Roger J. Zoorob, MD, MPH

Infections of the upper respiratory tract account for some of the most common acute illnesses seen in primary care settings. The term “upper respiratory infection” (URI) covers any infectious disease process that involves the respiratory system, starting with the nose and ending just before the lungs. Our study dealt exclusively with the common cold.

Most patients with typical URI syndromes can be treated symptomatically. Although antimicrobial therapy is indicated in the presence of bacterial infection, it is believed that most cases are viral in nature.¹ However, of those patients who seek a physician’s care for colds and bronchitis, 50% to 70% receive an antibiotic prescription.² Ten percent of all antibiotics prescribed are for the common cold and other URIs.² The percentage is even higher in the pediatric population where antibiotic prescriptions for colds, URIs, and bronchitis (ie, conditions not affected by antibiotics) accounted for more than 20% of all antibiotics prescribed to US children in 1992.³

Prescribing antibiotics for URIs does not improve patient outcome, and this practice does not benefit physicians by reducing return visits or increasing patient satisfaction.^4,5 It is also not a cost-effective strategy. Evidence from a Medicaid population suggests that the antibiotics used to treat colds account for 23% of the total cost of managing URIs and add more than $11 to the cost of managing every URI episode.⁶ Nevertheless, a 1996 study conducted on a Medicaid population concluded that a majority of individuals receiving medical care for the common cold are still given prescriptions for unnecessary antibiotics.⁷

Clinicians often report that they are motivated to prescribe antibiotics by patient expectations.⁸ For example, parents frequently have misconceptions about which illnesses warrant antibiotic therapy leading them to request these drugs for their children.⁹ A survey conducted in Kentucky showed that when patients do not recognize the normal presentation of a URI or understand the effectiveness of antibiotics, inappropriate use and expectations may arise.¹⁰ Also questionable is whether physicians are able to accurately identify situations for which antibiotics are appropriate. Even without the influence of misinformed patients, physicians may be prescribing antibiotics inappropriately because of misdiagnosis.¹¹

The purpose of our study was to determine what a select segment of the population (undergraduate college students) knows about URIs and the perceptions of antibiotic therapy held by members of that segment. The information provided can contribute to our understanding of what types of interventions are required to change patients’ perceptions about the appropriateness of antibiotic therapy.

Methods

Participants (n=425) were students aged 18 years and older on 3 college campuses in Louisiana and Indiana. Two of the colleges were public institutions; the third was private. Data were collected in November 1999 in accordance with human subject guidelines after approval by the appropriate institutional review boards. Research assistants distributed the surveys in public areas on each of the campuses.

Survey Instrument

Participants completed a self-report survey primarily composed of 3 symptom scenarios. Two of these scenarios were employed in previous studies.^10,12 The scenarios represented variations in presentation of an uncomplicated URI along 3 dimensions: duration of symptoms, color of nasal discharge, and the presence of a low-grade fever. The scenarios were: (1) “You have had an illness for 5 days with the following symptoms: sore throat, cough, and runny nose with clear nasal discharge”; (2) “You have had an illness for 5 days with the following symptoms: sore throat, cough, and runny nose with discolored (yellow, green, brown) discharge”; and (3) “You have had an illness for 3 days with the following symptoms: sore throat, cough, runny nose with clear discharge, and low grade fever (less than 101ÞF).”

Following each scenario’s presentation, a participant was asked to indicate on a 5-point Likert-type scale (1=very likely; 5=very unlikely) how likely he or she was to seek care from a physician for the illness and the likelihood of using several treatment modalities (eg, antibiotics, antihistamines, pain relievers, vitamin C) for the presented condition.

Participants were also queried about a variety of demographic variables, current and past smoking status, and their belief in the effectiveness of antibiotics against the common cold. Finally, participants were asked to indicate whether they would see a physician if they had a cold (no specific symptoms were provided to define “cold”). The questionnaire was designed for self-administration and required less than 5 minutes to complete.

Analysis

Likert-based responses on the questionnaire were dichotomized by combining “very likely” and “somewhat likely” into 1 group and “neutral,” “somewhat unlikely,” and “very unlikely” responses into another. These responses and the yes or no responses were analyzed using chi-square tests.

The likelihood of seeking care and using antibiotics to treat a cold were averaged across scenarios. We used bivariate analyses to examine the relationship of demographic characteristics to averaged likelihood of seeking care and antibiotic use.

Stepwise multiple regression analyses were employed to examine the effects of participant characteristics on likelihood of seeking care and likelihood of using antibiotics. Because the regression analysis for each individual scenario produced similar results, we only report the analysis employing averaged likelihood of seeking care and averaged likelihood of using antibiotics. Participant demographic characteristics (continuous and discrete) that were included as independent variables in these analyses were sex, race, age, type of health insurance, and year of college. In analyzing likelihood of seeking care we included the additional variable of belief in the effectiveness of antibiotics in treating the common cold as an independent variable. We performed an additional stepwise multiple regression analysis using belief in antibiotic effectiveness as the dependent variable and participant demographic characteristics as the independent variables.

Results

The demographic characteristics of the total sample and each recruitment site are provided in Table 1. In response to a free-format question on the survey, 24% of students in the total sample reported enrollment in a science-related field of study.

Responses to the questionnaire were first examined by campus. Although the campus samples differed significantly in some ways (eg, sex and racial distributions, average age, year in college, type of health insurance), no significant differences existed between campuses in terms of the study’s variables of focus. Therefore, we conducted all analyses on the total sample.

Antibiotic Effectiveness

Forty-one percent of the total sample believed that antibiotics were effective for treating the common cold Table 2. Of those who reported a belief that antibiotics were effective for cold treatment, 24% would see a physician for a cold (10% of the total sample). Of those who did not believe in the effectiveness of antibiotics for treating colds, 12% would still seek a physician’s care for a cold (7% of the total sample).

Symptom Complex Analysis

Analysis of antibiotic use by symptom complex Table 3 revealed that 63% of all students would be “somewhat likely “or “very likely” to use antibiotics in the scenario of 5 days with discolored discharge, compared with 53% in the 3 days with clear discharge with low-grade fever scenario, and 44% in the scenario of 5 days with clear discharge (P <.001 for each comparison). Percentages were higher for those students who believe antibiotics are effective in treating the common cold: 77%, 73%, and 64%, respectively. Even among those students reporting that antibiotics are not effective in treating colds, a high number of students endorsed “somewhat likely” or “very likely” antibiotic use when presented with the 3 scenarios (32% for 5 days with clear discharge; 42% for 3 days with clear discharge and low-grade fever; 55% for 5 days with discolored discharge).

Participants’ beliefs about whether they would seek a physician’s care were also analyzed by symptom complex Table 4. Fifty-six percent of all students surveyed reported being “somewhat likely” or “very likely” to see a physician in the scenario of 5 days with discolored nasal discharge, which was a significantly greater percentage than those who would see a physician for 3 days with clear discharge and a low-grade fever (44%) and those who would see a physician if they experienced 5 days of clear discharge (29%). Percentages of those seeking medical help followed the same pattern among those students who believe antibiotics are effective in treating the common cold and those who do not believe in the effectiveness of antibiotics.

Care-seeking and antibiotic use were also analyzed separately for students who would seek a physician’s care for a common cold and those who would not Table 5. Not surprisingly, more than 50% of the students who reported that they would seek a physician’s care for a common cold endorsed seeking care in each of the presented scenarios. Likelihood of antibiotic use did not differ by symptom complex within this group, with more than 70% reporting they would use antibiotics in each of the scenarios. Among students who would not seek a physician’s help for a common cold, a significant number reported that they would still see a physician when faced with the described sets of symptoms (23% to 49% based on the scenario). High numbers of students who reported that they would not seek treatment for a common cold still reported that they were likely to use antibiotics in the presented scenarios (39% to 59% based on symptom complex).

Comparative Data

We examined the relationship of demographic characteristics to average likelihood of seeking care and average likelihood of using antibiotics (across scenarios). Reported likelihood of using antibiotics was not significantly related to any of the demographic characteristics (sex, race/ethnicity, age, college year, smoking status, or type of health insurance). Women (mean=2.89±1.14) reported being more likely than men (mean=3.17±1.19) to seek care across scenarios (P <.017). Age was also significantly related to care seeking (r=17; P <.001). The relationships between college year and care seeking and between type of health insurance and care seeking are depicted in Table 6. Freshmen and sophomores were less likely to seek care than juniors and seniors. Those using university health services were more likely than those with a private physician or other health arrangement to seek care (P <.001). Smoking status and race/ethnicity were not found to be related to reported likelihood of seeking care within this sample.

We conducted stepwise multiple regression analyses to examine predictors of belief in the effectiveness of antibiotics for cold symptoms, reported likelihood of antibiotic use across scenarios, and likelihood of seeking care across scenarios. Year of college was the only significant predictor of belief in the effectiveness of antibiotics for cold symptoms (b=0.18; P=.001). Belief in antibiotic effectiveness decreased with increasing years of higher education. Age was the only significant predictor of antibiotic use (b=0.16; P=.001). Greater age was associated with increased likelihood of using antibiotics. Average reported likelihood of seeking care was predicted by type of health insurance (b=0.22; P=.001) and by belief in the effectiveness of antibiotics to treat common colds (b=0.11; P=.03).

Discussion

A majority of students surveyed in this study would use antibiotics for the symptoms of a common cold, especially when accompanied by low-grade fever or discolored nasal discharge. This belief persisted in a significant portion even for the scenario with 5 days of clear nasal discharge and no fever. This is commensurate with other studies of different populations in the literature.¹³ A majority of students who reported they would not see a physician for a common cold still thought they would seek care for the presented scenarios, indicating a tendency toward inaccurate self-diagnosis especially when faced with symptoms perceived to be indicators of greater illness (eg, fever, discolored nasal discharge). Thick and opaque nasal discharge is part of the natural course of common cold and is not an indication to use antimicrobial therapy unless the symptoms persist longer than 10 to 14 days without improvement,¹⁴ but this message does not appear to be reaching patients. The use of antibiotics for viral illness and for uncomplicated URIs will lead to resistance and is discouraged by researchers and infectious disease experts.¹⁵

Our study provides evidence that even educated individuals may not recognize common URI presentations and appropriate treatment. A significant portion of this sample was unable to link their stated beliefs about colds with symptom scenarios consistent with URIs. In this sample, demographic variables did not alter the likelihood of using antibiotics, indicating the broad-based nature of the misconceptions. Our findings are consistent with previous studies showing that patients in family practice, internal medicine clinics, or emergency department waiting rooms do not recognize symptoms of the common presentation of URIs.¹⁰ The same study hypothesized that education about normal presentation could reduce visits to the physician and the misuse of antibiotics. Another recent study showed that members of ethnically diverse communities believe in the effectiveness of antibiotics for treatment of colds and often obtain them without a prescription.¹²

In our study, women reported a greater likelihood of care seeking across all scenarios, a finding consistent with the literature.16 Another variable predictive of seeking care was college year. Freshmen and sophomores were less likely to seek care than students in later periods of their education. This finding may have been due to the relationship between health care use and increasing age.

Our study emphasizes the need for patient education to: (1) minimize the use of health services or self-limiting illnesses; (2) decrease the inappropriate use of antibiotics; and (3) promote increased selectivity in patients’ choices of nonprescription remedies (eg, promote the use of evidence-based remedies). The central role of the physician as educator and opinion leader in this process should not be overlooked. From previous research it remains unclear whether physicians really believe in the usefulness of antibiotics in treating URIs or whether they are responding to patient expectations. However, some findings indicate a continued need for physician education about the natural history of URIs. For example, Schwartz and colleagues¹¹ surveyed family physicians and pediatricians in Virginia with a questionnaire describing case scenarios that involve a single-day history of greenish-yellowish discharge and low-grade fever. A majority of the physicians surveyed endorsed prescribing antibiotics. Another study revealed that physicians confronted with colored nasal discharge, lack of response to decongestants, and fever (among other symptoms) diagnosed sinusitis and prescribed antibiotics in more than 98% of cases and prescribed the same for more than 13% of patients with URIs.¹⁷ In a 1999 study, pediatricians and family physicians in Georgia reported prescribing practices that were inconsistent with published recommendations for judicious antibiotic use in the treatment of URIs, again overprescribing anitibiotics.¹⁸ Given such study results can we blame our patients’ for their enduring confidence in antibiotic effectiveness? Targeted educational information provided by trusted physicians and a refusal by physicians to prescribe unnecessary antibiotics are vital components in influencing our patients’ beliefs. Although some patients will obtain antibiotics without prescriptions,¹² we can have a significant impact on the beliefs encouraging these practices. The ultimate responsibility for changing patient attitudes and prescribing habits of physicians remains with us.

Limitations

Participants in this self-report survey were volunteers, which may introduce a selection bias. Also, because current college students composed the study population, the ability to extrapolate these findings to other young adults, college-educated older adults, or adults in general is unknown.

Conclusions

Our results show that health care education is needed among college students, especially in the area of symptoms and treatments of common illnesses. Educational interventions for patients and physicians concerning the presentation of the common cold and the appropriate use of antibiotics should be the focus of continuing research. This may result in more medical resources and less-resistant organisms.

Infections of the upper respiratory tract account for some of the most common acute illnesses seen in primary care settings. The term “upper respiratory infection” (URI) covers any infectious disease process that involves the respiratory system, starting with the nose and ending just before the lungs. Our study dealt exclusively with the common cold.

Most patients with typical URI syndromes can be treated symptomatically. Although antimicrobial therapy is indicated in the presence of bacterial infection, it is believed that most cases are viral in nature.¹ However, of those patients who seek a physician’s care for colds and bronchitis, 50% to 70% receive an antibiotic prescription.² Ten percent of all antibiotics prescribed are for the common cold and other URIs.² The percentage is even higher in the pediatric population where antibiotic prescriptions for colds, URIs, and bronchitis (ie, conditions not affected by antibiotics) accounted for more than 20% of all antibiotics prescribed to US children in 1992.³

Prescribing antibiotics for URIs does not improve patient outcome, and this practice does not benefit physicians by reducing return visits or increasing patient satisfaction.^4,5 It is also not a cost-effective strategy. Evidence from a Medicaid population suggests that the antibiotics used to treat colds account for 23% of the total cost of managing URIs and add more than $11 to the cost of managing every URI episode.⁶ Nevertheless, a 1996 study conducted on a Medicaid population concluded that a majority of individuals receiving medical care for the common cold are still given prescriptions for unnecessary antibiotics.⁷

Clinicians often report that they are motivated to prescribe antibiotics by patient expectations.⁸ For example, parents frequently have misconceptions about which illnesses warrant antibiotic therapy leading them to request these drugs for their children.⁹ A survey conducted in Kentucky showed that when patients do not recognize the normal presentation of a URI or understand the effectiveness of antibiotics, inappropriate use and expectations may arise.¹⁰ Also questionable is whether physicians are able to accurately identify situations for which antibiotics are appropriate. Even without the influence of misinformed patients, physicians may be prescribing antibiotics inappropriately because of misdiagnosis.¹¹

The purpose of our study was to determine what a select segment of the population (undergraduate college students) knows about URIs and the perceptions of antibiotic therapy held by members of that segment. The information provided can contribute to our understanding of what types of interventions are required to change patients’ perceptions about the appropriateness of antibiotic therapy.

Methods

Participants (n=425) were students aged 18 years and older on 3 college campuses in Louisiana and Indiana. Two of the colleges were public institutions; the third was private. Data were collected in November 1999 in accordance with human subject guidelines after approval by the appropriate institutional review boards. Research assistants distributed the surveys in public areas on each of the campuses.

Survey Instrument

Participants completed a self-report survey primarily composed of 3 symptom scenarios. Two of these scenarios were employed in previous studies.^10,12 The scenarios represented variations in presentation of an uncomplicated URI along 3 dimensions: duration of symptoms, color of nasal discharge, and the presence of a low-grade fever. The scenarios were: (1) “You have had an illness for 5 days with the following symptoms: sore throat, cough, and runny nose with clear nasal discharge”; (2) “You have had an illness for 5 days with the following symptoms: sore throat, cough, and runny nose with discolored (yellow, green, brown) discharge”; and (3) “You have had an illness for 3 days with the following symptoms: sore throat, cough, runny nose with clear discharge, and low grade fever (less than 101ÞF).”

Following each scenario’s presentation, a participant was asked to indicate on a 5-point Likert-type scale (1=very likely; 5=very unlikely) how likely he or she was to seek care from a physician for the illness and the likelihood of using several treatment modalities (eg, antibiotics, antihistamines, pain relievers, vitamin C) for the presented condition.

Participants were also queried about a variety of demographic variables, current and past smoking status, and their belief in the effectiveness of antibiotics against the common cold. Finally, participants were asked to indicate whether they would see a physician if they had a cold (no specific symptoms were provided to define “cold”). The questionnaire was designed for self-administration and required less than 5 minutes to complete.

Analysis

Likert-based responses on the questionnaire were dichotomized by combining “very likely” and “somewhat likely” into 1 group and “neutral,” “somewhat unlikely,” and “very unlikely” responses into another. These responses and the yes or no responses were analyzed using chi-square tests.

The likelihood of seeking care and using antibiotics to treat a cold were averaged across scenarios. We used bivariate analyses to examine the relationship of demographic characteristics to averaged likelihood of seeking care and antibiotic use.

Stepwise multiple regression analyses were employed to examine the effects of participant characteristics on likelihood of seeking care and likelihood of using antibiotics. Because the regression analysis for each individual scenario produced similar results, we only report the analysis employing averaged likelihood of seeking care and averaged likelihood of using antibiotics. Participant demographic characteristics (continuous and discrete) that were included as independent variables in these analyses were sex, race, age, type of health insurance, and year of college. In analyzing likelihood of seeking care we included the additional variable of belief in the effectiveness of antibiotics in treating the common cold as an independent variable. We performed an additional stepwise multiple regression analysis using belief in antibiotic effectiveness as the dependent variable and participant demographic characteristics as the independent variables.

Results

The demographic characteristics of the total sample and each recruitment site are provided in Table 1. In response to a free-format question on the survey, 24% of students in the total sample reported enrollment in a science-related field of study.

Responses to the questionnaire were first examined by campus. Although the campus samples differed significantly in some ways (eg, sex and racial distributions, average age, year in college, type of health insurance), no significant differences existed between campuses in terms of the study’s variables of focus. Therefore, we conducted all analyses on the total sample.

Antibiotic Effectiveness

Forty-one percent of the total sample believed that antibiotics were effective for treating the common cold Table 2. Of those who reported a belief that antibiotics were effective for cold treatment, 24% would see a physician for a cold (10% of the total sample). Of those who did not believe in the effectiveness of antibiotics for treating colds, 12% would still seek a physician’s care for a cold (7% of the total sample).

Symptom Complex Analysis

Analysis of antibiotic use by symptom complex Table 3 revealed that 63% of all students would be “somewhat likely “or “very likely” to use antibiotics in the scenario of 5 days with discolored discharge, compared with 53% in the 3 days with clear discharge with low-grade fever scenario, and 44% in the scenario of 5 days with clear discharge (P <.001 for each comparison). Percentages were higher for those students who believe antibiotics are effective in treating the common cold: 77%, 73%, and 64%, respectively. Even among those students reporting that antibiotics are not effective in treating colds, a high number of students endorsed “somewhat likely” or “very likely” antibiotic use when presented with the 3 scenarios (32% for 5 days with clear discharge; 42% for 3 days with clear discharge and low-grade fever; 55% for 5 days with discolored discharge).

Participants’ beliefs about whether they would seek a physician’s care were also analyzed by symptom complex Table 4. Fifty-six percent of all students surveyed reported being “somewhat likely” or “very likely” to see a physician in the scenario of 5 days with discolored nasal discharge, which was a significantly greater percentage than those who would see a physician for 3 days with clear discharge and a low-grade fever (44%) and those who would see a physician if they experienced 5 days of clear discharge (29%). Percentages of those seeking medical help followed the same pattern among those students who believe antibiotics are effective in treating the common cold and those who do not believe in the effectiveness of antibiotics.

Care-seeking and antibiotic use were also analyzed separately for students who would seek a physician’s care for a common cold and those who would not Table 5. Not surprisingly, more than 50% of the students who reported that they would seek a physician’s care for a common cold endorsed seeking care in each of the presented scenarios. Likelihood of antibiotic use did not differ by symptom complex within this group, with more than 70% reporting they would use antibiotics in each of the scenarios. Among students who would not seek a physician’s help for a common cold, a significant number reported that they would still see a physician when faced with the described sets of symptoms (23% to 49% based on the scenario). High numbers of students who reported that they would not seek treatment for a common cold still reported that they were likely to use antibiotics in the presented scenarios (39% to 59% based on symptom complex).

Comparative Data

We examined the relationship of demographic characteristics to average likelihood of seeking care and average likelihood of using antibiotics (across scenarios). Reported likelihood of using antibiotics was not significantly related to any of the demographic characteristics (sex, race/ethnicity, age, college year, smoking status, or type of health insurance). Women (mean=2.89±1.14) reported being more likely than men (mean=3.17±1.19) to seek care across scenarios (P <.017). Age was also significantly related to care seeking (r=17; P <.001). The relationships between college year and care seeking and between type of health insurance and care seeking are depicted in Table 6. Freshmen and sophomores were less likely to seek care than juniors and seniors. Those using university health services were more likely than those with a private physician or other health arrangement to seek care (P <.001). Smoking status and race/ethnicity were not found to be related to reported likelihood of seeking care within this sample.

We conducted stepwise multiple regression analyses to examine predictors of belief in the effectiveness of antibiotics for cold symptoms, reported likelihood of antibiotic use across scenarios, and likelihood of seeking care across scenarios. Year of college was the only significant predictor of belief in the effectiveness of antibiotics for cold symptoms (b=0.18; P=.001). Belief in antibiotic effectiveness decreased with increasing years of higher education. Age was the only significant predictor of antibiotic use (b=0.16; P=.001). Greater age was associated with increased likelihood of using antibiotics. Average reported likelihood of seeking care was predicted by type of health insurance (b=0.22; P=.001) and by belief in the effectiveness of antibiotics to treat common colds (b=0.11; P=.03).

Discussion

A majority of students surveyed in this study would use antibiotics for the symptoms of a common cold, especially when accompanied by low-grade fever or discolored nasal discharge. This belief persisted in a significant portion even for the scenario with 5 days of clear nasal discharge and no fever. This is commensurate with other studies of different populations in the literature.¹³ A majority of students who reported they would not see a physician for a common cold still thought they would seek care for the presented scenarios, indicating a tendency toward inaccurate self-diagnosis especially when faced with symptoms perceived to be indicators of greater illness (eg, fever, discolored nasal discharge). Thick and opaque nasal discharge is part of the natural course of common cold and is not an indication to use antimicrobial therapy unless the symptoms persist longer than 10 to 14 days without improvement,¹⁴ but this message does not appear to be reaching patients. The use of antibiotics for viral illness and for uncomplicated URIs will lead to resistance and is discouraged by researchers and infectious disease experts.¹⁵

Our study provides evidence that even educated individuals may not recognize common URI presentations and appropriate treatment. A significant portion of this sample was unable to link their stated beliefs about colds with symptom scenarios consistent with URIs. In this sample, demographic variables did not alter the likelihood of using antibiotics, indicating the broad-based nature of the misconceptions. Our findings are consistent with previous studies showing that patients in family practice, internal medicine clinics, or emergency department waiting rooms do not recognize symptoms of the common presentation of URIs.¹⁰ The same study hypothesized that education about normal presentation could reduce visits to the physician and the misuse of antibiotics. Another recent study showed that members of ethnically diverse communities believe in the effectiveness of antibiotics for treatment of colds and often obtain them without a prescription.¹²

In our study, women reported a greater likelihood of care seeking across all scenarios, a finding consistent with the literature.16 Another variable predictive of seeking care was college year. Freshmen and sophomores were less likely to seek care than students in later periods of their education. This finding may have been due to the relationship between health care use and increasing age.

Our study emphasizes the need for patient education to: (1) minimize the use of health services or self-limiting illnesses; (2) decrease the inappropriate use of antibiotics; and (3) promote increased selectivity in patients’ choices of nonprescription remedies (eg, promote the use of evidence-based remedies). The central role of the physician as educator and opinion leader in this process should not be overlooked. From previous research it remains unclear whether physicians really believe in the usefulness of antibiotics in treating URIs or whether they are responding to patient expectations. However, some findings indicate a continued need for physician education about the natural history of URIs. For example, Schwartz and colleagues¹¹ surveyed family physicians and pediatricians in Virginia with a questionnaire describing case scenarios that involve a single-day history of greenish-yellowish discharge and low-grade fever. A majority of the physicians surveyed endorsed prescribing antibiotics. Another study revealed that physicians confronted with colored nasal discharge, lack of response to decongestants, and fever (among other symptoms) diagnosed sinusitis and prescribed antibiotics in more than 98% of cases and prescribed the same for more than 13% of patients with URIs.¹⁷ In a 1999 study, pediatricians and family physicians in Georgia reported prescribing practices that were inconsistent with published recommendations for judicious antibiotic use in the treatment of URIs, again overprescribing anitibiotics.¹⁸ Given such study results can we blame our patients’ for their enduring confidence in antibiotic effectiveness? Targeted educational information provided by trusted physicians and a refusal by physicians to prescribe unnecessary antibiotics are vital components in influencing our patients’ beliefs. Although some patients will obtain antibiotics without prescriptions,¹² we can have a significant impact on the beliefs encouraging these practices. The ultimate responsibility for changing patient attitudes and prescribing habits of physicians remains with us.

Limitations

Participants in this self-report survey were volunteers, which may introduce a selection bias. Also, because current college students composed the study population, the ability to extrapolate these findings to other young adults, college-educated older adults, or adults in general is unknown.

Conclusions

Our results show that health care education is needed among college students, especially in the area of symptoms and treatments of common illnesses. Educational interventions for patients and physicians concerning the presentation of the common cold and the appropriate use of antibiotics should be the focus of continuing research. This may result in more medical resources and less-resistant organisms.

Infections of the upper respiratory tract account for some of the most common acute illnesses seen in primary care settings. The term “upper respiratory infection” (URI) covers any infectious disease process that involves the respiratory system, starting with the nose and ending just before the lungs. Our study dealt exclusively with the common cold.

Most patients with typical URI syndromes can be treated symptomatically. Although antimicrobial therapy is indicated in the presence of bacterial infection, it is believed that most cases are viral in nature.¹ However, of those patients who seek a physician’s care for colds and bronchitis, 50% to 70% receive an antibiotic prescription.² Ten percent of all antibiotics prescribed are for the common cold and other URIs.² The percentage is even higher in the pediatric population where antibiotic prescriptions for colds, URIs, and bronchitis (ie, conditions not affected by antibiotics) accounted for more than 20% of all antibiotics prescribed to US children in 1992.³

Prescribing antibiotics for URIs does not improve patient outcome, and this practice does not benefit physicians by reducing return visits or increasing patient satisfaction.^4,5 It is also not a cost-effective strategy. Evidence from a Medicaid population suggests that the antibiotics used to treat colds account for 23% of the total cost of managing URIs and add more than $11 to the cost of managing every URI episode.⁶ Nevertheless, a 1996 study conducted on a Medicaid population concluded that a majority of individuals receiving medical care for the common cold are still given prescriptions for unnecessary antibiotics.⁷

Clinicians often report that they are motivated to prescribe antibiotics by patient expectations.⁸ For example, parents frequently have misconceptions about which illnesses warrant antibiotic therapy leading them to request these drugs for their children.⁹ A survey conducted in Kentucky showed that when patients do not recognize the normal presentation of a URI or understand the effectiveness of antibiotics, inappropriate use and expectations may arise.¹⁰ Also questionable is whether physicians are able to accurately identify situations for which antibiotics are appropriate. Even without the influence of misinformed patients, physicians may be prescribing antibiotics inappropriately because of misdiagnosis.¹¹

The purpose of our study was to determine what a select segment of the population (undergraduate college students) knows about URIs and the perceptions of antibiotic therapy held by members of that segment. The information provided can contribute to our understanding of what types of interventions are required to change patients’ perceptions about the appropriateness of antibiotic therapy.

Methods

Participants (n=425) were students aged 18 years and older on 3 college campuses in Louisiana and Indiana. Two of the colleges were public institutions; the third was private. Data were collected in November 1999 in accordance with human subject guidelines after approval by the appropriate institutional review boards. Research assistants distributed the surveys in public areas on each of the campuses.

Survey Instrument

Participants completed a self-report survey primarily composed of 3 symptom scenarios. Two of these scenarios were employed in previous studies.^10,12 The scenarios represented variations in presentation of an uncomplicated URI along 3 dimensions: duration of symptoms, color of nasal discharge, and the presence of a low-grade fever. The scenarios were: (1) “You have had an illness for 5 days with the following symptoms: sore throat, cough, and runny nose with clear nasal discharge”; (2) “You have had an illness for 5 days with the following symptoms: sore throat, cough, and runny nose with discolored (yellow, green, brown) discharge”; and (3) “You have had an illness for 3 days with the following symptoms: sore throat, cough, runny nose with clear discharge, and low grade fever (less than 101ÞF).”

Following each scenario’s presentation, a participant was asked to indicate on a 5-point Likert-type scale (1=very likely; 5=very unlikely) how likely he or she was to seek care from a physician for the illness and the likelihood of using several treatment modalities (eg, antibiotics, antihistamines, pain relievers, vitamin C) for the presented condition.

Participants were also queried about a variety of demographic variables, current and past smoking status, and their belief in the effectiveness of antibiotics against the common cold. Finally, participants were asked to indicate whether they would see a physician if they had a cold (no specific symptoms were provided to define “cold”). The questionnaire was designed for self-administration and required less than 5 minutes to complete.

Analysis

Likert-based responses on the questionnaire were dichotomized by combining “very likely” and “somewhat likely” into 1 group and “neutral,” “somewhat unlikely,” and “very unlikely” responses into another. These responses and the yes or no responses were analyzed using chi-square tests.

The likelihood of seeking care and using antibiotics to treat a cold were averaged across scenarios. We used bivariate analyses to examine the relationship of demographic characteristics to averaged likelihood of seeking care and antibiotic use.

Stepwise multiple regression analyses were employed to examine the effects of participant characteristics on likelihood of seeking care and likelihood of using antibiotics. Because the regression analysis for each individual scenario produced similar results, we only report the analysis employing averaged likelihood of seeking care and averaged likelihood of using antibiotics. Participant demographic characteristics (continuous and discrete) that were included as independent variables in these analyses were sex, race, age, type of health insurance, and year of college. In analyzing likelihood of seeking care we included the additional variable of belief in the effectiveness of antibiotics in treating the common cold as an independent variable. We performed an additional stepwise multiple regression analysis using belief in antibiotic effectiveness as the dependent variable and participant demographic characteristics as the independent variables.

Results

The demographic characteristics of the total sample and each recruitment site are provided in Table 1. In response to a free-format question on the survey, 24% of students in the total sample reported enrollment in a science-related field of study.

Responses to the questionnaire were first examined by campus. Although the campus samples differed significantly in some ways (eg, sex and racial distributions, average age, year in college, type of health insurance), no significant differences existed between campuses in terms of the study’s variables of focus. Therefore, we conducted all analyses on the total sample.

Antibiotic Effectiveness

Forty-one percent of the total sample believed that antibiotics were effective for treating the common cold Table 2. Of those who reported a belief that antibiotics were effective for cold treatment, 24% would see a physician for a cold (10% of the total sample). Of those who did not believe in the effectiveness of antibiotics for treating colds, 12% would still seek a physician’s care for a cold (7% of the total sample).

Symptom Complex Analysis

Analysis of antibiotic use by symptom complex Table 3 revealed that 63% of all students would be “somewhat likely “or “very likely” to use antibiotics in the scenario of 5 days with discolored discharge, compared with 53% in the 3 days with clear discharge with low-grade fever scenario, and 44% in the scenario of 5 days with clear discharge (P <.001 for each comparison). Percentages were higher for those students who believe antibiotics are effective in treating the common cold: 77%, 73%, and 64%, respectively. Even among those students reporting that antibiotics are not effective in treating colds, a high number of students endorsed “somewhat likely” or “very likely” antibiotic use when presented with the 3 scenarios (32% for 5 days with clear discharge; 42% for 3 days with clear discharge and low-grade fever; 55% for 5 days with discolored discharge).

Participants’ beliefs about whether they would seek a physician’s care were also analyzed by symptom complex Table 4. Fifty-six percent of all students surveyed reported being “somewhat likely” or “very likely” to see a physician in the scenario of 5 days with discolored nasal discharge, which was a significantly greater percentage than those who would see a physician for 3 days with clear discharge and a low-grade fever (44%) and those who would see a physician if they experienced 5 days of clear discharge (29%). Percentages of those seeking medical help followed the same pattern among those students who believe antibiotics are effective in treating the common cold and those who do not believe in the effectiveness of antibiotics.

Care-seeking and antibiotic use were also analyzed separately for students who would seek a physician’s care for a common cold and those who would not Table 5. Not surprisingly, more than 50% of the students who reported that they would seek a physician’s care for a common cold endorsed seeking care in each of the presented scenarios. Likelihood of antibiotic use did not differ by symptom complex within this group, with more than 70% reporting they would use antibiotics in each of the scenarios. Among students who would not seek a physician’s help for a common cold, a significant number reported that they would still see a physician when faced with the described sets of symptoms (23% to 49% based on the scenario). High numbers of students who reported that they would not seek treatment for a common cold still reported that they were likely to use antibiotics in the presented scenarios (39% to 59% based on symptom complex).

Comparative Data

We examined the relationship of demographic characteristics to average likelihood of seeking care and average likelihood of using antibiotics (across scenarios). Reported likelihood of using antibiotics was not significantly related to any of the demographic characteristics (sex, race/ethnicity, age, college year, smoking status, or type of health insurance). Women (mean=2.89±1.14) reported being more likely than men (mean=3.17±1.19) to seek care across scenarios (P <.017). Age was also significantly related to care seeking (r=17; P <.001). The relationships between college year and care seeking and between type of health insurance and care seeking are depicted in Table 6. Freshmen and sophomores were less likely to seek care than juniors and seniors. Those using university health services were more likely than those with a private physician or other health arrangement to seek care (P <.001). Smoking status and race/ethnicity were not found to be related to reported likelihood of seeking care within this sample.

We conducted stepwise multiple regression analyses to examine predictors of belief in the effectiveness of antibiotics for cold symptoms, reported likelihood of antibiotic use across scenarios, and likelihood of seeking care across scenarios. Year of college was the only significant predictor of belief in the effectiveness of antibiotics for cold symptoms (b=0.18; P=.001). Belief in antibiotic effectiveness decreased with increasing years of higher education. Age was the only significant predictor of antibiotic use (b=0.16; P=.001). Greater age was associated with increased likelihood of using antibiotics. Average reported likelihood of seeking care was predicted by type of health insurance (b=0.22; P=.001) and by belief in the effectiveness of antibiotics to treat common colds (b=0.11; P=.03).

Discussion

A majority of students surveyed in this study would use antibiotics for the symptoms of a common cold, especially when accompanied by low-grade fever or discolored nasal discharge. This belief persisted in a significant portion even for the scenario with 5 days of clear nasal discharge and no fever. This is commensurate with other studies of different populations in the literature.¹³ A majority of students who reported they would not see a physician for a common cold still thought they would seek care for the presented scenarios, indicating a tendency toward inaccurate self-diagnosis especially when faced with symptoms perceived to be indicators of greater illness (eg, fever, discolored nasal discharge). Thick and opaque nasal discharge is part of the natural course of common cold and is not an indication to use antimicrobial therapy unless the symptoms persist longer than 10 to 14 days without improvement,¹⁴ but this message does not appear to be reaching patients. The use of antibiotics for viral illness and for uncomplicated URIs will lead to resistance and is discouraged by researchers and infectious disease experts.¹⁵

Our study provides evidence that even educated individuals may not recognize common URI presentations and appropriate treatment. A significant portion of this sample was unable to link their stated beliefs about colds with symptom scenarios consistent with URIs. In this sample, demographic variables did not alter the likelihood of using antibiotics, indicating the broad-based nature of the misconceptions. Our findings are consistent with previous studies showing that patients in family practice, internal medicine clinics, or emergency department waiting rooms do not recognize symptoms of the common presentation of URIs.¹⁰ The same study hypothesized that education about normal presentation could reduce visits to the physician and the misuse of antibiotics. Another recent study showed that members of ethnically diverse communities believe in the effectiveness of antibiotics for treatment of colds and often obtain them without a prescription.¹²

In our study, women reported a greater likelihood of care seeking across all scenarios, a finding consistent with the literature.16 Another variable predictive of seeking care was college year. Freshmen and sophomores were less likely to seek care than students in later periods of their education. This finding may have been due to the relationship between health care use and increasing age.

Our study emphasizes the need for patient education to: (1) minimize the use of health services or self-limiting illnesses; (2) decrease the inappropriate use of antibiotics; and (3) promote increased selectivity in patients’ choices of nonprescription remedies (eg, promote the use of evidence-based remedies). The central role of the physician as educator and opinion leader in this process should not be overlooked. From previous research it remains unclear whether physicians really believe in the usefulness of antibiotics in treating URIs or whether they are responding to patient expectations. However, some findings indicate a continued need for physician education about the natural history of URIs. For example, Schwartz and colleagues¹¹ surveyed family physicians and pediatricians in Virginia with a questionnaire describing case scenarios that involve a single-day history of greenish-yellowish discharge and low-grade fever. A majority of the physicians surveyed endorsed prescribing antibiotics. Another study revealed that physicians confronted with colored nasal discharge, lack of response to decongestants, and fever (among other symptoms) diagnosed sinusitis and prescribed antibiotics in more than 98% of cases and prescribed the same for more than 13% of patients with URIs.¹⁷ In a 1999 study, pediatricians and family physicians in Georgia reported prescribing practices that were inconsistent with published recommendations for judicious antibiotic use in the treatment of URIs, again overprescribing anitibiotics.¹⁸ Given such study results can we blame our patients’ for their enduring confidence in antibiotic effectiveness? Targeted educational information provided by trusted physicians and a refusal by physicians to prescribe unnecessary antibiotics are vital components in influencing our patients’ beliefs. Although some patients will obtain antibiotics without prescriptions,¹² we can have a significant impact on the beliefs encouraging these practices. The ultimate responsibility for changing patient attitudes and prescribing habits of physicians remains with us.

Limitations

Participants in this self-report survey were volunteers, which may introduce a selection bias. Also, because current college students composed the study population, the ability to extrapolate these findings to other young adults, college-educated older adults, or adults in general is unknown.

Conclusions

Our results show that health care education is needed among college students, especially in the area of symptoms and treatments of common illnesses. Educational interventions for patients and physicians concerning the presentation of the common cold and the appropriate use of antibiotics should be the focus of continuing research. This may result in more medical resources and less-resistant organisms.