Parental Knowledge About Appropriate Antibiotic Use Still Poor

Diana Phillips

July 20, 2015

Despite widespread educational efforts designed to manage parental expectations and limit inappropriate use of antibiotics in children, widespread misperceptions still exist, particularly among the Medicaid population, a study shows.

To assess parental changes in antibiotic-related knowledge and attitudes, Louise Elaine Vaz, MD, MPH, from the Division of Pediatric Infectious Diseases at Oregon Health & Science University's Doernbecher Children's Hospital in Portland, and colleagues surveyed more than 700 parents of children younger than 6 years and compared the findings with those of a similar survey conducted in 2000. They report the findings of their new study in an article published online July 20 and in the August issue of Pediatrics.

The 2013 study sample included Massachusetts parents with children insured by a Medicaid-managed care plan (n = 353) or a commercial health plan (n = 354). The 2000 sample was drawn from a nonmanaged care Medicaid system and two commercial insurance plans.

In the 2013 sample, parents of Medicaid-insured children were younger than parents of commercially insured children, and they were more likely to be nonwhite and less educated, the authors report.

Medicaid-insured parents were significantly less likely to answer antibiotic knowledge questions correctly for nearly all the questions. "For example, 'How often are antibiotics needed for colds or flu?' was answered correctly by a greater proportion of commercially insured parents (78% vs 44%, P < .01), as was a question about antibiotics for green nasal discharge (53% vs 38%, P < .01)," the authors write.

Among both groups, a small number of parents answered the item about antibiotic use for deep cough or bronchitis correctly, with no difference between commercially insured and Medicaid-insured parents.

With respect to expectations, parents with Medicaid insurance were more likely than the commercially insured parents to indicate that they would rather give their child an antibiotic that might not be needed than wait to see whether the condition resolved.

In the comparison with 2000 survey data, knowledge that green nasal discharge did not require antibiotics improved among both Medicaid and commercially insured parents, but the increase was not as large among the Medicaid group, the authors observe.

One surprising finding was a decrease in 2013 from 2000 in the percentage of Medicaid parents correctly answering otitis media and strep throat questions, the authors write. In addition, low levels of understanding that antibiotics are rarely needed for bronchitis were observed, with only marginal improvements over time in both groups, they state.

"Among commercially insured, no significant differences over time were noted in the proportion of parents expressing a tendency to request antibiotics. However, Medicaid-insured parents in 2013 were more likely to answer ≥1 of these questions affirmatively compared with Medicaid-insured respondents in 2000," the authors write. This effect remained after adjustment for other predictors and their interactions over time for two expectation questions: satisfaction with the visit if no antibiotic was prescribed and preference for an antibiotic over watchful waiting.

"For example, among Medicaid-insured parents, the odds of answering that they would give an antibiotic instead of watching and waiting increased 1.4-fold. In contrast, the commercially insured parents were less likely to answer this question affirmatively in 2013, with an [odds ratio] of 0.17."

The survey also assessed parental sources of medical information. "Across insurance type, parents place high trust in their health care providers," the authors write, pointing to the importance of interventions that address decision-making at the physician–patient level.

Medicaid-insured respondents were less trusting than commercially insured parents of more formal avenues of information, including physicians, the Centers for Disease Control and Prevention, and the Department of Public Health. "Limiting educational interventions to these sources may miss opportunities to reach audiences that rely on other sources," the authors suggest.

Of interest, parents in both groups reported high levels of trust in information obtained through pharmacies, suggesting pharmacies may also be sites for educational interventions, "particularly as more care is provided in retail-based clinics," the authors note.

To this point, the development of additional population-level interventions "will require a deep understanding of disparities in access to specific streams of information and tailoring messages for families with varying health literacy levels," the authors explain. "New strategies to change expectations about antibiotic use must be a continued focus of public health initiatives. These initiatives will be more effective if they address local knowledge and attitudes and tailor interventions to combat specific misconceptions."

Despite substantial overall decreases in antibiotic use among children over the past decade, the observed widespread knowledge gaps point to the need for more targeted parental education, especially among parents of publicly insured children, the authors note. "Among both insurance groups, parents had high rates of acceptable answers regarding illnesses in which antibiotics are indicated (streptococcal pharyngitis, otitis media); however, they were not as good at identifying illnesses or symptoms for which antibiotics are not needed."

Some of the parental misperceptions and confusion may actually result from professional recommendations, Sharon B. Meropol, MD, PhD, and Mark E. Votruba, PhD, from Rainbow Babies and Children's Hospital in Cleveland, Ohio, suggest in an accompanying commentary.

"[A]lthough we advise parents that 'green colored mucus' does not require antibiotics, the American Academy of Pediatrics' Clinical Practice Guidelines list persistent purulent rhinorrhea with fever as a diagnostic criterion for acute bacterial sinusitis," they write. "Although physicians understand the difference between green-tinged mucous of a resolving virus versus a purulent bacterial sinusitis, this distinction may not be as clear to parents. Similarly, to parents, 'coughing that produces mucous' of viral bronchitis may be indistinguishable from the presentation of bacterial pneumonia."

Regarding the finding that Medicaid parents were more likely to expect antibiotics, "previous studies have revealed that children of color and those from socioeconomically disadvantaged backgrounds are less likely to receive antibiotics," the editorialists write. "It's important to ensure that future strategies to decrease unnecessary prescribing do not decrease prescribing that is medically indicated, and do not further widen treatment disparities."

One coauthor disclosed having stock ownership in Johnson & Johnson, Merck Co, Lily Eli & Company, and Pfizer Incorporated. The other authors and the editorialists have disclosed no relevant financial relationships.

Pediatrics. 2015;136:221-231, 387-388. Article abstract

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