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Patient Beliefs About the Characteristics, Causes, and Care of the Common Cold
METHODS: A total of 249 parents of symptomatic children and 257 symptomatic adults who sought medical advice in the spring of 1997 from 1 of 3 primary care clinics in the Minneapolis-St. Paul, Minnesota, area were surveyed by telephone 48 to 96 hours after contact with the medical system.
RESULTS: Of the adults seeking care for a child or themselves, 44% believed viruses alone cause the common cold; an additional 42% believed both viruses and bacteria play a role. Most thought rest (97%) and nonprescription medications (63%) were helpful for colds, which was consistent with published reports. Contrary to medical reports, however, most felt vitamin C (67%) and the inhalation of steam (70%) reduced cold symptoms, and 44% believed antibiotics help colds (c2=19.57; P=.0002). But 85% believed colds could resolve on their own.
CONCLUSIONS: Those adults seeking medical care for uncomplicated colds are misinformed about the primary cause of the common cold, the use of prescription medications for treating cold symptoms, and the effectiveness of some palliative care techniques. Care providers should address these perceptions rather than enabling overuse of antibiotics.
Most people (87%) treat their colds at home.1 Still, colds account for 22 million physician visits and 250 million restricted activity days per year.2 Despite extensive documentation of viral etiology,3,4 antibiotic use is prevalent in medical management of uncomplicated colds.5,6 Factors such as low environmental temperature and dampness neither facilitate getting a cold nor affect its severity;7 stress and less diverse social connections increase the frequency and severity8-10 of colds.
Cold management is limited to symptom relief. Folklore, anecdotes, and unsubstantiated beliefs persist regarding effective treatments. There is no role for antibiotic medications in managing uncomplicated colds5,6,11 or preventing secondary bacterial infections12; the therapeutic effect of vitamin C in preventing or alleviating symptoms has been inconsistently demonstrated.13-15 Some nonprescription medications relieve cold symptoms in older children and adults.16,17 In particular, aspirin and nonsteroidal drugs reduce headache and sore throat pain.2 Aspirin use in symptomatic children is contraindicated because of an association with Reye’s syndrome.18,19 Antihistamines reduce sneezing and nasal drainage;5,20 decongestants reduce nasal secretions.5,21 Coughing can be controlled with codeine.4 Inhaling moist warm heat22-24 and taking zinc25-27 do not alter the course of a cold.
In an unspecified patient sample, 31% of adults with uncomplicated colds thought antibiotics were helpful; 37% did not know.28 A survey of adult patients with uncomplicated colds residing in rural, suburban, or urban areas of the United Kingdom revealed that 87% believed antibiotics reduce symptoms.29 In a convenience sample of ethnically diverse healthy and ill adults with various conditions,30 61% believed antibiotics help reduce cold symptoms; at least 50% reported that vitamin C and over-the-counter medications were helpful.
Since the early 1970s, the medical literature has been replete with articles on colds and their management.31-35 It is unclear how this attention has influenced the knowledge and beliefs of those seeking medical care for uncomplicated colds. Previous studies focused on a few treatment options.28-30 Knowledge and beliefs may differ on the basis of a person’s ethnicity or socioeconomic status. The purpose of our study was to identify knowledge and beliefs about colds among generally healthy suburban people seeking medical care for their children or themselves during the early stages of an uncomplicated cold.
Methods
Study Sample
The medical staff and administrators of 3 independent suburban primary care clinics collaborated on our study. Each clinic identified consecutive patients who called the nurse triage line, the Urgent Care walk-in clinic, or the departments of family practice, internal medicine, or pediatrics because of cold symptoms. Approximately 80 parents of symptomatic children and 80 symptomatic adults at each site were selected from mid-March through mid-April 1997. Eligible adults had a primary complaint of respiratory symptoms, such as runny nose, cough, fever, or sore throat. Patients were excluded if they reported ear pain, asthma, or moderate to severe sore throat; if symptom duration exceeded 14 days in adults or 10 days in children; or if the patient was in poor general health. We included a total of 506 people (249 parents of symptomatic children and 257 symptomatic adults). The response rate was 90% for parents of symptomatic children and 94% for symptomatic adults.
Data Collection and Analysis
Trained interviewers conducted the telephone survey 48 to 96 hours after the respondent contacted the medical system. By that time, patients were more comfortable and better able to complete the survey. To assure eligibility, the script included the following statement: “We are talking with people who recently called or visited their clinic for care of cold symptoms or upper respiratory infections…” All questions included a reference to the cold or related symptoms.
The interviewers collected respondents’ personal characteristics and their beliefs about colds. Our specific areas of interest were the causes and characteristics of the common cold and the effectiveness of palliative care. We computed frequency distributions, and since chi-square analysis revealed no differences in beliefs between parents of symptomatic children and symptomatic adults, data were combined.
Results
The average age of the respondents was 37 (±9.2) years (range = 18 to 64 years). Most were women (78%) and white (98%). They were well educated: 41% were college graduates, and an additional 34% reported some education after high school. Most were employed full time (64%) or part time (19%). Almost all of the respondents had insurance coverage for their current symptoms (97%). Symptom duration was 3.5 (±2.6) days in children and 5.0 (±3.5) days in adults at the time they contacted the clinic. Symptom severity was reported as mild in 11% of the respondents, moderate in 43%, and severe in 46%.
Fewer than half of the respondents thought viruses alone cause the common cold (Table 1); an additional 42% said that both viruses and bacteria had a role. Most respondents believed getting tired or run-down caused a cold; few believed getting wet or chilled caused a cold.
Most respondents believed colds resolve on their own Table 1, but they were evenly split on whether antibiotics help colds. Among those believing antibiotics were not helpful, most were emphatic in their belief. More than half believed too many people take antibiotics for a cold, but 22% did not know. Respondents believed colds typically last 7.6 days (±3 days) in both children and adults. Rest was overwhelmingly chosen as an effective method of palliative care for colds Table 2.
The perceived cause of colds was associated with believing antibiotics help colds (c2=19.57; P = .0002). Those reporting only viruses cause colds were less likely to believe antibiotics help colds; those believing both viruses and bacteria cause colds were more likely to believe antibiotics help colds. There was no relation between perceived helpfulness and overuse of antibiotics for managing cold symptoms.
Discussion
We found agreement and differences between patients’ perceptions and medical opinion regarding causes, characteristics, and care of uncomplicated colds. Respondents generally agreed with clinical trials demonstrating that getting wet or chilled does not cause a cold but getting tired and run-down does contribute. In this well-educated sample, some respondents (41.9%) believed bacteria were a cause of colds, which was strongly associated with considering antibiotics helpful. Although research studies suggest that a few colds have bacterial etiology,4 viral etiology is far more common. Treatment recommendations do not differ by cause, however, and antibiotics are consistently ineffective. Patients’ expectations influence both their satisfaction with their medical care and physicians’ prescribing behavior.29,36 Physicians can address these expectations to ensure patient satisfaction while limiting antibiotic use by those patients with uncompli- cated colds.
Consistent with reports from clinical trials and observational studies, most of the respondents (63%) believed rest and nonprescription medications relieved symptoms. Our result is similar to reported beliefs in a convenience sample of adults.30 However, 26% of our respondents did not consider nonprescription medications helpful, which provides an opportunity for physicians to discuss the usefulness of over-the-counter medications for relieving symptoms.
Despite the documented ineffectiveness of vitamin C and inhaling steam, more than two thirds of our respondents believed those treatments were helpful. These beliefs were more common in our respondents than previously reported by nonsymptomatic adults.30 Although zinc was originally considered helpful, recent more rigorous studies demonstrated a lack of effect.25-27 The zinc debate seems to have bypassed many respondents. Our results suggest partial knowledge of medical research results among patients.
Also consistent with results published in the medical literature, most of our respondents believed colds resolve on their own and generally last a week or more for both adults and children. Yet, they still called inappropriately early for medical care. Providers can reinforce the normal progression of a cold and encourage self-management of future symptoms.
Limitations
The study sample must be considered when evaluating our results. The respondents tended to be in very good health, well educated, employed, and fully insured for medical evaluation of cold symptoms. The results of our study may not reflect the beliefs of those patients evaluated in medical practices serving a less-affluent and less-educated population. Similarly, informational needs may not be consistent with our sample. Finally, the relation between patients’ beliefs about colds and their acceptance of medical intervention was not evaluated in our study.
Conclusions
The beliefs of those patients seeking medical care for uncomplicated colds generally paralleled medical research findings regarding cold characteristics and management, although some medical study results may not have reached some people. Our respondents were misinformed, however, about the primary cause of the common cold, the use of prescription medications for treating cold symptoms, and the effectiveness of some palliative care techniques. The tasks for health care providers are to educate and reassure the patient, offer options for symptom relief, and minimize antibiotic use for uncomplicated colds.
Acknowledgments
Our research was funded by a grant from the Institute for Clinical Systems Improvement, Minneapolis, Minnesota. We gratefully acknowledge the assistance of Ruth Taylor, study manager; Mary Kvanbeck, Cheryl Craft, RN, and Susan Adlis, MS, in compiling and analyzing the dataset; Kay Rosheim, MS, for manuscript review; and Sharon McDonald, RN, PhD, and Diane Jacobsen, MPH, who served as liaisons with the Institute for Clinical Systems Improvement.
1. WJ, Levine N, Goel V. Visits by adults to family physicians for the common cold. J Fam Pract 1998;47:366-9.
2. Lorber B. The common cold. J Gen Intern Med 1996;11:229-36.
3. Monto AS, Bryan ER, Ohmit S. Rhinovirus infections in Tecumseh, Michigan: frequency of illness and number of serotypes. J Infect Dis 1987;156:43-9.
4. Gwaltney JM, Jr. The common cold. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and practice of infectious diseases. 4th ed. New York, NY: Churchill Livingstone; 1995;561-6.
5. Gonzales R, Steiner JF, Sande MA. Antibiotic prescribing for adults with colds, upper respiratory tract infections, and bronchitis by ambulatory care physicians. JAMA 1997;278:901-4.
6. Nyquist AC, Gonzales R, Steiner JF, Sande MA. Antibiotic prescribing for children with colds, upper respiratory tract infections, and bronchitis. JAMA 1998;279:875-7.
7. Hilding DA. Literature review: the common cold. ENT J 1994;73:639-47.
8. Cohen S, Doyle WJ, Skoner DP, Rabin BS, Gwaltney JM. Social ties and susceptibility to the common cold. JAMA 1997;277:1940-4.
9. Cohen S. Psychological stress and susceptibility to upper respiratory infections. Am J Respir Crit Care Med 1995;152:S53-8.
10. S, Tyrell DA, Smith AP. Psychological stress and susceptibility to the common cold. N Engl J Med 1991;325:606-12.
11. T, Stocks N, Thomas T. Systematic review of the treatment of upper respiratory tract infection. Arch Dis Child 1998;79:225-30.
12. D. What’s new on the common cold. Practitioner 1990;234:391-5.
13. TC. Effects of ascorbic acid on the common cold. Am J Med 1975;58:532-6.
14. MM. Vitamin C and the common cold. Nurs Homes 1971;20:30-1.
15. RM. Vitamin C and the common cold. J Can Med Assoc 1972;107:479-80.
16. JC, Kantner TR, Lilienfeld LS, et al. Effectiveness of antihistamines in the symptomatic management of the common cold. JAMA 1979;242:2414-7.
17. MBH, Feldman W. Over-the-counter cold medications. JAMA 1993;269:2258-63.
18. General’s advisory on the use of salicylates and Reye syndrome. MMWR Morb Mortal Wkly Rep 1982;31:289-90.
19. ED, Bresee JS, Holman RC, Khan AS, Shahriari A, Schonberger LB. Reye’s syndrome in the United States from 1981 through 1997. N Engl J Med 1999;340:1377-82.
20. RB, Connell JT, Dietz AJ, Greenstein SM, Tinkelman DG. The effectiveness of the nonsedating antihistamine loradine plus pseudoephedrine in the symptomatic management of the common cold. Ann Allergy 1989;63:336-9.
21. A, Klint T, Olen L, Rundcrantz H. Nasal decongestant effect of oxymetazoline in the common cold: an objective dose-response study in 106 patients. J Laryngol Otol 1989;103:743-6.
22. GJ, Macknin ML, Yen-Lieberman BR, Medendorp SV. Effect of inhaling vapor on symptoms of the common cold. JAMA 1994;271:1109-11.
23. ML, Mathew S, Medendorp SV. Effect of inhaling heated vapor on symptoms of the common cold. JAMA 1990;264:989-91.
24. D, Barrow I, Arthur J. Local hyperthermia benefits natural and experimental common colds. BMJ 1989;298:1280-3.
25. JL, Peterson C, Lesho E. A meta-analysis of zinc salts lozenges and the common cold. Arch Intern Med 1997;157:2373-6.
26. BM, Conner EM, Betts RF, Oleske J, Minnefor A, Gwaltney JM. Two randomized controlled trials of zinc gluconate lozenge therapy of experimentally induced rhinovirus colds. Antimicrob Agents Chemother 1987;31:1183-7.
27. RM, Miles HB, Moore BW, Ryan P, Pinnock CB. Failure of effervescent zinc acetate lozenges to alter the course of upper respiratory tract infections in Australian adults. Antimicrob Agents Chemother 1987;31:1263-5.
28. AS, Mathieu AE. Perceptions and behaviors of patients with upper respiratory tract infection. J Fam Pract 1982;15:277-9.
29. J, Holmes W, Macfarlane R, Britten N. Influence of patients’ expectations on antibiotic management of acute lower respiratory tract illness in general practice: questionnaire study. BMJ 1997;315:1211-4.
30. AG, Zoorob RJ, Oler MJ, Haynes DM. Patient knowledge of upper respiratory infections: implications for antibiotic expectations and unnecessary utilization. J Fam Pract 1997;45:75-83.
31. patient page: the common cold. JAMA 1998;279:2066.-
32. PI. Managing the common cold. Nurse Pract 1996;21:143-4.
33. the common cold. Harv Health Letter 1998;24:1-3.
34. J, Averill BW. Self care for colds: a cost effective alternative to upper respiratory infection management. Am J Public Health 1979;69:814-6.
35. CR, Imrey PB, Turner JD, Hosokawa MC, Alster JM. Reducing physician visits for colds through consumer education. JAMA 1983;250:1986-9.
36. RH, Hicks RJ, Bemben DA. Antibiotics and respiratory infections: are patients more satisfied when expectations are met. J Fam Pract 1996;43:56-62.
METHODS: A total of 249 parents of symptomatic children and 257 symptomatic adults who sought medical advice in the spring of 1997 from 1 of 3 primary care clinics in the Minneapolis-St. Paul, Minnesota, area were surveyed by telephone 48 to 96 hours after contact with the medical system.
RESULTS: Of the adults seeking care for a child or themselves, 44% believed viruses alone cause the common cold; an additional 42% believed both viruses and bacteria play a role. Most thought rest (97%) and nonprescription medications (63%) were helpful for colds, which was consistent with published reports. Contrary to medical reports, however, most felt vitamin C (67%) and the inhalation of steam (70%) reduced cold symptoms, and 44% believed antibiotics help colds (c2=19.57; P=.0002). But 85% believed colds could resolve on their own.
CONCLUSIONS: Those adults seeking medical care for uncomplicated colds are misinformed about the primary cause of the common cold, the use of prescription medications for treating cold symptoms, and the effectiveness of some palliative care techniques. Care providers should address these perceptions rather than enabling overuse of antibiotics.
Most people (87%) treat their colds at home.1 Still, colds account for 22 million physician visits and 250 million restricted activity days per year.2 Despite extensive documentation of viral etiology,3,4 antibiotic use is prevalent in medical management of uncomplicated colds.5,6 Factors such as low environmental temperature and dampness neither facilitate getting a cold nor affect its severity;7 stress and less diverse social connections increase the frequency and severity8-10 of colds.
Cold management is limited to symptom relief. Folklore, anecdotes, and unsubstantiated beliefs persist regarding effective treatments. There is no role for antibiotic medications in managing uncomplicated colds5,6,11 or preventing secondary bacterial infections12; the therapeutic effect of vitamin C in preventing or alleviating symptoms has been inconsistently demonstrated.13-15 Some nonprescription medications relieve cold symptoms in older children and adults.16,17 In particular, aspirin and nonsteroidal drugs reduce headache and sore throat pain.2 Aspirin use in symptomatic children is contraindicated because of an association with Reye’s syndrome.18,19 Antihistamines reduce sneezing and nasal drainage;5,20 decongestants reduce nasal secretions.5,21 Coughing can be controlled with codeine.4 Inhaling moist warm heat22-24 and taking zinc25-27 do not alter the course of a cold.
In an unspecified patient sample, 31% of adults with uncomplicated colds thought antibiotics were helpful; 37% did not know.28 A survey of adult patients with uncomplicated colds residing in rural, suburban, or urban areas of the United Kingdom revealed that 87% believed antibiotics reduce symptoms.29 In a convenience sample of ethnically diverse healthy and ill adults with various conditions,30 61% believed antibiotics help reduce cold symptoms; at least 50% reported that vitamin C and over-the-counter medications were helpful.
Since the early 1970s, the medical literature has been replete with articles on colds and their management.31-35 It is unclear how this attention has influenced the knowledge and beliefs of those seeking medical care for uncomplicated colds. Previous studies focused on a few treatment options.28-30 Knowledge and beliefs may differ on the basis of a person’s ethnicity or socioeconomic status. The purpose of our study was to identify knowledge and beliefs about colds among generally healthy suburban people seeking medical care for their children or themselves during the early stages of an uncomplicated cold.
Methods
Study Sample
The medical staff and administrators of 3 independent suburban primary care clinics collaborated on our study. Each clinic identified consecutive patients who called the nurse triage line, the Urgent Care walk-in clinic, or the departments of family practice, internal medicine, or pediatrics because of cold symptoms. Approximately 80 parents of symptomatic children and 80 symptomatic adults at each site were selected from mid-March through mid-April 1997. Eligible adults had a primary complaint of respiratory symptoms, such as runny nose, cough, fever, or sore throat. Patients were excluded if they reported ear pain, asthma, or moderate to severe sore throat; if symptom duration exceeded 14 days in adults or 10 days in children; or if the patient was in poor general health. We included a total of 506 people (249 parents of symptomatic children and 257 symptomatic adults). The response rate was 90% for parents of symptomatic children and 94% for symptomatic adults.
Data Collection and Analysis
Trained interviewers conducted the telephone survey 48 to 96 hours after the respondent contacted the medical system. By that time, patients were more comfortable and better able to complete the survey. To assure eligibility, the script included the following statement: “We are talking with people who recently called or visited their clinic for care of cold symptoms or upper respiratory infections…” All questions included a reference to the cold or related symptoms.
The interviewers collected respondents’ personal characteristics and their beliefs about colds. Our specific areas of interest were the causes and characteristics of the common cold and the effectiveness of palliative care. We computed frequency distributions, and since chi-square analysis revealed no differences in beliefs between parents of symptomatic children and symptomatic adults, data were combined.
Results
The average age of the respondents was 37 (±9.2) years (range = 18 to 64 years). Most were women (78%) and white (98%). They were well educated: 41% were college graduates, and an additional 34% reported some education after high school. Most were employed full time (64%) or part time (19%). Almost all of the respondents had insurance coverage for their current symptoms (97%). Symptom duration was 3.5 (±2.6) days in children and 5.0 (±3.5) days in adults at the time they contacted the clinic. Symptom severity was reported as mild in 11% of the respondents, moderate in 43%, and severe in 46%.
Fewer than half of the respondents thought viruses alone cause the common cold (Table 1); an additional 42% said that both viruses and bacteria had a role. Most respondents believed getting tired or run-down caused a cold; few believed getting wet or chilled caused a cold.
Most respondents believed colds resolve on their own Table 1, but they were evenly split on whether antibiotics help colds. Among those believing antibiotics were not helpful, most were emphatic in their belief. More than half believed too many people take antibiotics for a cold, but 22% did not know. Respondents believed colds typically last 7.6 days (±3 days) in both children and adults. Rest was overwhelmingly chosen as an effective method of palliative care for colds Table 2.
The perceived cause of colds was associated with believing antibiotics help colds (c2=19.57; P = .0002). Those reporting only viruses cause colds were less likely to believe antibiotics help colds; those believing both viruses and bacteria cause colds were more likely to believe antibiotics help colds. There was no relation between perceived helpfulness and overuse of antibiotics for managing cold symptoms.
Discussion
We found agreement and differences between patients’ perceptions and medical opinion regarding causes, characteristics, and care of uncomplicated colds. Respondents generally agreed with clinical trials demonstrating that getting wet or chilled does not cause a cold but getting tired and run-down does contribute. In this well-educated sample, some respondents (41.9%) believed bacteria were a cause of colds, which was strongly associated with considering antibiotics helpful. Although research studies suggest that a few colds have bacterial etiology,4 viral etiology is far more common. Treatment recommendations do not differ by cause, however, and antibiotics are consistently ineffective. Patients’ expectations influence both their satisfaction with their medical care and physicians’ prescribing behavior.29,36 Physicians can address these expectations to ensure patient satisfaction while limiting antibiotic use by those patients with uncompli- cated colds.
Consistent with reports from clinical trials and observational studies, most of the respondents (63%) believed rest and nonprescription medications relieved symptoms. Our result is similar to reported beliefs in a convenience sample of adults.30 However, 26% of our respondents did not consider nonprescription medications helpful, which provides an opportunity for physicians to discuss the usefulness of over-the-counter medications for relieving symptoms.
Despite the documented ineffectiveness of vitamin C and inhaling steam, more than two thirds of our respondents believed those treatments were helpful. These beliefs were more common in our respondents than previously reported by nonsymptomatic adults.30 Although zinc was originally considered helpful, recent more rigorous studies demonstrated a lack of effect.25-27 The zinc debate seems to have bypassed many respondents. Our results suggest partial knowledge of medical research results among patients.
Also consistent with results published in the medical literature, most of our respondents believed colds resolve on their own and generally last a week or more for both adults and children. Yet, they still called inappropriately early for medical care. Providers can reinforce the normal progression of a cold and encourage self-management of future symptoms.
Limitations
The study sample must be considered when evaluating our results. The respondents tended to be in very good health, well educated, employed, and fully insured for medical evaluation of cold symptoms. The results of our study may not reflect the beliefs of those patients evaluated in medical practices serving a less-affluent and less-educated population. Similarly, informational needs may not be consistent with our sample. Finally, the relation between patients’ beliefs about colds and their acceptance of medical intervention was not evaluated in our study.
Conclusions
The beliefs of those patients seeking medical care for uncomplicated colds generally paralleled medical research findings regarding cold characteristics and management, although some medical study results may not have reached some people. Our respondents were misinformed, however, about the primary cause of the common cold, the use of prescription medications for treating cold symptoms, and the effectiveness of some palliative care techniques. The tasks for health care providers are to educate and reassure the patient, offer options for symptom relief, and minimize antibiotic use for uncomplicated colds.
Acknowledgments
Our research was funded by a grant from the Institute for Clinical Systems Improvement, Minneapolis, Minnesota. We gratefully acknowledge the assistance of Ruth Taylor, study manager; Mary Kvanbeck, Cheryl Craft, RN, and Susan Adlis, MS, in compiling and analyzing the dataset; Kay Rosheim, MS, for manuscript review; and Sharon McDonald, RN, PhD, and Diane Jacobsen, MPH, who served as liaisons with the Institute for Clinical Systems Improvement.
METHODS: A total of 249 parents of symptomatic children and 257 symptomatic adults who sought medical advice in the spring of 1997 from 1 of 3 primary care clinics in the Minneapolis-St. Paul, Minnesota, area were surveyed by telephone 48 to 96 hours after contact with the medical system.
RESULTS: Of the adults seeking care for a child or themselves, 44% believed viruses alone cause the common cold; an additional 42% believed both viruses and bacteria play a role. Most thought rest (97%) and nonprescription medications (63%) were helpful for colds, which was consistent with published reports. Contrary to medical reports, however, most felt vitamin C (67%) and the inhalation of steam (70%) reduced cold symptoms, and 44% believed antibiotics help colds (c2=19.57; P=.0002). But 85% believed colds could resolve on their own.
CONCLUSIONS: Those adults seeking medical care for uncomplicated colds are misinformed about the primary cause of the common cold, the use of prescription medications for treating cold symptoms, and the effectiveness of some palliative care techniques. Care providers should address these perceptions rather than enabling overuse of antibiotics.
Most people (87%) treat their colds at home.1 Still, colds account for 22 million physician visits and 250 million restricted activity days per year.2 Despite extensive documentation of viral etiology,3,4 antibiotic use is prevalent in medical management of uncomplicated colds.5,6 Factors such as low environmental temperature and dampness neither facilitate getting a cold nor affect its severity;7 stress and less diverse social connections increase the frequency and severity8-10 of colds.
Cold management is limited to symptom relief. Folklore, anecdotes, and unsubstantiated beliefs persist regarding effective treatments. There is no role for antibiotic medications in managing uncomplicated colds5,6,11 or preventing secondary bacterial infections12; the therapeutic effect of vitamin C in preventing or alleviating symptoms has been inconsistently demonstrated.13-15 Some nonprescription medications relieve cold symptoms in older children and adults.16,17 In particular, aspirin and nonsteroidal drugs reduce headache and sore throat pain.2 Aspirin use in symptomatic children is contraindicated because of an association with Reye’s syndrome.18,19 Antihistamines reduce sneezing and nasal drainage;5,20 decongestants reduce nasal secretions.5,21 Coughing can be controlled with codeine.4 Inhaling moist warm heat22-24 and taking zinc25-27 do not alter the course of a cold.
In an unspecified patient sample, 31% of adults with uncomplicated colds thought antibiotics were helpful; 37% did not know.28 A survey of adult patients with uncomplicated colds residing in rural, suburban, or urban areas of the United Kingdom revealed that 87% believed antibiotics reduce symptoms.29 In a convenience sample of ethnically diverse healthy and ill adults with various conditions,30 61% believed antibiotics help reduce cold symptoms; at least 50% reported that vitamin C and over-the-counter medications were helpful.
Since the early 1970s, the medical literature has been replete with articles on colds and their management.31-35 It is unclear how this attention has influenced the knowledge and beliefs of those seeking medical care for uncomplicated colds. Previous studies focused on a few treatment options.28-30 Knowledge and beliefs may differ on the basis of a person’s ethnicity or socioeconomic status. The purpose of our study was to identify knowledge and beliefs about colds among generally healthy suburban people seeking medical care for their children or themselves during the early stages of an uncomplicated cold.
Methods
Study Sample
The medical staff and administrators of 3 independent suburban primary care clinics collaborated on our study. Each clinic identified consecutive patients who called the nurse triage line, the Urgent Care walk-in clinic, or the departments of family practice, internal medicine, or pediatrics because of cold symptoms. Approximately 80 parents of symptomatic children and 80 symptomatic adults at each site were selected from mid-March through mid-April 1997. Eligible adults had a primary complaint of respiratory symptoms, such as runny nose, cough, fever, or sore throat. Patients were excluded if they reported ear pain, asthma, or moderate to severe sore throat; if symptom duration exceeded 14 days in adults or 10 days in children; or if the patient was in poor general health. We included a total of 506 people (249 parents of symptomatic children and 257 symptomatic adults). The response rate was 90% for parents of symptomatic children and 94% for symptomatic adults.
Data Collection and Analysis
Trained interviewers conducted the telephone survey 48 to 96 hours after the respondent contacted the medical system. By that time, patients were more comfortable and better able to complete the survey. To assure eligibility, the script included the following statement: “We are talking with people who recently called or visited their clinic for care of cold symptoms or upper respiratory infections…” All questions included a reference to the cold or related symptoms.
The interviewers collected respondents’ personal characteristics and their beliefs about colds. Our specific areas of interest were the causes and characteristics of the common cold and the effectiveness of palliative care. We computed frequency distributions, and since chi-square analysis revealed no differences in beliefs between parents of symptomatic children and symptomatic adults, data were combined.
Results
The average age of the respondents was 37 (±9.2) years (range = 18 to 64 years). Most were women (78%) and white (98%). They were well educated: 41% were college graduates, and an additional 34% reported some education after high school. Most were employed full time (64%) or part time (19%). Almost all of the respondents had insurance coverage for their current symptoms (97%). Symptom duration was 3.5 (±2.6) days in children and 5.0 (±3.5) days in adults at the time they contacted the clinic. Symptom severity was reported as mild in 11% of the respondents, moderate in 43%, and severe in 46%.
Fewer than half of the respondents thought viruses alone cause the common cold (Table 1); an additional 42% said that both viruses and bacteria had a role. Most respondents believed getting tired or run-down caused a cold; few believed getting wet or chilled caused a cold.
Most respondents believed colds resolve on their own Table 1, but they were evenly split on whether antibiotics help colds. Among those believing antibiotics were not helpful, most were emphatic in their belief. More than half believed too many people take antibiotics for a cold, but 22% did not know. Respondents believed colds typically last 7.6 days (±3 days) in both children and adults. Rest was overwhelmingly chosen as an effective method of palliative care for colds Table 2.
The perceived cause of colds was associated with believing antibiotics help colds (c2=19.57; P = .0002). Those reporting only viruses cause colds were less likely to believe antibiotics help colds; those believing both viruses and bacteria cause colds were more likely to believe antibiotics help colds. There was no relation between perceived helpfulness and overuse of antibiotics for managing cold symptoms.
Discussion
We found agreement and differences between patients’ perceptions and medical opinion regarding causes, characteristics, and care of uncomplicated colds. Respondents generally agreed with clinical trials demonstrating that getting wet or chilled does not cause a cold but getting tired and run-down does contribute. In this well-educated sample, some respondents (41.9%) believed bacteria were a cause of colds, which was strongly associated with considering antibiotics helpful. Although research studies suggest that a few colds have bacterial etiology,4 viral etiology is far more common. Treatment recommendations do not differ by cause, however, and antibiotics are consistently ineffective. Patients’ expectations influence both their satisfaction with their medical care and physicians’ prescribing behavior.29,36 Physicians can address these expectations to ensure patient satisfaction while limiting antibiotic use by those patients with uncompli- cated colds.
Consistent with reports from clinical trials and observational studies, most of the respondents (63%) believed rest and nonprescription medications relieved symptoms. Our result is similar to reported beliefs in a convenience sample of adults.30 However, 26% of our respondents did not consider nonprescription medications helpful, which provides an opportunity for physicians to discuss the usefulness of over-the-counter medications for relieving symptoms.
Despite the documented ineffectiveness of vitamin C and inhaling steam, more than two thirds of our respondents believed those treatments were helpful. These beliefs were more common in our respondents than previously reported by nonsymptomatic adults.30 Although zinc was originally considered helpful, recent more rigorous studies demonstrated a lack of effect.25-27 The zinc debate seems to have bypassed many respondents. Our results suggest partial knowledge of medical research results among patients.
Also consistent with results published in the medical literature, most of our respondents believed colds resolve on their own and generally last a week or more for both adults and children. Yet, they still called inappropriately early for medical care. Providers can reinforce the normal progression of a cold and encourage self-management of future symptoms.
Limitations
The study sample must be considered when evaluating our results. The respondents tended to be in very good health, well educated, employed, and fully insured for medical evaluation of cold symptoms. The results of our study may not reflect the beliefs of those patients evaluated in medical practices serving a less-affluent and less-educated population. Similarly, informational needs may not be consistent with our sample. Finally, the relation between patients’ beliefs about colds and their acceptance of medical intervention was not evaluated in our study.
Conclusions
The beliefs of those patients seeking medical care for uncomplicated colds generally paralleled medical research findings regarding cold characteristics and management, although some medical study results may not have reached some people. Our respondents were misinformed, however, about the primary cause of the common cold, the use of prescription medications for treating cold symptoms, and the effectiveness of some palliative care techniques. The tasks for health care providers are to educate and reassure the patient, offer options for symptom relief, and minimize antibiotic use for uncomplicated colds.
Acknowledgments
Our research was funded by a grant from the Institute for Clinical Systems Improvement, Minneapolis, Minnesota. We gratefully acknowledge the assistance of Ruth Taylor, study manager; Mary Kvanbeck, Cheryl Craft, RN, and Susan Adlis, MS, in compiling and analyzing the dataset; Kay Rosheim, MS, for manuscript review; and Sharon McDonald, RN, PhD, and Diane Jacobsen, MPH, who served as liaisons with the Institute for Clinical Systems Improvement.
1. WJ, Levine N, Goel V. Visits by adults to family physicians for the common cold. J Fam Pract 1998;47:366-9.
2. Lorber B. The common cold. J Gen Intern Med 1996;11:229-36.
3. Monto AS, Bryan ER, Ohmit S. Rhinovirus infections in Tecumseh, Michigan: frequency of illness and number of serotypes. J Infect Dis 1987;156:43-9.
4. Gwaltney JM, Jr. The common cold. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and practice of infectious diseases. 4th ed. New York, NY: Churchill Livingstone; 1995;561-6.
5. Gonzales R, Steiner JF, Sande MA. Antibiotic prescribing for adults with colds, upper respiratory tract infections, and bronchitis by ambulatory care physicians. JAMA 1997;278:901-4.
6. Nyquist AC, Gonzales R, Steiner JF, Sande MA. Antibiotic prescribing for children with colds, upper respiratory tract infections, and bronchitis. JAMA 1998;279:875-7.
7. Hilding DA. Literature review: the common cold. ENT J 1994;73:639-47.
8. Cohen S, Doyle WJ, Skoner DP, Rabin BS, Gwaltney JM. Social ties and susceptibility to the common cold. JAMA 1997;277:1940-4.
9. Cohen S. Psychological stress and susceptibility to upper respiratory infections. Am J Respir Crit Care Med 1995;152:S53-8.
10. S, Tyrell DA, Smith AP. Psychological stress and susceptibility to the common cold. N Engl J Med 1991;325:606-12.
11. T, Stocks N, Thomas T. Systematic review of the treatment of upper respiratory tract infection. Arch Dis Child 1998;79:225-30.
12. D. What’s new on the common cold. Practitioner 1990;234:391-5.
13. TC. Effects of ascorbic acid on the common cold. Am J Med 1975;58:532-6.
14. MM. Vitamin C and the common cold. Nurs Homes 1971;20:30-1.
15. RM. Vitamin C and the common cold. J Can Med Assoc 1972;107:479-80.
16. JC, Kantner TR, Lilienfeld LS, et al. Effectiveness of antihistamines in the symptomatic management of the common cold. JAMA 1979;242:2414-7.
17. MBH, Feldman W. Over-the-counter cold medications. JAMA 1993;269:2258-63.
18. General’s advisory on the use of salicylates and Reye syndrome. MMWR Morb Mortal Wkly Rep 1982;31:289-90.
19. ED, Bresee JS, Holman RC, Khan AS, Shahriari A, Schonberger LB. Reye’s syndrome in the United States from 1981 through 1997. N Engl J Med 1999;340:1377-82.
20. RB, Connell JT, Dietz AJ, Greenstein SM, Tinkelman DG. The effectiveness of the nonsedating antihistamine loradine plus pseudoephedrine in the symptomatic management of the common cold. Ann Allergy 1989;63:336-9.
21. A, Klint T, Olen L, Rundcrantz H. Nasal decongestant effect of oxymetazoline in the common cold: an objective dose-response study in 106 patients. J Laryngol Otol 1989;103:743-6.
22. GJ, Macknin ML, Yen-Lieberman BR, Medendorp SV. Effect of inhaling vapor on symptoms of the common cold. JAMA 1994;271:1109-11.
23. ML, Mathew S, Medendorp SV. Effect of inhaling heated vapor on symptoms of the common cold. JAMA 1990;264:989-91.
24. D, Barrow I, Arthur J. Local hyperthermia benefits natural and experimental common colds. BMJ 1989;298:1280-3.
25. JL, Peterson C, Lesho E. A meta-analysis of zinc salts lozenges and the common cold. Arch Intern Med 1997;157:2373-6.
26. BM, Conner EM, Betts RF, Oleske J, Minnefor A, Gwaltney JM. Two randomized controlled trials of zinc gluconate lozenge therapy of experimentally induced rhinovirus colds. Antimicrob Agents Chemother 1987;31:1183-7.
27. RM, Miles HB, Moore BW, Ryan P, Pinnock CB. Failure of effervescent zinc acetate lozenges to alter the course of upper respiratory tract infections in Australian adults. Antimicrob Agents Chemother 1987;31:1263-5.
28. AS, Mathieu AE. Perceptions and behaviors of patients with upper respiratory tract infection. J Fam Pract 1982;15:277-9.
29. J, Holmes W, Macfarlane R, Britten N. Influence of patients’ expectations on antibiotic management of acute lower respiratory tract illness in general practice: questionnaire study. BMJ 1997;315:1211-4.
30. AG, Zoorob RJ, Oler MJ, Haynes DM. Patient knowledge of upper respiratory infections: implications for antibiotic expectations and unnecessary utilization. J Fam Pract 1997;45:75-83.
31. patient page: the common cold. JAMA 1998;279:2066.-
32. PI. Managing the common cold. Nurse Pract 1996;21:143-4.
33. the common cold. Harv Health Letter 1998;24:1-3.
34. J, Averill BW. Self care for colds: a cost effective alternative to upper respiratory infection management. Am J Public Health 1979;69:814-6.
35. CR, Imrey PB, Turner JD, Hosokawa MC, Alster JM. Reducing physician visits for colds through consumer education. JAMA 1983;250:1986-9.
36. RH, Hicks RJ, Bemben DA. Antibiotics and respiratory infections: are patients more satisfied when expectations are met. J Fam Pract 1996;43:56-62.
1. WJ, Levine N, Goel V. Visits by adults to family physicians for the common cold. J Fam Pract 1998;47:366-9.
2. Lorber B. The common cold. J Gen Intern Med 1996;11:229-36.
3. Monto AS, Bryan ER, Ohmit S. Rhinovirus infections in Tecumseh, Michigan: frequency of illness and number of serotypes. J Infect Dis 1987;156:43-9.
4. Gwaltney JM, Jr. The common cold. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and practice of infectious diseases. 4th ed. New York, NY: Churchill Livingstone; 1995;561-6.
5. Gonzales R, Steiner JF, Sande MA. Antibiotic prescribing for adults with colds, upper respiratory tract infections, and bronchitis by ambulatory care physicians. JAMA 1997;278:901-4.
6. Nyquist AC, Gonzales R, Steiner JF, Sande MA. Antibiotic prescribing for children with colds, upper respiratory tract infections, and bronchitis. JAMA 1998;279:875-7.
7. Hilding DA. Literature review: the common cold. ENT J 1994;73:639-47.
8. Cohen S, Doyle WJ, Skoner DP, Rabin BS, Gwaltney JM. Social ties and susceptibility to the common cold. JAMA 1997;277:1940-4.
9. Cohen S. Psychological stress and susceptibility to upper respiratory infections. Am J Respir Crit Care Med 1995;152:S53-8.
10. S, Tyrell DA, Smith AP. Psychological stress and susceptibility to the common cold. N Engl J Med 1991;325:606-12.
11. T, Stocks N, Thomas T. Systematic review of the treatment of upper respiratory tract infection. Arch Dis Child 1998;79:225-30.
12. D. What’s new on the common cold. Practitioner 1990;234:391-5.
13. TC. Effects of ascorbic acid on the common cold. Am J Med 1975;58:532-6.
14. MM. Vitamin C and the common cold. Nurs Homes 1971;20:30-1.
15. RM. Vitamin C and the common cold. J Can Med Assoc 1972;107:479-80.
16. JC, Kantner TR, Lilienfeld LS, et al. Effectiveness of antihistamines in the symptomatic management of the common cold. JAMA 1979;242:2414-7.
17. MBH, Feldman W. Over-the-counter cold medications. JAMA 1993;269:2258-63.
18. General’s advisory on the use of salicylates and Reye syndrome. MMWR Morb Mortal Wkly Rep 1982;31:289-90.
19. ED, Bresee JS, Holman RC, Khan AS, Shahriari A, Schonberger LB. Reye’s syndrome in the United States from 1981 through 1997. N Engl J Med 1999;340:1377-82.
20. RB, Connell JT, Dietz AJ, Greenstein SM, Tinkelman DG. The effectiveness of the nonsedating antihistamine loradine plus pseudoephedrine in the symptomatic management of the common cold. Ann Allergy 1989;63:336-9.
21. A, Klint T, Olen L, Rundcrantz H. Nasal decongestant effect of oxymetazoline in the common cold: an objective dose-response study in 106 patients. J Laryngol Otol 1989;103:743-6.
22. GJ, Macknin ML, Yen-Lieberman BR, Medendorp SV. Effect of inhaling vapor on symptoms of the common cold. JAMA 1994;271:1109-11.
23. ML, Mathew S, Medendorp SV. Effect of inhaling heated vapor on symptoms of the common cold. JAMA 1990;264:989-91.
24. D, Barrow I, Arthur J. Local hyperthermia benefits natural and experimental common colds. BMJ 1989;298:1280-3.
25. JL, Peterson C, Lesho E. A meta-analysis of zinc salts lozenges and the common cold. Arch Intern Med 1997;157:2373-6.
26. BM, Conner EM, Betts RF, Oleske J, Minnefor A, Gwaltney JM. Two randomized controlled trials of zinc gluconate lozenge therapy of experimentally induced rhinovirus colds. Antimicrob Agents Chemother 1987;31:1183-7.
27. RM, Miles HB, Moore BW, Ryan P, Pinnock CB. Failure of effervescent zinc acetate lozenges to alter the course of upper respiratory tract infections in Australian adults. Antimicrob Agents Chemother 1987;31:1263-5.
28. AS, Mathieu AE. Perceptions and behaviors of patients with upper respiratory tract infection. J Fam Pract 1982;15:277-9.
29. J, Holmes W, Macfarlane R, Britten N. Influence of patients’ expectations on antibiotic management of acute lower respiratory tract illness in general practice: questionnaire study. BMJ 1997;315:1211-4.
30. AG, Zoorob RJ, Oler MJ, Haynes DM. Patient knowledge of upper respiratory infections: implications for antibiotic expectations and unnecessary utilization. J Fam Pract 1997;45:75-83.
31. patient page: the common cold. JAMA 1998;279:2066.-
32. PI. Managing the common cold. Nurse Pract 1996;21:143-4.
33. the common cold. Harv Health Letter 1998;24:1-3.
34. J, Averill BW. Self care for colds: a cost effective alternative to upper respiratory infection management. Am J Public Health 1979;69:814-6.
35. CR, Imrey PB, Turner JD, Hosokawa MC, Alster JM. Reducing physician visits for colds through consumer education. JAMA 1983;250:1986-9.
36. RH, Hicks RJ, Bemben DA. Antibiotics and respiratory infections: are patients more satisfied when expectations are met. J Fam Pract 1996;43:56-62.