From the Division of General Pediatrics, Boston Medical Center,
Boston University School of Medicine, Boston, Massachusetts.
Sixty-one percent of the physician surveys were returned after two
mailings and a follow-up phone call. The pediatricians had been in
practice for a median of 12 years, seeing a median of 110 patients per
week. Fifty-eight percent of pediatricians reported that some, many, or
most of the parents in their practices were worried that their children
were receiving too many antibiotics. Seventy-one percent indicated
that four or more times during the previous month, a parent had
requested an antibiotic when the physician believed it was unnecessary,
and 35% said that at least occasionally they went along with these
requests. Sixty-one percent reported that parents requested a different
antibiotic from the one they were going to prescribe at least four
times in the previous month, and 30% of pediatricians said that they
agreed to parents' requests often or most of the time.
Pediatricians have become familiar with the growing problem of
bacterial resistance to antibiotics, especially as it relates to
pneumococcal disease, including acute otitis media
(AOM).1,2 Otitis media is the most common diagnosis
during an ill visit to a pediatrician. More than 70% of children have
had at least one middle ear infection by the age of 3 years and 33%
have had three or more episodes.3 The incidence of AOM is
increasing, as evidenced by the doubling of prescriptions written for
AOM in the last decade from 12 million in 1980 to 24 million in
1992.4 This increase in antibiotic usage is likely due to a
number of factors, including increase in real disease, due in part to
widespread day care attendance,5,6 improved access to
care,7,8 and overprescription of antibiotics.
Increased prescription of antibiotics may be contributing to the
emergence of bacterial resistance.4,9 Hofmann et
al10 found a higher incidence of infection with resistant
pneumococci among white and suburban children and postulate that this
finding may be due to an increased use of antimicrobial agents in an
affluent population. Zenni et al11 also showed an increase
in the incidence of unresolved otitis media associated with
nasopharyngeal colonization with penicillin-resistant pneumococci.
Many pediatricians have had the experience of parents demanding
antibiotics for illnesses such as viral upper respiratory infections,
nonspecific diarrhea, or sore throats. However, recently there has been
increasing discussion in the print media about the dangers of
antibiotics (Newsweek, March 28, 1994:47-51;
Time, September 12, 1994: 62-69, Consumer
Reports, July 1995:492-493; Mothering, Fall
1992:45-49), and some parents have begun to question the necessity of
antibiotic therapy.
We undertook this study to determine parents' range of knowledge and
understanding of antibiotics and to determine the experience of
pediatricians with respect to prescribing oral antibiotics. Specifically, we were interested in parents' experiences and concerns regarding antibiotics, their knowledge of the indications for antibiotics, whether there was antibiotic use without physician knowledge, and whether parents were concerned that their children had
received antibiotics unnecessarily. We wanted to compare parents' views with pediatricians' interpretation of parents' understanding and concerns.
METHODS
A convenience sample of parents was interviewed in each of three
practices in the Boston area. Two sites were private practices in the
suburbs: one was a group practice with two pediatricians (P1) and one
was a larger practice of seven pediatricians (P2). Both practices
participate in medical student education and have previously
participated in descriptive research projects. The third site was an
inner-city community health center (CHC). Medical students and
residents from Boston Medical Center receive ambulatory pediatric
training.
During the study, a research assistant approached one parent from each
family before the child's visit with the physician and asked the
parent to participate in a study about his or her opinions and
experiences with antibiotics for children. Parents were interviewed by
the research assistant in the waiting room and were asked questions
related to demographic information and about their experiences with
antibiotics. Most questions were yes/no or Likert scale in type.
Several open-ended questions were also included about parents'
perceptions of possible antibiotic side effects and illnesses that
required an antibiotic prescription. Sample questions included: "Tell
me how frequently you believe that antibiotics are helpful in treating
these illnesses
ear infection?" (possible responses, always,
sometimes, never, don't know); and "Have you ever felt that any of
your children needed an antibiotic when the doctor did not prescribe
one?" (possible responses, yes or no, and if yes, how frequently, one
to three times, four to six times, more than six times).
2 analysis was used to analyze categorical
variables. The study was approved by the Human Studies Committees of
Boston City Hospital and Boston University School of Medicine and also
by appropriate committees at each of the practices.
In a second, related survey, 100 pediatricians across Massachusetts
were asked about their opinions regarding parents' views on
antibiotics, using a mailed questionnaire. We chose names of physicians
from the Fellowship Directory of the American Academy of Pediatrics,
selecting one pediatrician from each town, and choosing the first,
alphabetically, excluding resident fellows, emeritus fellows, and
subspecialty fellows until 100 physicians had been chosen. The
exclusion criteria served to select a sample of practicing general
pediatricians. Each physician was mailed a 2-page questionnaire and was
requested to complete it and return it in a self-addressed, stamped
envelope. The questions contained in the physician survey dealt mostly
with physician perception of parents' concerns and were designed to
mirror those in the parent survey. Sample questions included: "How
many times in the past month has a parent requested an antibiotic for
his or her child when you did not feel one was indicated?"; and
"How many times in the past month has a parent requested a specific
antibiotic or requested that you prescribe a different one than you
were going to prescribe?". Questions related to how often an event had occurred in the past month were quantified as follows: never; one
to three times; four to six times; seven or more times.
2 analysis was used to analyze categorical variables.
The study was approved by the Human Studies Committees of
Boston City Hospital and Boston University School of Medicine.
RESULTS
Parent Survey
Four hundred parents were interviewed. Seventy-four of 87 parents
(85%) approached in P1 and 226 of 296 (76%) in P2 consented to participate. The first 100 parents approached in the CHC agreed to
participate.
The demographics were identical in the two private practices (PP) and
have been combined (Table 1). The parents from the PP were
largely white (84%) and had completed college (81%). They were older
than the health center parents, had a higher family income, and were
more likely to have commercial insurance for their children. The
parents in the CHC were mostly black (80%) and had not completed
college (91%).
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Table 1.
Demographic Characteristics of Parents
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The majority of parents (78%) had experience giving their children
oral antibiotics. Fifty-three percent had done so in the past 6 months
and 73% in the past year. With respect to the most recent antibiotic
that parents had given any of their children, 89% (262/296) were
satisfied with the ability of the antibiotic to cure their child's
illness, and 78% said they were able to give their child every single
dose. The responses to these questions did not differ between parents
from the PP and the CHC.
When parents were asked whether they were worried that any of their
children were receiving too many antibiotics, 29% answered yes (32%
in the PP compared with 20% in the CHC, P = .054).
Eighty-five percent of parents believed that there could be problems
with receiving too many antibiotics. In an open-ended question in which parents were asked to list potential problems with receiving too many
antibiotics, 55% mentioned immunity or resistance. Ineffectiveness was
mentioned by 15% of parents, and other responses such as allergies, vomiting, and diarrhea were listed by <10% of parents. Despite these
concerns, 18% of parents said they had given an antibiotic at home
before consulting a physician.
We asked parents if they believed that antibiotics were helpful in
treating a variety of illnesses (Table 2). Most parents answered that antibiotics were always or sometimes helpful in ear
infections and throat infections, but a large number also responded
that antibiotics were useful in treating colds, coughs, and fever. More
parents in the PP indicated that antibiotics were helpful for ear
infections (95%) and throat infections (87%) than parents in the CHC
(88% and 71%, respectively). More parents from the CHC believed that
antibiotics were useful in treating colds (59%) than did parents from
the PP (23%). Fifty-eight percent of parents, overall, responded that
antibiotics were useful for cough and fever, and responses for these
symptoms did not differ between the PP and CHC.
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Table 2.
Parents' Understanding of Antibiotic Use
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Table 3 describes parents' interactions with physicians
around antibiotic prescriptions. When parents were asked "Has your child ever needed an antibiotic when the doctor did not prescribe one?" 14% said yes. More parents from the CHC (22%) responded affirmatively to this question than parents from the private practices (12%, P = .014). Ear infections (32%) and colds
(26%) were the most common reasons for parents to believe that their
child required an antibiotic.
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Table 3.
Parent/Physician Interaction Concerning Antibiotic Issues (%)
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Parents whose children had received antibiotics in the past were asked
whether they believed that an antibiotic had ever been prescribed
unnecessarily and whether they had ever requested that a physician
prescribe a specific antibiotic. Significantly more parents from the PP
(12%) believed that an unnecessary antibiotic had been prescribed, in
comparison with the CHC families (3%, P = .019).
Again, the most common reasons were ear infections (50%) and colds
(10%). Thirty percent of parents had at some time requested that their
child's physician prescribe a specific antibiotic (PP = 34%,
CHC = 19%, P = .021). Eighty-two percent of these
parents said that their doctor had prescribed the antibiotic requested (PP = 83%, CHC = 77%, P = .783).
Forty-seven percent of parents from the PP had read an article about
the use of antibiotics in children compared with 19% of parents from
the CHC (P = .000).
Parents were given a list of five antibiotic factors (cost, dosing
schedule or how many times a day the antibiotic is given, side effects,
strength or effectiveness, and taste) and asked to choose the two that
they believed were the most important. Parents from both the PP and the
CHC selected side effects (82%) much more frequently than any other
factor. Forty-one percent of parents believed that the strength or
effectiveness of an antibiotic was important, 37% chose taste, and
33% thought that the dosing schedule was important. Cost was chosen
least frequently (7%), probably because most parents reported that
they had insurance that covered part or all of the cost of medications
(see Table 1).
Physician Survey
Sixty-one of 100 pediatricians returned the survey after two
mailings and a follow-up phone call. Most physicians worked in a group
practice in the suburbs, had been in practice for a median of 12 years,
and saw a median of 110 patients per week (Table 4).
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Table 4.
Demographic Characteristics of Physicians (N = 61)
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We asked the physicians if they believed that any parents in their
practice were worried that their children were receiving too many
antibiotics. Fifty-eight percent of pediatricians reported that some,
many, or most of the parents were worried that their children were
receiving too many antibiotics. Seventy-one percent of physicians said
that at least four times in the past month (23%
four to six times in
the past month, 48%
seven or more), a parent had requested an
antibiotic when the physician did not believe one was indicated (Table
5). Thirty-five percent said that at least occasionally they
went along with the request. Sixty-one percent of pediatricians
reported parents requesting a specific antibiotic at least four times
in the past month (31%
four to six, 30%
seven or more), and
physicians were more likely to agree to parents' requests in this
situation (30% responded often or most of the time). Fifty-four
percent of physicians reported a parent requesting an antibiotic over
the phone at least four times in the previous month (26%
four to six,
28%
seven or more), but 81% of physicians rarely or never agreed to
this request. There was no difference among physicians, based on length
of time in practice, in their willingness to prescribe an antibiotic
when they believed it was unnecessary or to prescribe a specific
antibiotic requested by parents.
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Table 5.
Physician Responses to Questionnaire (N = 61)
[View Table]
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Physicians were asked to choose two of five antibiotic factors that
they believed were most important to parents (cost, dosing schedule,
side effects, effectiveness, taste). Pediatricians were most likely to
believe that parents were concerned about dosing schedule (63%).
Fifty-three percent believed parents thought effectiveness was
important, 37% chose cost, and 32% responded that parents were
concerned about taste. Only 15% of physicians believed that parents
were concerned about side effects. Twenty-seven percent of
pediatricians believed that children received the entire 10-day course
of antibiotics as prescribed always or most of the time.
DISCUSSION
Growing bacterial resistance to antibiotics represents a global
threat to the health of the world's population. Although antibiotic resistance has been a long-observed problem, there is concern that the
widespread use of antibiotics in humans and animals and the use of
broad-spectrum antibiotics has accelerated the pace of emerging
bacterial resistance.12
We are unaware of any other data published in peer-reviewed journals
about parent and physician beliefs, concerns, and experiences with
antibiotics. Our parent survey suggests that parents have misconceptions about appropriate indications for antibiotics and often
give antibiotics without physician knowledge. It is possible that
parents misunderstood the questions about specific signs of illness and
indications for antibiotics. For example, if they had prior experience
with a child having a cold, had sought care, and a physician had made
the diagnosis of an ear infection, parents may have responded that
antibiotics are indicated in treating a cold. In some regards, this
scenario illustrates the complexity in understanding what parents know
and believe about antibiotics. With respect to the physician survey,
physicians reported that parents request antibiotics when they are not
indicated. Both surveys suggest that parents have impact on which
antibiotics are prescribed.
Prescriptions for AOM are likely to reach 30 million in 1996, an
increase of 150% since 1982.4 The reasons for this change include an increase in the incidence of AOM, improvement in access to
care, and possible unwarranted use of antibiotics. The number of young
children attending day care has increased significantly over the past
decade. Day care attendance is associated with frequent respiratory
infections, some of which are accompanied by AOM.5,6 Several studies have shown that access to care for children has improved with approximately 90% of parents indicating that their children have a regular source of care.7,8 We believe that improved access to care is accompanied by increased diagnoses of minor
infections and increased oral antibiotic use. Unnecessary prescription
of antibiotics also occurs. How much is unclear, although in our
survey, one-third of physicians reported at least occasionally
prescribing antibiotics when they were not indicated and 19% at least
occasionally prescribe antibiotics over the phone. Which of these three
factors
increase in real disease, improvement in access to care, or
unwarranted antibiotic use
is contributing most to the increase in
antibiotic prescriptions is unknown.
Anecdotal information from our colleagues in PP and those who practice
at Boston Medical Center suggests that parents exert pressure on
physicians to dispense antibiotics. Marcy,15 in an address
at a meeting on improving antibiotic use practices sponsored by the
National Managed Health Care Congress, stated that the primary cause of
overuse of antibiotics is parental coercion. Although we would like to
believe that clinicians prescribe antibiotics only when indicated, it
is often difficult in a busy practice or emergency room setting to
explain to a parent why an antibiotic is not indicated. It is less
time-consuming to write a prescription than to engage in a lengthy
discussion with parents about the natural history of an upper
respiratory infection, diarrhea, or sore throat. In addition to
parental coercion and time constraints, concerns of malpractice and
litigation may also contribute to physician prescribing practices.
Finkelstein and Platt16 recently presented data on
nurse-practitioner and physician management of febrile children in an
office setting and showed wide variation in prescription of antibiotics
among clinicians in the study. Nonspecific fever in young children is
always a cause for concern because of the risk of meningitis. The
variation demonstrated by Finkelstein and Platt16 may
reflect concern of litigation or simply variation in prescribing
patterns.
This study represents an initial step in understanding the complex
relationship between parents and physicians as it relates to
antibiotics. There are some limitations to this study. First, our
population represents only 400 parents from two distinct socioeconomic groups and 61 pediatricians in Massachusetts; our results may not be
able to be generalized to different populations of parents or
physicians. Second, 39 physicians did not respond to the questionnaire. It is possible that their responses would have been different from
those of the responders. Third, we relied on self-report. It is not
known how accurately parents and physicians recall actual experiences
with antibiotics. In studying parents' attitudes about antibiotics,
other methods, such as focus groups could be used to assess opinions
and beliefs. We previously conducted focus groups with adolescents
about their understanding of acquired immunodeficiency syndrome and
found them useful in exploring a broad range of responses from
participants and in uncovering unexpected information not elicited
during structured interviews.17 With respect to physician
prescribing patterns, a prospective observational study would be
helpful in determining if actual practice is similar to self-report.
Physician prescribing patterns are influenced by physician and
parental knowledge about antibiotics. The literature on antibiotic compliance sheds some light on how prescribing patterns could be
changed. Many studies have documented an increase in parent compliance
with antibiotic treatment using various written, visual, and telephone
reminders for parents.18 Maiman et al21
have also shown that a continuing medical education intervention aimed at physicians to improve their compliance-teaching strategies has a
positive effect on parent compliance. Recently, Wall et al22 reported the effectiveness of a brief office-based
intervention, delivered during a well-baby visit, in decreasing
maternal smoking. Whether any of these strategies would be useful in
altering the parent-physician interaction to allow more appropriate
prescription of antibiotics is unknown.
CLINICAL IMPLICATIONS
We believe that some parents are beginning to question the use of
antibiotics. Bacterial resistance has been widely discussed in the
press and many parents are becoming knowledgeable about the issue of
resistance. Forty percent of parents in this study had read an article
about antibiotics. It may be possible to tap into growing parental
concern by educating parents about appropriate indications and the
risks and benefits of antibiotics. If parents can better understand the
role of antibiotics in the treatment of disease, they may exert less
pressure on physicians to dispense antibiotics inappropriately.
Received for publication Oct 4, 1996; accepted Dec 10, 1996.
Reprint requests to (H.B.) Director, Division of General
Pediatrics, 1 Boston Medical Center Place, Maternity 415, Boston, MA
02118.
This study was supported in part by grants from the Health
Resources and Services Administration, Bureau of Health Professions, Division of Medicine (D28 PE51008 and T32 PE10014).
The authors thank Jerome Klein, MD, and Chris McElroy for their
spirited discussion about these topics. We thank Colleen Pearson and
Katherine Zuckerman, our research assistants, for their dedication and
enthusiasm, and we also thank the physicians and staff of the three
practices in which we conducted the interviews, especially Jonathan
Benjamin, MD, Pamela Zuckerman, MD, and Cynthia Osman, MD.
AOM, acute otitis media.
CHC, community health
center.
PP, private practice.