Resea ch A icle
Sel -Ca e P ac ices o Common Colds by P ima y
Ca e Pa ien s: S udy P o ocol o a Eu opean Mul icen e
Su ey—The COCO S udy
Bi gi a M. Wel e mann,1Biljana Ge asimo ska-Ki ano ska,2
Anika Thielmann,1Julie e Chambe,3Heid un Lingne ,4Enzo Pi o a,5
K zysz o Buczkowski,6Selda Tekine ,7Slawomi Czachowski,6Tame Edi ne,8
And zej Zielinski,9Hülya Yikilkan,10 Tuomas Koskela,11 Fe dinando Pe azzuoli,12
Robe D. Ho man,13 Ma ija Pe ek Š e ,14 Cla a Guede Fe nández,15 AyGegül UludaL,16
Ka h yn Ho mann,17 Vildan Me sim,18 and Sanda K ei maye Pes ic19
1Ins i u e o Gene al Medicine, Essen Uni e si y Hospi al, Uni e si y o Duisbu g-Essen, Hu elands aße 55,
45147 Essen, Ge many
2Depa men o Family Medicine and Depa men o Neph ology, Ss. Cy il and Me hodius Uni e si y o Skopje,
Vodnjanska S ee 17, Skopje, Macedonia
3Depa men o Gene al P ac ice, Uni e si y o S asbou g, 2a ue de B an ˆ
ome, 67100 S asbou g, F ance
4Cen e o Public Heal h and Heal hca e, Hanno e Medical School, Ca l-Neube g-S aße 1, 30625 Hanno e , Ge many
5SNAMID, I alian Socie y o Gene al P ac i ione s and ASL Roma B, Via Tuscolana, 859 Rome, I aly
6Depa men o Family Medicine, Nicolaus Cope nicus Uni e si y, Skłodowskiej-Cu ie 9, 85-094 Bydgoszcz, Poland
7Depa men o Family Medicine, Ibni Sina Hospi al, Anka a Uni e si y School o Medicine, Samanpaza ı,
06100 Anka a, Tu key
8Depa men o Family Medicine, Uni e si y o Pamukkale, PAU Tip Fakul esi, Aile Hekimligi AD, Kinikli Kampus,
Denizli, Tu key
9Blekinge Cen e o Compe ence and Lyckeby P ima y Heal h Ca e Cen e, K¨
alle ¨
agen 12, 37162 Lyckeby, Sweden
10Family Medicine Depa men , Dıs¸kapı Yıldı ım Beyazı T aining and Resea ch Hospi al, I an Basbug Caddesi, Dıs¸kapı,
06110 Anka a, Tu key
11 Depa men o Gene al P ac ice, Uni e si y o Tampe e, L¨
a¨
ak¨
a ika u 1, 33014 Tampe e, Finland
12Depa men o Clinical Sciences in Malm¨
o, Cen e o P ima y Heal h Ca e Resea ch, Lund Uni e si y, Malm¨
o, Sweden
13Depa men so FamilyMedicineandMedicalEduca ion,Sakla MedicalSchool,TelA i Uni e si y,8Go donS ee ,
76291 Reho o , Is ael
14Depa men o Family Medicine, Uni e si y o Ljubljana, Poljanski Nasip 58, SI-1000 Ljubljana, Slo enia
15EOXI Vigo, Uni e si y o Vigo, Calle Za agoza, Vigo, 36203 Pon e ed a, Spain
16Depa men o Family Medicine, Facul y o Medicine, C¸anakkale Onsekiz Ma Uni e si y, Te zio˘
glu Campus,
17100 C¸anakkale,Tu key
17Depa men o Gene al P ac ice and Family Medicine, Cen e o Public Heal h, Medical Uni e si y o Vienna,
Kinde spi algasse 15, 1s Floo , 1090 Vienna, Aus ia
18Depa men o Family Medicine, Dokuz Eyl¨
ul Uni e si y Facul y o Medicine, Izmi , Tu key
19Medical Facul y Tuzla, Family Medicine Depa men and Heal h Cen e Tuzla, Depa men o Gene al/Family Medicine,
Ma salaTi a199,75000Tuzla,BosniaandHe zego ina
Co espondence should be add essed o Bi gi a M. Wel e mann; bi gi a.wel e [email p o ec ed]
Recei ed 29 May 2015; Accep ed 26 July 2015
Academic Edi o : Wa is Qidwai
Copy igh © 2015 Bi gi a M. Wel e mann e al. This is an open access a icle dis ibu ed unde he C ea i e Commons A ibu ion
License, which pe mi s un es ic ed use, dis ibu ion, and ep oduc ion in any medium, p o ided he o iginal wo k is p ope ly ci ed.
Hindawi Publishing Co po a ion
E idence-Based Complemen a y and Al e na i e Medicine
Volume 2015, A icle ID 272189, 6 pages
h p://dx.doi.o g/10.1155/2015/272189
2 E idence-Based Complemen a y and Al e na i e Medicine
Backg ound. Sel -ca e o common colds is equen , ye li le is known abou he spec um, egional di e ences, and po en ial
isks o sel -ca e p ac ices in pa ien s om a ious Eu opean egions. Me hods/Design. We desc ibe he s udy p o ocol o a c oss-
sec ional su ey in 27 p ima y ca e cen e s om 14 Eu opean coun ies. A all si es, 120 consecu i e adul pa ien s, who isi hei
gene al p ac i ione o any eason, illed in a sel -adminis e ed 27-i em ques ionnai e. This add esses pa ien s’ sel -ca e p ac ices
o common colds. Sepa a ely, he subjec i e le el o discom o when ha ing a common cold, knowing abou he diseases’ sel -
limi ed na u e, and medical and sociodemog aphic da a a e eques ed. Addi ionally, physicians a e su eyed on hei use o and
ecommenda ions o sel -ca e p ac ices. We a e in e es ed in in es iga ing which sel -ca e p ac ices o common colds a e used,
whe he he numbe o sel -ca e p ac ices used is in luenced by knowledge abou he sel -limi ed na u e o he disease, and he
subjec i e le el o discom o when ha ing a cold and o iden i y po en ial ad e se in e ac ions wi h ch onic physician-p esc ibed
medica ions. Fu he ac o s ha will be conside ed a e, o example, demog aphic cha ac e is ics, ch onic condi ions, and sou ces
o in o ma ion o sel -ca e p ac ices. All desc ip i e and analy ical s a is ics will be pe o med on he pooled da ase and s a i ied
by coun y and si e. Discussion. To ou knowledge, COCO is he i s Eu opean su ey on he use o sel -ca e p ac ices o common
colds. The s udy will p o ide new insigh in o pa ien s’ and gene al p ac i ione s’ sel -ca e measu es o common colds ac oss
Eu ope.
1. In oduc ion
Wo ldwide, common colds a e he mos equen ly encoun-
e edhumandisease[1].Commoncoldisacon en ional e m
o a he e ogeneous g oup o mild uppe espi a o y illnesses
caused by mo e han 100 i uses such as hino i uses, RSVs,
in luenza A i uses, adeno i uses, and pa ain luenza ype 3
i uses [2, 3]. The incidence o common colds is known o
be age-speci ic [4], wi h a yea ly a e age o 6–8 episodes in
younge child en dec easing o 2–4 episodes in adul hood
[5, 6]. Acco ding o a US Ame ican s udy (2015) wi h 3333
pa icipan s, 85% o he popula ion abo e 18 yea s o age will
de elop a leas 1 common cold pe yea , las ing be ween 3 and
7 days [7]. To ou knowledge, no Eu opean da a a e a ailable.
The incidence o he Eu opean egion is likely compa able.
The socioeconomic cos s caused by common colds a e a
bu den o socie y, especially cos s due o sick lea es [8].
The e idence o common cold ea men s is poo wi h
only ew medica ions p o en e ec i e in elie ing symp oms
o in educing he du a ion o he disease, o example,
nons e oidal an i-in lamma o y d ug [9], o al an ihis amine-
deconges an -analgesic combina ions [10], nasal deconges-
an s [11], and zinc (lozenges o sy up) [8]. Despi e poo
e idence, sys ema ic and unsys ema ic obse a ions show
ha pa ien s use a wide a ie y o sel -ca e p ac ices o his
sel -limi ed disease [12–16].
Following he de ini ion o he WHO [17], his s udy
unde s ands sel -ca e as “(...) heabili yo indi iduals,
amilies and communi ies o p omo e heal h, p e en disease,
and main ain heal h and o cope wi h illness and disabili y
(...). I is a b oad concep encompassing (...)nu i ion
(...), li es yle (...) (and) sel -medica ion.” Thus, sel -ca e
p ac ices in ol e all pa ien d i en heal h ac ions, including
he dimensions: sel -medica ion, complemen a y medicine,
and he so-called home emedies [16].
Un ilnow,nos udyexis s ha compa essel -ca ep ac-
ices o common colds in di e en Eu opean coun ies.
The opic is o in e es o se e al easons: (1) he spec um
o sel -ca e p ac ices used o common colds is unknown;
(2) po en ial medica ion in e ac ions in pa ien s on ch onic,
physician-p esc ibed medica ions ha e no been e alua ed;
(3) ac o s which in luence he use o sel -ca e p ac ices
a e poo ly unde s ood. Ye , i may be impo an o be e
unde s and hese opics because he same ac o s may d i e
he high demand and o e p esc ip ion o an ibio ics o
common colds, despi e public campaigns in o ming abou
he benign and sel -limi ed disease cou se. The Eu opean
wo king g oup on sel -ca e was o med o add ess hese
issues. The g oup consis s o membe s o he Eu opean
Gene al P ac ice Resea ch Ne wo k (www.egp n.o g).
2. Me hods and Ma e ials
The p ima y aim o his s udy is o de e mine which sel -
ca e p ac ices o common colds a e used by p ima y ca e
pa ien s om di e en Eu opean coun ies and o iden i y
ac o s in luencing sel -ca e p ac ices. To in es iga e sel -ca e
p ac ices o common colds, we a e conduc ing a mul icen e
c oss-sec ional su ey in 14 Eu opean coun ies.
2.1. Hypo heses. The s udy will in es iga e he ollowing
speci ic hypo heses:
(1) The e a e di e ences in he use o sel -ca e p ac ices
o common colds be ween coun ies (Pu chasing
Powe S anda d, egion) and wi hin coun ies ( u al/
u ban a eas).
(2) The e a e di e ences in he use o sel -ca e p ac ices
acco ding o pa ien s’ socioeconomic ac o s (age,
gende , mig a ion backg ound, heal h insu ance s a-
us,andnumbe o schoolyea s(includinghighe
educa ion)), knowing abou he sel -limi ed na u e o
common colds, subjec i e le el o discom o when
ha ing a common cold, li es yle ac o s (smoking),
ch onic condi ions, numbe o able s aken daily, and
sou ces o in o ma ion.
(3) The use o sel -ca e p ac ices in he subg oup o
pa ien s on ch onic physician-p esc ibed medica ions
bea s he isk o po en ial ad e se e ec s due o
in e ac ions be ween sel -ca e p ac ices and medica-
ions. This isk e alua ion will be pe o med using a
pha macological e iew on in e ac ions be ween, o
example, wa a in, coumadin, ASA/aspi in, and o al
con acep i es/“ he pill” (e.g., wa a in and lico ice,
E idence-Based Complemen a y and Al e na i e Medicine 3
ibup o en and willow, con acep i es, and an idep es-
san ssuchasami ip ylineandSSRIwi hS .John’s
wo ) [18].
In addi ion o hese speci ic hypo heses, he s udy will explo e
sel -ca e p ac ices o pa icipa ing gene al p ac i ione s:
which sel -ca e p ac ices do hey apply hemsel es and which
do hey ecommend o hei pa ien s?
2.2. Coo dina ion and Pa icipa ing Si es o he COCO S udy.
This c oss-sec ional s udy was ini ia ed by p ima y ca e
physician esea che s om h ee Eu opean coun ies (Ge -
many, Macedonia, and Bosnia and He zego ina) du ing
a con e ence o he Eu opean Gene al P ac ice Resea ch
Ne wo k (EGPRN) in Oc obe 2012. The s ee ing commi ee
used subsequen EGPRN mee ings in 2013 o ec ui addi-
ional academic p ima y ca e physicians om he EGPRN
aswo kingg ouppa ne s.The inalwo kingg oupconsis s
o 25 EGPRN membe s om 14 Eu opean and associa ed
coun ies: Aus ia, Bosnia and He zego ina, Finland, F ance,
Ge many, Is ael, I aly, Macedonia, Poland, Romania, Slo e-
nia, Spain, Sweden, and Tu key. A each si e, he coo dina o s
a e esponsible o he ansla ion o he English ques ion-
nai e in o he si e language, i s dis ibu ion o pa ien s, he
back- ansla ion o pa ien ’s answe s o open ques ions in o
English, and ei he he ans e o he ques ionnai e o da a
en y a he s udy cen e in Essen, Ge many, o he da a en y
on-si e wi h subsequen ansmission o he da ase o he
s udy cen e .
The coo dina o s a each si e signed a consen o m o he
ou line o he s udy plan and de ails on expec ed pa icipa ion
equi emen s, ha is, he ansla ion o he ques ionnai e, he
sampling p ocess, and he da a handling. Coo dina o s a e
esponsible o ollowing he s udy plan.
The i s e hical app o al was ob ained om he E hics
Commi ee o he Uni e si y o Duisbu g-Essen, Ge many
(13-5495-BO). This e hical app o al was p o ided o he
coo dina o s o all pa icipa ing si es who ob ained any
app o als equi ed, including, i necessa y, an addi ional
e hical app o al acco ding o local laws and guidelines.
2.3. S udy Ins umen s and Ques ionnai e Design P ocess. The
ques ionnai e was de eloped based on a p eceding su ey in
10 p ima y ca e physicians om se en Eu opean coun ies
and one associa ed coun y (Aus ia, Bosnia and He zego -
ina, Ge many, Is ael, I aly, Macedonia, Poland, and Tu key).
Physicians we e asked o name ypical sel -ca e i ems used by
hei pa ien s o common cold [19]. The physicians’ answe s
we e g ouped o cons uc he su ey ins umen . The inal
ques ionnai e consis s o 27 ques ions wi h a o al o 94
sel -ca e i ems in 11 ca ego ies: o e - he-coun e medica ion
(11 i ems), speci ic ood o d inks (11 i ems), he bal ea (18
i ems), alcoholic d ink (3 i ems), sel -p epa ed special ecipe
(7 i ems), pas illes o d ops (10 i ems), some hing o he nose
(4 i ems), inhala ion (8 i ems), ga gle o sp ay o he h oa
(4 i ems), some hing ex e nal (5 i ems), and ex as a home
(13 i ems). Fo each ca ego y, an addi ional ee- ex op ion
is p o ided. The ques ionnai e app oach o a combina ion o
closed and open ques ions was chosen because pa icipan s
a emo elikely o ecall ea men swhenclosedo semiclosed
p oduc -speci ic ques ions a e p o ided a he han a single
open ques ion only [20].
Fu he mo e, he ques ionnai e elici s he ollowing
pa ien cha ac e is ics: age, gende , place o bi h, o igin
o amily,heal hinsu ances a us,numbe o schoolyea s,
numbe o pills aken daily, egula in ake o speci ic medi-
ca ions (i.e., an icoagulan s, bi h con ol, and aspi in) daily
smoking, money spen o he las common cold, sou ce o
in o ma ion o sel -ca e p ac ices, whe he sel -ca e p ac-
ices we e ecommended o o he s, and ha ing one o he
ollowing ch onic condi ions: dep ession, ch onic kidney
disease, ch onic pain/a h i is, as hma/ch onic b onchi is,
high blood p essu e, hea disease, and diabe es. Following
he Common Sense Sel -Regula ion Model (CS-SRM) [21],
hesubjec i ele elo discom o ismeasu edaskingwhe he
one “ eels e y bad when ha ing a common cold” (answe
op ions: “yes,” “no,” and “do no know”). The pe cep ion
ega ding con ol and cu e is measu ed ocusing on he sel -
limi edness o he disease “i a common cold goes away by
i sel ” (answe op ions: “yes,” “no,” and “do no know”).
Ra he han p o iding a de ailed de ini ion o common
colds, we elied on he pa icipan s’ in ui i e unde s anding
as laymen o wha is mean by common colds. The comple e
pa ien ques ionnai e is displayed in addi ional ile 1 in
Supplemen a y Ma e ial a ailable online a h p://dx.doi.o g/
10.1155/2015/272189.
A e a p e es in 10 p ima y ca e pa ien s each in Macedo-
niaandGe manyaswellasawo kingg oupdiscussiona he
all EGRPN mee ing in Kus¸adası, Tu key, he ques ionnai e
was inalized. The o iginal ques ionnai e was de eloped in
English. Each s udy si e coo dina o is esponsible o i s
ansla ion in o he na i e languages and i s e iew by a
second physician.
Fo da a analysis, he ca ego ies a e eclassi ied acco ding
o hemodeo applica ion oa oido e lapbe weeng oups:
o al applica ion, in anasal applica ion, inhala ion, opical
use in h oa , ex e nal use on he body, and ex as a
home. Foods u s a e ea ed as a sepa a e ca ego y, al hough
o mally hey would belong o he o al applica ion g oup.
All indus y-p epa ed i ems om he pha macy/d ug s o e
which equi e no p esc ip ion a e g ouped as o e - he-
coun e (OTC) medica ions.
A all si es, a sho ques ionnai e collec s cha ac e is ics o
he pa icipa ing p ac ices and physicians: numbe o physi-
cians in p ac ice, o al numbe o pa ien s in he p e ious
yea , a e age pa ien con ac s pe day by he physician, age
dis ibu ion o pa ien s in he p e ious yea , pe cen age o
pa ien s wi h mig a ion backg ound, and whe he he p ac-
ice is loca ed in an u ban o u al a ea. Fo all pa icipa ing
physicians, he numbe o yea s wo king in he p ac ice,
he h ee ypical sel -applied measu es o colds, and he
h ee mos equen ly ecommended measu es o pa ien s
a e ob ained (see addi ional ile 2).
2.4. Da a Collec ion and Managemen
2.4.1. SamplingP ocedu e. Each si e coo dina o was ins uc ed
how o pe o m he s anda dized ques ionnai e ansla ion
4 E idence-Based Complemen a y and Al e na i e Medicine
and he da a collec ion in he selec ed p ima y ca e p ac-
ice(s) o cen e (s). To ensu e a andom sample, ques ion-
nai es a e dis ibu ed o consecu i e pa ien s ul illing he
inclusion c i e ia, independen o hei eason o he p ac ice
isi . The inclusion c i e ia a e age abo e 18 yea s and su -
icien language capabili ies o answe he sel -adminis e ed
ques ionnai e o being in a endance o someone able o
p o ide assis ance (in eading, ansla ing, o o he suppo ).
The si e coo dina o o ganizes he dis ibu ion o he ques-
ionnai es a he ecep ion desk o be comple ed by he pa ien
in he wai ing oom. In g oup p ac ices o cen e s wi h se e al
physicians, ques ionnai es will be dis ibu ed o consecu i e
pa ien s, ega dless o he physician in cha ge o he pa ien .
To calcula e p ac ice esponse a es, e used o un illed
ques ionnai es a e collec ed oge he wi h he comple ed
ques ionnai es. De ails abou he sampling p ocess in each
pa icipa ing si e (e.g., esponse a e pe si e) will be included
in hemainpublica ion.
2.4.2. Da a Managemen . Da a en y is o ganized using IBM
SPSS S a is ics o Windows, Ve sion 22.0. Pa icipa ing
si es a e ee o choose be ween uploading he da a in o
a cus om-designed SPSS da a ile o ha ing he da a en y
a anged a he s udy cen e in Essen, Ge many. In he la e
case, pa icipa ing si es ei he uploaded scanned anonymous
ques ionnai es o a secu ed uni e si y se e d op box o
mailed he o iginal ques ionnai es using a ce i ied mail
se ice. To ensu e da a quali y, 10% o he da a en e ed in
Essen a e checked h ough double en y by a second pe son.
I e o s a e g ea e han 5%, he comple e ques ionnai e is
double en e ed.
2.4.3. Da a Quali y. Plausibili y checks o con adic o y
answe s a e pe o med. The numbe o pills aken daily is
adjus ed i a pe son ma ks “0” bu answe s ha hey ake,
o example, a con acep i e. F ee- ex answe s a e checked i :
(a) an answe is only gi en as ee- ex hough p o ided in a
mul iple choice o ma (co ec ion: ee- ex answe s dele ed
and mul iple choice ques ion ma ked); (b) he same answe
is gi en as in he mul iple choice ques ion (co ec ion: ee-
ex i em dele ed); (c) answe s a e gi en in he w ong ca ego y
(co ec ion: ea anged). All cu encies a e ans e ed in o
Eu o.
2.5. Sample Size Calcula ion and S a is ical Analysis
2.5.1. Sample Size Calcula ion. The a ge ed sample size
o eachsi ewases ima ed ompowe calcula ionsusing
Ge man da a on nons e oidal analgesic use a es because no
da a we e a ailable on he u iliza ion a e o sel -ca e p ac ices
o all pa icipa ing coun ies. Wi h 62 million packages used
by 80 million people, abou 77% o he popula ion used such
medica ions in 2012 (IMS Pha maScope Na ional by IMS
HEALTH GmbH & Co. OHG). Assuming ha some pa ien s
usemo e hanonepackagepe yea ,wees ima ed ha abou
40% o he adul popula ion ook nons e oidal painkille s
such as ace ylsalicylic acid, ibup o en, o pa ace amol a leas
once a yea .
Aiming a es ima ing he sample size necessa y o ob ain
a ep esen a i e sample o a p ac ice wi h 3,000 pa ien s, a
o al o 94 pa ien s need o be s udied (CI 95%; SE 0.05). In
a p ac ice sample o 1,000 pa ien s wi h all o he pa ame e s
kep equal, a o al o 88 pa ien s would need o be su eyed.
Simila ly, in a p ac ice wi h 10,000 pa ien s, a o al o 96
pa ien s would need o comple e he ques ionnai e. These
es ima es a e based on wo assump ions. (1) The sample o
pa ien s su eyed is andom o he espec i e p ac ice. (2)
The sample size o 100 pa ien s is a adeo be ween s a is ical
powe and p ac icabili y. To accoun o a non esponse a e o
25%, o e sampling by 25% is planned, leading o an adjus ed
sample size o 117.5 (94 + 23.5 pa ien s), ounded o 120
pa ien s pe p ima y ca e p ac ice o cen e .
2.5.2. Response plus Rep esen a i eness. The esponse is cal-
cula ed as pe cen age o he ques ionnai es illed ou in
ela ion o he 120 ques ionnai es dis ibu ed. Due o da a
p o ec ion easons, no cha ac e iza ion o non esponde s
is possible. Analyses o ull and pa ial esponde s will be
pe o med.
The powe calcula ion ocuses on he ep esen a i eness
o he samples on p ac ice le el. In addi ion, we will in es i-
ga e whe he he collec ed da a a e also ep esen a i e on a
coun y le el. To add ess his issue, we a e using ou analy ic
app oaches:
(1) In coun ies wi h ≥2 samples om di e en si es
wi hin one ci y and i s adjacen subu bs, equencies
o sel -ca e i ems will be compa ed be ween he
di e en si es (F ance, Tu key). The eby, di e en
socioeconomic and geog aphical a eas ( u al/u ban)
will be compa ed.
(2) In coun ies wi h ≥2 di e en ci ies, he equencies o
sel -ca e i ems will be compa ed be ween he di e en
ci ies (Ge many, Tu key, and Poland). In one case,
we will compa e a p ac ice sample (𝑛 = 120)wi h
a na ionally ep esen a i e sample ob ained h ough
elephone in e iews conduc ed on he basis o he
COCO ques ionnai e (Aus ia).
(3) Due o demog aphic he e ogenei y be ween coun-
ies, we will pe o m age and i needed sex s anda d-
iza ion.
(4) S anda diza ion o egional cha ac e is ics (u ban/
u al) will be conside ed as well.
2.5.3. Pooled and Coun y Speci ic Analyses. In p epa a ion
o pooledanalysesac oss14coun ies,po en ialsou ces
o he e ogenei y wi hin he da a will be iden i ied be o e
combining he da ase s.
All desc ip i e s a is ics will be pe o med on he pooled
da ase ands a i iedbycoun yandsi e.Thep e alenceo
i emsusedwillbep esen edasp opo ions.
We will use chi-squa e es s o ca ego ical and ANOVA
o con inuous a iables o iden i y ac o s in luencing sel -
ca e i ems (age, sex, u ban/ u al a ea, numbe o school yea s,
mig a ion backg ound, heal h insu ance s a us, subjec i e
le el o discom o , knowing abou he diseases’ sel -limi ed
E idence-Based Complemen a y and Al e na i e Medicine 5
na u e o common colds, sel -g owing o plan s/he bs, smok-
ing, ch onic condi ions, numbe o able s aken daily, and
di e en sou ces o in o ma ion). Analyses acco ding o he
Pu chasing Powe S anda d [22] will be pe o med on he
basis o he ollowing g oupings: G oup I: Aus ia, Sweden,
Ge many, and Finland; G oup II: F ance, Is ael, I aly, Spain,
and Slo enia; G oup III: Poland, Tu key, Romania, Mace-
donia, and Bosnia and He zego ina. Di e ences be ween
geog aphical egion, u al/u ban a ea, and cul u al back-
g ound will be es ed using he chi-squa e s a is ic. Fo he
compa ison o mo e han wo means (Pu chasing Powe
S anda d), ANOVA will be calcula ed. Logis ic eg ession
analyses will be used o de e mine p edic o s o sel -ca e
p ac ices. All analyses will be pe o med in he o al da ase
and sepa a ely pe si e and coun y and Eu opean egion.
3. Discussion
The COCO s udy aims a desc ibing sel -ca e p ac ices o
common colds used by p ima y ca e pa ien s in di e en
Eu opean coun ies o iden i y he spec um used, o quan i y
sel -ca e p ac ices, o desc ibe di e ences ac oss coun ies
and egions, and o explo e he isk o possible in e ac ions
wi h ch onic physician-p esc ibed medica ions. In e es ingly,
despi e hei high p e alence and hei impac on indi iduals
andsocie ies,commoncoldsandespeciallysel -ca ep ac ices
o hisha mlessdiseaseha eba elybeenasubjec o in e es
o he medical communi y.
In con as o ecen p io s udies on sel -ca e, which
mos ly ocus on single dimensions, ha is, sel -medica ion
o home emedies [12, 23], his s udy explo es sel -ca e o
common colds based on he comp ehensi e WHO de ini ion,
including OTC and nonmedicinal home emedies. This
b oad WHO de ini ion is chosen because o he poo p io
knowledge on he spec um o i ems used in he pa icipa ing
coun ies, cul u al di e ences, and he expec ed di e ences
due oheal hca esys ems.Ino de osu ey helikely
ange o sel -ca e p ac ices used in he pa icipa ing coun ies
and because o he lack o a s anda dized ques ionnai e, he
ques ionnai e design chosen includes closed ques ions and
allows o ee- ex answe s.
This pan-Eu opean mul icen e s udy is conduc ed using
a low budge s a egy, he eby ep esen ing an example o
u u e p ojec s. Ne e heless, he e a e se e al me hodolog-
ical challenges and limi a ions o his s udy: Fi s , al hough
he high numbe o pa icipa ing si es h oughou Eu ope
is a s eng h o he COCO s udy, his p ojec is acing a
majo me hodological challenge wi h ega d o he ep e-
sen a i eness o i s esul s on p ac ice, local, egional, and
na ional le el. This challenge will be add essed by combining
a iousanaly ics a egies:Dependingon henumbe o
indi idual samples wi hin a coun y, equencies o sel -ca e
i ems will be compa ed ei he be ween di e en a eas o he
same ci y o be ween di e en ci ies wi hin one coun y. An
addi ional na ionally ep esen a i e sample ob ained h ough
elephonein e iewson hebasiso heCOCOques ionnai e
allows o a compa ison o single p ima y ca e p ac ices and
a na ional sample. Fu he , age and sex s anda diza ion as
well as s anda diza ion o egional cha ac e is ics will be
conside ed. Second, his c oss-sec ional ques ionnai e su ey
is based on he pa ien s’ ecall o sel -ca e p ac ices du ing
hei las common cold. This may imply a decla a ion and
ecall bias. In o de o limi hose, he ques ionnai e is
dis ibu ed a he end o win e ime du ing he ypical peak
season o common colds. Also, i is unlikely ha pa ien s
comple ely change sel -ca e p ac ices om one common cold
o ano he , hus implying a he s able answe ing beha io .
Fu he mo e, he ques ionnai e was only wo pages long
and included p oduc -speci ic ques ions. This ques ionnai e
design has been p o en o o e come he ecall bias o
ea men s [20].
4. Conclusion
The COCO s udy will p o ide insigh in o pa ien s’ sel -
ca e beha io s o common colds. The esul s no only will
be in e es ing om a desc ip i e pe spec i e wi h ega d o
egional di e ences wi hin Eu ope, bu will also help o guide
esea ch on educa ional in e en ions on he ha mlessness
o common colds and app op ia e sel -ca e p ac ices. Also,
he esul s will help o de elop s a egies o be e p o ec
pa ien s on ch onic medica ions om ad e se medica ion
in e ac ions due o sel -ca e p ac ices o common colds.
Abb e ia ions
COCO: Common Cold s udy
WHO: Wo ld Heal h O ganiza ion.
T ial S a us
Pa icipan s’ ec ui men inished in Ap il 2014.
Con lic o In e es s
The au ho s decla e ha he e is no con lic o in e es s
ega ding he publica ion o his pape .
Au ho s’ Con ibu ion
Bi gi a M. Wel e mann and Biljana Ge asimo ska-
Ki ano ska de eloped he s udy idea. Bi gi a M. Wel e mann
and Biljana Ge asimo ska-Ki ano ska con en ionalized he
s udy and de eloped he ques ionnai e d a . The membe s
o he EGPRN wo king g oup on sel -ca e e ised he
ques ionnai e d a . Bi gi a M. Wel e mann and Biljana
Ge asimo ska-Ki ano ska secu ed i s unding. Bi gi a M.
Wel e mann and Anika Thielmann d a ed he i s e sion
o he pape . Anika Thielmann, Bi gi a M. Wel e mann,
Julie e Chambe, and Enzo Pi o a de ailed he discussion.
All o he au ho s (Julie e Chambe, Heid un Lingne ,
K zysz o Buczkowski, Slawomi Czachowski, Selda Tekine ,
Tame Edi ne, And zej Zielinski, H¨
ulya Yikilkan, Tuomas
Koskela, Fe dinando Pe azzuoli, Robe D. Ho man, Ma ija
Pe ek ˇ
S e , Cla a Guede Fe n´
andez, Ays¸eg¨
ul Uluda˘
g, Ka h yn
Ho mann, Vildan Me sim, and Sanda K ei maye Pes ic)
c i ically e iewed he di e en pape e sions and p o ided
eedback on i . Bi gi a M. Wel e mann, Anika Thielmann,
and Biljana Ge asimo ska-Ki ano ska inalized he pape .
All au ho s ead and app o ed he inal pape .

6 E idence-Based Complemen a y and Al e na i e Medicine
Acknowledgmen s
The s udy ecei ed unding om he Eu opean Gene al
P ac ice Resea ch Ne wo k. All au ho s we e suppo ed by
hei a ilia ed ins i u ions. The au ho s wish o hank Melida
Hasanagic o he help in de eloping he s udy idea and
g an applica ion. The au ho s also hank Anja Viehmann
(Ins i u e o Gene al Medicine, Uni e si y o Duisbu g-
Essen, Essen) and P o esso D . Ka l-Heinz J¨
ockel (Ins i u e
o Medical In o ma ics, Biome y and Epidemiology, Uni-
e si y o Duisbu g-Essen, Essen) o hei s a is ical ad ice
and Ch is ine Ke s ing o he c i ical e iew o he pape .
Special hanks go o he pa icipa ing physicians, p ac ices,
and pa ien s o hei ime and con ibu ions.
Re e ences
[1] S. N. G ie , “Uppe espi a o y in ec ions,” P ima y Ca e, ol.
40, no. 3, pp. 757–770, 2013.
[2] A. S. Mon o, E. R. B yan, and S. Ohmi , “Rhino i us in ec ions
in Tecumseh, Michigan: equency o illness and numbe o
se o ypes,” Jou nal o In ec ious Diseases, ol.156,no.1,pp.43–
49, 1987.
[3] M. J. M¨
akel¨
a, T. Puhakka, O. Ruuskanen e al., “Vi uses and
bac e ia in he e iology o he common cold,” Jou nal o Clinical
Mic obiology, ol. 36, no. 2, pp. 539–542, 1998.
[4] F. W. Denny J ., “The clinical impac o human espi a o y i us
in ec ions,” The Ame ican Jou nal o Respi a o y and C i ical
Ca e Medicine, ol. 152, pp. S4–S12, 1995.
[5] A.S.Mon oandB.M.Ullman,“Acu e espi a o yillnessinan
Ame ican communi y. The Tecumseh S udy,” The Jou nal o he
Ame ican Medical Associa ion, ol.227,no.2,pp.164–169,1974.
[6] A. S. Mon o, “S udies o he communi y and amily: acu e
espi a o y illness and in ec ion,” Epidemiologic Re iews, ol.16,
no. 2, pp. 351–373, 1994.
[7] M. S. Blaiss, P. V. Dicpinigai is, R. Eccles, and M. A.
Winge zahn, “Consume a i udes on cough and cold: US
(ACHOO) su ey esul s,” Cu en Medical Resea ch & Opinion,
pp. 1–12, 2015.
[8]T.J.B amley,D.Le ne ,andM.Sa nes,“P oduc i i ylosses
ela ed o he common cold,” Jou nal o Occupa ional and
En i onmen al Medicine, ol.44,pp.822–829,2002.
[9] S.Y.Kim,Y.-J.Chang,H.M.Cho,Y.-W.Hwang,andY.S.Moon,
“Non-s e oidal an i-in lamma o y d ugs o he common cold,”
The Coch ane Da abase o Sys ema ic Re iews, ol.6,A icleID
CD006362, 2013.
[10] A. I. De Su e , M. L. an D iel, A. A. Kuma , O. Lessla , and
A. Sk , “O al an ihis amine-deconges an -analgesic combina-
ions o he common cold,” Coch ane Da abase o Sys ema ic
Re iews, ol.2,A icleIDCD004976,2012.
[11] D. Ta e ne and G. J. La e, “Nasal deconges an s o he
common cold,” Coch ane Da abase o Sys ema ic Re iews,no.1,
A icle ID CD001953, 2007.
[12] L. M. Pa isius, B. S ock-Sch ¨
oe , S. Be ge , K. He mann, and
S. Joos, “Use o home emedies: a c oss-sec ional su ey o
pa ien s in Ge many,” BMC Family P ac ice, ol.15,a icle116,
2014.
[13]M.Sa oh,A.Ma sumo o,A.Ha ae al.,“Asu eyo sel -
medica ion p ac ices and ela ed ac o s in he gene al popu-
la ion: he ohasama s udy,” Yakugaku Zasshi, ol.134,no.12,pp.
1347–1355, 2014.
[14] W. J. McIsaac, N. Le ine, and V. Goel, “Visi s by adul s o amily
physicians o he common cold,” Jou nal o Family P ac ice, ol.
47,no.5,pp.366–369,1998.
[15]J.Padbe gandT.Baue ,“E k
¨
al ungsk ankhei en,” Deu sche
Medizinische Wochensch i , ol.131,pp.2341–2349,2006.
[16] A. Segall, “A communi y su ey o sel -medica ion ac i i ies,”
Medical Ca e, ol.28,no.4,pp.301–310,1990.
[17] WHO, The Role o he Pha macis in Sel -Ca e and Sel -
Medica ion, WHO, 1998.
[18] H.-H. Tsai, H.-W. Lin, A. Simon Picka d, H.-Y. Tsai, and G. B.
Mahady, “E alua ion o documen ed d ug in e ac ions and con-
aindica ions associa ed wi h he bs and die a y supplemen s:
a sys ema ic li e a u e e iew,” In e na ional Jou nal o Clinical
P ac ice, ol. 66, no. 11, pp. 1056–1078, 2012.
[19] B. Wel e mann, B. G. Ki ano ska, M. Hasanagic e al., Which
Measu es Do P ima y Ca e Physicians Conside As Typical
Sel -Medica ion and Home Remedies Used by Thei Pa ien s
o Common Colds? A C oss-Sec ional S udy among Physicians
om Se e al Eu opean P ima y Ca e Si es, EGPRN Wo king
G oup on Sel -Medica ion and T adi ional Remedies in Eu ope,
Valle a, Mal a, 2013.
[20] H. Gama, S. Co eia, and N. Lune , “E ec o ques ionnai e
s uc u e on ecall o d ug u iliza ion in a popula ion o
uni e si y s uden s,” BMC Medical Resea ch Me hodology, ol.
9,no.1,a icle45,2009.
[21] M. S. Hagge and S. O bell, “A me a-analy ic e iew o he
common-sense model o illness ep esen a ions,” Psychology &
Heal h, ol.18,no.2,pp.141–184,2003.
[22] Eu os a : Tabelle: B u oinlandsp oduk (BIP) p o Kop . In
Kau k a s anda ds (KKS), Index (EU-27=100), ausgew¨
ahl e
eu op¨
aische S aa en, 2012. [ able: g oss domes ic p oduc
(GDP)—in Powe Pu chasingS anda d(PPS), Index (EU-27=100),
selec ed Eu opean S a es, 2012, h p://www.bpb.de/wissen/
72UZFD,0,B u oinlandsp oduk (BIP) p o Kop .h ml.
[23]A.Raal,D.Volme ,R.S
˜
oukand, S. H a ke i ˇ
s, and R. Kalle,
“Complemen a y ea men o he common cold and lu wi h
medicinal plan s— esul s om wo samples o pha macy cus-
ome s in Es onia,” PLoS ONE, ol.8,no.3,A icleIDe58642,
2013.