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Article Excerpt
Evidence-based practice (EBP) is the integration of research, clinician experience, and patient values; however, most studies focus on research and clinician experience and ignore patient values. Acute respiratory infections (ARIs) are experienced routinely by both adults and children and are often mistreated with antibiotics, despite findings from multiple research studies indicating that antibiotics do not decrease the severity or duration of ARIs. Several studies indicate that clinicians tend to prescribe antibiotics for ARIs when they perceive that patients want them; however, little is known about actual patient values related to ARI management and even less is known about rural patient values. The aim of this study was to learn more about the values, beliefs, and attitudes held by rural individuals and families regarding ARI management. Focus group interviews were conducted with 42 individuals from five rural communities in Wyoming. Four themes emerged from the data: (a) "cowboy up," (b) access, (c) self and family knowledge, and (d) community as family. These themes have important implications for rural health care providers and EBP.
Keywords: rural, patient values, evidence-based practice, respiratory infections
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Health care and related issues are a continual challenge to the well-being of rural families (Rural Policy Research Institute, 2002). Issues regarding cost, quality, and access to care are among the stressors facing rural families (Institute of Medicine, 2005). A specific challenge that rural families face regarding quality of care is that primary health care providers (HCPs), such as physicians and nurse practitioners, may lack information concerning the unique values and circumstances of the rural individuals and families in their practices. This is problematic because without this knowledge, HCPs are unable to fully implement evidence-based practice (EBP) in the care of their rural patients.
EBP is often associated with excellence in health care and clinical decision-making (Folden & Kneipp, 2007). One of the best known and frequently used definitions of EBP is "the integration of best research evidence with clinical expertise and patient's values and circumstances" (Straus, Richardson, Glasziou, & Haynes, 2005, p.1). In recent years, EBP has received much attention, and almost every health-related discipline has witnessed an explosion in "best evidence" literature. However, several obstacles prevent clinicians from truly incorporating EBP, including scarcity of research evidence available for many clinical problems (Doherty, 2005; Melnyk & Fineout-Overholt, 2005; Straus et al., 2005), clinicians' lack of readiness to interpret research findings (West & Ficalora, 2007; Windish, Huot, & Green, 2007), and the time it takes for clinicians to develop clinical expertise (Cabana et al., 1999; Pravikoff, Tanner, & Pierce, 2005). Furthermore, there is a relative literature void regarding patient values related to health care, and no clear sense on exactly how clinicians are supposed to elicit patient values and incorporate these values into their evidence-based decision-making.
The term, patient values, is defined as "the unique preferences, concerns and expectations each patient brings to a clinical encounter" (Straus et al., 2005, p.1). Although patient values are seen as an integral aspect of EBP, very little is known about what patients and families value and expect in relation to health care. Even less is known about rural patient and family values related to health care. Because of the multiple challenges faced by rural individuals and families in relation to health care (e.g., access, affordability, etc.), it is critical that both primary and other HCPs have a thorough understanding of the values, so that they may incorporate these into their clinical decision-making processes.
The literature related to the health beliefs and behaviors of rural individuals and families reveals that they tend to associate health with the ability to work, be productive, and do usual tasks (Long, 1998). In addition, they are generally thought to be more self-reliant than their urban counter parts and more likely to use informal sources of help, often resisting assistance from those perceived as outsiders (Weinert & Burman, 1994). However, despite being hardy, self-sufficient, and independent, rural families often have difficulty accessing health care services, most often because of the long travel distances required (Ricketts, 2001). They tend to "wait out" their symptoms; relying on rest and resources such as books to manage their symptoms (Jirojwong & MacLennan, 2002). In addition, many rural families lack informal resources from which to obtain health care information and support and rely on internal coping mechanisms such as humor and hope (Sullivan, Weinert, & Cudney, 2003).
The literature regarding how rural people perceive and manage common illnesses, such as acute respiratory infections (ARIs) is scant. A national study comparing health care utilization among children living in rural versus nonrural settings revealed that nonrural children were more likely to see clinicians for ARIs than rural children (Cayce et al., 2005). In addition, a study of suburban versus urban parents in New Jersey found that suburban parents were more likely to have administered an antibiotic to their child without the consultation of a physician than urban parents; however, urban parents were more likely to have gone to another HCP if the initial provider did not prescribe an antibiotic for their child (Edwards, Richman, Bradley, Eskin, & Mandell, 2002). Results from these two studies indicate that rural families may engage in more self-care practices related to ARIs; however, this has not been substantiated, and as of this writing, no studies related to rural families' values and beliefs related to ARIs have been published.
ARI is a broad term used to characterize several infections of the upper respiratory tract including the common cold, acute sinusitis, acute pharyngitis (sore throat), and acute bronchitis. The ARI is an interesting illness to examine because it is the most frequently occurring illness experienced by humans (Monto, 2002), with adults typically experiencing two to four ARIs per year and children experiencing six to eight (Monto, Fendrick, & Sarnes, 2001). It is believed that ARIs are an "equal opportunity" illness at least in geographic terms, with rural and urban individuals experiencing ARI symptoms in equal proportions; however, there are no research data to support or deny this assertion.
Despite the fact that most ARIs are viral in etiology, HCPs prescribe antibiotics for ARIs with alarming frequency, with recent studies indicating that antibiotics are prescribed for ARIs greater than 50% of the time (Metlay et al., 2007; Running, Kipp, & Mercer, 2006). This trend is especially concerning given that antibiotic overuse is associated with increased rates of antibiotic resistant infections (Centers for Disease Control & Prevention, 2007; Chung et al., 2007).
Results from the prior studies indicate that many HCPs believe that they are making "best evidence" clinical decisions for their patients with ARIs but are often basing these decisions on outdated or incorrect sources of information (Hart, Pepper, & Gonzales, 2006). They may also make faulty assumptions about the expectations of patients who present with ARI symptoms (Mangione-Smith,...
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