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Clinical Infection & Immunity

Original Article

Volume 3, Number 2, June 2018, pages 37-44

Internet Survey Regarding Knowledge About the Common Cold in Japan

Japan currently faces a serious depletion of medical resources, including a shortage of physicians [1], and there is an urgent need to review the social security system and to take measures to ensure its sustainability [2]. Therefore, to reduce the utilization of health care services, Japanese government introduced approaches involving external pressure, such as a gradual increase in out-of-pocket medical expenses and a revision of the medical service fee system, and will also promote self-medication and the use of over-the-counter (OTC) drugs.

Self-medication, an important part of self-care, is defined by the World Health Organization as taking “responsibility for one’s own health and dealing with minor ailments by oneself”. In order to promote appropriate self-medication, self-care must be balanced with the decision to seek medical consultation.

However, the Japanese healthcare system provides free access to medical services and people can seek medical consultation at their own discretion or that of their family. Therefore, many people visit secondary or tertiary medical centers even for conditions that can be sufficiently treated at the primary care level [3].

In addition, it has been reported that health literacy problems such as excessive expectations of medical services [4], insufficient knowledge about diseases, and poor awareness of self-care practices contribute to the consumption of medical resources [5]. Especially the common cold is a widespread, self-limiting condition [6, 7], and 67% of adults and 87% of children are affected at least once a year [8]. As a result, the promotion of self-care and self-medication can effectively reduce the consumption of medical resources associated with this illness [9].

However, many patients visit medical facilities seeking early treatments for the common cold, such as injections, and this increases the use of medical resources and leads to high human resources and economic costs. It has been reported that across Japan, approximately 30,000 patients see a doctor for the common cold every day [10].

To change this behavior of medical consultation, the Japanese government, the Ministry of Health and Welfare started the self-medication taxation in 2017 with an aim to refrain patients from seeing a doctor for the common cold [11]. When lay people purchase OTC drugs without going to a clinic or any hospital, they can receive an income deduction for purchase cost in paying their tax. However, their behavior obviously cannot be controlled because self-medication usage levels do not seem to be influenced by advertising. Health promotion programs to promote their healthcare awareness do play a big role in more advanced societies [12].

Even though the health promotion programs based on health literacy are needed, few studies have assessed the accuracy of people’s knowledge about the common cold. Understanding their expectations of early symptom relief by high cost intravenous infusion or injection as medical resources, it will be an opportunity to resolve it. In addition, we can develop the health promotion program to increase health literacy if we clarify how their beliefs affect their decision about whether to seek medical consultation for a common cold.

Therefore, this study sought to characterize people’s knowledge about preventing the common cold and their behaviors for coping with the common cold. It also aimed to determine whether they believe that an infusion or injection can provide early relief of cold symptoms, and if so, what factors affect this belief.

This study was conducted by a research firm with a registry comprising potential participants across Japan. The survey was administered via the Internet to publicly recruited study participants aged 20 to 79, excluding healthcare professionals, for 7 days beginning on February 2, 2012. The participants were stratified by gender and then into six groups by age (20s, 30s, 40s, 50s, 60s, and 70s). The sample size of each age group was adjusted to eliminate excessive bias between groups, and the target number of responses was set to 300.

The participants were asked not to refer to external sources of information when they answered the questions because the survey was intended to evaluate their existing knowledge.

Data were excluded from the analysis if they were entered extremely rapidly, if age or sex was inconsistent between the time of enrollment and the questionnaire administration, and if there were one or more missing answers. The research firm anonymized the data, and we used only this anonymized data in our analysis.

The questionnaire consisted of questions about age, sex, educational background, presence or absence regular office visits, hospitalization history, subjective health status, as well as statements designed to evaluate knowledge about the “prevention” (six questions), “clinical issues” (four questions) and “treatment” (seven questions) of the common cold.

The 17 statements concerning the common cold are listed in Table 1. Because no relevant previous studies were available, these statements (excluding one about antibiotics) were created in cooperation with 14 healthcare professionals, including nine physicians, one health sociologist, one nurse, one public health nurse, one care worker, and one dietician, based on their considerable experience, specifically regarding what behaviors and ideas they considered to be typical.

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Table 1. Survey Questions on the Common Cold

The participants were asked to choose one of five answers on a Likert scale: “strongly disagree”; “disagree”; “agree”; “strongly agree”; and “neither agree nor disagree”. Answers were categorized into the “disagreement group”, which comprised “strongly disagree” and “disagree”; and the “agreement group”, which comprised “agree” and “strongly agree”; and those who responded “neither agree nor disagree” excluded. Participants’ knowledge on “prevention”, “clinical issues” and “treatment” of the common cold was descriptively analyzed.

Responses to the statement, “you can recover from a cold earlier if you receive an infusion or injection”, were classified into agreement and disagreement groups, and factors contributing to the answers were analyzed by univariate analysis.

These two groups were compared by the Chi-square test, with the statements defined as categorical variables. Student’s t-test was used to compare the means, and the Chi-square test was used to compare the (statements defined as) categorical variables between the two groups. Then, a logistic regression analysis (forced entry method) was performed, with the items that showed a significant difference in the univariate analysis defined as independent variables, and agreement or disagreement with the idea that “you can recover from a cold earlier if you receive an infusion or injection” defined as the dependent variable.

Even among variables that showed a significant difference in the univariate analysis, those with a correlation coefficient of 0.7 or higher were highly likely to exhibit multicollinearity; therefore, one of such variables were excluded from the independent variables when a multivariate analysis was performed. The software program SPSS version 22.0 for Windows was used and the significance level was defined as 5% for all the analyses.

This study was approved by the Ethics Committee of the Faculty of Medicine, University of Tsukuba (approval #1227).

The objectives and description of this study were displayed on the computer monitor used to respond to the survey items, and participants were instructed to proceed with the survey only if they consented to participate in this study. Those who answered the questions were considered to have provided consent.

Of 706 people who were asked to participate in the survey, 353 responded. Excluding five people who met the exclusion criteria, 348 respondents were included in the analysis (response rate: 49.3%). They consisted of 178 males and 170 females, with a mean age of 48.6 ± 16.9 years (Table 2). Figure 1 shows participants’ knowledge about “prevention” of the common cold. More than 90% of participants indicated that wearing a mask, frequent hand washing, frequent gargling, room humidification, and sufficient nutrition are effective for preventing the common cold. In response to the statement that “taking cold medicine before you get sick” can prevent the common cold, 17.0% of participants replied “Agree”. Figure 2 shows participants’ knowledge about the “clinical issues” and “treatment” of the common cold.

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Table 2. Respondent Characteristics (N = 348)

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Figure 1. Survey about knowledge concerning “prevention” of the common cold. The participants were asked to choose one of the five answers on a Likert scale: “strongly disagree”; “disagree”; “agree”; “strongly agree”; and “neither agree nor disagree”. Answers were categorized into the “disagreement group” which comprised “strongly disagree” and “disagree” and the “agreement group” which comprised “agree” and “strongly agree”.

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Figure 2. Survey about knowledge concerning “clinical issues” and “treatment” of the common cold. The participants were asked to choose one of the five answers on a Likert scale: “strongly disagree”; “disagree”; “agree”; “strongly agree”; and “neither agree nor disagree”. Answers were categorized into the “disagreement group” which comprised “strongly disagree” and “disagree” and the “agreement group” which comprised “agree” and “strongly agree”.

In response to the statement that “antibiotics are not effective for common colds caused by viruses”, 40.2% of participants responded “Agree”. As to whether “a body temperature over 40 °C causes brain damage”, 59.2% of participants replied “Agree”, and regarding whether “you should see a doctor when you catch a cold”, 63.5% answered “Agree”.

Regarding behaviors for recovering more rapidly from the common cold, 84.2%, 78.2%, and 77.6% of participants answered “Agree” to the questions of whether “gargling”, “taking cold medicines” and “receiving an infusion or injection” are effective, respectively. As to whether “consuming energy drinks” and “covering yourself with many blankets to sweat” are effective, nearly half of the participants (54.6% and 45.4%, respectively) answered “Agree”.

An analysis was performed to determine which factors were associated with agreement of the idea that “you can recover from a cold earlier if you receive an infusion or injection”. The univariate analysis of the participants’ basic characteristics and their knowledge about “clinical issues” and “treatment” of the common cold showed that agreement with this idea was correlated with younger age (P = 0.022) and was higher in participants who disagreed with the statement that “antibiotics are not effective for common colds caused by viruses” (P = 0.033) and those who agreed with the statements that “you will not catch a cold if you already had influenza that winter”, “a body temperature over 40°C causes brain damage”, “you can recover from a cold earlier if you take cold medicines”, “you can recover from a cold earlier if you consume energy drinks”, and “you can recover from a cold earlier if you cover yourself with many blankets to sweat” (Table 3).

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Table 3. Association Between the Agreement/Disagreement to the Idea of “You Can Recover From a Cold Earlier if You Receive an Infusion or Injection” and the Knowledge on “Clinical Issues” and “Treatment” of Common Cold (N = 225)

A logistic regression analysis was also performed to determine which factors were associated with agreement of the idea that “you can recover from a cold earlier if you receive an infusion or injection”. In the univariate analysis, all variables were entered as independent variables because none of the variables that significantly correlated with agreement of the idea had a correlation coefficient of 0.7 or higher.

The results of the logistic regression analysis showed that the following factors were independently associated with agreement of the idea that “you can recover from a cold earlier if you receive an infusion or injection”: younger age (odds ratio (OR): 0.975, 95% confidence interval (CI): 0.952 - 0.997) and the statements that “antibiotics are not effective for common colds caused by viruses” (OR: 0.433, 95% CI: 0.204 - 0.922), “a body temperature over 40°C causes brain damage” (OR: 2.507, 95% CI: 1.187 - 5.293), “you can recover from a cold earlier if you take cold medicines” (OR: 2.965, 95% CI: 1.305 - 6.738) and “you can recover from a cold earlier if you cover yourself with many blankets to sweat” (OR: 2.352, 95% CI: 1.064 - 5.200) (Table 4).

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Table 4. Factors Associated With the Idea That “You Can Recover From a Cold Earlier if You Receive an Infusion or Injection.” (N = 225)

It is, therefore, younger participants and those who agreed with the statements “antibiotics are effective for the common cold”, “a body temperature over 40°C causes brain damage”, “you can recover from a cold earlier if you take cold medicines”, and “you can recover from a cold earlier if you cover yourself with many blankets to sweat” were correlated with agreement of the idea that “you can recover from a cold earlier if you receive an infusion or injection”.

In this study, we found that the level of people’s knowledge about “prevention” of the common cold was relatively high, while their knowledge about “clinical issues” and “treatment” of the common cold was insufficient. In addition, the study revealed that younger age, inaccurate knowledge about a common cold, and a few misperceptions about how to treat the common cold were correlated to the expectation of the effect of infusion or injection.

The findings that knowledge about “prevention” of the common cold was widespread have been shown in other studies well. Some studies illustrated that many people are appropriately aware of the preventive value of wearing a mask and frequent handwashing [13], as well as gargling [14], and humidification of rooms [15, 16]. This may be the result of thorough health promotion education that has been implemented over the years both at schools and by the government, the latter through community publications.

Regarding knowledge about “clinical issues” and “treatment” of the common cold, approximately 80% of the participants agreed with the following statements: “you can recover from a cold earlier if you receive an infusion or injection”, and “you can recover from a cold earlier if you take cold medicines”. A previous study [17] asked participants the following question: “Within how many days do you expect to recover from the symptoms of a common cold?” More than half of the participants answered, “within the day” (16.6%) or “by the following day” (38.9%). Based on this and the previous study, it might be interpreted that they have high expectations that cold medicines reduce the duration of symptoms. In addition, people might be interested in the way to relieve cold symptoms earlier even though there are no effective measures to reduce the duration of the common cold.

In this survey, more than half of the participants had incorrect opinions about whether antibiotics are effective against viruses. A survey in South Korea [18] also reported that people with poor knowledge about the efficacy of and resistance to antibiotics tended to take inappropriate actions such as “requesting a prescription for antibiotics for the common cold” or had inaccurate ideas such as “antibiotics are helpful for early recovery from a cold”. This indicates that the lack of knowledge about the ineffectiveness of antibiotics against viruses may lead to medical consultations with the goal of requesting a prescription for antibiotics.

Moreover, we explored factors affected the belief that an infusion or injection can improve cold symptoms. The belief was independently correlated to younger age and agreement of the ideas that “antibiotics are not effective for common colds caused by viruses” and “you can recover from a cold earlier if you take cold medicines”. There are few previous non-Japanese studies on infusion therapy for cold symptoms, and medical consultations in which patients request infusion or injection therapy for the common cold may be unique to Japan. These findings might be associated with inaccurate knowledge about the common cold and the expectation of early recovery, as described above.

Nearly 80% of the participants in this study had positive feelings about infusion or injection therapy for the common cold. Since both treatments incur manpower, time, and economic costs, people’s beliefs about the common cold should be corrected. In addition, many participants agreed that “you can recover from a cold earlier if you cover yourself with many blankets to sweat”; however, this may lead to dehydration, so education is required on this topic as well.

The Japanese central and local governments have implemented campaigns to prevent medical consultations for cold symptoms, with the main aim of reducing the number of visits to secondary or tertiary medical centers and visits to emergency medical centers. However, the effects of such campaigns will be limited unless they focus on patients’ inaccurate knowledge and their expectation of achieving early relief of symptoms by medical treatment.

Based on these findings, more effective health literacy education for common cold may be provided if the findings of this study are considered. Similarly, proper self-medication should be promoted as methods of self-care for the common cold. To achieve it, we should emphasize that prescription drugs have the same efficacy as OTC drugs [19]. Achieving these goals will help prevent excessive consumption of medical resources and their associated costs.

This study has four limitations as follows. First, individuals who are able to use the Internet may have certain characteristics, such as educational background and occupations that differ from those of the nation as a whole [20]. In particular, study participants in their 70s are likely to have higher information and communication technology literacy compared to the average population of the same generation. Second, since there was no time limit for completing the survey, respondents could have based their responses on search engine results or another person’s opinion. However, we sought to reduce this possibility and to encourage firsthand responses by preventing participants from returning to previous survey Web pages once the most recent one was displayed. The other limitations are related with questions. Third, the questions about the common cold were simplified to reduce the burden of long sentences and to facilitate understanding among non-healthcare professionals. Given the lack of detail, it is possible that the intention of each question was not communicated adequately, making it difficult for respondents to respond properly. Fourth, the questions focused on knowledge about the common cold. Whether general people seek medical consultations or not for common cold might be influenced other than the knowledge adopted in this study. Further studies are warranted to assess not only the knowledge but also interpretation model related widely to medical consultations for common cold.

In this study, participants’ knowledge regarding “prevention” of the common cold was relatively sufficient but their understanding of “clinical issues” and “treatment” was not.

The expectation that infusion or injection therapy would provide early relief of symptoms of the common cold was associated with younger age and inaccurate knowledge about cold treatment; including the misperceptions for antibiotics and hasten recovery by taking cold medicine earlier.

Acknowledgments

We are grateful to Dr. Hiroshi Kurihara, MD, Dr. Naoto Ishimaru, MD, Dr. Sachiko Ozone, MD and Dr. Tomohiro Taguchi, MD, who supported the development of the questionnaire for this study. We would like to express our deep appreciation for Dr. Ryoko Ebina, a health sociologist, Mr. Tomoyuki Minayoshi, a dietician, Ms. Noriko Otaki, a public health nurse and Ms. Noriko Seshimo, a nurse.

Grant Support

This study was supported by a Japan Society for the Promotion of Science KAKENHI grant (JP 22659129).

Conflict of Interest

None of the authors have any potential conflict of interest associated with this research.

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