Perceptions of threat from illness
Perceived illness severity
The perceived threat of a cough to a child included a combination of the severity of the illness and the susceptibility of a particular child to developing a cough. Parents from all backgrounds did not feel confident about caring for a child at home with a persistent cough. They suggested that a cough alone was less serious, but in combination with fever, croup, breathing difficulty or a child not eating, it was felt to be more serious and likely to cause them to seek help from primary care. Their perception of the risk of the illness was linked to the child’s symptoms and their own experience.
“I’m more worried about a high temperature more than anything”. (mid-SES, 2 children 9 & 12y)
“I think a cough is about a couple of weeks normally. And if it’s prolonged then I go to the doctor.” (high-SES, 2 children 11 & 13y)
“Also when they’re just not themselves. So some kids (…) are sort of quite lifeless and, you know, exhausted or sleepy or whatever, then they’re obviously feeling ill”. (high-SES, 2 children 11 & 13y)
“(…) kind of the ferocity of the cough, (..) is it kind of – is it making them really kind of go red in the face when they are coughing? “ (mid-SES, 1 child 11m)
“ He’ll eat anything, so if he’s off his food I know it’s something serious”. (mid-SES, 2 children 1 & 7y)
“More of a harsh cough as well like.(…) like a smoker’s, like when it’s really harsh and, yeah, and it’s like they’re sort of gasping as they’re coughing”. (low-SES, 2 children 3 & 5y)
Child’s susceptibility
Several parents described perceived vulnerability or susceptibility when a child was particularly prone to coughs or suffered a lot compared to other children or siblings. Sometimes this was attributed to a particular event (previous illness), to something that ran in the family (genetic predisposition) or to a perceived underlying problem or weakness in the child’s immunity.
“Weak chests, you know, um in my family, you know, most of my family have, you know, had asthma…. I never even thought that children could get pneumonia…. now I know that it’s possible, I’m obviously gonna be on the case every time she [] gets a snuffle or a cold or a slight cough, I wouldn’t hesitate to take her to the doctor…because she’s got a weakness now, hasn’t she, well like a vulnerability?” (low-SES, 2 children 6 & 11y)
“He had chicken pox at three months old, so he become quite unwell then… and then once he did suffer with all those colds and coughs I worried a bit more… his immune system was low and I was thinking, “Well why does he keep getting them?” One night he was really snuffly, he couldn’t really breathe, and I took him to the Walk in Centre then, and that’s who explained to me about his immune system.” (low-SES, 2 children 3 & 5y).
Parents sought information and advice about coughs from a range of sources including lay and professional people within their social network (family, friends, health visitors, nursery workers and pharmacists), written information and advice available on websites, books and leaflets. No single information source was used by all parents and they often referred to multiple sources before deciding what to do, if anything. When assessing the trustworthiness of information sources, parents felt that ‘professional’ sources were more credible. NHS branded websites were generally more trusted than other internet sources, as were people in their social network with some health training. However, those with extensive personal experience of children's illness were also trusted. Contradictory information or advice was likely to contribute to a decision to consult.
Social network:
“I would go to either my sister (she has 5 daughters) or my gran and speak to them about it, see what they say and I’d sort of mention it to friends”. (high-SES, 2 children 11 & 13y)
“I would ask health professionals that are in the family. My aunt is a GP, so I would ask her”. (mid-SES, 1 child 11m)
“I just go to my mum, and she’s normally right”. (low-SES, 1 child 5y)
Using the internet:
“One site I used a lot when he was tiny was Baby Centre. I still go back, because they are quite – it’s a very small amount of information, and it’s very contained and it’s very matter of fact. It gives you sources of information to go to, but it’s not – it’s not like a forum”. (high-SES, 1 child 11m)
“Oh well, I would Google something and then I would look at something like Net Doctor or (Net Health)”. (high-SES, 2 children 11 & 13y).
“We will Google (…,) my daughter had a cough that she couldn’t shake off and we were starting to check symptoms and work on it before we went to the GP, but you want to be going to a reputable website, you don’t want somebody saying, “These symptoms mean your child can die.” (mid-SES, 2 children 10 & 12y)
“But sometimes it comes up with (…) worrying stuff (…) it can make it a bit scary sometimes just using Google, I reckon. And then when you look on the NHS it’s something like totally different. So I do try and tend to stick to the NHS one”. (low-SES, 2 children 10m & 5y)
Other sources:
“I’ve been to pharmacy about say a cough or something, rather than going to the doctor” (high-SES 2 children 11 & 13)
“My books are more accessible than my family and friends”. (high-SES, 1 child 1y)
“I’ve phone NHS Direct before, you know the non-emergency one? Like just to ask them for advice?” (low-SES, 1 child 5y)
”I usually go to the pharmacist near my work and ask him just ‘cos usually you can ask pharmacist there and then”. (low-SES, 1 child 10m)
Perceived triggers, benefits, and barriers to consulting for a cough
Consultation triggers
Fears and uncertainties were similar for parents from all demographic backgrounds and encouragement from others and their own uncertainty caused them to consult primary care.
Social pressures and sanctioning
Parents from all backgrounds mentioned feeling uncertain (about identifying and interpreting symptoms, child’s diagnosis), feeling that it was safer to consult if in doubt, and sanctioning or pressure from friends or family. Sometimes this sanctioning advice appeared to be a trigger for consultation when they might not otherwise have gone; sometimes it appeared to be a welcome confirmation that they were justified in consulting. Sanctioning was similar across parents from different backgrounds and with older and younger children.
“ I think mostly, the only time I have been to the doctor is when I felt pressurised into going from my mum really, or other people who have said, “You must take her to the doctor, she sounds awful,” and then you go,”. (mid-SES, 2 children 11 & 12y)
“…I’ve so far relied on the nursery telling me to go to the doctor. Because when he was getting really bad the nursery were like, “Well, you know, I’d get that seen by the doctor.” (low-SES, post grad, 1 child 1y)
Uncertainty and failure of home management
Parents talked about whether or not symptoms responded to home management and wanted guidance about potentially serious symptoms which needed to be seen by a doctor. They talked about both the severity of symptoms (how chesty the cough / how high the temperature) and the duration of symptoms (how long should a cough go on for before consulting the doctor) and their need for information and advice in relation to these could trigger consultation.
Over-the-counter medicines, home remedies and perceived failure of home management were all mentioned as key triggers to consultation. Sometimes it was specific ‘rules’, such as if the paediatric paracetamol (Calpol) doesn’t bring the temperature down, or if the child wasn’t better within a certain time frame.
“I do remember recently administering cough medicine at home, and thinking to myself, “Is this the right cough medicine? Is it tickly or is it a chesty one?” (..)I think it would be quite useful to have a little bit more of an elaborate definition of what’s tickly and what’s chesty.” (mid-SES, 2 children 9 & 12y)
“After 24 hours of doing that, I suppose I might phone. But I might not. I’m not quite sure actually at what point. So I mean I would find it quite useful actually, what is the pattern of a chest infection.” (mid-SES, 2 children 10 & 13y)
“You want to know how to soothe them. How I can just make it manageable.” (mid-SES, 1 child 11m)
Perceived benefits of the consultation
Once they had decided to consult primary care, most parents saw the benefit as receiving a medical evaluation of their child’s illness by a clinician. This was referred to as having a ‘proper check’ and was often described in terms of the physical examination, particularly the clinician listening to the child’s chest with a stethoscope. Parents believed that a clinician would be able to tell whether or not their child had a serious illness when the parents themselves were uncertain.
“The safest bet is to talk to a proper doctor. Yeah it’s just peace of mind that, you know deep down in your heart that it’s probably only going to be a virus, but you just want for it to be double checked to make sure”. (low-SES, 3 children 6, 12 & 15y)
“I was concerned that I wasn’t sure if it was a chest infection or not, so I wanted to get it checked out. […] I don’t really know what the symptoms of chest infection actually are.” (high-SES, 1 child 1 y)
Parents also wanted information to help them understand and support their management of the illness including signs of serious illness (when do I need to worry?), how to care for child (what might help, what to avoid?), what is normal, and how to prevent or reduce future episodes. This could be conceived as a benefit to them as they were reassured or gained knowledge.
“It was for me to establish whether that was a chesty cough or not, so that I would know for future.” (high-SES, 1 child 1y)
“The answer I want is at what point do I need to start worrying? – that’s the answer that you don’t ever seem to get”. (high-SES 1 child 11m)
Several parents were seeking or hoping for treatment or advice on treatment other than antibiotics, mainly to alleviate symptoms to reduce their child’s suffering and impacts on the child’s and family’s life. Others sought treatment to address a perceived chronic problem or underlying problem with the child’s immune system – something to boost the child’s immunity and reduce the frequency with which they had acute cough.
“I’m looking for somebody to give me some advice on something I can do to alleviate the frequency that this child is having these illnesses. Any advice on how to increase her immune system, because this is just constant from November to January.” (high-SES, 2 children 4 & 6 y)
“… some way of them not being sick, some magic cough mixture that would stop them reacting like that.” (high-SES, 2yr twins)
Some parents expected antibiotics from the consultation. A few were fairly confident they knew when their child had an RTI which needed antibiotics. This was usually based on past experience of their child having antibiotics for something similar, or remembering having antibiotics for similar illnesses themselves in childhood. A few parents believed that certain illnesses (tonsillitis, ear ache) needed antibiotics or that a specific child needed antibiotics when they got RTIs as they couldn’t recover themselves.
“Because I’m unclear. (..) Now I don’t actually want to go to the doctor until I think it’s an infection. What is it about the cough? You know, there’s all these other coughs, is this a normal cough which presumably is viral and not an infection”. (mid-SES, 2 children 10 & 13y)
Barriers to consulting
The few barriers raised by parents included feeling that they were wasting the doctors time as it was ‘only a cough’, the time and effort involved in getting to the surgery and bad previous experiences when a serious chest infection had been missed resulting in a loss of confidence in their doctor. However, they still may go to Accident & Emergency or the Walk in Centre if they were still worried by the illness.
“Because I’d just been told it was cough all the time or a cold, you do feel like a right plonker, keep going back there with your child and saying, “Look, I know something’s wrong,” and they’re telling you, “No.” And you feel like you’re wasting their time. .. It does make you reluctant. And you think well I don’t want to waste their time. I don’t want them to be talking about me wasting their time, you know.” (low-SES, 2 children 2 & 11 y)
“And I just thought, I’m not going back to the doctors; no one is listening to me.” (low-SES, 2 children, 5m & 5y)
Perceived parental efficacy, reassurance and experience
Experience was the key factor which parents reported increased their self-efficacy [
21], that is their confidence that home care was likely to be successful and thus reduce their need to consult or re-consult the doctor. Less experienced parents described their difficulties in differentiating between serious and minor coughs and some admitted to finding the frequency with which young children suffered from cough a surprise – highlighting the role of un-realistic expectations and the need for more appropriate information.
Parents described how they were unable to obtain helpful information or advice to facilitate their decision to consult. In relation to cough, they expressed uncertainty about the way to distinguish between a “normal” cough which would be self-limiting and a cough which needed to be seen and treated by a doctor. They were then consulting because they were not sufficiently reassured by the information they had found and felt it safer to consult the doctor.
“I remember being in the doctor’s surgery three days running; it would be nice to know that quite early on, that actually your child is going to catch lots of coughs and colds. And I know you look back and think, yeah, I can kind of see that that would happen, but you don’t [realize]” (high-SES, 1 child 11m)
“I don’t want a prescription every time I go, I just want reassurance that I’ve done the right thing in coming.” (high-SES, 2 children 7m & 23m)
“The first year you look up a lot of things, then you sort of learn to treat the most usual things and the signs to alarm or not. (…) When you’re still learning about all these childhood non-serious illnesses it takes some learning”. (mid-SES, 1 child 3y)
“I think a lot of the time you just go by your instincts anyway, because you automatically know what your children are like and how bad they are. And once you’ve had the first one, it’s just experience then, I reckon”. (low-SES, 2 children 10 & 12y)
Views were compared and across and between groups of different socio-economic status and with different ages of children. Although some differences emerged within groups, they did not differ substantially between the groups.