Parents’ Expectations and Experiences of Antibiotics for Acute Respiratory Infections in Primary Care

The purpose of this study was to elicit caregiver experience and beliefs regarding antibiotics use for the treatment of upper respiratory infections (URI). As the authors state, URIs are very prevalent among children and parental demands are commonly blamed for the overuse of antibiotics. No previous studies have been conducted to assess parent's beliefs surrounding antibiotic necessity, benefits, or harms.

The authors conducted a phone survey of parents of children aged 1-12 years using randomly selected household landlines in Australia. The student discussion group pointed out the inherent bias of conducting landline phone surveys. Many people do not have landline phones, especially in younger generations. The sample may be biased toward individuals who are older and from a higher socioeconomic status. The student discussion group also discussed how pilot testing the survey produces more valid and reliable data for analysis. Pilot testing was a necessary step in development of this survey because no previous studies have approached this topic. We discussed different types of pilot testing including face validity and cognitive testing. The group concluded face validity was important to establish, since the topic concerned parental beliefs.

The results of the study included parental experiences with three common URI complaints: cough, sore throat, and acute otitis media. The authors were able to complete 400 interviews from 14,500 random calls. The final respondent pool was majority white females, English speaking and had a higher education level. The student group highlighted that most survey data is skewed toward female respondents, as women are generally more willing to participate. The group discussed that despite a higher level of education, parents had false beliefs regarding the benefits of antibiotics. Since most respondents were English speaking, language was not a factor in doctor/patient communication.

The student group highlighted the finding that the majority of parents thought antibiotics were needed, especially for acute otitis media (92%), while only a minority thought they did not provide any benefit. Furthermore, parents overestimated the benefits of antibiotics, believing complications (e.g. hearing loss in acute otitis media) would result if the infection was not treated with antibiotics. Although the majority of parents knew about the potential harm of antibiotics, some were not able to accurately explain the mechanism of antibiotic resistance (16% believed the body would become tolerant or resistant to antibiotics).

The study participants were asked to recall their discussion with the doctor from previous visit. The student discussion group pointed out that, although this was pertinent information to collect, this data may be influenced by patient recall bias. Average duration since last visit tended to be long, ranging from 9 weeks to 104 weeks. The student group would have liked the authors to report the standard deviation of average duration since last visit.

The discussion group also summarized that the study found a lack of communication to patients about the benefits and harms of antibiotic use. In the student group's personal experience, we found that it is important to explain to patients the sources of infection and why or why not a provider would prescribe antibiotics. The authors also proposed this shared decision making as a solution. From the provider's perspective, a major limitation to shared decision making is time allotted per visit. The group discussed giving parents printed reading material regarding the benefits and harms of antibiotics to provide further education.

The discussion group found several ways to apply the data collected from this study, including emphasizing education of parents about the indications, harms, and benefits of antibiotics. The group also discussed using the study data to shape the content of educational material, and conduct a follow up study to see if this educations changed parent misconceptions. The group proposed further expanding the original study to include more diverse cultures, in order to discern cultural differences regarding use and beliefs surrounding antibiotics. Similarly, if the original study were repeated in the United States, it would be interesting to see how health insurance factors into patient beliefs surround antibiotic use. The student group was composed of several medical students who plan to practice in rural communities. Like communities in Australia, transportation and access to care are barriers to treatment in the rural United States. The group discussed how traveling long distances to see a provider may influence the parent's belief that they should leave the office with an antibiotic prescription.

Overall the group felt the authors produced a quality study of the previously unexplored topic of parents' perceptions of antibiotic use in the treatment of upper respiratory infections. The study will serve as an excellent foundation for further studies looking into the influence of social determinants of health such as cultural belief and insurance coverage.

Competing interests: None declared

1. Referring to Table 3, one of the questions is "Were reasons you might not want to use an antibiotic discussed with the doctor?". Comments: a) The question can be ambiguous largely because of the use of negativity. b) Perhaps the intended question was, "Did the doctor explain why antibiotics was not prescribed?" c) In any case, a doctor should not be expected to discuss with the parent in every case wherein an antibiotic therapy is not indicated. In contrast, the discussion in every case wherein an antibiotic is indicated can be justified.

2. There were two similar concepts were explored: whether the parent thought antibiotics could help, and whether not using antibiotics was an option. There may be correlation between them: a person who believes that antibiotics is essential (ie. a "must", and not optional), surely that person believes it is or will be helpful, in normal circumstances.

Thanks.

Competing interests: None declared

Thanks to Professor Ebell for commenting on our article. Although the finding that people think antibiotics are more beneficial than they really are is probably suspected by many clinicians, the quantification of antibiotic benefits for acute respiratory infections that this study measured has not previously been reported. This information is very important for any process in which there is discussion about the benefits and harms of antibiotics for these indications.

In response to the specific points raised: 1) We agree that the physician is ultimately responsible for prescribing antibiotics (although of course, whether the patient actually takes them, even if prescribed, is the patient's decision). However, physicians in primary care have long-term relationships with their patients and are anxious to maintain their relationship with them, and so rank managing patients' fears, concerns, and expectations high. Patients' beliefs cannot be ignored and should be considered and discussed as part of the consultation. Physicians sometimes misapprehend patients' expectations for when they seek help for an ARI [1], and understanding the patient's beliefs about the illness and its treatment is important.

2) We agree with the influence of the market-based primary care system. Although exploring patients' concerns and expectations and helping patients to make informed decisions is more than just patient satisfaction, and is important in capitation systems and with salaried clinicians too;

3) We also agree that near-patient testing may assist refine the immense diagnostic challenges of acute respiratory infections into the subgroups that respond better. While safety remains an over-riding concern, recent observational data from the UK, which suggests that high antibiotic prescribers provide little benefits for safety compared with low, should be very reassuring for physicians.[2] However, good communication skills underpin all situations so that patients can be reassured, and the likely benefits and harms of the recommended course of action discussed.

[1] van Driel ML, De Sutter A, Deveugele M, Peersman W, Butler CC, De Meyere M, et al. Are sore throat patients who hope for antibiotics actually asking for pain relief? Ann Fam Med. 2006;4:494-9.

[2] Gulliford MC, Moore MV, Little P, Hay AD, Fox R, Prevost AT, et al. Safety of reduced antibiotic prescribing for self limiting respiratory tract infections in primary care: cohort study using electronic health records. BMJ. 2016;354:i3410

Competing interests: Authors of the paper