Racial/Ethnic Variation in Parent Expectations for Antibiotics: Implications for Public Health Campaigns

Abstract

Context. Widespread overuse and inappropriate use of antibiotics are a major public health concern. Little is known about racial/ethnic differences in parents seeking antibiotics for their children's upper respiratory illnesses. Objective. To examine racial/ethnic differences in parent expectations about the need for antibiotics and physician perceptions of those expectations. Design. We conducted a nested, cross-sectional survey of parents who were coming to see their child's pediatrician because of cold symptoms between October 2000 and June 2001. Parents completed a previsit survey that collected information on demographics, their child's illness, and a 15-item previsit expectations inventory that included an item asking how necessary it was for the physician to prescribe antibiotics. Physicians completed a postvisit survey that collected information on diagnosis, treatment, and whether the physician perceived the parent expected an antibiotic. The encounter was the unit of analysis. Multivariate logistic regression analyses were performed to evaluate predictors of dichotomized parental expectations for antibiotics, dichotomized physician perceptions of those expectations, diagnostic patterns, and antibiotic-prescribing patterns. Setting. Twenty-seven community pediatric practices in the Los Angeles, Calif, metropolitan area. Participants. A volunteer sample of 38 pediatricians (participation rate: 64%) and a consecutive sample of 543 parents (participation rate: 83%; ∼15 participating for each enrolled pediatrician) seeking care for their children's respiratory illnesses. Pediatricians were eligible to participate if they worked in a community-based managed care practice in the Los Angeles area. Parents were eligible to participate if they could speak and read English and presented to participating pediatricians with a child 6 months to 10 years old who had cold symptoms but had not received antibiotics within 2 weeks. Main Outcome Measures. Parental beliefs about the necessity of antibiotics for their child's illness, physician perceptions of parental expectations for antibiotics, bacterial diagnosis rates, and antibiotic-prescribing rates. Results. Forty-three percent of parents believed that antibiotics were definitely necessary, and 27% believed that they were probably necessary for their child's illness. Latino and Asian parents were both 17% more likely to report that antibiotics were either definitely or probably necessary than non-Hispanic white parents. Physicians correctly perceived that Asian parents expected antibiotics more often than non-Hispanic white parents but underestimated the greater expectations of Latino parents for antibiotics. Physicians also correctly perceived that parents of children with ear pain or who were very worried about their child's condition were significantly more likely to expect antibiotics. Physicians were 7% more likely to make a bacterial diagnosis and 21% more likely to prescribe antibiotics when they perceived that antibiotics were expected. Conclusions. Parent expectations for antibiotics remain high in Los Angeles County. With time, traditional public health messages related to antibiotic use may decrease expectations among non-Hispanic white parents. However, both public health campaigns and physician educational efforts may need to be designed differently to reach other racial/ethnic groups effectively. Despite public health campaigns to reduce antibiotic overprescribing in the pediatric outpatient setting, physicians continue to respond to parental pressure to prescribe them. To effectively intervene to decrease rates of inappropriate antibiotic prescribing further, physicians need culturally appropriate tools to better communicate and negotiate with parents when feeling pressured to prescribe antibiotics.