Attitudes to Upper Respiratory Infections, Antibiotics and Bacterial Resistance
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Attitudes to Upper Respiratory Infections, Antibiotics and Bacterial Resistance: Managing common respiratory infections and promoting the appropriate use of antibiotics by the general population Nancy J Hawkings Thesis submitted for the degree of Doctor of Philosophy Cardiff University School of Medicine January 2009 UMI Number: U585562 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. Dissertation Publishing UMI U585562 Published by ProQuest LLC 2013. Copyright in the Dissertation held by the Author. Microform Edition © ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code. ProQuest LLC 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106-1346 DECLARATION This work has not previously been accepted in substance for any degree and is not concurrently submitted in candidature for any degree. Signed . .............. (candidate) Date ............. STATEMENT 1 This thesis is being submitted in partial fulfillment of the requirements for the degree of .......................................... (insert MCh, MD, MPhil, PhD etc, as appropriate) Signed .. v. .......... (candidate) Date . .r?.^-rr. Vrr. & ............ STATEMENT 2 This thesis is the result of my own independent work/investigation, except where otherwise stated. Other sources are acknowledged by explicit references. Signed ................. (candidate) Date . .......................................... STATEMENT 3 I hereby give consent for my thesis, if accepted, to be available for photocopying and for inter-library loan, and for the title and summary to be made available to outside organisations. Signed .. ......(candidate) Date .. rfife .. Sk r.Q. .0. ....... STATEMENT 4: PREVIOUSLY APPROVED BAR ON ACCESS I hereby give consent for my thesis, if accepted, to be available for photocopying and for inter-library loans after expiry of a bar on access previously approved by the Graduate Development Committee. Signed ................................... (candidate) Date Acknowledgements I would like to thank Cardiff University for funding the studentship which made this PhD possible. Thanks to Professor Chris Butler for continuously steering me in the right direction with inspirational reflections, and to Dr Fiona Wood for her enthusiastic support throughout the last four years. Special thanks to Professor Roisin Pill for her constructive methodological advice at the early stages of the study. To all my colleagues within the Department of Primary Care and Public Health, a special thank you for your friendship, humour and support. This thesis would not have been possible without the community leaders who eagerly welcomed me and enabled me to meet so many willing volunteers. I am extremely grateful to the members of public who freely gave up their time to participate in this study. Finally, thanks to Phil and mum for their support, encouragement and for looking after everyone at home so that I could study. Abstract The public, as the users of antibiotics, can contribute to the control of bacterial resistance. National and international campaigns have recommended public education to promote the judicious and safe use of antibiotics, and in particular, reducing antibiotic use and misuse in upper respiratory tract infections. Campaigns, however, have not been informed by detailed understanding of public attitudes to the problem. Although previous studies have explored lay perceptions of common infections and antibiotics, public attitudes to bacterial resistance, beliefs about antibiotic use in relation to bacterial resistance and the attitudes towards respiratory tract infection influencing antibiotic use are under researched. This thesis addresses this gap using a grounded theory approach. Semi-structured interviews with members of community groups were conducted across South East Wales. By analysing patterns and connections between various beliefs this thesis shows that historical antecedents and beliefs about dirt and germs act as prototypes for current beliefs about resistant infection. Most respondents did not feel that they have a personal role in either the cause or control of bacterial resistance. Lay beliefs about aetiology resided in both traditional and biomedical models. There was a reliance on medicines, and specifically antibiotic attachment, which contributed to self-medication and expectations for antibiotics during upper respiratory tract infection (URTI). Promoting public engagement in the control of bacterial resistance requires a number of approaches to behavioural change. In relation to antibiotic use efforts to promote adherence to antibiotic regimes need to address beliefs about antibiotics, forgetfulness and practical barriers to adherence but also to reduce public expectations for antibiotics for upper respiratory tract infections by enhancing understanding about the microbial causes of URTI. Efforts to reduce antibiotic use, however, need also to address the wider meaning and the reliance on antibiotics. Public engagement in the control of infection through hand washing should be promoted as an effective way to reduce the risk community acquired resistant infection. Contents Chapter 1: Setting the Scene 1.0 Introduction ................................................................................................................. 1 1.1 Rationale and Aims of the Study ............................................................................ 2 1.1.1 Funding and Personal Note ....................................................................................6 1.2 The Scientific Context of the Study .........................................................................6 1.2.1 Bacteria and Infection ............................................................................................ 7 1.2.2 Respiratory Tract Infections (RTIs) ......................................................................8 1.2.3 Antibiotics: Modes of action and adverse effects .............................................. 10 1.2.4 The Scientific Basis of Bacterial Resistance ......................................................14 1.2.5 The Publics’ Influence on Bacterial Resistance: Antibiotic prescribing and adherence behaviours ..................................................................................... 18 1.3 Efforts to Control Bacterial Resistance ................................................................. 22 1.4 The South East Wales Context.............................................................................. 23 1.5 Structure of the Thesis............................................................................................. 26 Chapter 2: Literature Review 2.0 Introduction ..............................................................................................................30 2.1 Lay Beliefs about the Causes of URTIs ................................................................ 33 2.2 Illness Behaviour associated with URTIs .............................................................40 2.2.1 Self Care.................................................................................................................40 Self care with non-pharmaceutical remedies: .................................................... 40 Self-care with pharmaceutical products:............................................................43 2.2.2 The Use of Primary Care Services for URTI .................................................... 45 2.3 Lay Attitudes towards Antibiotics and Their use During URTI ..................... 49 2.3.1 Mixed Views of Antibiotics ................................................................................ 49 2.3.2 Perceptions of Antibiotic Efficacy during URTI ..............................................52 2.3.3 Adherence to Antibiotic Regimes: The extent of the problem ....................... 55 v 2.3.4 Modifying Antibiotic Treatment Regimes: Sub-optimal adherence ...............57 2.3.5 Influences on Antibiotic Adherence Behaviours ..............................................60 The characteristics of the consumer and the illness experience...................... 60 Characteristics of the course of treatment ..........................................................61 The characteristics of the clinician and consultation ....................................... 62 2.4 Public Awareness and Beliefs about Resistant Infections .................................. 63 2.5 Summary ................................................................................................................... 67 Chapter 3: Methods 3.0 Introduction ...............................................................................................................70 3.1 The Research Question and Approach .................................................................. 70 3.2 Grounded Theory and the Research Approach ................................................... 72 3.3 Interpretative Grounded Theory ............................................................................ 73 3.4 Sampling ................................................................................................................... 75 3.4.1 Issues Surrounding Research with Children......................................................76