Attitudes to Upper Respiratory Infections, Antibiotics and Bacterial Resistance

350 Pages·2013·11.07 MB·English

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
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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
3.4.2 The Socio-Demographic and Geographic Basis of Sampling.........................77
3.4.3 Recruitment............................................................................................................79
3.5 Data collection...........................................................................................................83
3.5.1 Interviewing Respondents....................................................................................83
3.6 Data Management....................................................................................................89
3.7 Analytical Process....................................................................................................91
3.7.1 Open, Focused and Axial Coding.......................................................................92
3.7.2 Theoretical Coding..............................................................................................94
3.7.3 Constant Comparison, Memoing and Discontinuing Evidence.....................94
3.7.4 Discontinuing Evidence: Scrutinising unusual cases......................................95
3.7.5 Delayed Theoretical Sampling and Theoretical Saturation.............................96
3.7.6 The Use of Literature...........................................................................................98
3.8 Data Presentation.....................................................................................................98
3.9 Reflexivity................................................................................................................99
3.10 Ethical Issues.........................................................................................................100
3.11 Critiques of Grounded Theory Study.................................................................101
3.12 Trustworthiness...................................................................................................103
3.13 Summary...............................................................................................................105
Chapter 4: Prelude to the Empirical Chapters: Respondent characteristics and
the nature of their accounts
4.0 Introduction............................................................................................................107
4.1 Respondent Characteristics..................................................................................107
4.2 Factual, Responsible, Uncertain and Inconsistent Accounts:
Artefacts of lay beliefs systems?........................................................................114
4.2.1 Factual Accounts................................................................................................116
4.2.2 Responsible Accounts.......................................................................................116
4.2.3 Uncertain and Inconsistent Accounts...............................................................117
4.3 Summary.................................................................................................................121
Chapter 5: Infection and Resistance: A world of unseen dangers
5.0 Introduction............................................................................................................122
5.1 Germ Warfare........................................................................................................123
5.1.1 Demonising Germ...............................................................................................123
5.2 Defences against Germs.......................................................................................129
5.2.1 Health Practices..................................................................................................130
5.2.3 Preventative Procedures....................................................................................132
5.2.4 Disruption of Equilibrium: Increased infection risk......................................137
5.2.5 Bodily Defences.................................................................................................138
5.3 ‘Good Bacteria’......................................................................................................140
5.4 The Threat of Bacterial Resistance.....................................................................143
5.4.1 Uncertainty about the Causes and Consequences of Bacterial Resistance.. 143
I really don’t know the cause of them’............................................................144
‘That's the thing you get in hospital’..................................................................150
5.4. 2 The Public’s Acquisition of Knowledge: Media images of Resistant
Infection..............................................................................................................152
5.4.3 Lack of Individual Ownership for Resistant Infection.................................154
T don't worry about it’.......................................................................................154
‘There's nothing I can do’..................................................................................155
‘It’s not my responsibility’.................................................................................157
5.5 Summary................................................................................................................158
Chapter 6: Overcoming Infection; Experiences of respiratory tract symptoms
6.0 Introduction.............................................................................................................161
6.1 Experiences of Respiratory Tract Symptoms......................................................161
6.2 Lay Beliefs about URTI: An ethnomodel...........................................................164
6.2.1 Hot-cold Influences.............................................................................................165
6.2.2 Traditional Beliefs Focused on Equilibrium....................................................167
6.2.3 Beliefs about Microbes and UTRI....................................................................167
6.2.4 ‘I’m not ill, I’ve got a cold’................................................................................170
6.2.5 A Synergy of Belief: An ‘ethnomodel of RTI................................................172
6.3 Consistent Illness Behaviour: Medicine consumption and child care............174
6.3.1 Child Care.............................................................................................................180
6.3.2 Reservation about Medicines.............................................................................181
6.3.3 The use of Complementary, Alternative, Home and Traditional
Remedies..............................................................................................................182
6.4 Advice Seeking....................................................................................................187
6.4.1 The Demise of the Lay Referral System..........................................................189
6.4.2 Transition to Real Illness...................................................................................192
‘Coughing up gunk’..............................................................................................193
Fever Phobia........................................................................................................194
Unable to ‘work through’..................................................................................195
Illness Lasting Longer than Expected..............................................................195
Complications of Asthma..................................................................................196
Worried Parents.................................................................................................196
6.5 Summary..............................................................................................................201
Chapter 7: Drug offensives Against Germs: Public attitudes towards antibiotics
7.0 Introduction...........................................................................................................202
7.1 Self Reported Antibiotic Consumption............................................................202
7.2 Confidence in the Efficacy and Safety of Antibiotics......................................204
7.2.1 ‘Getting rid of infection’..................................................................................204
7.2.2 Disadvantages of Antibiotics..........................................................................209
7.3 Adherence Behaviour: The case of antibiotics...............................................214
7.3.1 Doing ‘What the Doctor Says’........................................................................215
7.3.2 Challenges to Adherence: Work, child care and social constraints...........219
7.3.3 Forgetting...........................................................................................................224
7.3.4 ‘Feeling Better’..................................................................................................227
7.3.5 ‘Leftover’ Antibiotics and Self -medication..................................................228
7.3.6 Avoiding Antibiotics........................................................................................233
7.4 Changing Health Priorities..................................................................................234
7.5 A Typology of Antibiotic Users Behaviour in the Community...........................235
7.6 Summary...............................................................................................................237
Chapter 8: Discussion and Recommendations
8.0 Introduction...........................................................................................................240
8.1 Public Indifference and Bacterial Resistance...................................................241
8.1.1 The Meaning of ‘Resistance’...........................................................................431
8.1.2 ‘It doesn’t affect me’........................................................................................243
8.1.3 Diffusion of Responsibility and Bystander Apathy......................................245
8.1.4 Lay versus Professional Knowledge...............................................................249
8.1.5 The Influence of the Media on Public Attitudes towards Bacterial
Resistance.............................................................................................................250
8.2 Prototypes of Infection and the Hygiene Panacea: The omission of hand
washing.................................................................................................................252