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author:("Joshi, pufa")
1.  Expectations for consultations and antibiotics for respiratory tract infection in primary care: the RTI clinical iceberg 
The British Journal of General Practice  2013;63(612):e429-e436.
Respiratory tract infection (RTI) is the commonest indication for community antibiotic prescriptions. Prescribing is rising and is influenced by patients’ consulting behaviour and beliefs.
To build up a profile of the ‘RTI clinical iceberg’ by exploring how the general public manage RTI, visit GPs and why.
Design and setting
Two-phase qualitative and quantitative study in England.
Qualitative interviews with 17 participants with acute RTI visiting pharmacies in England, and face-to-face questionnaire survey of 1767 adults ≥15 years in households in England during January 2011.
Qualitative interviews: interviewees with RTI visited GPs if they considered their symptoms were prolonged, or severe enough to cause pain, or interfered with daily activities or sleep. Questionnaire: 58% reported having had an RTI in the previous 6 months, and 19.7% (95% CI = 16.8 to 22.9%) of these contacted or visited their GP surgery for this, most commonly because ‘the symptoms were severe’; or ‘after several days the symptoms hadn’t improved’; 10.3% of those experiencing an RTI (or 53.1% of those contacting their GP about it) expected an antibiotic prescription. Responders were more likely to believe antibiotics would be effective for a cough with green rather than clear phlegm. Perceptions of side effects of antibiotics did not influence expectations for antibiotics. Almost all who reported asking for an antibiotic were prescribed one, but 25% did not finish them.
One-fifth of those with an RTI contact their GP and most who ask for antibiotics are prescribed them. A better public understanding about the lack of benefit of antibiotics for most RTIs and addressing concerns about illness duration and severity, could reduce GP consultations and antibiotic prescriptions for RTI.
PMCID: PMC3693799  PMID: 23834879
antibiotics; beliefs; family practice; qualitative research; questionnaire; respiratory tract infections
2.  Stool submission by general practitioners in SW England - when, why and how? A qualitative study 
BMC Family Practice  2012;13:77.
We know little about when and why general practitioners (GPs) submit stool specimens in patients with diarrhoea. The recent UK-wide intestinal infectious disease (IID2) study found ten GP consultations for every case reported to national surveillance. We aimed to explore what factors influence GP’s decisions to send stool specimens for laboratory investigation, and what guidance, if any, informs them.
We used qualitative methods that enabled us to explore opinions and ask open questions through 20 telephone interviews with GPs with a range of stool submission rates in England, and a discussion group with 24 GPs. Interviews were transcribed and subjected to content analysis.
Interviews: GPs only sent stool specimens to microbiology if diarrhoea persisted for over one week, after recent travel, or the patient was very unwell. Very few had a systematic approach to determine the clinical or public health need for a stool specimen. Only two GPs specifically asked patients about blood in their stool; only half asked about recent antibiotics, or potential food poisoning, and few asked about patients’ occupations. Few GPs gave patients advice on how to collect specimens.
Results from interviews and discussion group in relation to guidance: All reported that the HPA stool guidance and patient collection instructions would be useful in their clinical work, but only one GP (an interviewee) had previously accessed them. The majority of GPs would value links to guidance on electronic requests. Most GPs were surprised that a negative stool report did not exclude all the common causes of IID.
GPs value stool culture and laboratories should continue to provide it. Patient instructions on how to collect stool specimens should be within stool collection kits. Through readily accessible guidance and education, GPs need to be encouraged to develop a more systematic approach to eliciting and recording details in the patient’s history that indicate greater risk of severe infection or public health consequences. Mild or short duration IID (under one week) due to any cause is less likely to be picked up in national surveillance as GPs do not routinely submit specimens in these cases.
PMCID: PMC3481435  PMID: 22870944
Stool specimens; Microbiology; Laboratory submission; Diarrhoea; Primary care; Qualitative; National guidance
3.  Have the public's expectations for antibiotics for acute uncomplicated respiratory tract infections changed since the H1N1 influenza pandemic? A qualitative interview and quantitative questionnaire study 
BMJ Open  2012;2(2):e000674.
To investigate the effect of the H1N1 influenza pandemic on the public's expectations for a general practice consultation and antibiotic for acute respiratory illness.
Mixed methods.
Qualitative interviews: 17 participants with acute respiratory tract infection (RTI) visiting English pharmacies. Face-to-face survey: about 1700 adults aged 15 years and older were recruited from households in England in January 2008, 2009 and 2011.
The qualitative data indicated that the general public had either forgotten about the ‘swine flu’ (H1N1 influenza) pandemic or it did not concern them as it had not affected them directly or affected their management of their current RTI illness. Between 2009 and 2011, we found that there was little or no change in people's expectations for antibiotics for runny nose, colds, sore throat or cough, but people's expectations for antibiotics for flu increased (26%–32%, p=0.004). Of the 1000 respondents in 2011 with an RTI in the previous 6 months, 13% reported that they took care of themselves without contacting their general practitioners and would not have done so before the pandemic, 9% reported that they had contacted their doctor's surgery and would not have done so before the pandemic and 0.6% stated that they had asked for antibiotics and would not have done so before the pandemic. In 2011, of 123 respondents with a young child (0–4 years) having an RTI in the previous 6 months, 7.4% requested antibiotics and would not have done so before the pandemic. Unprompted, 20% of respondents thought Tamiflu© (oseltamivir) was a vaccine.
Expectations of the general public for a consultation or antibiotics with an RTI are similar now to before the H1N1 influenza pandemic; therefore, public antibiotic campaign messages and general practice advice to patients can remain unchanged. Parents with young children and those with personal experience of the H1N1 influenza are more likely to consult and will need more reassurance. The public need more education about Tamiflu©.
Article summary
Article focus
The H1N1 (2009) pandemic has ‘medicalised’ acute respiratory illness presenting with flu-like symptoms, including cough, cold, sore throat and fever.
The general public may now have a greater expectation that they should seek a consultation with a health professional and have a greater expectation for antibiotics when they next have an acute respiratory illness presenting with flu-like symptoms, including cough, cold, sore throat and fever.
To determine if expectations for a consultation or an anti-infective have changed as a result of the publics' experiences of the recent (2009) H1N1 influenza pandemic and to explore the publics' understanding of anti-infectives.
Key messages
The H1N1 influenza pandemic has not changed the general public's expectations for a general practitioner's consultation or antibiotics when they have a runny nose, cough, cold or sore throat but may have increased people's expectations for antibiotics for influenza.
Most have either forgotten about the influenza outbreak or it did not concern them as it had not affected them directly.
The smaller subsets of the public with young children and those who have had suspected or confirmed H1N1 influenza themselves are now more likely to consult and request an antibiotic for an RTI and, therefore, these groups will need more guidance and reassurance.
A fifth of the public believe that Tamiflu© (oseltamivir) is a vaccine, implying that enhanced information sharing is needed in this area.
Strengths and limitations of this study
This was a large survey of the general population, repeating some of the questions asked before the 2009 H1N1 flu epidemic, using the same sampling methods.
The qualitative interviews had recruitment problems with many potential interviewees not being at home when telephoned. However, the purpose of qualitative interviews was mainly to enrich our data, and they did help explain our quantitative findings.
The questionnaire survey asked to recall their most recent RTI in the previous 6 months and what actions they took on that occasion. This will be subject to some recall bias.
PMCID: PMC3323811  PMID: 22457479

Results 1-3 (3)