Family Practice Advance Access originally published online on June 1, 2007
Family Practice 2007 24(4):302-307; doi:10.1093/fampra/cmm016
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More physician consultations and antibiotic prescriptions in families with high concern about infectious illness—adequate response to infection-prone child or self-fulfilling prophecy?
a Centre for Clinical Research, Dalarna, Falun
b Unit of R&D, Kronoberg County Council, Växjö
c Department of Clinical Science in Malmö—General Practice/Family Medicine, Lund University, Malmö
d Unit of R&D in Primary Health Care, Jönköping
e General Practice, Department of Health and Science, Faculty of Health Society, Linköping, Sweden
Correspondence to: Malin André, Centre for Clinical Research, Dalarna, Nissers väg 3, 791 82 Falun, Sweden; Email: malin.andre{at}ltdalarna.se
Received 25 October 2006; Revised 21 February 2007; Accepted 18 March 2007.
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Abstract |
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Background. Respiratory tract infections (RTI) in children is the most common cause of prescription of antibiotics. It is important to describe and analyse non-medical factors in order to develop more rational use of antibiotics.
Objectives.To compare families with high and low concern about infectious illness with regard to social variables, perception of infection proneness and beliefs in antibiotics and to relate the concern for infectious illness to reported morbidity, physician consultations and antibiotic prescriptions for the 18-month-old child in the family.
Methods. A prospective, population-based survey was performed. During 1 month, all infectious symptoms, physician consultations and antibiotic treatments for 18-month-old children were noted. The 818 families also answered questions about their socio-economic situation, illness perception and concern about infectious illness.
Results. High concern about infectious illness was associated with more frequent physicians consultations and more prescriptions of antibiotics. There was no significant difference in reported days with symptoms of RTI, but the parents more often experienced their children with RTI without fever as being ill. The variables of infection proneness in the child, inadequate beliefs in antibiotics and the factor of being the only child were important explanatory factors for concern about infectious illness.
Conclusions. High concern about infectious illness is an important determining factor for physician consultations and antibiotic prescription for small children. An adequate consultation, where the doctor deals with the parents' worries and gives appropriate information about symptoms and disease, might contribute to less antibiotic prescribing with preserved parental satisfaction.
Keywords. Anti-bacterial agents, attitudes to health, child, parents, preschool, respiratory tract infections.
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Introduction |
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In the economically developed part of the world, respiratory tract infections (RTI) are no longer a considerable threat to childrens' life and health, but still they constitute the most common cause of acute morbidity, physician consultations and prescription of antibiotics.1 In recent decades, the tendency to prescribe antibiotics to patients with mild infections such as upper RTI has been questioned, as a consequence of the increasing worldwide problems associated with bacterial resistance.2
The pattern of antibiotic prescription differs greatly between countries and between regions in the same country.3 In a recent study, we showed that morbidity, measured as reported symptoms, could not explain differences in antibiotic prescription to children in high-prescribing communities compared with children in low-prescribing communities in Sweden.4 In a number of studies, several non-medical factors have been identified, which seem to determine different tendencies to see a doctor and have antibiotics prescribed for a child with RTI.3,5–9 In our previous study, high concern about infectious illness in the family was the single most important factor for antibiotic prescription for the child.4 It is important to describe and analyse these non-medical factors in order to develop more rational use of antibiotics in society, for the good of patients today and in the future.
The aim of this study was to describe families with high, medium and low concern about infectious illness with regard to social variables, perception of infection proneness, belief in antibiotics and relate the concern for infectious illness to morbidity, physician consultations and antibiotic prescriptions for the 18-month-old child in the family.
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Methods |
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Seven municipalities took part, two urban and five rural in southern and central Sweden. The nurses working at the 30 child health clinics studied informed the parents who brought their children to routine check-ups at 18 months about the study in writing and orally, and the families who agreed to participate were asked to give their written informed consent. The children were included consecutively from 1 October 2002 until the 11 April 2003. Families that did not master the Swedish language in the judgement of the nurses at child health clinic were excluded.
Questionnaire
All participating families answered a questionnaire, given to them by the nurses, regarding socio-economic status, ethnicity, smoking in the family and occupation. The questionnaire also asked whether the children had asthma/allergies, if they were in day care outside the home and if any of the family members were perceived as infection prone.
The following four statements were made about concern for illness, each with four alternative answers:
- (i) Your child's infections worry you a lot.
- (ii) Every time your child is ill, you are afraid it is something serious.
- (iii) Your child becomes ill more frequently than other children of the same age.
- (iv) You are often afraid that your child may become seriously ill.
- (ii) Every time your child is ill, you are afraid it is something serious.
The answers were rated from 1 to 4: ‘fully agree’ 1, ‘partly agree’ 2, ‘partly disagree’ 3 and ‘totally disagree’ 4. Thus families could score from 4 to 16. Families who scored 4–7 were classified as perceiving high infectious illness threat, 8–12 as medium and 13–16 as perceiving a low illness threat.10
To examine beliefs in antibiotics, the parents had to score concordantly on the two statements: ‘Most respiratory infections in children go away without antibiotics’ and ‘Most respiratory infections in adults go away without antibiotics’. Parents who did not fully agree with the statements were classified to have inadequate beliefs in antibiotics.
Logbook
The parents were asked to note all their child's infectious symptoms during 1 month, according to preset alternatives, in a logbook. The symptoms were noted day by day.
Fever >38°C was to be noted but no instructions were given on how to take the child's temperature. In the logbook, the parents also noted whether the child seemed healthy or ill, consulted a physician or received antibiotic treatment.
Nurses from the child health clinic phoned the family twice during the month to remind them about the registration and to remind them that the logbooks should be sent in, in the prepaid envelope.
Definitions
Respiratory tract symptoms were defined as at least one of the following: runny nose, cough, earache, sore throat, with or without tiredness and fever. In the logistic regression analysis, families who reported high and medium concern about infectious illness were combined into the high-concern group.
Statistical analysis
Chi-square tests for trend were performed with EpiInfo Version 6 for social data, illness perception and antibiotic knowledge in relation to concern about infectious illness. The remaining statistical analyses were performed with SPSS (Version 13.0.1) software. Chi-square tests, or Fisher's test, when appropriate, were used for univariate analysis. A P-value of 0.05 was regarded as statistically significant. Logistic regression with backwards analysis was used to compute odds ratios and their 95% confidence intervals. In families with twins, only the first registered twin was included. Study group in the logistic regression analysis refers to families living in high- or low-prescribing communities.4
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Results |
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A total of 1185 families in the studied geographical area had children who reached the age of 18 months during the study period. Seven families did not attend appointments at the child health clinic and 38 families were not invited to take part in the study because of language difficulties, in accordance with the exclusion criteria. In all, 1140 families were asked to take part in the study. Of these, 154 declined without stating any reason, 30 because of their difficult social situation and 2 moved away during the study period. Thus, a total of 84% (954/1140) of the families were included. Of those who consented to take part in the study, 818 families (86%) completed the logbook registrations and answered the questions about illness perception. In the studied families, there was 17 pair of twins aged 18 months.
Scale consistency was good for the four questions used for concern about infectious illness (Cronbach's alpha 0.76). Most families (57.1%) rated low concern about infectious illness in the 18-month-old child, 38.0% a medium score and only 4.9% a high score. Table 1 shows that there were differences between the families in the three groups regarding several social indicators, belief in antibiotics and perceived proneness to infections concerning mothers and children. During the studied month, there was no difference between the children in the families regarding number of days with RTI (chi-square 7.95, P = 0.24) (Table 2). In 14.1% of the days with RTI, the families reported that the child had fever. Families with high concern about infectious illness reported more often that the child had RTI with a fever than families with medium and low concern (chi-square 38.11, P < 0.001)). In 42.6% of the days when the child had RTI without a fever, the child was reported to be ill. Families with high concern reported more often that the child with RTI without a fever was ill than families with medium or low concern (chi-square 56.88, P < 0.001). They also consulted the physician more frequent and were more often prescribed antibiotics (Table 3).
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Table 4 shows logistic regression analyses concerning factors of importance for medium/high concern about infectious illness in the 18-month-old child. The variables of illness proneness, belief in antibiotics and asthma of the 18-month-old child were analysed and shown not to interact statistically. Model 1 (including relevant social factors), resulted in several significant factors. When beliefs in antibiotics and infectious proneness in any of the parents and the child were added to the analysis (model 2), the importance of the social factors declined. The variables of infection proneness in the child and inadequate antibiotic beliefs plus the variable of being the only child turned out to be important explanatory factors. Although the social factors were significant in the bivariate analyses and some (no sibling, living in rental flat and no parent with academic education) remained significant in the last model, the parent's beliefs and perception turned out as more important factors for concern about infectious illness in the 18-month-old child.
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Discussion |
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In this study, we show that high concern about infectious illness was associated with more physician consultations and more prescriptions of antibiotics to the infected children. There was no significant difference in reported days with symptoms of an infection, but the parents with high concern experienced more often that their children with RTI without a fever were ill.
Parents with higher concern about infectious illness were overrepresented in groups with low social status i.e. they often had less education, were smokers, lived in a rental flat or were single parents. In a logistic regression analysis concerning high concern about infectious illness, the variables of infection proneness in the child, inadequate beliefs in antibiotics plus the factor of being the only child turned out to be important explanatory factors.
Methods
The study was prospective, population-based with relatively few dropouts. The design made it possible to register symptoms, experiences of symptoms/illness and actions taken simultaneously, without the risk of recall bias, which is a clear weakness in all kind of retrospective studies. The logbooks were complete and accurately filled in, much thanks to repeated telephone reminders from the nurses at the child health care centres.
The dropout rate (27%) was not, in fact, negligible. The reasons for not participating in the study were in 2.6% unspecified social reasons such as ‘too much to do’, ‘there is too much happening around us just now’. We could not analyse the dropouts further, and consequently, we cannot exclude an overrepresentation of families with psychosocial problems in the dropout group. Even if the logbooks were complete and well filled in, in the majority of cases, we did not make any external validation of reported symptoms and actions taken.
The instrument ‘concern about infectious illness’ was slightly modified from the original ‘General Health Threat’.11 Thus, the first out of four statements was limited to ‘concern about infections’ instead of general concern about illness. In our opinion, this more specific question was reasonable and unproblematic to use. The original instrument had been developed on the basis of a validated questionnaire.12
Comparisons with other studies
The large differences between European countries3 and between communities in our own country cannot be explained by differences in morbidity.4 Non-medical factors of importance in determining consultation rates and the possibility to have an antibiotic prescribed are related to context (i.e. access to care, cultural differences),3,8 to the patient (i.e. educational level, social class, expectations and knowledge of antibiotics)7,9 and to the doctor (i.e. years of practice, medical knowledge, attitudes, rules of thumb).6
Only a few studies have focused on parents' concern about their childrens' infectious diseases. Hansen studied concern about illnesses in general among parents of small children. Parents who reported experiencing a high degree of illness threat in general for their children reported more morbidity in their children.11 They also reported high illness threat for the current illness episode, even when there was a trivial diagnosis.10 In a comprehensive study in Scotland, 113 families were followed during 1 year and with diaries during 4 weeks.13 The mothers rated the level of anxiety for themselves and for the child daily. Both authors found that first time parents were more anxious about their child, which agrees with our findings. Level of anxiety was strongly correlated to perception of symptoms and was an important determining factor for physician consultations.13
In our study, there was no difference in reported days with symptoms of an infectious illness, but parents with high concern reported more days with fever during the RTI. No instructions were given about how to take the child's temperature and no validation of data was done. Hence, it is possible that children of parents with a high level of concern were more seriously ill when they had infections, but another equally possible explanation could be different amount of attention paid to the children. This interpretation is supported by the fact that parents with a high level of concern about infectious illness more often reported that their children were ill when they had RTI without a fever.
Interpretation of symptoms, expectations and perceptions of expectations are concepts used to understand the course of events during an infectious illness. Perception and interpretation often takes place simultaneously. We see what we recognize and expect to see.14 This is also true for evaluation of infectious symptoms. One study in Holland and Belgium clearly showed how different infectious symptoms were evaluated and labelled. In Holland, upper RTI are called ‘flu’ or ‘cold’, something to manage or treat by yourself, while corresponding symptoms in Belgium are called ‘bronchitis’, which ought to be treated with antibiotics.8
In our study, the parents with a high level of concern about infectious illness more often reported their 18-month-old child and the mother of the child as infection prone (Table 1). A comprehensive longitudinal study from primary health care in Holland, where families were followed through generations found marked similarities between parents and children regarding diseases and illness behaviour. There was a significant relationship between children and their grandmothers for new episodes of illnesses.15 The parents' idea that this child is especially infectious prone may express a genuine knowledge,16 but it has also been shown that the idea of infection proneness has no medical basis in about 40 % of the cases.17 Worry about serious disease is a relatively unusual reason for making an emergency doctor's consultation,18 but fear of recurrence of an earlier medical problem could be one important source of concern.17 Asthma was more often reported by the high-concern parents in our study. In line with earlier discussion, this could either be explained by real augmented proneness to infections among children with asthma or by a general concern about the asthma as such.
The high-concern parents in our study not only experience their children as sicker but also took them to a physician more often and had unrealistic expectations about the effects of antibiotics. A study from US showed that level of anxiety increased not only the probability a parent would believe antibiotic was necessary but also physicians' perception of parental expectation.19 In several studies, parents' expectations, even unspoken, about antibiotics have been shown to be a determining factor for antibiotic prescription, confirming both the opinion that antibiotics were necessary and that the child was sick.7 In that way, the health care system contributes to maintaining a vicious circle. Studies have shown that parents who had antibiotics prescribed at an earlier consultation expect them to be prescribed again, when they consult a doctor the next time.5 A good and informative consultation with a doctor or a nurse should make it possible to break such a pattern.
Parental satisfaction with the consultation has little to do with whether or not antibiotics were prescribed. The most important issue for the parents is if they have the impression that the doctor listens to them and shares their concern about the sick child,20 and whether or not the doctor gave adequate information, not only a contingency plan for what to do if the child does not recover within a certain time but also positively framed recommendations for symptomatic treatment.9 It has been shown to be an important factor for recovery among adults that a doctor's consultation makes them feel less worried.21
A study of management of children with upper RTI to whom antibiotics were not prescribed revealed how GPs with the aid of a physical examination swiftly minimized the cause of concern, appealed to the competence of the parents and gave consoling advice and symptomatic treatment.22 Most parents also believe that more information about common diseases would have a comforting effect.20 In Sweden, as in many other Western countries, the prescription of antibiotics to preschool children has been reduced by almost half since mid-1990s. Information in the media and from child health care has probably contributed to this development. A limited educational programme for parents offered by child health care in England gave increased certainty about home care and a reduction in visits to the child health clinic but the parents also indicated feeling less confident and knowledgeable.23 This clearly shows that attitudes, knowledge and actions functions in highly complex interplay.
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Conclusions |
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Concern about infectious illness was a strong determinant for physician consultations and antibiotic prescription and was associated with a perception of infection proneness in the child. It was also associated with unrealistic expectations about antibiotics for an infected child. An appropriate consultation, where the doctor deals with the parents' worries and gives adequate information about symptoms and disease, might contribute to less prescribing of antibiotics with preserved parental satisfaction. More interventional studies in this area are needed.
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Declaration |
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Funding: The study was supported by the Swedish strategic programme for the rational use of antimicrobial agents and surveillance of resistance, the Center for Clinical Research, the Dalarna County Council, Falun, and the Unit for Research and Development Kronoberg Count Council, Växjö, Sweden.
Ethical approval: The study was approved by the committees on research ethics at Linköping, Lund and Uppsala Universities (Drn 02-147).
Conflicts of interest: None
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Notes |
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André M, Hedin K, Håkansson A, Mölstad S, Rodhe N and Petersson C. More physician consultations and antibiotic prescriptions in families with high concern about infectious illness—adequate response to infection-prone child or self-fulfilling prophecy? Family Practice 2007; 24: 302–307.
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References |
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