Brief discussion
respiratory infections, anxiety
RESPIRATORY INFECTIONS, CHRONIC ILLNESSES
Study 2 provides the first comprehensive evidence of the general acceptability of clinical placebo use by the UK general population. Our nationally representative online study confirmed beliefs in efficacy and general support for the use of open-label impure placebos to replace unnecessary antibiotic treatments for respiratory infections in primary care. Below follows a detailed discussion of our specific hypotheses.The content analysis of free text answers confirmed the qualitative hypothesis—the theme of deception featured highly in both the participants’ definitions of placebos, as well as in their identifications of disadvantages associated with placebo use. This was also echoed in the suggestion that a further disadvantage to placebo use would be the loss of trust in healthcare providers for potentially misleading patients.Our framing hypothesis was partially confirmed. The framing group produced significant interaction effects, but the effects differed from our predictions. General and personal acceptability of blinded pure placebos were higher in the placebo group compared to the sugar pill group. Even though effect sizes were small, these findings appear to suggest that describing placebos as “sugar pills” could decrease people’s acceptability for clinical placebo use, specifically with regard to blinded pure placebo types.Our treatment type hypothesis was partially confirmed. The treatment condition had significant effects on placebo attitudes in the hypothetical patient scenario, but the effects differed slightly from out predictions. Open-label impure placebos were rated highest in terms of general acceptability and predicted effectiveness, but scored slightly lower in terms of personal acceptability. Indeed, in terms of personal acceptability, participants showed a significant preference for antibiotic treatment. This suggests that even though the UK general public expressed general support for open-label placebo use, their attitudes differed if they imagined themselves to be the patients. These findings link in with patient attitudes in wider healthcare settings. For example, UK national surveys suggest that almost 90% of the population believe emergency care services are used inappropriately [Our demographic hypothesis was again partially confirmed. Most of the demographic and medical history variables investigated had significant effects on placebo attitudes. As predicted, younger participants had more favourable attitudes towards placebo treatments compared to older participants. This might be explained by a greater openness of younger people towards new or alternative treatment options. Additionally, interesting sex differences were found, with female participants being more dismissive of blinded pure placebos and having stronger faith in the efficacy of open-label pure placebos compared to males. This seems to suggest that women are more sensitive to deception, supporting previous findings that women are more averse to lying than men [Finally, our covariate hypothesis on the effects of health anxiety, health literacy and health-related risk-taking was partially confirmed. Health anxiety had significant effects on placebo attitudes. Higher anxiety levels resulted in higher acceptability of antibiotic use and lower acceptability of the no treatment option, which might be explained by higher levels of risk aversion leading to a preference of medicine treatments over placebo use. It is possible that anxious patients have stronger preferences for “real” medication and feel more apprehensive about less established treatment alternatives including placebos. Additionally, our findings suggested that patients with lower levels of health literacy may hold more favourable attitudes towards the use of antibiotics and blinded pure placebos. A potential reason for their antibiotic treatment preference could be lower awareness of the threat imposed by antimicrobial resistance. Their comparatively stronger acceptance of blinded pure placebos might be explained by lower levels of objection towards deception, but further qualitative investigations are needed to explore the reasons in detail.Overall, our findings suggest generally favourable attitudes towards open-label placebo use to replace antibiotic medication that lacks a clear indication. However, our findings of different preferences when making personal treatment choices (as opposed to expressing more general attitudes) need to be addressed. The personal preference for antibiotic treatment could present a challenge when trying to implement clinical placebo use in practice. Given that this personal preference is likely to be fuelled by higher levels of personal risk and loss aversion, strategies of patient safety-netting (e.g. regular reviews post-placebo prescription) might provide reassurance and result in a greater personal willingness to forgo unnecessary prescriptions of active medicines. In any case, the use of placebo treatments may need to take into account individual patient characteristics. Our results suggest that older individuals with chronic illnesses or high levels of health anxiety might be less open to placebo prescriptions and that patients with lower health literacy may have a stronger preference for real medicines and blinded pure placebos, thus making them less accepting of open-label placebos specifically. Additionally, the use of blinded pure placebos appears to be particularly unacceptable to female individuals. To gain a more thorough understanding of attitudinal predictors and influences, follow-up qualitative investigations could be fruitfully employed.