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clinmed/2000050003v1 (May 15, 2000)
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Patients have access to a variety of sources of information about medical matters. This paper looks at the information available in the UK lay press about the prevention and alleviation of urinary tract symptoms (cystitis), a common condition often managed by women themselves, without or before recourse to a medical advisor. Much of the information is based on old wives tales, not on scientific evidence, and where there is some scientific refutation of such old advice and or remedies these still retain credence in both lay and medical culture. The lay press has much to offer in communication health information to the general public. Health professionals should encourage the publication of accurate, accessible and scientifically evidence based material in women’s and other popular magazines.
Little has been written about where, apart from their doctor and the lay referral system, or how, women (who themselves are part of the lay referral system), get advice about health matters. This is important as women's knowledge and understanding is likely to influence their self-care and adherence to doctors' advice. Medicine used to dominate media coverage of health and illness. With the proliferation of "alternative" therapies and the growth of different types of counsellors and therapists for a variety of health and welfare issues, women's magazines in particular have a ready source of material. 65% of the 490 women studied by O’Dowd (O'Dowd, TC., Parker, S., & Kelly, A., 1996) et al informed themselves about vaginal symptoms from encyclopaedia, leaflets and women’s magazines.
The public has become more consumerist, with a feeling of need for more choice and information, in its approach to its medical advisers. This consumerist approach to health is challenging the dominance of the medical profession and the bio-medical model of health and illness; although contemporaneously the bio-medical model is perhaps being strengthened by the increasing emphasis on the practice of evidence based medicine. The power and social influence of traditional professional groups, including doctors, is being eroded, at the same time there is a general shift in society towards a power exerted by the media, its personalities and the agenda its professionals set (Karpf, A., 1988).
Advances in information technology, processing and presentation have enabled an increasingly wide variety and source of detailed and accessible material. There has been a massive rise in the number of lay publications, articles and radio and TV coverage potentially influencing the lives, knowledge, attitudes and beliefs of all patients. Media personalities and their views on health and illness provide copy for magazines and newspapers that like "personal" stories of the famous and how they cope as "examples" to us all.
While advances in medicine have effectively eradicated for example tuberculosis and measles, women are reported as being disillusioned that no cure has been discovered for a disorder as "simple" as cystitis (Kilmartin, A., 1989). One of the main sources of information for a woman about health matters is her family doctor (Worsley, A., 1989) but she will look for alternative sources of advice, information and help. Many women with symptoms of the urinary tract do not consult and manage their symptoms themselves. Accurate information should be available in the community and in the lay referral system. The lay media therefore has an important role to play.
As part of a larger survey (Rink, E., 1998) a random selection of 1385 women registered with one of three UK general (family) practices were sent questionnaires asking about their knowledge, beliefs and sources of information about urinary tract symptoms.
Also, a press cutting service (Romeike and Curtice) was used to collate every lay article, published over two periods, that mentioned the word "cystitis" or "urinary/urine tract infection" to assess the nature of information that women are exposed to. The articles, from daily and weekly newspapers, and weekly and monthly magazines from England, Wales and Scotland were analysed to categorise the types of article.
817 (59%) women responded to the questionnaire survey, of whom 531(65%) had a history of urinary tract symptoms. 184 (35%) of whom had never consulted a doctor with the symptoms. Not all women reported doing anything specific to prevent attacks. Forty (23%) of the 192 women who did, had read advice about prevention from magazines. Amongst the 326 (61%) women who did something to alleviate their symptoms, 44 (13%) had read relevant advice in magazines. This compares with 84 (26%) who reported having been advised by their doctor about alleviation of symptoms.
The professional cutting service collected 249 articles in the nine months between September 1991 and May 1992, and proportionally fewer, 46 articles between April to June 1997. Most national newspapers had at least one article related to cystitis in the periods, as did many of the women's interest magazines, particularly those aimed at a younger readership.
The articles generally were accurate in terms of biomedical content; only one, describing female anatomy got its basic facts wrong. However, even where the content was similar, differences in emphasis, journalistic style and presentation meant that some were considerably more readable and the information was more accessible.
Whatever the focus of the article the most common advice given was to drink three or four pints of water a day, to avoid the use of perfumed soaps and bubble baths, and to wipe the bottom from front to back after defecation. Rarely did an article give any reasons or explanations for these pieces of advice. The terms "cystitis" and "urinary tract infection" were used interchangeably in general, usually without any definition beyond "a burning sensation on urination". Most articles assumed that the reader knew what cystitis was.
On analysis the articles from 1992 were grouped into four main categories. Those linked to "alternative" therapies (n=33, 13%), those linked to "conventional" medicine (n=66, 26%), those linked to a proprietary drug or promoted by a pharmaceutical association (n=116,47%), and those which referred to another source of information without providing many facts themselves (n=34, 14%).
At first sight the 1997 articles appeared to be broadly similar but the proportions in each group was different and yet fitting them into the earlier four categories gave surprising results. Sixteen (34%) fell into the "conventional" category, only 8 (14%) were linked to a proprietary drug or promoted by a pharmaceutical association, and 4 (9%) referred to another source of information. Several did not fit at all –two discussed interstitial cystitis, a subject only mentioned in the scientific literature in 1992, and three reported on work published in Science on a vaccine against E coli so far only tested on mice.
Drinking cranberry juice, which has been used as a folk medicine remedy for decades particularly in the United States, was reported in the scientific press (Ofek, I., Goldhar, J., & Zafriri, D., 1991) as having a significant protective effect against E coli colonising the bladder. Cranberry juice was recommended both as a preventative measure and as a cure in the lay press in mid 1991; a total of nine of the 33 "alternative" articles mentioned it. Nine articles were also found in the 1997 search, but out of a total of 12 articles in this category.
Amongst the "alternative medicine" or "kitchen medicine" articles there were almost as many suggestions as writers. Cystitis was often reported as a disorder which could not be cured by drugs and which was more likely to be exacerbated by current drug therapies. These therapies were reported to be likely to trigger further unpleasant symptoms, in particular those associated with vaginal thrush. Alternative therapies were offered, and in the majority of articles, there was no suggestion that the reader should consult a qualified medical practitioner or reference to severity of symptoms being indicative of serious infection. There was a general veiled criticism of the medical profession in this group of articles; medical practitioners were not portrayed in a sympathetic light.
Herbal remedies suggested include drinking cranberry juice as above, an infusion of dried couch grass root reputed to act as a diuretic and antibiotic, or of goose grass considered to be a pain-killer. Other writers recommended tea made from the silk of ears of corn, powdered marshmallow root, ribwort plantain, agrimony, meadowsweet or yarrow as other remedies. In order to alkalise the urine and to provide vitamin C drinking commercially prepared lemon barley water was encouraged in many articles. The alternative therapist was specific that it should be home-made as the mucilage from the barley would soothe the bladder wall.
The use of marigold flowers or camomile tea bags in the bath were suggested as being both antiseptic and soothing. Leeks in the diet were said to be antiseptic and diuretic; parsley seed and dandelion salads were also recommended but red meat, prunes, lettuce, carrots and green beans were to be avoided.
Aromatherapists recommended the use of a few drops of oil of bergamot in water as a douche which would act as an antibiotic, antiseptic and diuretic. Other essential oils mentioned were juniper thought to be diuretic, eucalyptus considered to be antiseptic and sandalwood, a stimulant to the immune system. None of the articles addressed the issue that oils made from different parts of the plant or from different species of the same genus have very different properties; no mention was made of quantity or frequency of application.
Claims were made that acupuncture, reflexology, palmistry or hydrotherapy can be used to treat cystitis, but most articles made no more than this passing comment. One "instant cure" for both flu and cystitis was given in a national paper with wide circulation-500 mg vitamin C with 500 mg calcium chelate; there was no mention of frequency or duration of this dose.
"Conventional" articles generally recommended that a general practitioner should be consulted and suggested drinking quantities of water, with perhaps the addition of lemon barley water or bicarbonate of soda. A few listed symptoms and causes which included not drinking enough liquid, stress, hygiene, female anatomy, sexual intercourse, heat or cold, chemicals or additives in food or bath or toilet paper and contraception. Wearing cotton underwear, not wearing tight trousers or tights, and wiping after defaecation from front to back were suggested to promote a clean dry environment so that bacteria would not colonise. There was specific advice against the use of perfumed bubble baths and soaps without, in most articles, any justification. Diaphragm users with symptoms were recommended to change their form of contraception. Other recommendations included washing and urinating respectively before and after sexual intercourse and the use of antibiotics continuously as a prophylactic if symptoms were recurrent
Other causes mentioned are bicycle riding, wearing mini-skirts and not sitting on toilet seats while urinating. The last of these was as a result of an article (Moore, KH., Richmond, DH., Sutherst, JR., Imrie, AH., & Hutton, JL., 1991) reporting that incomplete bladder voiding occurs when women crouch as opposed to sit to urinate. As there is an association between increased residual urine volume and urine tract infection, the suggestion was that women disposed to getting urinary tract symptoms should make sure that they sit down on the toilet to avoid recurrence.
The largest group (47%) of articles in 1992, appeared in Dear Doctor or Ask your Pharmacist columns mainly in weekly provincial newspapers. This format had largely disappeared by 1997. Promoted by the National Pharmaceutical Association, they suggested going to the chemist for advice or for a leaflet; or by a drug company, they named a proprietary remedy. This format was less common in the later survey.
Clearly research evidence does find its way into the body of knowledge of the working doctor, the lay media and thence to the patient. However the results of research are rarely unequivocal and even when the results of research work are published or guidelines produced, this has little effect on patient management (Davis, DA., Thomson, MA., Oxman, A., & Haynes, RB., 1995), (Oxman, A., Thomson, MA., Davis, DA., & Haynes, RB., 1995), (Stocking, B., 1992), (Roberston, N., Baker, R., & Hearnshaw, H., 1996), (Fahy, T. & Silagy, C., 1994).
Most of the lay articles about cystitis reiterated the advice to drink copious water to alleviate symptoms. However a wide variety of alternative dietary and bathing recommendations were made; many perpetuated the theories (or "old wives tales"), which have been refuted by research amongst groups of sufferers (Foxman, B., 1990a) (Foxman, B., 1990b) (Foxman, B. & Frerichs, R R., 1985) about the supposed deleterious effects of diet, clothing, and bubble bath. Few included information about urinating after sexual intercourse which has been given credence in the medical journals.
So called "quality" and "popular" newspapers differ in their coverage of health issues with the quality press publishing considerably more informative articles about health issues and the popular newspapers using a human interest story as a vehicle for the information. Suggestions for prevention and cure were not clearly separated in most articles. In 1991 the one "new" prevention and cure reported was to drink cranberry juice, an old American wives tale now given credence by scientific work and made possible by its more widespread availability in UK. It is not a remedy that was suggested by any of the doctors, and only a few of the women. By 1997 this was much more commonplace. The "new" cure being reported in 1997 was a vaccine being trialled in mice.
The impact of articles in the lay press does not seem to have been great, with no more than one fifth of women in the larger survey (Rink, E., 1998) using information gained from magazines to help them with their symptoms. However, media effects are almost impossible to tease out from other influences, which arise in the normal course of other social and family contacts; particularly as other members of society are in turn affected by the media. While it is impossible to assess how many individuals read and assimilated information in the articles analysed in this survey, they undoubtedly have an effect on the lay knowledge which is circulated amongst families and friends and reified as a result of being written down.
The content of lay publications has changed, particularly in relation to the number of publications including advice about the preventative and alleviating properties of cranberry juice. This is based on limited scientific evidence, but then there is little or no evidence for much information given in many of the ‘alternative’ articles. Indeed much of what GPs recommend, for example, about not using bubble bath and tight clothing has been refuted in recent work. Furthermore, where there is evidence this has not been translated into frequently given advice. Health professionals could work with lay editors to improve the standard and style of articles written in the popular press, and increasingly for publication on line.
Davis, DA., Thomson, MA., Oxman, A., & Haynes, RB. (1995). Changing physician performance. A systematic review of the effect of continuing medical education strategies. Journal of American Medical Asssociation, 274, 700-705.
Fahy, T. & Silagy, C. (1994). General practitioners' knowledge of and attitudes to the management of hypertension in elderly patients. British Journal of General Practice, 44, 446-449.
Foxman, B. (1990b). Health behaviour and urinary tract infection in college women. Journal of Clinical Epidemiology, 43, 329-337.
Foxman, B. (1990a). Recurring Urinary Tract Infection:Incidence and Risk Factors. American Journal of Public Health, 80, 331-333.
Foxman, B. & Frerichs, R. R. (1985). Epidemiology of urinary tract infection:I.Diaphragm use and sexual intercourse. American Journal of Public Health, 75, 1308-1313.
Karpf, A. (1988). Medicine and the Media. British Medical Journal, 296, 1389.
Kilmartin, A. (1989). Understanding Cystitis. (2 ed.) London: Arrow.
Moore, KH., Richmond, DH., Sutherst, JR., Imrie, AH., & Hutton, JL. (1991). Crouching over the toilet seat: prevalence among Britssh gynaecolofical outpatients and its effect upon micturition. British Journal of Obstetrics and Gynaecology, 98, 569-572.
O'Dowd, TC., Parker, S., & Kelly, A. (1996). Women's experiences of general practitioner management of their vaginal symptoms. British Journal of General Practice, 46, 415-418.
Ofek, I., Goldhar, J., & Zafriri, D. (1991). Anti-E.coli adhesin activity of cranberry and blueberry juices. New England Journal of Medicine, 324, 1599.
Oxman, A., Thomson, MA., Davis, DA., & Haynes, RB. (1995). No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. Canadian Medical Association Journal, 153, 1423-1431.
Rink, E. (1998). Risk factors for urinary tract symptoms in women: beliefs of general practitioners and women and their effect on patient management. British Journal of General Practice, 48, 1155-1158.
Roberston, N., Baker, R., & Hearnshaw, H. (1996). Changing the clinical behaviour of doctors: a psychological framework. Quality in Health Care, 5, 51-54.
Romeike and Curtice. The Press Clipping Bureau, Hale House, 290 Green Lane London N13 5TP
Stocking, B. (1992). Promoting change in clinical care. Quality in Health Care, 1, 56-60.
Worsley, A. (1989). Perceived reliability of sources of health information. Health Education Research, 4, 367-376.
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