Research Article|Articles in Press

Parent care-seeking decisions for pediatric acute respiratory tract infections in the US: a mental models approach

Published:March 03, 2023DOI:



      To understand US parent health care-seeking decisions in the context of multiple in-person and telehealth care options. As the health care landscape evolves, new research is needed to explain how parents now decide when and where to seek acute pediatric health care.


      We applied a mental models approach, focusing on the archetypal example of care-seeking for pediatric acute respiratory tract infections (ARTIs), by first reviewing pediatric ARTI guidelines with 16 health care professionals to inform 40 subsequent semi-structured interviews with parents of young children in 2021. Interviews were qualitatively coded using thematic analysis, with code frequency and co-occurrence informing the final influence model of parent health care-seeking decisions.


      Parent interviewees identified 33 decisional factors which were synthesized into seven dimensions influencing care-seeking decisions: perceived illness severity, perceived child susceptibility, parental self-efficacy, expected accessibility of care, expected affordability of care, expected quality of clinician, and expected quality of site. The first three dimensions (perceived severity, perceived susceptibility, parental self-efficacy) influenced an initial decision about whether to seek care, while all seven factors influenced a subsequent decision about where to seek care (e.g., in-person primary care, primary care-based telehealth, urgent care, direct-to-consumer telehealth). Uncertainty was present within many dimensions (e.g., severity, access, quality) indicating potential targets to support parent decision making processes and optimize care-seeking behaviors.


      A mental models approach identified dimensions influencing parent choice to seek care and choice of care site for children with ARTIs, suggesting targets to advance family-centered practice and policy.


      ARTI (acute respiratory tract infection), DTC (direct-to-consumer), ED (emergency department), CHIP (Children’s Health Insurance Plan), PCP (primary care provider), US (United States)


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Academic Pediatrics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Conners G.P.
        • Kressly S.J.
        • Perrin J.M.
        • et al.
        Nonemergency acute care: when it's not the medical home.
        Pediatrics. 2017; 139
        • Ray K.N.
        • Shi Z.
        • Ganguli I.
        • Rao A.
        • Orav E.J.
        • Mehrotra A.
        Trends in pediatric primary care visits among commercially insured US children, 2008-2016.
        JAMA Pediatr. 2020; 174: 350-357
        • Poon S.J.
        • Schuur J.D.
        • Mehrotra A.
        Trends in visits to acute care venues for treatment of low-acuity conditions in the United States from 2008 to 2015.
        JAMA Intern Med. 2018; 178: 1342-1349
        • O'Brien B.C.
        • Harris I.B.
        • Beckman T.J.
        • Reed D.A.
        • Cook D.A.
        Standards for reporting qualitative research: a synthesis of recommendations.
        Acad Med. 2014; 89 (Sep): 1245-1251
        • Ray K.N.
        • Shi Z.
        • Poon S.J.
        • Uscher-Pines L.
        • Mehrotra A.
        Use of commercial direct-to-consumer telemedicine by children.
        Acad Pediatr. 2019; 19: 665-669
        • Schweiberger K.
        • Patel S.Y.
        • Mehrotra A.
        • Ray K.N.
        Trends in pediatric primary care visits during the Coronavirus disease of 2019 pandemic.
        Acad Pediatr. 2021; 21: 1426-1433
      1. Schmitt B. Pediatric telephone protocols: office version. 14th edition. ed. American Academy of Pediatrics; 2014 .

        • Weiss A.J.
        • Jiang H.J.
        Most Frequent Reasons for Emergency Department Visits. 2021; 2018
        • Ingram J.
        • Cabral C.
        • Hay A.D.
        • Lucas P.J.
        • Horwood J.
        TARGET TEAM. Parents' information needs, self-efficacy and influences on consulting for childhood respiratory tract infections: a qualitative study.
        BMC Fam Pract. 2013; 14 (Jul 28): 106
        • Cabral C.
        • Lucas P.J.
        • Ingram J.
        • Hay A.D.
        • Horwood J.
        "It's safer to." parent consulting and clinician antibiotic prescribing decisions for children with respiratory tract infections: an analysis across four qualitative studies.
        Soc Sci Med. Jul 2015; 136-137: 156-164
        • Hansen M.P.
        • Howlett J.
        • Del Mar C.
        • Hoffmann T.C.
        Parents' beliefs and knowledge about the management of acute otitis media: a qualitative study.
        BMC Fam Pract. Jul 7 2015; 16: 82
        • Rouse W.
        • Morris N.
        On looking into the black box: prospects and limits in the search for mental models.
        Psych Bull. 1986; 100: 349-363
        • Morgan M.
        • Fischhoff B.
        • Bostrom A.
        • Atman C.J.
        Risk Communication: A Mental Models Approach.
        Cambridge University Press, 2001
        • Krishnamurti T.
        • Eggers S.L.
        • Fischhoff B.
        The impact of over-the-counter availability of "Plan B" on teens' contraceptive decision making.
        Soc Sci Med. 2008; 67 (Aug): 618-627
        • Downs J.S.
        • de Bruin W.B.
        • Fischhoff B.
        Parents' vaccination comprehension and decisions.
        Vaccine. 2008; 26: 1595-1607
        • Krishnamurti T.
        • Davis A.L.
        • Wong-Parodi G.
        • Fischhoff B.
        • Sadovsky Y.
        • Simhan H.N.
        Development and testing of the MyHealthyPregnancy app: a behavioral decision research-based tool for assessing and communicating pregnancy risk.
        JMIR Mhealth Uhealth. 2017; 5 (Apr 10)e42
        • Ralston S.L.
        • Lieberthal A.S.
        • Meissner H.C.
        • et al.
        Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis.
        Pediatrics. 2014; 134 (Nov): e1474-e1502
        • Shulman S.T.
        • Bisno A.L.
        • Clegg H.W.
        • et al.
        Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America.
        Clin Infect Dis. 2012; 55 (Nov 15): 1279-1282
        • Wald E.R.
        • Applegate K.E.
        • Bordley C.
        • et al.
        Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years.
        Pediatrics. Jul 2013; 132: e262-e280
        • McSwain S.D.
        • Bernard J.
        • Burke Jr., B.L.
        • et al.
        American Telemedicine Association operating procedures for pediatric telehealth.
        Telemed J E Health. 2017; 23 (Sep): 699-706
        • Gerber J.S.
        • Ross R.K.
        • Bryan M.
        • et al.
        Association of Broad- vs Narrow-Spectrum Antibiotics With Treatment Failure, Adverse Events, and Quality of Life in Children With Acute Respiratory Tract Infections.
        JAMA. 2017; 318 (Dec 19): 2325-2336
        • Lovie-Toon Y.G.
        • Chang A.B.
        • Newcombe P.A.
        • et al.
        Longitudinal study of quality of life among children with acute respiratory infection and cough.
        Qual Life Res. 2018; 27 (Apr): 891-903
        • Shaikh N.
        • Kearney D.H.
        • Colborn D.K.
        • et al.
        How do parents of preverbal children with acute otitis media determine how much ear pain their child is having.
        J Pain. 2010; 11 (Dec): 1291-1294
        • Szymczak J.E.
        • Klieger S.B.
        • Miller M.
        • Fiks A.G.
        • Gerber J.S.
        What parents think about the risks and benefits of antibiotics for their child's acute respiratory tract infection.
        J Pediatric Infect Dis Soc. 2018; 7 (Dec 3): 303-309
        • Mangione-Smith R.
        • McGlynn E.A.
        • Elliott M.N.
        • Krogstad P.
        • Brook R.H.
        The relationship between perceived parental expectations and pediatrician antimicrobial prescribing behavior.
        Pediatrics. 1999; 103 (Apr): 711-718
        • Lucas P.J.
        • Cabral C.
        • Hay A.D.
        • Horwood J.
        A systematic review of parent and clinician views and perceptions that influence prescribing decisions in relation to acute childhood infections in primary care.
        Scand J Prim Health Care. 2015; 33 (Mar): 11-20
        • Berry A.
        • Brousseau D.
        • Brotanek J.M.
        • Tomany-Korman S.
        • Flores G.
        Why do parents bring children to the emergency department for nonurgent conditions? A qualitative study.
        Ambul Pediatr. 2008; 8 (Nov-Dec): 360-367
        • May M.
        • Brousseau D.C.
        • Nelson D.A.
        • et al.
        Why parents seek care for acute illness in the clinic or the ED: the role of health literacy.
        Acad Pediatr. 2018; 18 (Apr): 289-296
        • Uscher-Pines L.
        • Pines J.
        • Kellermann A.
        • Gillen E.
        • Mehrotra A.
        Emergency department visits for nonurgent conditions: systematic literature review.
        Am J Manag Care. 2013; 19: 47-59
        • Coster J.E.
        • Turner J.K.
        • Bradbury D.
        • Cantrell A.
        Why do people choose emergency and urgent care services? A rapid review utilizing a systematic literature search and narrative synthesis.
        Acad Emerg Med. 2017; 24 (Sep): 1137-1149
        • Chudner I.
        • Goldfracht M.
        • Goldblatt H.
        • Drach-Zahavy A.
        • Karkabi K.
        Video or in-clinic consultation? Selection of attributes as preparation for a discrete choice experiment among key stakeholders.
        Patient. 2018; (Jun 9) (Jun 9)
        • Martinez K.A.
        • Rood M.
        • Jhangiani N.
        • et al.
        Patterns of use and correlates of patient satisfaction with a large nationwide direct to consumer telemedicine service.
        J Gen Intern Med. 2018; 33 (Oct): 1768-1773
        • Ando H.
        • Cousins R.
        • Young C.
        Achieving Saturation in Thematic Analysis: Development and Refinement of a Codebook.
        Comprehensive Psychology. 2014; 3 (2014/01/01)
        • Ryan G.
        • Bernard H.
        Data management and analysis methods.
        in: Denzin N. Lincoln Y. Handbook of Qualitative Research. Sage, 2000: 769-802
        • Rosenstock I.M.
        • Strecher V.J.
        • Becker M.H.
        Social learning theory and the Health Belief Model.
        Health Educ Q. 1988; 15 (Summer): 175-183
        • Levesque J.F.
        • Harris M.F.
        • Russell G.
        Patient-centred access to health care: conceptualising access at the interface of health systems and populations.
        Int J Equity Health. 2013; 12 (Mar 11): 18
        • Andersen R.
        • Newman J.F.
        Societal and individual determinants of medical care utilization in the United States.
        The Milbank Memorial Fund Quarterly Health and Society. 1973; 51: 95-124
        • Han P.K.J.
        • Babrow A.
        • Hillen M.A.
        • Gulbrandsen P.
        • Smets E.M.
        • Ofstad E.H.
        Uncertainty in health care: towards a more systematic program of research.
        Patient Educ Couns. 2019; 102: 1756-1766