Cough: impact, beliefs, and expectations from a national survey

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1 Dl Negro et l. Multidisciplinry Respirtory Medicine (2016) 11:34 DOI /s ORIGINAL RESEARCH ARTICLE Open Access Cough: impct, eliefs, nd expecttions from ntionl survey Roerto W. Dl Negro 1*, Mssimilino Mzzolini 2, Pol Turco 3 nd Alessndro Znsi 4 Astrct Bckground: Cough is one of the most common discomforts ffecting generl popultion, which cn disrupt sujects qulity of life due to its physicl, socil, nd psychologicl effects. Aim of the study ws to investigte the impct of cough nd relted eliefs of generl popultion. Methods: A cross-sectionl telephone survey ws crried out y mens of specific, vlidted questionnire on representtive smple of Itlin generl popultion. All the interviews were crried out ccording to the Computer Assisted Telephone Interview (CATI) methodology y expert, professionl interviewers. Distriutions of ll nswers were clculted in the overll smple. Results: A totl of 1,251 sujects (men ge: 49 yers; femles 44.2 %) completed the interviews. The overll numer of telephone clls ws 5362, nd the corresponding redemption rte ws 1/4.3 (23.%). The smple ws representtive of ntionl popultion in terms of geogrphicl distriution, ge, gender, nd smoking hit. The mjority of respondents ws convinced tht cough is merely symptom of severl different diseses, ut 46.4 % of respondents ffirmed tht cough should e regrded s disese per se. Only % of sujects sy tht they usully do not complin of ny cough over the yer, while 18.4 % reported 3 episodes of cough/yer. These episodes hve durtion rnging dys in 19.9 % of sujects, nd > 30 dys in 6.9 % of sujects. The mjority of respondents is worried out their cough only fter 1 week, ut 76.9 % of sujects is much more worried if cough ffects child. After few dys of cough, 23.1 % of sujects use domestic remedies; 20.9 % sk their phrmcist, nd 33.4 % their doctor, eing GPs (69.6 %) nd lung physicins (16.2 %) the most sked professionls. The occurrence of ronchitis, pneumoni, upper irwy infections, nd llergic troules re the most fered events. The mjority of respondents re convinced tht ntiiotics nd steroids should not e regrded s the gold stndrd for treting persistent cough (61.2 nd 58.2 %, respectively), while nti-tussive drugs nd erosols in generl re regrded s the most effective strtegies (69.1 nd %, respectively). Moreover, 33.8 % of the smple is in fvour of homeopthic drugs, while 23.2 % hd lredy used n homeopthic nti-tussive syrup, nd 27.6 % of sujects re relly interested in using the homeopthic pproch. The willingness to py for n effective nti-tussive remedy ws: 46.3 % up to 10 ; 27.8 % up to 20, nd 13.3 % more thn 20. Conclusions: Cough confirms its high impct in Itly, nd sustntil proportion of individuls regrds cough s disese. Only one out of three Itlins refers to their doctor, ut when cough is lredy persistent. Cough in children is much more fered thn in dults. The mjority of Itlins hve proper nd conservtive position versus oth ntiiotic nd the systemic steroid uses ginst cough. The Itlin ttitude to erosol therpy confirms very high. Differently from the cough guidelines, nti-tussive drugs re highly vlued mong Itlin people. The ttitude nd the interest to homeopthic nti-tussive remedies proves high. Finlly, the willingness to py for n effective nti-tussive remedy is quite high in Itly. Keywords: CATI, Cough, Cough impct, Ntionl survey, People eliefs, Pulic opinion * Correspondence: roertodlnegro@gmil.com 1 Ntionl Centre for Respirtory Phrmcoeconomics nd Phrmcoepidemiology- CESFAR, Veron, Itly Full list of uthor informtion is ville t the end of the rticle 2016 The Author(s). Open Access This rticle is distriuted under the terms of the Cretive Commons Attriution 4.0 Interntionl License ( which permits unrestricted use, distriution, nd reproduction in ny medium, provided you give pproprite credit to the originl uthor(s) nd the source, provide link to the Cretive Commons license, nd indicte if chnges were mde. The Cretive Commons Pulic Domin Dediction wiver ( pplies to the dt mde ville in this rticle, unless otherwise stted.

2 Dl Negro et l. Multidisciplinry Respirtory Medicine (2016) 11:34 Pge 2 of 8 Bckground Cough is one of the most frequent events for which ptients sk for medicl consult nd it cn represent true chllenge in dily prctice. There re epidemiologicl, ptient-relted, nd therpeutic fctors which my complicte the etiologicl dignosis nd the mngement of cough. Acute cough is frequently linked to common cold nd upper respirtory trct infections (URTIs) [1]. Physicl impirment is frequent compliction of cough, while more psychologicl spects (such s, depression nd socil retirement) emerge when cough ecomes chronic [2]. The impct of cough on ptient s life rnges from miniml discomfort to disling symptoms. Indeed, ptients presenting cute cough my experience trnsient illness due to URTIs, which leds to lose work nd school dys, nd increse the overll cost for cough mngement [3, 4]. On the other hnd, ptients often seek for medicl ttention due to their poor knowledge nd unwreness of cough. Usully, sujects concerns tend to increse when their cough lsts for more thn week, in contrst with the expected durtion of cute cough [3]. In rel life, the net result is often the seek for consult nd of phrmcologicl tretment, even if the most prescried therpeutic options lck of strong evidence of efficcy [5]. Aim of the present investigtion ws to crry out ntionl survey on cough impct nd eliefs mong dults individuls of generl popultion. Methods A cross-sectionl telephone survey ws crried out etween July 21 st -29 th, 2015 on individuls ged 18 yers. The principl instrument used y investigtors to collect dt ws specific, vlidted questionnire. The questionnire consisted of 24 simple pre-determined questions: 20/24 were closed questions (83.3 %), while question # 5; 6; 20, nd 24 were open (Additionl file 1). Possile nswers for closed questions were Yes ; No ; doutful. As concerning open questions # 5; # 6, nd # 24, ll respondents hd to indicte their own opinion relted to ech specific question, while question # 20 ttined to their ge to e reported in yers. All interviews were crried out ccording to the Computer Assisted Telephone Interview (CATI) methodology [6] y expert, professionl interviewers. Distriutions of ll nswers were clculted in the overll smple. The interviewer ws provided with one work sttion consisting of personl computer connected to centrl processing unit. The centrl unit ws lso equipped with specific softwre for the rndom choice of individuls (such s, the telephone numers) to contct. Compred to conventionl telephone interview, the CATI technique lso llowed to rndomize the questions to put. Moreover, this system worked s supervisor of the interviewer s ctivity: if the interviewer forgot some questions or even n entire section of the questionnire, the pc would hve lert him, thus voiding errors due to missed questions. As previously mentioned, the smpling strtegy dopted in the present survey ws the rndom selection of n dequte numer of sujects. A minimum numer of 1178 respondents ws previously clculted for chieving the representtivity of Itlin popultion in terms of ge, gender, eduction, smoking hit, nd ntionl geogrphicl distriution (y 3 % mximum error, nd 95 % proility) [6]. All interviews were lwys preceded y short explntion of the im of the survey, nd hd men durtion of 5 min. Results A totl of 1,251 sujects (men ge: 49 yers; femles 44.2 %) completed the interview. The overll telephone contcts were 5362, nd the corresponding redemption rte (such s the proportion of cll properly completed nd relile for the investigtion) ws 1/4.3 (23.%). The geogrphicl distriution of respondents throughout Itly ws: from Northern = 45.0 %; Centrl = 14.5, nd Southern Regions = 42.9 %. Active smokers were 21.4 %, nd ex-smokers 12.4 %. As concerning the jo distriution, white collrs were 36.0 %, while retired persons were 24.8 %; housewives 14.6 %; lue collrs 14.5 %, nd students 9.7 %, respectively, while non-respondents to this question were 0.4 %. Responses to the questionnire s questions were divided in five groups, ccording to their min intrinsic mening, nmely: 1) sujects sic convincement on cough; 2) cough generl impct; 3) sujects pproch to cough; 4) sujects therpeutic expecttions, nd 5) willingness to py for mnging cough effectively. 1) Sujects sic elief Even if the mjority of respondents ws convinced tht cough hs to e merely considered s symptom of severl different diseses, sustntil (46.4 %) proportion of respondents climed tht cough should e regrded s disese per se (Fig. 1 nd ). 2) Generl clinicl impct Only 29.1 % of sujects reported tht they usully never hve cough over the yer, while 18.4 % of them reported 3 episodes of cough/yer (Fig. 2). These episodes were descried s hving different durtion, rnging from 10 to 30 dys in 19.9 % of sujects, nd longer thn 30 dys in 6.9 % of sujects (Fig. 2). Dry cough ws descried s slightly more frequently occurring (53.2 % vs 45.1 %), even if cough with secretions ws more frequent in respondents ged < 18 yers. The mjority of respondents (71.7 %) worried out their own cough only fter 1-week durtion, even if

3 Dl Negro et l. Multidisciplinry Respirtory Medicine (2016) 11:34 Pge 3 of 8 Fig. 1 How is cough perceived mong the generl popultion. Beliefs of sujects who regrded cough merely s symptom (pnel ), rther thn disese (pnel ) the gret mjority of sujects (76.9 %) ffirmed to e worried out cough much erlier nd much more if cough ffects child. 3) Sujects pproch to cough Moreover, while 21.0 % of respondents declred to remin still witing during the first dys of cough, 23.1 % of respondents ffirmed tht they strt using domestic remedies for mnging their cough quite erly; 20.9 % sk their phrmcist for ny phrmcologicl support, nd 33.4 % cll their GPs for medicl consulttion fter few dys of cough (Fig. 3 nd ). GPs (69.6 %) nd lung physicins (16.2 %) resulted the most sked professionls for cough. The occurrence of ronchitis, rther thn pneumoni, or upper irwy infections, or llergic troules were the four most fered events. 4) Sujects therpeutic expecttions The mjority of respondents ffirmed tht ntiiotics nd steroids should not e regrded s the gold stndrd for treting persistent cough (61.2 nd 58.2 %, respectively) (Fig. 4 nd ), while nti-tussive drugs nd erosol therpy were generlly regrded s the most effective Fig. 2 Men nnul frequency (pnel ) nd durtion (pnel ) of cough episodes

4 Dl Negro et l. Multidisciplinry Respirtory Medicine (2016) 11:34 Pge 4 of 8 Fig. 3 The generl sujects pproch to cough. Wht sujects do fter 2-3 dys of cough (pnel ), nd fter when sujects strt to e worried out their cough (pnel ) therpeutic options (69.1 nd 74.1 %, respectively) (Fig. 5 nd ). Moreover, 33.8 % of the smple declred to e in fvour of homeopthic drugs (Fig. 6), while 23.2 % hd lredy used n homeopthic nti-tussive syrup, nd 27.6 % of sujects ffirmed to e truly interested in using the homeopthic pproch for mnging their cough (Fig. 7 nd ). 5) Willingness to py Finlly, the willingness to py for n effective ntitussive remedy ws: 46.3 % of respondents ccepted to py up to 10 ; 27.8 % up to 20, nd 13.3 % more thn 20 (Fig. 8). Discussion Despite cough is one of the most frequent events reported in respirtory medicine, its ssessment still is not fully defined lso from the scientific point of view in severl conditions. Actully, people s perception not lwys corresponds to the etiologicl origin or the severity of cough, nd sujects tend usully to e eqully worried out their cough, prticulrly when long lsting, even in the sence of disling conditions. Unfortuntely, there re some fctors nd vrile conditions which cn contriute to complicte the etiologicl definition, the discrimintion of different clinicl mnifesttions, nd the mngement of cough in rel life [1 3]. Also due to the poor sujects knowledge of cough, its perception cn consequently result vrile either y cougher nd non-cougher individuls. Even if some studies were crried out with the im to investigte the prevlence of cough in our country, the perception of cough ws not s well investigted Fig. 4 Ptients opinion on ntiiotics (pnel ) nd systemic steroids (pnel ) use in persistent cough

5 Dl Negro et l. Multidisciplinry Respirtory Medicine (2016) 11:34 Pge 5 of 8 vision etween the generl popultion nd the scientific community will llow new gte for more effective entrnce into the cough world, thus leding to ever interesting scientific developments in the next future. Cough once gin confirmed s very common disorder occurring in generl popultion, either in terms of incidence of episodes nd of their durtion. No prticulr ehviourl tendency emerged from the present survey s the respondents declred ctions for fcing cough were eqully rnging from I dowit to I sk my Doctor for ny id, minly fter 1 week of cough. This time intervl ppered s the most frequent threshold since when the mjority of people strt to worry out their cough nd to fer ny possile respirtory compliction, prticulrly if cough ffects child. In generl, respondents proved well oriented on the possile cuses of their cough s well s on the kind of specilist to refer to in cse of clinicl progression of the events. Another interesting informtion cme out from the nlysis of the people s eliefs on the therpeutic options to tke ginst cough, nd in prticulr ginst persistent cough. Actully, the gret mjority of respondents climed to e not in fvour of the immedite use of ntiiotics nd/or systemic steroids for mnging cough. Once gin, generl popultion shred the right position of the scientific community, even if the prescription of these therpeutic options still is unfortuntely extremely diffuse in clinicl prctice nd ttins lso to gret proportion of GPs nd lung physicins everywhere. In other words, people s nd doctors positions seem conflicting, even if it is well known tht the consumption of ntiiotics nd/or systemic steroids, ut lso the self-mediction with these drugs, re quite high in our country. Furthermore, the gret mjority of respondents documented strong ttitude in fvour of present nti Fig. 5 Ptients opinion on present nti-tussive drugs (pnel ) nd erosols (pnel ) in persistent cough mong the generl popultion in terms of people s specific perception nd eliefs; of their ehviourl pproch, nd of therpeutic expecttions. Surprisingly, esides the consolidted sujects convincement tht cough merely represents non-specific symptom shred y severl different diseses, it is quite interesting to pinpoint tht, even if oviously fully unwre of the underlying scientific ckground, more thn 46 % of respondents in the present survey supported the hypothesis tht cough my represent disese per se. Their position is prticulrly intriguing nd chllenging s it is fitting with the most recent scientific vision on cough, which ctully regrds cough s the trnsversl clinicl effect of the cough hypersensitivity syndrome. In other words, cough is now suggested s disese due to the hypersensitive condition of irwy sensory nerves, independently of the prticulr etiology of cough [7 9]. In our opinion, this unexpected common Fig. 6 The sujects generl opinion on homeopthic drugs

6 Dl Negro et l. Multidisciplinry Respirtory Medicine (2016) 11:34 Pge 6 of 8 Fig. 7 The sujects experience with (pnel ) nd disposition to (pnel ) the use homeopthic drugs ginst cough tussive drugs, nd regrded the erosols in generl s the right therpeutic option ginst cough. From generi point of view, it should e pointed out tht n effective tretment ginst cough is still missing in mny cses, nd mny of the most prescried products lck of strong evidence of efficcy. In prticulr, mong overthe-counter (OTC) medictions, symptomtic drugs (nti-tussives nd mucolytics) re the most used, oth s self-mediction nd s prescried tretment fter medicl consult [5]. Those preprtions showed controversil results in clinicl settings [10] nd their use is not fully supported y guidelines, which, on the contrry, suggest to refrin from tretment in cute uncomplicted cough [10 13]. Besides the symptomtic tretment, there is still high prescription of ntiiotics [14, 15], lthough the evidence ginst their use is strong [16 18]. If the esy ccessiility explins the wide use of the OTC products, severl fctors influence the high prescriing rtes of ntiiotics for cute uncomplicted cough, nmely the doctor s dignostic uncertinty nd the ptient s expecttions [19]. Moreover, ptient s eliefs nd expecttions cn e influenced y the high vilility of uncontrolled helth-relted informtion [20, 21] which lter the delicte lnce of the doctor-to-ptient reltionship [22, 23]. In terms of the therpeutic pproch ginst cough, to note tht more thn one third of respondents ffirmed Fig. 8 The ptients willingness to py for n effective nti-tussive drug

7 Dl Negro et l. Multidisciplinry Respirtory Medicine (2016) 11:34 Pge 7 of 8 their interest in homeopthic drugs. This is sustntil proportion, in our opinion, which tends to further confirm the generl need of nti-tussive medictions. This position is reinforced y the evidence tht one out of four of respondents hs lredy ssumed homeopthic drugs (nmely, n nti-tussive homeopthic syrup) for mnging his cough, ut lso y the evidence tht n ever higher proportion of respondents (such s, one third) clim their propensity to use homeopthic remedy ginst cough. Even if the present survey ws not plnned to investigte the etiology of cough nd no dt re ville concerning the resons of people s ttitude to ntitussive therpeutic strtegies, it is nyhow plusile tht the high numer of individuls tht mnifested such n incresing interest in homeopthic nti-tussive remedies would hve likely e leded to this disposition y the poor results otined y using the trditionl nti-tussive drugs presently ville in the mrket. On the other hnd, this hypothesis my e lso supported y the incresing numer of controlled trils imed to investigte nd compre the clinicl effects of homeopthic versus usul nti-tussive drugs in recent yers [24, 25]. Finlly, the non complete stisfction of pulic opinion concerning the efficcy of the present pproch to cough tretment is clerly mirrored y their high disposition to py sum rnging from 10 to more thn 20 out-ofpocket for otining ny effective nti-tussive remedy in phrmcy. Conclusions Cough confirms its high impct in Itly, nd t present sustntil proportion of individuls regrd cough s disese. Only one out of three dult Itlins refers to his doctor, ut when cough is lredy persistent. Cough in children is much more fered thn in dults. The mjority of Itlins hve proper nd restrictive position versus the use of oth ntiiotics nd the steroids for treting cough. The Itlin ttitude to erosol therpy confirms very high. Differently from the content of the current cough guidelines, nti-tussive drugs re highly vlued mong Itlin people. Moreover, the ttitude to homeopthic nti-tussive remedies proves high nd still incresing. Finlly, the willingness to py for n effective nti-tussive remedy is quite high in Itly. Additionl file Additionl file 1: The questionnire used for the interviews. (DOCX 19 k) Arevitions CATI, computer ssisted telephone interview; URTIs, upper respirtory trct infections Acknowledgements No cknowledgements. Funding Not pplicle, ecuse the study ws spontneous investigtion. Avilility of dt nd supporting mterils section The uthors do not wish to shre their dt, without their permission. Authors contriutions All uthors red nd pproved the finl mnuscript. Competing interests The uthors declre tht they hve no competing interests. Consent for puliction Before ech interview the ptient ws requested to consent or not the interview nd he ws informed tht the content of the interview could e used only for scientific purposes (communiction, dt puliction, nd so on); if yes ech suject ws informed of the im of the interview which ws nonymous nd in greement with the current lw of privcy. After the suject s consent the interview ws crried out. Ethics pprovl nd consent to prticipte The study ws pproved y the Ethicl nd Scientific Commission of the Ntionl Centre for Respirtory Phrmcoeconomics nd Phrmcoepidemiology in the session of June 16 th, Author detils 1 Ntionl Centre for Respirtory Phrmcoeconomics nd Phrmcoepidemiology- CESFAR, Veron, Itly. 2 Deprtment of Specilist-Dignostic nd Experimentl Medicine (DIMES), Respirtory nd Criticl Cre Medicine, S. Orsol-Mlpighi Hospitl, University of Bologn, Bologn, Itly. 3 Reserch & Clinicl Governnce, Veron, Itly. 4 Itlin Assocition for Cough Study (AIST), Bologn, Itly. 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