PEDIATRICS Vol. 108 No. 3 September 2001, pp. 591-596

Impact of a Waiting Room Videotape Message on Parent Attitudes Toward Pediatric Antibiotic Use

J. Gary Wheeler, MD, Melinda Fair, BSN, MSW, Pippa M. Simpson, PhD, Leigh Ann Rowlands, MA, Mary E. Aitken, MPH, MD, and Richard F. Jacobs, MD

From the Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas.

	ABSTRACT

Top Abstract Methods Results Discussion References

Objective.  To reduce the injudicious use of antibiotics, we developed an educational strategy that focused on parents of pediatric patients and their physicians.

Methods.  This intervention was conducted in 5 pediatric practices in Arkansas during a 9-month period. Baseline data on parent attitudes about antibiotics and physician practice habits were measured by questionnaire. During the following 36 weeks, an educational videotape about the judicious use of antibiotics was played in waiting rooms. The videotape on antibiotics used a standard script based on the recommendations of the American Academy of Pediatrics. The physicians and staff at each site were actors in the videotape. During week 2 and week 36 of videotape use, parent attitudes were measured again. After the baseline week, the physicians and staff in each site were provided a standard in-service review of the American Academy of Pediatrics recommendations for judicious use of antibiotics. A study nurse recruited patients, administered questionnaires, and reviewed charts onsite.

Results.  Parents who were exposed to the videotape were significantly less inclined to seek antibiotics for viral infections. Passively provided pamphlets were not read. No significant change in antibiotic prescribing by physicians was seen.

Conclusion.  Parent-focused passive education tools are effective at changing parent attitudes toward the use of antibiotics. Although physicians have blamed parent attitudes and demands for the overuse of antibiotics, changes in parent attitudes in this study were not associated with changes in prescribing rates. Changes in parent attitudes may be necessary but do not seem sufficient for changes in antimicrobial prescribing patterns.  Key words:  judicious use of antibiotics, patient education, videotape.

The overuse of antibiotics has been associated with the development of multiresistant bacteria now implicated in serious diseases of children and adults.^1-4 Epidemiologic data confirm the overuse of antibiotics in outpatient illness when antibiotics are not required.^5-8 There now is a consensus that this inappropriate overuse of antibiotics must be curtailed to reduce the prevalence of bacterial resistance.^9-11 The American Academy of Pediatrics (AAP) has compiled recommendations for appropriate antibiotic use.⁴

Although physicians have expressed a willingness to change their use of antibiotics, they also have acknowledged a number of considerations that may lead to the overprescription of antibiotics. The demand for antibiotics has been hypothesized to have occurred for several reasons, including physicians' and patients' shared dependence on antibiotics for mild illnesses, coercion by parents, time constraints, fear of litigation after a missed or delayed diagnosis of bacterial infection (defensive medicine), treatment-oriented physician competitors, concern over excessive return visits for persistent "untreated" viral illness, and parent dissatisfaction.^312-16

It has been suggested that a major determinant of pediatrician antimicrobial prescribing behavior is the parental expectation that a prescription will be provided.^12,17,18 Although physicians have blamed parent/patient demand for the overprescribing of antibiotics, it is unclear whether changing parental attitudes will lead to more judicious use of antibiotics. It is possible that if parents are educated about appropriate indications for antibiotics, then they may not only exert less pressure on physicians to prescribe antibiotics but also influence physician behavior by questioning the role that antibiotics play in the treatment of medical conditions.³

With an identified goal of changing parental attitudes and behaviors regarding antibiotic use in children, a videotape was designed to deliver a message on judicious use of antibiotics in addition to standardized written materials. Videotape was chosen as the method of delivery as it has been shown to be an effective method to provide parent education¹⁹ and offers a time-saving, efficient means of education. The videotaped message was delivered in part by the local physician, reflecting the hypothesis that parents might be more receptive to advice from their own physician, and all physicians and staff in each practice received a provider-directed intervention on the importance of reduced antibiotic use.

	METHODS

Top Abstract Methods Results Discussion References

Videotapes

We designed an 8-minute videotape featuring local physicians, nurses, and families. We used a standardized script based on the AAP recommendations on judicious antibiotic use.⁴ The premise of this intervention was that patients would be more receptive to an educational message if it came from their own physician. However, a portion of the videotape message was delivered by one of the authors (R.F.J.), who was identified in the videotape as an expert in infectious diseases to validate the authority of the patient's physician. Each practice assisted in the creation of its own videotape, which was taped before the onset of the peak respiratory infection season of the year.

For an unrelated control medium, the videotape "R.F. Ant," a 20-minute educational cartoon-based videotape about the dangers of stimulant use, was shown (with the permission of Dr Kim Light). During the intervention period, the antibiotic videotape was spliced into the "R.F. Ant" videotape so that the antibiotic videotape played before, at 2 points during, and after the antidrug cartoon. The videotapes were run in a continuous mode on monitors provided by the study in the waiting areas of the physician offices. The cartoon portion of the videotape was used to provide child entertainment interspersed with the adult message for the waiting room environment.

Participants

Participants were identified in 5 pediatric practices from small to mid-size communities in central Arkansas. The practices were selected on the basis of location. All invited practices chose to participate. Parent-child dyads were selected serially to participate in the study on presentation to the offices; only 2 families declined to participate. Charts were reviewed on all patients whose parents consented to the study. Parent questionnaires were administered regardless of the child's diagnosis. Data collected from each patient's chart included age, gender, race, diagnosis, physician, and antibiotic prescribed. Patients with problems that were considered high risk (eg, sickle cell disease, immunodeficiency disorders) were excluded from evaluation. Children who were older than 19 years were excluded from evaluation. The Human Research Advisory Committee of the University of Arkansas for Medical Sciences reviewed and approved this study. Consent was obtained before participant interview and chart review.

Design

The study was a prospective cohort design to measure immediate and cumulative impact of the intervention. The intervention was begun during the respiratory virus season of the first year (December 1999-March 2000) and continued into the respiratory virus season of the second year (October-November 2000) to increase the number of monitored visits with viral infections. The periods of study were staggered to accommodate the 5 practices, but all basically conformed to the timeline in Fig 1. Although these represented different periods of the viral infection season and it was expected that different pathogens might be circulating, it was believed that this would have a minimal impact on parent or physician attitudes toward antibiotics.

View larger version (23K): [in this window] [in a new window]   Fig. 1.   Scheme of parent and physician interventions. The staff and MD seminar occurred at the end of week 1.

During the evaluation, the videotapes were shown in the waiting rooms of 5 pediatric physicians' offices over approximately a 36-week period. Parent attitudes and physician prescribing practices were monitored before showing of the videotape; during week 2, when the videotape was shown; and approximately 36 weeks later. All physicians and staff in each practice received a 1- to 2-hour inservice training session on judicious antibiotic use at the end of week 1 before the showing of the antibiotic videotape.

Baseline data on antibiotic use were collected by questionnaire from the patients of a single physician in each of 5 separate practices. During week 1, when baseline data were collected, the control videotape message (on drug abuse) was used and no written materials on antibiotics were present in the waiting rooms. During weeks 2 through 36, the antibiotic videotape was alternated with the control tape. In addition, the pamphlet "Your Child and Antibiotics"²⁰ was available in the waiting room at the time that patients arrived for registration. It was not specifically given to the parent. The questionnaire was completed after the patient finished the physician visit. Data on antibiotic prescribing patterns and parental attitudes were collected during week 2, when the antibiotic videotape was present in the waiting rooms, and again after approximately 36 weeks during the next respiratory viral season. The nurse monitor was onsite and distributed and collected the questionnaires

Data collected from the self-administered parent questionnaire included parent contact with videotape/handout (no specific time minimum was required for a positive answer), parent attitude regarding antibiotic use for viral infection, and what source most influenced the parents' attitude regarding antibiotic usage. Parents who were identified as having a positive attitude regarding antibiotic use for viral infections were those who responded with "sometimes," "rarely," or "never" (as opposed to a "mostly" or "always" response) when asked whether antibiotics should be prescribed for a cold with fever. The information gathered from the chart and questionnaire was paired and entered into a database without personal identifiers. To measure the impact of the videotape on parent attitudes, we compared the answers of parents who did not see the videotape by self-report with those who did.

Chart Evaluation

The nurse monitor reviewed charts for a single visit at the time of the patient visit. During the review process, the diagnosis written by the physician in the chart was recorded. Difficulty in reading the physician's note was resolved by consulting with office staff to verify the diagnosis. All diagnoses were categorized as infectious or noninfectious. Infectious categories were specified as viral (upper respiratory infections, viral syndromes, viral pharyngitis, bronchiolitis, or otitis media with effusion/serous otitis), bacterial (acute otitis media [unilateral or bilateral], bacterial conjunctivitis, sinusitis, urinary tract infection/pyelonephritis, wound infection, cellulitis/pyoderma, lymphadenitis, streptococcal pharyngitis, pneumonia, osteomyelitis, animal/human bite), and other. When a patient carried both a viral and a bacterial diagnosis, he or she was considered in the database to have a bacterial diagnosis. All antibiotics prescribed were noted.

Physician Follow-up

Approximately 6 months after completion of the study, physicians whose patients were the focus of the study as well as 4 other physicians who practiced in the same offices but whose patients were not studied were surveyed by telephone to determine their response to the videotape program. They were asked about their response to the study and how their practice changed as a result of the program.

Statistics

Data were evaluated for each individual practice as well as for all practices combined. Data in this study represented cohorts of patients that were compared before and after the intervention. A priori power analysis was based on an expected incidence of 25% to 35% inappropriate use of antibiotics. ² analysis was used to determine the significance of the compiled data. Fisher's exact test was used to determine the significance of data when the sample size was small.

	RESULTS

Top Abstract Methods Results Discussion References

Demographics

Fifty-two percent of the participants in this study were male; 80% were white, and 18% were black. The median age was 3 years, 0 months (range: 1 month-20 years). These demographic variations from clinic to clinic were not related significantly to either parent attitudes or antibiotic use. There were 16 total physicians at the 5 sites. One site was a solo practice. Patients of 5 physicians (1 at each site) were studied. All of the physicians were male. One was black.

Videotape and Pamphlet Use

Of a total of 771 parents surveyed prospectively, 2%, 57%, and 53% at weeks 1, 2, and 36 reported watching some or all of the videotape (Table 1). Few parents (7 during week 1, 20 during week 2, and 1 during week 36) reported reading the pamphlet on judicious antibiotic use at the time of service (Table 1). Periodic contact with the clinics revealed that parents and clinic staff became increasingly noncompliant when the videotape was shown continuously. Over time, parents or staff would turn off the videotape or replace it.

Parental Attitudes

Because of the small number of patients who were exposed to the pamphlet during the intervention period (n = 21) and because only 5 were exposed to the pamphlet alone (Table 1), videotape and pamphlet exposure were combined for the parental attitude evaluation. Significant changes were noted in parental responses to the global hypothetical question, "Do you think antibiotics should be used in treating a child with fever and a cold?" when considering the parents who viewed all or part of the antibiotic videotape (Table 2). In a comparison of the number of positive responses, fewer parents thought antibiotics were indicated for viral infections between weeks 1 and 2 (², P < .0027) and between weeks 1 and 36 (², P < .0001) when parents were exposed to the antibiotic videotape. Parent attitudes toward antibiotic use in treating viral infections did not change significantly in the surveyed group of parents who did not view the videotape. When direct comparisons were made to the parent group that did not see the videotape, parents in the videotape group were significantly less likely to desire antibiotics at either week 2 or week 36 (P < .0001). This observation remained significant regardless of how the Likert analysis was grouped.

Specific parental expectations (response to the question, "Did you want/expect your pediatrician to prescribe antibiotics for your child with a cold with fever?") changed over the course of the study (Table 3). During week 1, 39% stated that they expected the physician to prescribe antibiotics for a cold with fever (101 of 257); by week 2, 31% expected antibiotics to be prescribed (83 of 263); and by week 36, 28% of parents reported that would expect the physician to prescribe antibiotics for a cold with fever (69 of 245). Of the parents who viewed the videotape, 42 of 152 (27.6%) stated that they expected antibiotics. Forty-one of 111 (36.9%) parents who did not view the videotape stated that they expected antibiotics for a cold with fever. During week 36, 18 of 130 parents who viewed the videotape (13.8%) stated that they would expect the physician to prescribe antibiotics, whereas 51 of the 115 parents who did not see the videotape (44.3%) stated that they would expect the physician to prescribe antibiotics for a cold with fever. There was a significant difference (P < .0001) in the responses of parents who viewed the videotape and those who did not: more parents who viewed the videotape stated that they did not want/expect the physician to prescribe antibiotics for a cold with fever.

Antibiotic Use

The clinics surveyed averaged a 6.8% baseline rate of antibiotic prescriptions for viral infections (5 antibiotic prescriptions written for 73 viral diagnoses). There was some variation from clinic to clinic; 2 clinics had generally higher use than the other 3 clinics. During the first week the videotape was shown (the week after the physicians and staff had their in-service training session), the antibiotic prescription rate for viral infections was 6.6% (5 antibiotic prescriptions written for 76 viral diagnoses). At week 36, the antibiotic prescription rate for viral infections was 4.2% (3 antibiotic prescriptions written for 71 viral infections). There seemed to be a slight downward trend in the prescription rate of the 220 charts reviewed, which was not statistically significant

Among physicians, there were consistent differences in prescribing habits; in the 2 "high use" practices, injudicious prescribing declined during the intervention period more than in the low-use practices after the intervention (data not shown) but did not reach significance. There was no apparent change in the pattern of diagnosing illnesses as bacterial versus viral during the study period. The percentage of all infections with viral diagnoses was 52.6% during week 1, 55.3% during week 2, and 55% during week 36. Given constant rates of antibiotic use for viral and bacterial infections observed (antibiotic use per encounter), these data exclude changing diagnostic categories as an explanation for failure to see differences in antibiotic prescribing.

Information Preferences

The vast majority of parents identified the physician as the primary influence on their opinions regarding antibiotic use (212 [88%] of 242 during week 1, 195 [78%] of 249 during week 2, and 218 [91%] of 240 during week 36.) Parents who were surveyed during weeks 1 and 2 were asked about previous exposure to the antibiotic message. The responses indicated that a percentage of parents had heard something about the judicious use of antibiotics from media sources (28% from television, 20% from newspapers or magazines, and 1% from radio). There was no significant difference in previous exposure to the antibiotic message from media sources between the parents who viewed the videotape and those who did not.

Physician Follow-up

Five of 9 physicians reported that they had an increase in their comfort level about not prescribing antibiotics during the study period; the other 4 reported no change. Five of 9 believed that their prescribing habits changed during the study period. Eight of 9 said that they discussed antibiotic resistance with patients more during the study than before. Most said that they discussed the videotape or pamphlet messages with their patients on a regular or occasional basis (7 of 9). Four of 5 practices were still using the videotape on an occasional to regular basis, including seasonal use. All agreed that educational videotapes could be an effective tool as a regular part of health maintenance visits. All physicians surveyed made positive comments about the interventions.

	DISCUSSION

Top Abstract Methods Results Discussion References

The problems of antibiotic resistance and injudicious use of antimicrobials are widely accepted without any widely accepted solutions. A number of investigators have attempted to develop solutions that result in more judicious use of antibiotics, specifically promoting the restraint in the use of antibiotics for probable viral infections. These potential solutions have included focused educational programs for patients or doctors or both groups, mass marketing of educational messages, and manipulation of physician behaviors through report cards. We chose a hybrid approach, using a message directed at patients along with limited physician education. We attempted to secure physician buy-in by having them deliver the message in videotapes produced specifically for each practice.

The intervention had 5 components: 1) a parent-directed videotape, 2) a parent-directed pamphlet, 3) staff inservice training, 4) staff participation in the videotape production, and 5) study personnel on-site during the monitoring. The questionnaire allowed us to determine whether the parent had seen the videotape or the pamphlet. The pamphlet was read by only a few patients and was believed to have little impact. Because the other interventions affected all patients, the questionnaire allowed us to measure the specific effect of the videotape.

Our study yielded 3 main findings: 1) videotapes can be effective in changing parent attitudes, 2) passively provided pamphlets were not effective because they were not read, and 3) changing parent attitudes did not translate into reduced antibiotic prescriptions for viral diseases.

The videotape intervention resulted in a significant change in parent attitudes among parents who watched the videotape. Written information also was made available, but very few parents reported reading the provided information. Busy waiting rooms, caring for the sick child, short waiting times, noise, and other waiting room distractions were cited as reasons for not watching the videotape or reading the pamphlet. Possible ways to improve the saturation of the intervention in future studies could include shorter videotape to improve exposure, showing the videotape in the patient rooms while patients are waiting for the physician, postdiagnosis targeting of the videotape to parents whose child has a viral infection, directed mailings of the pamphlet, or use of a specific verbal presentation by a member of the health team. Finally, cumulative exposure to this intervention over 9 months was not associated with significant changes in physician prescribing practice.

The physician perception that parents expect or demand antibiotics when they bring their child in for viral infections was confirmed in approximately 40% of the patients at week 1 in this study (Table 3). However, parents overwhelmingly endorsed their physician as their primary influence in decisions about antibiotic use. Improving communication between parent and physician regarding parental expectations (as well as appropriate indications for antibiotic use) could be a focus of future efforts to educate with the goal of promoting judicious use of antibiotics.¹⁸

Our study had several limitations. We were unable to detect a change in the rate of antibiotic prescribing for viral infections by physicians. The original power analysis for the study assumed a rate of 25% to 35% injudicious use of antibiotics. It was surprising that the physicians who participated in the study prescribed antibiotics for viral infection at a much lower rate before the onset of the videotape intervention. Prestudy exposure to the message by participating in the making of the videotapes may have contributed to this low level. Alternatively, the effectiveness of the educational message in both the physician lecture and the videotape may have been insufficient to change antibiotic prescribing and was not specifically tested.

The Hawthorne effect (the effect on experimental results created by participants' knowing that they are participating in a study) likely had an impact on this study. Physicians participated in the production of the videotape. This was an intentional effort to persuade physicians to reduce antibiotic use and cooperate with the study. They were reminded frequently of the study by the continuous videotape in their waiting rooms and by the study monitor who was present during the chart review.

Gerber and Marcy²¹ pointed out that chart review tends to reduce the reported degree of injudicious antibiotic use. Because we recognized that inappropriate use of antibiotics was lower than expected, we added to our study a retrospective chart review, which is not reported above. In it we surveyed the charts of patients of all 16 physicians in the 5 sites from periods when no study monitors were on-site before and 9 months after the intervention began. The rates of inappropriate antibiotic prescribing were significantly greater in the retrospective component of the study pre- and postintervention (25.0% and 23.8% retrospective compared with 6.9% and 4.2% prospective; P < .05). Although this observation is problematic because it compares single physicians versus groups of physicians, it suggests that on-site monitoring may have played a role in the results.

An external control group of practices was not followed during the study period. The large amount of publicity about the dangers of antibiotic overuse in the media also may have influenced parent attitudes. Further studies should include this control to validate the impact of the intervention, because this study indicated that at least 27.6% of parents had heard something about the judicious use of antibiotics from media and other sources before the onset of the study. However, because the evaluations were done 1 week apart, it is unlikely that the nature of this specific intervention was affected by the larger media attention to this subject. The 9-month follow-up clearly could have been affected by media influences, but in this case no differences in prescribing habits were seen. It cannot be excluded that parent attitudes may have shifted during the 9-month follow-up as a result of the increased media exposure; however, the changes noted from the first to second week likely were not due to this effect. The serendipitous finding that approximately half of the parents did not see the videotape resulted in an internal comparison group for this study. However, parents with particular attitudes may have self-selected to observe or not to observe the videotape. The subsets of patients who had viral infections and received antibiotics were too small to break down by exposure to the videotape. A larger group of subjects might have revealed whether videotape exposure affected antibiotic prescribing.

We did not explore the volume of patients and its relationship to the variation in practice that we saw in our 5 study sites. Arnold et al²² suggested that increased workload does correlate with increased inappropriate prescribing habits, presumably because an antibiotic prescription is quicker than a discussion about not needing antibiotics.

The importance of using the local physician to deliver the antibiotic message was not tested for validity. Comparing the effectiveness of the locally produced message with a more generic nationally produced message would help determine the value of this method of delivery. However, patients clearly derived most of their opinions about antibiotics from their own physicians. There were many positive comments from parents about the use of the local physician and staff in the videotape, but there was no way to assess how this affected the impact of the message.

Physician responses to the videotape intervention generally were positive. The small number of participating physicians limits the strength of these observations. Most important, the educational videotapes did result in more conversations with parents, and physicians did believe that these educational videotapes were an effective tool in regular health maintenance visits. Patients who receive physician advice in conjunction with educational materials may be more likely to alter their behavior.²³

Our findings are consistent with other studies from other centers that studied the injudicious use of antibiotics. Like the Toronto group,²¹ we found a low rate of pediatricians prescribing antibiotics injudiciously in a chart review method. We did not study family doctors, who have had higher rates within the same methodological reviews,⁵ but this would be a sensible target for future interventions. Like Gonzales et al,²⁴ who studied adults in Denver, we found that pamphlet use when provided in a passive setting was not effective. We did not provide guaranteed delivery of the pamphlet, which, when combined with an intensive intervention as used in the Denver study, did result in reduced injudicious use of antibiotics.

This study demonstrated that a videotape intervention was well received and effective in improving parent attitudes toward antibiotic prescribing but failed to show changes in prescribing patterns by physicians. These observations suggest that changes in patient attitudes are necessary but not sufficient to change the current pattern of antibiotic use. More effective ways of persuading physicians to lower antibiotic prescribing rates than simple 1-time lecture presentations are needed. The differences in "observed" versus "unobserved" antibiotic use further suggest that some type of monitoring might be the most effective way to reduce injudicious use. Studies done in the future will need to be larger, should incorporate family practitioners as well as pediatricians, and should have an arm in which monitoring alone is a variable in the study design.

	ACKNOWLEDGMENTS

This study was supported by the Horace C. Cabe Foundation.

This study was presented at the Society for Pediatric Research, Boston, Massachusetts, May 14, 2000.

We thank Horace Green, MD; Wesley Kluck, MD; Alan Lucas, MD; Michael Agyepong, MD; James Hughes, MD; and their colleagues and staff for their generous cooperation in this study; the Media Services group of the University of Arkansas for Medical Sciences for their assistance in the production of videotape materials; and Ben Schwartz, MD, for his helpful review and suggestions regarding our study.

	FOOTNOTES

Received for publication Jul 24, 2000; accepted Jan 16, 2001.

Reprint requests to (J.G.W.) Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, 800 Marshall St, Little Rock, AR 72202. E-mail: wheelergary{at}exchange.uams.edu

	ABBREVIATIONS

AAP, American Academy of Pediatrics.

	REFERENCES

Top Abstract Methods Results Discussion References

1. Neu HC The crisis in antibiotic resistance. Science 1992; 257:1064-1073
2. Cohen ML Epidemiology of drug resistance: implications for a post-antimicrobial era. Science 1992; 257:1050-1055
3. Bauchner H, Pelton SI, Klein JO Parents, physicians, and antibiotic use. Pediatrics 1999; 103:395-398 [Abstract/Free Full Text]
4. American Academy of Pediatrics. Principles of Judicious Use of Antimicrobial Agents, A Compendium for the Health Care Professional. Elk Grove Village, IL: American Academy of Pediatrics; 1998
5. Watson RL, Dowell SF, Jayaraman M, Keyserling H, Kolczak M, Schwartz B Antimicrobial use for pediatric upper respiratory infections: reported practice, actual practice, and parent beliefs. Pediatrics 1999; 104:1251-1257 [Abstract/Free Full Text]
6. Guillemot D, Carbon C, Vauzelle-Kervroedan F, Inappropriateness and variability of antibiotic prescription among French office-based physicians. J Clin Epidemiol 1998; 51:61-68 [CrossRef][Medline]
7. Wang EEL, Einarson TR, Kellner JD, Conly JM Antibiotic prescribing for Canadian preschool children: evidence of overprescribing for viral respiratory infections. Clin Infect Dis 1999; 29:155-160 [Medline]
8. Nyquist CA, Gonzales R, Steiner JF, Sande MA Antibiotic prescribing for children with colds, upper respiratory tract infections, and bronchitis. JAMA 1998; 279:875-877 [Abstract/Free Full Text]
9. Murray B Can antibiotic resistance be controlled? N Engl J Med 1994; 330:1229-1230 [Free Full Text]
10. Tomasz A Multiple antibiotic resistant pathogenic bacteriaa report on the Rockefeller University Workshop. N Engl J Med 1994; 330:1247-1251 [Free Full Text]
11. Lederberg J Infection emergent. JAMA 1996; 275:243-245 [CrossRef][Medline]
12. Bauchner H, Philipp B Reducing inappropriate oral antibiotic use. A prescription for change. Pediatrics 1998; 101:163-184 [Abstract/Free Full Text]
13. Butler CC, Rollnick S, Pill R, Maggs-Rapport F, Stott N Understanding the culture of prescribing: qualitative study of general practitioners' and patients' perceptions of antibiotics for sore throats. Br J Med 1998; 317:637-642
14. Pichichero ME Understanding antibiotic overuse for respiratory tract infections in children. Pediatrics 1999; 104:1384-1387 [Free Full Text]
15. McCaig LF, Hughes JM Trends in antimicrobial drug prescribing among office based physicians in the united states. JAMA 1995; 273:214-219 [Abstract]
16. Schwartz B Why do physicians prescribe antibiotics for children with upper respiratory tract infections? JAMA 1998; 279:881-882 [Free Full Text]
17. Cockburn J, Pit S Prescribing behavior in clinical practice. Patients' expectations and doctors' perceptions of patients' expectationsa questionnaire study. Br Med J 1997; 315:1211-1214 [Abstract/Free Full Text]
18. Mangione-Smith R, McGlynn EA, Elliot MN, Krogstad P, Brook RH The relationship between perceived parental expectations and pediatrician antimicrobial prescribing behavior. Pediatrics 1999; 103:711-718 [Abstract/Free Full Text]
19. Dunn RA, Shenouda PE, Martin DR, Schultz AJ. Videotape increases parent knowledge about poliovirus vaccines and choices of polio vaccination schedules. Pediatrics. 1998;102(2). URL:http://www.pediatrics.org/cgi/content/full/102/2/e26
20. American Academy of Pediatrics, Centers for Disease Control and Prevention, American Society for Microbiology. Your Child and Antibiotics. Elk Grove Village, IL: American Academy of Pediatrics; 1997
21. Gerber MA, Marcy SM Editorial response: judicious use of antimicrobial agents for respiratory tract infections in children -why are the pediatricians in Toronto doing so well? Clin Infect Dis. 1999; 29:318-320 [Medline]
22. Arnold SR, Allen UD, Al-Zahrani M, Tan DHS, Wang EEL Antibiotic prescribing by pediatricians for respiratory tract infection in children. Clin Infect Dis 1999; 29:312-317 [Medline]
23. Kreuter MW, Chheda SG, Bull FC How does physician advice influence patient behavior? Arch Fam Med 2000; 9:426-433 [Abstract/Free Full Text]
24. Gonzales R, Steiner JF, Lunn A, Barrett PH Jr Decreasing antibiotic use in ambulatory practice. Impact of a multidimensional intervention on the treatment of uncomplicated acute bronchitis in adults. JAMA 1999; 218:1512-1519