Misconceptions About Colds and Predictors of Health Service Utilization
* Divisions of Infectious Diseases
General Pediatrics, Children’s Hospital, Boston, Massachusetts
Department of Ambulatory Care and Prevention, Harvard Pilgrim Health Care, Boston, Massachusetts
|| Clinical Research Program, Children’s Hospital, Boston, Massachusetts
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Objective. Colds accounted for 1.6 million emergency department (ED) visits and 25 million ambulatory visits by children and adults in 1998. Although most colds are caused by viruses and do not require medical intervention, many families seek health care for the treatment of colds. Parental misconceptions about the cause and appropriate treatment of colds may contribute to unnecessary health service utilization. The objective of this study was to determine predictors of reported ED use and ambulatory care use for colds among families with young children.
Methods. This study was an observational, prospective cohort study to determine attack rates for respiratory illnesses within families that have at least 1 child who is 6 months to 5 years of age and enrolled in out-of-home child care. Families were randomly selected from 5 pediatric practices in Massachusetts and were considered eligible when the child was enrolled in child care with at least 5 other children for 
10 hours per week. Enrolled families were asked to complete a survey that assessed knowledge about colds, antibiotic indications, and frequency of health service utilization. Predictors of self-reported use of health care services were assessed in multivariate logistic regression models.
Results. Of the 261 families enrolled in the study, 197 families (75%) returned completed surveys. Although 93% of parents understood that viruses caused colds, 66% of parents also believed that colds were caused by bacteria. Fifty-three percent believed that antibiotics were needed to treat colds. Parents reported that they would visit the ED (23%) or their doctor’s office (60%) when their child had a cold. Predictors of ED use on multivariate analysis included Medicaid insurance (odds ratio [OR]: 17.6 [2.2–139.3]), history of wheezing (OR: 18.3 [4.4–75.8]), and belief that antibiotics treat colds (OR: 4.2 [1.4–12.9]). Predictors of ambulatory care use included parent younger than 30 years (OR: 10.0 [1.6–64.3]), history of wheezing (OR: 5.6 [1.1–29.7]), and belief that antibiotics treat colds (OR: 3.8 [1.7–8.5]).
Conclusions. Misconceptions about the appropriate treatment of colds are predictive of increased health service utilization. Targeted educational interventions for families may reduce inappropriate antibiotic-seeking behavior and unnecessary health service utilization for colds.
Key Words: colds • upper respiratory infections • health service utilization • antibiotics • child care
Abbreviations: URI, upper respiratory tract infection • ED, emergency department • OR, odds ratio
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Upper respiratory tract infections (URIs) are a common reason for physician visits and incur substantial health and economic burdens.1 Approximately 1.6 million emergency department (ED) visits and 25 million ambulatory care visits occur each year for uncomplicated colds or nonspecific URIs in adults and children.2,3 Although most colds are caused by viruses and do not require medical intervention, many families still seek physician advice for the treatment of colds.
In turn, these unnecessary health care visits generate a significant number of antibiotic prescriptions. In a study examining the use of antibiotics for URIs in Kentucky, 60% of outpatient visits and 48% of ED visits resulted in an antibiotic prescription.4 According to the National Ambulatory Medical Care Survey, 7.4 million prescriptions were written for viral URIs in the United States in 1998 at an estimated cost of $227 million.2 Such inappropriate antibiotic use has also contributed to growing concern over the emergence of antibiotic-resistant organisms in the community.5,6
Because health care visits for colds have resulted in inappropriate antibiotic prescribing, previous research studies have focused on the physician-patient interaction during the health encounter to identify potential areas for intervention at the physician level.7–11 However, little research has addressed factors that prompt parents to bring their child to the physician for a self-limited viral illness. We sought to understand the reasons that parents initiate unnecessary health care visits to determine potential areas for intervention at the family level.
Our objectives were to determine patterns of reported pediatric health service utilization for colds among families with young children. In addition, we evaluated the association between parental knowledge and beliefs about colds and reported health service utilization. We hypothesized that pediatric health service utilization for colds would be frequent in this population and that misconceptions about the causes and appropriate treatment of colds would predict higher reported rates of health service utilization.
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METHODS |
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Subjects
This study was part of an observational, prospective cohort study to determine attack rates for respiratory and gastrointestinal illnesses within families that have at least 1 child who is between 6 months and 5 years of age and enrolled in out-of-home child care. Families were recruited from 5 different pediatric practices in the metropolitan Boston area. We chose 3 urban practices and 2 suburban practices to include a diverse study population with respect to socioeconomic status and race/ethnicity. Because the primary purpose of the cohort study was descriptive, we estimated that 200 families would provide reasonable confidence intervals for secondary attack rates due to respiratory and gastrointestinal illnesses. We estimated that one third of contacted families would be eligible for the study, 70% would agree to participate, and 80% would complete the study. Thus, a random number generator was used to identify 250 families from each practice for a total of 1250 families. Subjects were sent recruitment letters and subsequently screened for eligibility and recruited by telephone to participate in this 5-month study. Inclusion criteria for study entry were 1) family had at least 1 child who was 6 months to 5 years of age, 2) the child was enrolled in out-of-home child care with at least 5 other children for
10 hours per week for the duration of the study, 3) the family planned to reside in the metropolitan Boston area for the duration of study, 4) the family had access to a telephone, and 5) the primary caregiver could speak English or Spanish. Families were excluded when their home also functioned as a family child care center for >5 children or when a household member’s occupation included working with children under the age of 6 for >10 hours per week. Of the 1250 families randomly selected, 49% did not meet eligibility criteria defined above, 22% were eligible and contacted for study participation, and 29% were not contacted because study enrollment was complete for each pediatric practice (at least 50 families per practice enrolled). Of the 278 eligible families that were contacted, 17 families refused to participate and 261 (94%) families were enrolled in the study from November 17, 2000, to January 16, 2001 (Fig 1). Those who agreed to participate were mailed a survey at the beginning of the study.
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The study was reviewed and approved by the Institutional Review Board of Children’s Hospital, Boston. Of the 261 enrolled families, 197 returned completed surveys for a response rate of 75% based on enrolled families and 71% for all eligible families.
Survey Instrument
The survey was designed after 2 focus groups were convened to address causes of illness, illness transmission, and prevention of the spread of illnesses. These focus group participants were recruited from a pediatric practice in the Boston area to identify potential questions for the survey. The survey consisted of 37 items that addressed family characteristics, health perceptions, knowledge about the causes of illness, beliefs regarding illness transmission, household practices such as hand hygiene and surface disinfection, and perceptions about appropriate antibiotic indications. The format of the question responses included multiple choice, Likert scale, and yes-no answers. The survey was piloted in English to ensure understanding of all questionnaire items. The instrument was then translated into Spanish and back-translated into English.
Outcome Variables
The main outcome of interest was reported pediatric health service utilization for colds. We examined ED use and ambulatory care use in 2 separate models. The outcome variable for ED use for colds was dichotomized a priori into users (usually, sometimes, or rarely) versus nonusers (never). Because some parents may visit their doctor’s office to obtain physician assurance that the child does not have a focal complication such as otitis media, we decided a priori to dichotomize the outcome variable for ambulatory care use into frequent users (usually or sometimes) versus infrequent users (rarely or never).
Statistical Analysis
We performed a descriptive analysis of parental beliefs and practices using percentages. A summary scale of "folk" beliefs about the causes of colds was constructed. These causal beliefs were identified during focus group discussions and included cold weather, changes in the weather, not wearing enough clothes, going outside with wet hair in cold weather, teething, and walking barefoot outside. Each folk belief contributed 1 point to a summary scale ranging from 0 to 6 points. Cronbach’s 
was calculated to determine the internal consistency of these items. These 6 items that composed the belief score had a Cronbach’s of 0.84.
To adjust for the variation in demographic characteristics of the families in pediatric practices from which we enrolled, pediatric practice was included in our logistic regression models as a fixed effect. We considered the following potential predictors in bivariate models: demographic covariates, knowledge about causes of colds and mechanisms of cold transmission, and beliefs about antibiotic use. For the variable "antibiotics are needed to treat colds," we a priori dichotomized the answers into yes (usually, sometimes, or rarely) versus no (never) on the basis of published principles of judicious antibiotic use for colds.12 Predictors were considered significant at P < .05. Multivariate logistic regression models were based on significant bivariate predictors. We included pediatric practice as a fixed effect and entered a priori selected variables into the model. In addition, we performed forward and backward selection with set at 0.15 to enter and remove terms from the model and found that all 3 approaches led to the same final model. All analyses were performed in Stata Intercooled 7.0.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Characteristics of Respondents
Table 1 summarizes characteristics of the 197 respondents who were enrolled in the study. The mean age of respondents was 34.6 years with a range of 20 years to 50 years of age. Most of the respondents were female (95.4%). A significant number of respondents identified themselves as multiracial (31%), and a majority of families had individual or employee-sponsored health insurance.
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Knowledge, Attitudes, and Beliefs About Colds
The frequency of responses to items concerning knowledge about causes of colds is shown in Table 2. Although 93% of parents understood that viruses caused colds, 66% of parents also believed that colds were caused by bacteria. Other nonproven beliefs, or "folk" beliefs, about causes of colds, such as changes in the weather, not wearing enough clothes, going outside with wet hair in cold weather, cold weather alone, teething, and walking outside barefoot, were also thought to be important contributors. Twenty-five percent of respondents believed that 5 or more of these "folk" beliefs were true. Parental beliefs about the treatment of colds were also assessed to better understand the determinants of health care-seeking behavior. We asked families how often antibiotics were needed to treat colds. Fifty-three percent of respondents erroneously reported that antibiotics were needed for colds.
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Health Service Utilization
Respondents were asked about their frequency of pediatric health service utilization for colds. Twenty-nine percent of families reported usually, sometimes, or rarely visiting the ED for colds (Fig 2). Sixty percent of families reported usually or sometimes visiting their doctor’s office or health center for colds, whereas 40% rarely or never visited their doctor for a cold.
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Factors Associated With ED Use
Bivariate predictors of reported ED use adjusted for pediatric practice included Medicaid health insurance, household income <$60 000, child younger than 6 years and with a history of wheezing or reactive airways disease, high folk belief score (a 6-point scale used to identify parents with misconceptions about the causes of colds), belief that over-the-counter cold medications are needed to prevent illness, and belief that antibiotics are needed to treat colds (Table 3). A multivariate logistic regression model was used to predict reported ED use for colds (Table 4). Predictors in the final model included Medicaid insurance (odds ratio [OD]: 17.6), child younger than 6 years and with a history of wheezing or reactive airways disease (OR: 18.3), and the belief that antibiotics are needed to treat colds (OR: 4.2).
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Factors Associated With Ambulatory Care Use
Bivariate predictors of reported ambulatory care use adjusted for pediatric practice included respondent younger than 30 years, child younger than 6 years and with wheezing or reactive airways disease, high folk belief score, and the belief that antibiotics are needed to treat colds (Table 3). Predictors that remained in the multivariate logistic regression model included respondent younger than 30 years (OR: 10.0), child younger than 6 years and with a history of wheezing or reactive airways disease (OR:, 5.6), and the belief that antibiotics are needed to treat colds (OR: 3.8; Table 4).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Our results show that misconceptions about the causes and treatment of colds are common. A significant number of families believe that bacteria cause colds and that antibiotics are needed to treat colds. We also examined factors predictive of reported health service utilization for colds in families with young children enrolled in child care. Previous studies have focused on the relationship of demographic predictors such as race, income, and insurance status or clinical predictors such as having asthma or other chronic illness to the outcome of health care utilization.13,14 Our study found that Medicaid insurance was an independent predictor of ED utilization, which is consistent with findings from several other studies.15–18 Although household income was significant in bivariate analysis, the final model did not include income after adjusting for insurance status. In addition, children with wheezing or reactive airways disease were more likely to visit the ED for a cold, which also supports previous studies that have shown increased health service utilization in children with asthma.18–20
The role of parental beliefs as a potential predictor of reported health service utilization has not been previously examined. Our study shows that the belief that antibiotics are needed to treat colds is an independent predictor of ED utilization. Thus, we have identified another potential area for intervention. For reducing unnecessary ED utilization for colds, factors such as improving access to primary health care and optimizing outpatient management plans for children with asthma need to be addressed.13,21 In addition, family education about the causes and appropriate treatment of colds may help to reduce unnecessary ED visits for colds.
When we examined predictors of reported ambulatory care use, we found that older respondents were less likely to visit their child’s pediatrician for a cold. This may be attributed to the accrued experience of the parent and reflect that older parents feel more comfortable treating a child at home without physician advice. Children with a history of wheezing were also more likely to visit their physician in the outpatient setting, which is not surprising because URIs often trigger wheezing episodes in children. This finding is supported by previous studies that have shown that children with asthma are more likely to have outpatient visits than children without asthma.17 However, we also found that misconceptions about the need for antibiotics remained an independent predictor for ambulatory care use. Again, appropriate educational interventions may reduce these ambulatory care visits for colds.
The concern about unnecessary health service utilization for colds is driven not only by costs but also the larger problem of antibiotic resistance in the community. Many studies have shown that a significant number of antibiotic prescriptions are written during these health care encounters, suggesting that the decision to seek care for colds places a child at risk for receipt of unnecessary antibiotics.2–4,22 To address this issue, 1 approach has been to change physician-prescribing practices through physician-directed campaigns, focused on promoting the judicious use of antibiotics.23–25 However, our study suggests that a 2-pronged approach in which efforts are directed at both physicians and families is needed. By informing families in the community about causes of colds and appropriate antibiotic indications, parental expectations for antibiotics may be reduced. In turn, these efforts may also reduce unnecessary health service utilization and antibiotic prescriptions for colds. Preliminary data regarding judicious antibiotic use in a private pediatric practice have supported this approach thus far.26 Judicious antibiotic use does not seem to result in an increase in return office visits or in the rate of bacterial infections.
There are several limitations to our study. First, our outcome measure of health service utilization for colds was based on parental report. Provider records of health care visits were not available for verification in this study. However, previous work has suggested that self-report is a reasonably accurate method for obtaining data on health care utilization.27 In fact, several studies have found that patients tend to underreport their utilization of health services when compared with provider records.27–29 Such an underreporting bias would have made it more difficult for us to identify associations between predictors and the outcomes of ED use and ambulatory care use. Second, parental misconceptions regarding the definition of a cold may have affected their belief regarding the role of antibiotics in treating colds. Because these families were also participating in a longitudinal study that compared family-defined illnesses with physician-defined illnesses, we did not wish to bias their perception of illness by providing a definition of a cold. However, our results agree with previous studies on patient expectations for antibiotics that have found that up to 50% of parents believe that antibiotics are required for treatment of colds.9,30,31
Third, we were unable to delineate fully the relationship between having a child with wheezing and health service utilization. Previous studies have shown that health service utilization in children with asthma is confounded by many factors, including access to care, severity of illness, and the presence or absence of detailed outpatient management plans.21 Because the questionnaire was conducted at the family level rather than at the child level, we were unable to address this issue fully in our study. Finally, because the majority of families were highly educated and enrolled in individual or employee-sponsored health insurance plans in our study, our reported rates of health service utilization for colds may not be generalizable.
We believe that misconceptions about the causes and treatment of colds should be addressed at the family level. Targeted educational interventions for the family about appropriate antibiotic use may reduce unnecessary health service utilization and antibiotic prescriptions for self-limited viral illnesses.
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ACKNOWLEDGMENTS |
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Dr Lee was supported by an Agency for Healthcare Quality and Research training grant (T32 HS000063), and Dr Friedman was supported by a Health Research and Services Administration Training grant (T32 PE10018). This study was funded by Reckitt-Benckiser, Inc.
We are indebted to Sitso Bediako, Eva Zasloff, Keren Nicole Rivera, and all of the pediatric practices and families that participated in this study. We also gratefully acknowledge the efforts of Drs Penelope Dennehy, Owen Hendley, and Charles Huskins on the study committee for their collaboration and Dr Jonathan Finkelstein for carefully reviewing our manuscript.
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FOOTNOTES |
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Received for publication May 22, 2002; Accepted Aug 21, 2002.
Reprint requests to (G.M.L.) Children’s Hospital Boston, Division of Infectious Diseases, 300 Longwood Ave, Boston, MA 02115. E-mail: grace.lee{at}tch.harvard.edu
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