Challenging life stages

April 2014

Research

Up close – reasons why parents attend their general practitioner when their child is sick

Volume 43, No.4, April 2014 Pages 233-226

Mohna Sharma

Tim Usherwood

Background

This study aimed to explore the reasons prompting Australian parents to seek medical advice for their sick children, and to define the factors influencing their decision. International data suggest non-clinical reasons for general practitioner (GP) visits.

Methods

Twenty-two parents from eight general practices were interviewed using a semi-structured questionnaire while they waited to see their GP. The interviews were tape-recorded, de-identified, transcribed and analysed thematically.

Results

Five emergent themes were fears about possible scenarios; personal and vicarious experiences; resources and convenience; being seen to do the right thing; and reassurance and guidance about management.

Discussion

Parents reported several reasons for seeking medical advice for their sick child and often a combination of factors influenced their decision, consistent with research findings from other countries. Awareness and understanding of this decision-making process could significantly improve primary care for patients in Australia and contribute to training of medical students and GP registrars.

Many childhood illnesses are not brought to medical attention. A Dutch study reported only 27% of children (aged <18 years) with upper respiratory tract symptoms attended their general practitioner (GP.) The probability of consulting increased with younger age, co-existing fever, increased duration of symptoms, living in an urban area, parental worry and cueing of the parent by another person.1 In contrast, in a UK study most illnesses in pre-school children led to a consultation.2

An Australian survey of parents of pre-school children reported that they were more likely to consult for fevers if high or persistent.3 A Melbourne study identified the predominant factors affecting parents’ selection of doctor of first contact for their sick children were closeness to home or work and recommendation of good service.4 However, neither of these studies explored the reasons parents gave for consulting.

A more detailed Scandinavian study5 suggested that consulting for illness in children aged up to 2 years was triggered by the parents’ need to re-evaluate the situation, their theories about the child’s symptoms, their previous experience of illness, their sense of responsibility towards other people seeing the child, their need to reorganise everyday life and their anxieties associated with the illness.

We set out to explore the reasons why parents consult GPs about illness in their children in urban Australia.

Method

We approached general practices from our student placement network in western Sydney and the Blue Mountains area to assist with this study. In practices that agreed, MS sat in the waiting room and parents presenting with a child were given written information about the study and a consent form by the reception staff. Parents who signed the form agreeing to participate were then approached and interviewed by MS. No record was kept of the number of parents declining to take part.

The interviews were semi-structured and addressed topics detailing the nature and circumstances surrounding their child’s illness on the day, including patient demographics, parental concerns, beliefs and social expectations and actions considered and undertaken prior to the medical consultation (Table 1). These topics and their associated initial and probe questions were informed by the Theory of Planned Behavior, which posits that human behaviours are governed by beliefs about, and attitudes towards, the likely consequences of an action, social expectations concerning the action and its consequences, and the need for a sense of control.6

All interviews were undertaken by MS, tape-recorded, de-identified and transcribed. Analysis was concurrent with data collection and interviews ceased at theoretical saturation.7 Analysis was thematic and informed by the Theory of Planned Behavior.

This study was approved by the University of Sydney Human Research Ethics Committee (reference number 2012/595).

Table 1. Interview guide
Area of interestInitial broad descriptive questionsPossible probing questions (guide only)
Description of the child’s illness Could you tell me about your child’s illness today?
  • What is the age, sex, gender and birth order of the child?
  • What is the duration of this illness?
  • What symptoms are most concerning?
  • What is the past medical history of the child?
  • When was the last visit to the doctor?
  • What have been the experiences related to his illnesses?
  • Is the child well and attending for other reasons for example immunisations, health checks etc?
All actions prior to medical consultation Can you tell me about what you did prior to coming to see your general practitioner today?
  • What practical steps did you take prior to this visit?
  • What information did you have available and utilise?
  • Who did you speak to for advice?
  • Why did you choose to seek their advice?
Concerns leading to this visit to their general practitioner What led to the decision to consult your general practitioner today?
  • Was there a particular trigger to visit the doctor today?
  • How were you feeling prior to attending today?
  • Was there a specific symptom that was worrying you?
  • What were your thoughts in general?
  • What were your fears if any?
Other actions considered but not pursued What other things did you do or think of doing prior to seeing your general practitioner today?
  • What other avenues did you explore prior to consultation today?
  • Did you find these useful resources?
  • What were some of the reasons you chose not to take these other options?
Belief and social expectations relating to this decision to consult What do you hope to achieve from this consultation?
  • What are your expectations from your general practitioner?
  • Will you be disappointed if these are not met?
  • What will you do then?

Results

Of the first ten practices we approached, eight agreed to participate and we recorded interviews with 22 parents; although we did not set out to exclude fathers, all were mothers. Details of their children are reported in Table 2.

Table 2. Socio-demographic characteristics of participants
AgeGenderBirth orderEthnicityNature of illnessDuration of illness
3 years Female 1 Caucasian Hirsutism 1 month
7 years Female 1 Caucasian Sore throat 2 days
6 years Male 1 Caucasian Earache 1 day
8 months Male 3 Caucasian Respiratory distress 1 week
10 months Male 4 Caucasian Head injury 6 hours
1 years Female 1 Caucasian Dairy intolerance 5 months
8 year Female 1 Caucasion Respiratory distress 2 days
12 years Male 1 Middle Eastern Respiratory distress 3 weeks
4 years Female 1 Caucasian Immunizations  
6 years Male Only Caucasian Cough 1 week
12 months Female 3 Caucasian Fever 5 weeks
5 months Female 1 of twins Caucasian Skin infection 2 weeks
4 months Female 2 Caucasian Cough 1 week
18 months Female 2 Caucasian Rash 1 week
15 years Male 1 Caucasian Acne 1 month
7 years Male 1 Caucasian Constipation 3 months
2 years Female 2 Indian Cough 1 week
12 months Female 2 Caucasian Cough 1 month
10 months Male 3 Caucasian Fever 2 days
8 months Male 1 Indian Fever 1 week
9 months Male 2 Indian Fever 1 week
12 years Male 1 Islander Abscess 1 week

The children’s ages ranged from 4 months to 15 years. There were 11 girls. Illness duration ranged from 6 hours to 5 months. Three of the children were consulting for a second time and one for a third time about their presenting illness. We identified five emergent themes (Table 3).

Table 3. Emergent themes
  • Fear about the possible scenarios
  • Personal and vicarious experiences
  • Resources and convenience
  • Being seen to do the right thing
  • Reassurance and guidance about current and future treatment

Fear about possible scenarios

Parental anxiety was consistently evident in the interviews. Parents were concerned about symptoms that differed from previous illnesses, or if their usual management did not improve their child’s condition.

‘The most concerning thing is that he says he can’t breathe and his chest hurts, although it is not like his asthma this time. I can tell the difference.’
‘Yes, I did feel anxious and worried that something was wrong or that when we thought we were helping her by using these creams for eczema we were causing another problem.’

Parents worried about specific diseases.

‘I mean a couple of people have just mentioned that measles has been out recently and the symptoms were fever, rash and whatever.’
‘It’s just a dry cough, but because there’s a whooping cough outbreak and we just got a letter from his school that a child was diagnosed we want him to get checked out.’

Parents preferred to have a diagnosis so that they could work towards management.

‘I would be disappointed if he didn’t know what it was. I walk away and we go, oh we don’t know.’
‘If there is something that needs to be treated then it needs to be treated.’
‘Well, a diagnosis would be good, and a plan to get her better or antibiotics to help.’

Personal and vicarious experiences

Parental concerns about their child’s illness often stemmed from earlier illness experiences of their own or others.

‘She’s had a persistent cough for a long while, not only that, she had a sister… who had hypoplastic heart syndrome and she passed away so we are on pins and needles all the time with this one.’
‘I’ve heard a horror story recently about a child inhale an almond when they were screaming and it lodged in. So I just - I’m being over cautious.’

Discussion with a spouse, family member or friend for advice for the most part was comforting but there were some negative experiences.

‘If there’s someone that’s been through the same issues it’s a lot easier to talk to them cos they know what to do, and can kind of tell you whether it’s worthwhile bringing your child in or not?’
‘Oh sometimes, people like to exaggerate their stories or like to tell you their bad experiences and then you kind of put two and two together and it’s not good.’

Resources and convenience

Access to medical services was important when deciding to take a sick child to the GP. Shorter practice opening hours, long distances to travel and availability of alternative options such as the chemist and community nurses were strong determining factors.

‘Sometimes I talk to the chemist. I’ve been going to them for years so I trust them. We tried some cream that he recommended and it hasn’t done anything after a week and we thought, we need to see someone further.’
‘There is a family nurse at our local pharmacy on Wednesdays so if it’s something simple I ask her.’
‘The problem is that it’s Friday and I knew that we wouldn’t then be able to get to the doctor till Monday so if it got worse over the weekend, we’d have to probably go to a different doctor that we don’t usually go to.’

Parents reported reading books, magazines and resources on the internet to seek information about what might be wrong, their treatment options and when to seek medical assessment. However, some were critical readers and could be left more anxious and uncertain.

‘I read and also search on the internet and found so many things I could do at home. It’s good because I can’t come every time for little things.’
‘Internet can actually cause you to be more concerned, I’d rather ask the doctor. I would look things up if there was a name to it but sometimes looking things up on Google can make you a bit more worried than not.’

In some cases, the GP consultation fitted conveniently with other reasons for being at the practice.

‘We had to come in anyways, so I just thought to get it all done as well.’
‘Only for vaccinations this time, but she has been a little congested and had a cough last week so I just wanted the doctor to have a listen to her chest to make sure it was okay.’

Being seen to do the right thing

Perceived social pressure to do the right thing as a parent was a strong reason for attending the GP.

‘I did have her eyes tested yesterday, which I heard was something you are supposed to do at 4 years of age.’
‘It’s because she’s going to start school next year, so I need to make sure she is ok and up to date.’

Reassurance and guidance about management

Many parents wanted some reassurance about their management, and guidance on future treatment of their child.

‘That maybe there’s still the acid in her stomach which is not neutralised enough and she might need a bit more of her medication. Just need a second opinion, and if not then a direction on where to go next.’
‘I suppose I just wanted to confirm it was the right cream for him, and that he doesn’t need to take any tablets and just to see if we stay on that treatment and for how long.’
‘I have read and I know, but now the doctor has told me that’s a big big relief. So my mind is relaxed now.’

Discussion

The five themes listed in Table 3 summarise the reasons for parents seeking medical attention for their sick children. Although all parents interviewed were, in fact, mothers, there is no a priori reason to expect that fathers would have reported different reasons for seeking attention. Parents rarely reported reasons relating to just one theme; more often, several considerations led to a medical consultation.

Not all practices were willing to permit our research, and not all parents agreed to take part, so that as in most studies using similar methods the interview sample was not representative. Nevertheless, the study’s qualitative method enabled us to explore participants’ responses in depth to get a detailed understanding of the reasons they attended their GP when their child was sick. Thematic saturation was achieved with 22 interviews, although it is possible that a more diverse sample – including culturally and linguistically diverse respondents, or recruiting in rural and remote practices – might have led to the identification of a broader range of themes.

Our findings are consistent with those of previous research.8 It seems from our results that parents’ decisions to seek medical attention for their children reflect fears and concerns about possible scenarios and outcomes of the child’s illness. This echoes the findings of Ertmann et al5 and of Cornford et al9 who noted that mothers sought medical attention for their coughing children out of fear that their child might die from choking on phlegm or vomit, or through an asthma attack or cot death, or that they would develop long-term chest damage. Such fears and concerns are likely to be informed by personal experiences or stories heard from others,10 and may also reflect information learned from the internet, as noted by several of our participants. A difference from patterns of past illness or failure to respond to usual management is to be of particular concern to parents.11 The accessibility of services is an important facilitator,4 as is perceived social pressure to do the ‘right thing’.6 Many parents seek reassurance and guidance about current and future treatments, which may reflect not just the desire for advice on optimal care but the need for a sense of control at an anxious time.12

Awareness and understanding of this decision-making process can guide the general practitioner in their interaction with the family. Many parents fear a worst-case scenario, which should be explored and addressed. Parents may consult on the basis of their own experiences or those of others, and it can be useful to elicit and discuss such stories during the consultations. Respondents in this study highlighted the reassuring value of a diagnosis, and other clinicians and researchers have noted the value of giving a clear diagnosis where feasible.13 There is good evidence that addressing patients’ fears, concerns and expectations will not only reduce their anxiety but may improve the outcomes of care.14 These lessons are important not just for clinical practice but for the training of medical students and GP registrars.

Competing interests: None.
Provenance and peer review: Not commissioned; externally peer reviewed.

References

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  2. Hay Ad, Heron J, Ness A. The prevalence of symptoms and consultations in preschool children in Avon Longitudinal Study of Parents and Children (ALSPAC): a prospective cohort study. Fam Pract 2005;22:367–74.
  3. Walsh A, Edwards H, Fraser J. Parents’ childhood fever management: community survey and instrument development. J Adv Nurs 2008;63:376–88.
  4. Dunt DR, Oberklaid F, Temple-Smith MJ. Factors affecting the selection of doctor of first contact in the western region of Melbourne: an interview study of parents of sick children. Aust Paediatr 1988;24:132–37.
  5. Ertmann RK, Soderstrom M, Reventlow S. Parents’ motivation for seeing a physician. Scand J Primary Health Care 2005;23:154–58.
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  7. Coyne IT. Sampling in qualitative research. J Advanced Nursing 1997;26:623–30.
  8. Campbell SM, Roland MO. Why do people consult the doctor? Family Practice 1996:13;75–83.
  9. Cornford CS, Morgan M, Ridsdale L. Why do mothers consult when their children cough? Family Practice 1993;10:193–96.
  10. Mckinlay JB. Social networks, lay consultation and help-seeking behavior. Social Forces 1973;51:275–92.
  11. Irvine S, Cunningham-Burley S. Mother’s concepts of normality, behaviour change and illness in their children. Br J Gen Pract 1991;41:371–74.
  12. Ingram J, Cabral C, Hay AD, Lucas PJ, Horwood J, TARGET Team. Parents’ information needs, self-efficacy and influences on consulting for childhood respiratory tract infections. BMC Fam Pract 2013;14:106.
  13. Thomas KB. General practice consultations: is there any point in being positive? Br Med J (Clin Res Ed) 1987;294:1200–22.
  14. Street RL Jr, Makoul G, Arora NK, Epstein RM. How does communication heal? Pathways linking clinician-patient communication to health outcomes. Patient Educ Couns 2009;74:295–301.

Correspondence afp@racgp.org.au

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