Lack of Knowledge of Antibiotic Risks Contributes to Primary Care Patients’ Expectations of Antibiotics for Common Symptoms
=============================================================================================================================

* Lindsey A. Laytner
* Barbara W. Trautner
* Susan Nash
* Roger Zoorob
* Jennifer O. Okoh
* Eva Amenta
* Kiara Olmeda
* Juanita Salinas
* Michael K. Paasche-Orlow
* Larissa Grigoryan

## Abstract

Patient expectations of receiving antibiotics for common symptoms can trigger unnecessary use. We conducted a survey (n = 564) between January 2020 to June 2021 in public and private primary care clinics in Texas to study the prevalence and predictors of patients’ antibiotic expectations for common symptoms/illnesses. We surveyed Black patients (33%) and Hispanic/Latine patients (47%), and over 93% expected to receive an antibiotic for at least 1 of the 5 pre-defined symptoms/illnesses. Public clinic patients were nearly twice as likely to expect antibiotics for sore throat, diarrhea, and cold/flu than private clinic patients. Lack of knowledge of potential risks of antibiotic use was associated with increased antibiotic expectations for diarrhea (odds ratio [OR] = 1.6; 95% CI, 1.1-2.4) and cold/flu symptoms (OR = 2.9; 95% CI, 2.0-4.4). Lower education and inadequate health literacy were predictors of antibiotic expectations for diarrhea. Future antibiotic stewardship interventions should tailor patient education materials to include information on antibiotic risks and guidance on appropriate antibiotic indications.

Key words:
*   antibiotic use
*   antimicrobial stewardship
*   primary care
*   antibiotic risks
*   patient expectations

## INTRODUCTION

Patients often receive antibiotic prescriptions to treat common viral symptoms/illnesses, such as respiratory tract infection,1-6 cold/flu,7,8 and diarrhea,9,10 despite guidelines recommending against these practices.11-15 Individuals’ knowledge, beliefs, and expectations may contribute to inappropriate antibiotic use.3,7-9,16,17 These prior studies, however, did not examine the independent effects of knowledge of antibiotic risks and sociodemographic factors on patient expectations of antibiotics for common symptoms/illnesses. This study examined the (1) prevalence of patient antibiotic expectations for acute diarrhea, sore throat, cold/flu, sinus infection, and bronchitis symptoms/illnesses, (2) differences in the prevalence of patient antibiotic expectations between primary care patients in a public and private health care system, and (3) predictors of patients’ antibiotic expectations for each symptom/illness.

## METHODS

A survey was administered between January 2020 to June 2021 in 6 public primary care clinics and 2 private emergency departments serving sociodemographically diverse patients in Harris County, Texas.18 We provided the details on the survey development in a prior publication.18 The maximum expected prevalence of non-prescription antibiotic use based on prior US-based studies was 30%. To obtain a precision of 0.05 and adjust for possible nonresponse, we selected 564 respondents.18 Participating clinic staff provided a recruitment flyer to every patient who checked in for a visit. Patients interested in participating approached study coordinators who were present in the waiting areas. The surveys were conducted in person when permitted during the COVID-19 pandemic (n = 197) and by telephone (n = 367) when coordinators were not permitted to be inside the clinic (March 2020-May 2020). Participants were offered a payment of $15. Children aged under 18 years and those unable to answer the survey questions were excluded.18 The Institutional Review Board for Baylor College of Medicine approved this protocol (H-45709).

To assess patient expectations of antibiotics for each symptom/illness, we stated, “When you have (specific symptom/illness)”: “Taking antibiotics will help you get better quickly,” and “You should take antibiotics to avoid getting sicker.” Patients responded on a 5-point Likert scale ranging from 1-strongly agree to 5-strongly disagree, which we dichotomized into 1-expectation (combining strongly agree and agree responses) and 0-no expectation (combining undecided, disagree, or strongly disagree) of antibiotics. Patients responding with N/A were not included in the analyses. See [Supplemental Appendix](https://www.annfammed.org/lookup/suppl/doi:10.1370/afm.3161/-/DC1) for the survey instrument.

Patient sociodemographic factors, antibiotic risk(s) knowledge, and health literacy are detailed in **Table 1**. Individuals answering “Yes” to “Do you know about any risk associated with antibiotic use?” were considered knowledgeable ([Supplemental Appendix](https://www.annfammed.org/lookup/suppl/doi:10.1370/afm.3161/-/DC1)). Patients who acknowledged knowing about antibiotic risks were asked to specify, and their responses included knowledge of resistance, disruption of the microbiome, adverse side effects/interactions, and concerns regarding taking medications in general (**Table 1**). Health literacy was measured using a validated brief health literacy screening tool.19,20

View this table:
[Table 1.](http://www.annfammed.org/content/22/5/421/T1)

Table 1. 
Patient Sociodemographic, Symptom/Illness Characteristics by Health Care System, and Differences Between the Public and Private Health Care Systems (*χ*2 *P* Value <0.05)

We used *χ*2 tests to compare patient characteristics and antibiotic expectations for each symptom/illness between health care systems. If symptoms/illnesses significantly differed between the clinics, we applied a multivariable logistic regression analysis with each symptom/illness as a separate outcome, and education, health care system, antibiotic risk knowledge, and health literacy were predictor variables (**Table 2**). All statistical analyses were conducted using SPSS version 28 (IBM Corp).

View this table:
[Table 2.](http://www.annfammed.org/content/22/5/421/T2)

Table 2. 
Multivariate Results. Sociodemographic Predictors of Patient Expectations of Antibiotics for Diarrhea, Sore Throat, Cold/Flu, and Overall (Any Symptom/Illness)

## RESULTS

Of those surveyed, approximately 84% believed that antibiotics would improve bronchitis, followed by sinus infections (72%), sore throat (66%), cold/flu (64%), and diarrhea (36%). The proportions of patients who believed antibiotics would improve diarrhea, sore throat, and cold/flu symptoms were higher among public than private clinic patients (*P* ≤0.02). Univariate regression results are presented in the [Supplemental Table](https://www.annfammed.org/lookup/suppl/doi:10.1370/afm.3161/-/DC1). In the multivariate regression analysis, the health care system was associated with patient antibiotic expectations after adjusting for sociodemographic factors. Compared with private, public clinic patients were nearly twice as likely to expect antibiotics for diarrhea (odds ratio [OR] = 1.8; 95% CI, 1.2-2.8; *P* = 0.009), sore throat (OR = 2.2; 95% CI, 1.5-3.2; *P* <0.001), cold/flu (OR =1.5; 95% CI, 1.0-2.3; *P* = 0.002), and overall (OR = 1.6; 95% CI, 1.1-2.3; *P* <0.016). Educational level predicted patient antibiotic expectations for diarrhea, with patients with less than a high school education expecting antibiotics 2 times more than college-educated patients (95% CI, 1.2-3.5; *P* = 0.01). Additionally, patients with adequate health literacy were 30% less likely to expect antibiotics to help treat diarrhea (*P* = 0.04) (**Table 2**). Sex, race/ethnicity, health insurance, survey language, and country of birth were not significantly associated with patient antibiotic expectations for these symptoms.

Overall, 37% of patients lacked knowledge of antibiotic risks. The proportion of patients with knowledge of antibiotic resistance was higher in private compared with public clinic patients, and the proportion of patients with knowledge of antibiotic side effects was lower in private vs public clinic patients (**Table 1**). Lack of knowledge about antibiotic risk(s) was significantly associated with increased antibiotic expectations for diarrhea (OR = 1.6; 95% CI, 1.1-2.4; *P* = 0.01) and cold/flu symptoms (OR = 2.9; 95% CI, 2-4.4; *P* <0.001) and was marginally associated with sore throat symptoms (*P* = 0.06) (**Table 2**).

## DISCUSSION

We found high proportions of patients expecting antibiotics to treat bronchitis, followed by sinus infection, sore throat, cold/flu, and diarrhea. Patients from the public health care system had significantly higher antibiotic expectations for the symptoms/illnesses studied. Lack of knowledge of antibiotic risks was associated with higher expectations of receiving antibiotics for sore throat and diarrhea.

Our results align with prior studies indicating that patients have high expectations of antibiotics for minor illnesses and have limited knowledge of risks.17,21 Other studies have shown that patients with high antibiotic expectations and limited knowledge of risks also expressed trust in clinical advice, including willingness to consider alternative/non-antibiotic treatment options if counseled appropriately and involved in shared decision making.17,22 In addition, patient-clinician counseling on patient-level adverse outcomes (eg, *C. difficile* infection and severe drug interactions/complications) may be more impactful than discussing societal harms or antibiotic resistance.16,23

Our study may not be fully generalizable to outpatients in less sociodemographically diverse urban areas of the United States. Additionally, public clinic patients may be more psychosocially and medically complex, affecting their antibiotic expectations.24 Though questions were phrased neutrally, a social desirability response bias may have occurred. Lastly, patient antibiotic expectations may have been impacted by unforeseen contextual changes associated with the COVID-19 pandemic.25,26

## CONCLUSIONS

Differences in patient education, knowledge of harms/risks, health literacy, and the health care system impact inappropriate patient expectations of antibiotics for common symptoms. Future stewardship interventions to reduce inappropriate patient antibiotic expectations should (1) inform patients of the symptoms/illnesses that antibiotics treat and (2) emphasize the individual harms/risks (or harms/risks to others close to an individual) of antibiotics.17,23 Using these findings, we are developing a patient-clinician antibiotic education tool to educate and empower patients on proper antibiotic use and assist clinicians in discussing alternative (non-antibiotic) treatment options with their patients.

## Acknowledgments

We thank the Harris Health System and Memorial Hermann Hospital staff and patients for collaborating and contributing to this study.

## Footnotes

*   Conflicts of interest: B.W.T. reports grants or contracts from VA Health Services Research & Development, Agency for Healthcare Research and Quality (AHRQ) R18, Craig H. Neilson Foundation, Genentech, and Peptilogics, Inc; payment from George Washington ID Board for a Review Course; travel support for meeting attendance from VA Office of Research & Development and the Infectious Diseases Society of America; and an unpaid role on a DSMB for CSP #2004. L.G. reports grants or contracts from AHRQ R18, Craig H. Neilsen Foundation, VA Health Services Research & Development, Texas Academy of Family Physicians, and a research education grant (1R25AA028203-01) from the National Institute on Alcohol Abuse and Alcoholism Award. All other authors report none.

*   [Read or post commentaries in response to this article.](https://www.annfammed.org/content/22/5/421/tab-e-letters)

*   **Funding support:** This work was supported by grant number R01HS026901 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. L.A.L.’s work is supported by a Ruth L. Kirschstein National Research Service Award (NRSA T-32 6T32HC10031). B.W.T.’s work is supported in part by the US Department of Veterans Affairs Health Services Research and Development Service (grant no. CIN 13 to 413) at the Center for Innovations in Quality, Effectiveness, and Safety. The sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

*   **Disclaimer:** The contents presented herein do not represent the views of the US Department of Veterans Affairs or the US government.

*   **Previous presentations**: Society of Healthcare Epidemiology of America (SHEA); April 11-14, 2022; Colorado Springs, Colorado; AcademyHealth Annual Research Meeting (ARM); June 24-27, 2023; Seattle, Washington

*   [Supplemental materials](https://www.annfammed.org/lookup/suppl/doi:10.1370/afm.3161/-/DC1)

*   Received for publication August 24, 2023.
*   Revision received June 6, 2024.
*   Accepted for publication June 7, 2024.


*   © 2024 Annals of Family Medicine, Inc.

## References

1.  1.Havers FP, Hicks LA, Chung JR, et al. Outpatient antibiotic prescribing for acute respiratory infections during influenza seasons. JAMA Netw Open. 2018; 1(2): e180243-e180243. doi:10.1001/jamanetworkopen.2018.0243
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1001/jamanetworkopen.2018.0243&link_type=DOI) 

2.  2.Schmidt ML, Spencer MD, Davidson LE. Patient, provider, and practice characteristics associated with inappropriate antimicrobial prescribing in ambulatory practices. Infect Control Hosp Epidemiol. 2018; 39(3): 307-315. doi:10.1017/ice.2017.263
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1017/ice.2017.263&link_type=DOI) 
    
    [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=29378672&link_type=MED&atom=%2Fannalsfm%2F22%2F5%2F421.atom) 

3.  3.Ong S, Nakase J, Moran GJ, Karras DJ, Kuehnert MJ, Talan DA; EMERGEncy ID NET Study Group. Antibiotic use for emergency department patients with upper respiratory infections: prescribing practices, patient expectations, and patient satisfaction. Ann Emerg Med. 2007; 50(3): 213-220. doi:10.1016/j.annemergmed.2007.03.026
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1016/j.annemergmed.2007.03.026&link_type=DOI) 
    
    [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=17467120&link_type=MED&atom=%2Fannalsfm%2F22%2F5%2F421.atom) 
    
    [Web of Science](http://www.annfammed.org/lookup/external-ref?access_num=000249218900001&link_type=ISI) 

4.  4.Barnett ML, Linder JA. Antibiotic prescribing for adults with acute bronchitis in the United States, 1996-2010. JAMA. 2014; 311(19): 2020-2022. doi:10.1001/jama.2013.286141
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1001/jama.2013.286141&link_type=DOI) 
    
    [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=24846041&link_type=MED&atom=%2Fannalsfm%2F22%2F5%2F421.atom) 
    
    [Web of Science](http://www.annfammed.org/lookup/external-ref?access_num=000336122800026&link_type=ISI) 

5.  5.Li D, Conson M, Kim N, et al. Patient and provider characteristics and outcomes associated with outpatient antibiotic overuse in acute adult bronchitis. Proc (Bayl Univ Med Cent). 2020; 33(2): 183-187. doi:10.1080/08998280.2019.1708667
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1080/08998280.2019.1708667&link_type=DOI) 

6.  6.Morley VJ, Firgens EPC, Vanderbilt RR, et al. Factors associated with antibiotic prescribing for acute bronchitis at a university health center. BMC Infect Dis. 2020; 20(1): 177. doi:10.1186/s12879-020-4825-2
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1186/s12879-020-4825-2&link_type=DOI) 

7.  7.Vanden Eng J, Marcus R, Hadler JL, et al. Consumer attitudes and use of antibiotics. Emerg Infect Dis. 2003; 9(9): 1128-1135. doi:10.3201/eid0909.020591
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.3201/eid0909.020591&link_type=DOI) 
    
    [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=14519251&link_type=MED&atom=%2Fannalsfm%2F22%2F5%2F421.atom) 
    
    [Web of Science](http://www.annfammed.org/lookup/external-ref?access_num=000185100900016&link_type=ISI) 

8.  8.Watkins LKF, Sanchez G. V., Albert, A.P., Roberts, R.M., Hicks, L.A. Knowledge and attitudes regarding antibiotic use among adult consumers, adult hispanic consumers, and health care providers — United States, 2012–2013. MMWR Morb Mortal Wkly Rep. 2015; 64(28): 767-770. doi:10.15585/mmwr.mm6428a5
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.15585/mmwr.mm6428a5&link_type=DOI) 
    
    [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=26203631&link_type=MED&atom=%2Fannalsfm%2F22%2F5%2F421.atom) 

9.  9.Karras DJ, Ong S, Moran GJ, et al; EMERGEncy ID NET Study Group. Antibiotic use for emergency department patients with acute diarrhea: prescribing practices, patient expectations, and patient satisfaction. Ann Emerg Med. 2003; 42(6): 835-842. doi:10.1016/s0196-0644(03)00602-4
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1016/S0196-0644(03)00602-4&link_type=DOI) 
    
    [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=14634611&link_type=MED&atom=%2Fannalsfm%2F22%2F5%2F421.atom) 
    
    [Web of Science](http://www.annfammed.org/lookup/external-ref?access_num=000187009300018&link_type=ISI) 

10. 10.Collins JP, King LM, Collier SA, et al. Antibiotic prescribing for acute gastroenteritis during ambulatory care visits-United States, 2006-2015. Infect Control Hosp Epidemiol. 2022; 43(12): 1880-1889. doi:10.1017/ice.2021.522
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1017/ICE.2021.522&link_type=DOI) 

11. 11.ABIM Foundation. Advancing a national dialogue around avoiding unnecessary medical tests and treatments. Published 2023. [https://www.choosingwisely.org](https://www.choosingwisely.org)
    
    

12. 12.Zoorob R, Sidani MA, Fremont RD, Kihlberg C. Antibiotic use in acute upper respiratory tract infections. Am Fam Physician. 2012; 86(9): 817-822.
    
    [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=23113461&link_type=MED&atom=%2Fannalsfm%2F22%2F5%2F421.atom) 

13. 13.Thomas M, Bomar PA. Upper Respiratory Tract Infection. StatPearls Publishing; 2023.
    
    

14. 14.Sur DKC, Plesa ML. Antibiotic use in acute upper respiratory tract infections. Am Fam Physician. 2022; 106(6): 628-636.
    
    

15. 15.Shane AL, Mody RK, Crump JA, et al. 2017 Infectious Diseases Society of America clinical practice guidelines for the diagnosis and management of infectious diarrhea. Clin Infect Dis. 2017; 65(12): 1963-1973. doi:10.1093/cid/cix959
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1093/cid/cix959&link_type=DOI) 

16. 16.Sun G, Manzanares K, Foley KA, Zhou Y, MacGeorge EL. Antibiotic stewardship with upper respiratory tract infection patients at student health centers: providers’ communication experiences and strategies. Am J Infect Control. 2023; 51(2): 154-158. doi:10.1016/j.ajic.2022.05.013
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1016/j.ajic.2022.05.013&link_type=DOI) 

17. 17.Spicer JO, Roberts RM, Hicks LA. Perceptions of the benefits and risks of antibiotics among adult patients and parents with high antibiotic utilization. Open Forum Infect Dis. 2020; 7(12): ofaa544. doi:10.1093/ofid/ofaa544
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1093/ofid/ofaa544&link_type=DOI) 

18. 18.Grigoryan L, Paasche-Orlow MK, Alquicira O, et al. Antibiotic use without a prescription: a multi-site survey of patient, health system, and encounter characteristics. Clin Infect Dis. 2023; 77(4): 510-517. doi:10.1093/cid/ciad241
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1093/cid/ciad241&link_type=DOI) 

19. 19.Chew LD, Bradley KA, Boyko EJ. Brief questions to identify patients with inadequate health literacy. Fam Med. 2004; 36(8): 588-594.
    
    [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=15343421&link_type=MED&atom=%2Fannalsfm%2F22%2F5%2F421.atom) 
    
    [Web of Science](http://www.annfammed.org/lookup/external-ref?access_num=000223730600013&link_type=ISI) 

20. 20.Chew LD, Griffin JM, Partin MR, et al. Validation of screening questions for limited health literacy in a large VA outpatient population. J Gen Intern Med. 2008; 23(5): 561-566. doi:10.1007/s11606-008-0520-5
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1007/s11606-008-0520-5&link_type=DOI) 
    
    [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=18335281&link_type=MED&atom=%2Fannalsfm%2F22%2F5%2F421.atom) 
    
    [Web of Science](http://www.annfammed.org/lookup/external-ref?access_num=000255195300008&link_type=ISI) 

21. 21.Seipel MBA, Prohaska ES, Ruisinger JF, Melton BL. Patient knowledge and experiences with antibiotic use and delayed antibiotic prescribing in the outpatient setting. J Pharm Pract. 2021; 34(4): 618-624. doi:10.1177/0897190019889427
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1177/0897190019889427&link_type=DOI) 

22. 22.Coxeter PD, Mar CD, Hoffmann TC. Parents’ expectations and experiences of antibiotics for acute respiratory infections in primary care. Ann Fam Med. 2017; 15(2): 149-154. doi:10.1370/afm.2040
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTUvMi8xNDkiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzIyLzUvNDIxLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

23. 23.Miller BJ, Carson KA, Keller S. Educating patients on unnecessary antibiotics: personalizing potential harm aids patient understanding. J Am Board Fam Med. 2020; 33(6): 969-977. doi:10.3122/jabfm.2020.06.200210
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFiZnAiO3M6NToicmVzaWQiO3M6ODoiMzMvNi85NjkiO3M6NDoiYXRvbSI7czoyMzoiL2FubmFsc2ZtLzIyLzUvNDIxLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

24. 24.Loeb, D.F., Bayliss, E.A., Candrian, C. et al. Primary care providers’ experiences caring for complex patients in primary care: a qualitative study. BMC Fam Pract 17, 34 (2016). doi:10.1186/s12875-016-0433-z
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1186/s12875-016-0433-z&link_type=DOI) 

25. 25.Centers for Disease Control and Prevention. COVID-19 & Antimicrobial Resistance. Accessed Sep 20, 2022. [https://www.cdc.gov/antimicrobial-resistance/data-research/threats/covid-19.html?CDC\_AAref\_Val](https://www.cdc.gov/antimicrobial-resistance/data-research/threats/covid-19.html?CDC_AAref_Val)=[https://www.cdc.gov/drugresistance/covid19.html](https://www.cdc.gov/drugresistance/covid19.html)
    
    

26. 26.Ayosanmi OS, Alli BY, Akingbule OAA, et al. Prevalence and correlates of self-medication practices for prevention and treatment of COVID-19: A Systematic Review. Antibiotics (Basel). 2022; 11(6): 808. doi:10.3390/antibiotics11060808
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.3390/antibiotics11060808&link_type=DOI)