participate in the study, we do not know if those who did not participate were different from our sample regarding their beliefs and behaviours about URTIs. Furthermore, all except one of the participants did not have symptoms of URTI at the time of interview. This allowed us to recruit more participants in a shorter time period. URTIs are very common in the society, and even if the participants did not have any symptoms at the time of the interview, they have had experienced it before, and could tell us about their perceptions and experiences. Therefore, those interviews relied on participants’ past experiences and may have been affected in part by recall bias. Despite these limitations, our findings were supported in part by other studies that investigated patient perceptions about managing URTIs and provided valuable insight into improving patient-physician communication to improve self-management of URTI symptoms and reduce antibiotic prescribing.