International Journal of Pediatric Otorhinolaryngology 78 (2014) 300–306
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Acute otitis media in young children – What do parents say? Colin Barber a,*, Susanne Ille b, Anne Vergison c, Harvey Coates d a
Department of Paediatric Otolaryngology, Starship Hospital, 2 Park Road, Grafton, Auckland 1023, New Zealand GfK SE, Nordwestring 101, Nu¨rnberg, Germany c Department of Paediatric Infectious Diseases, Infection Control and Epidemiology Unit, ULB-Hopital Universitaire Des Enfants, J.J. Crocq 15, 1020 Brussels (Laken), Belgium d School of Paediatrics and Child Health, The University of Western Australia, Perth, 208 Hampden Road, Nedlands, Western Australia 6009, Australia b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 6 August 2013 Received in revised form 21 November 2013 Accepted 24 November 2013 Available online 3 December 2013
Objectives: The Ear infections Attitudes Research study investigated parental attitudes and awareness towards acute otitis media (AOM) and evaluated the burden of AOM for affected children, their families, and parental work capabilities. Methods: This study, conducted via online interviews in October–November 2010, included parents (N = 2867) from 12 countries, whose children aged 3.5 years had experienced 1 professionally diagnosed AOM episode in the last 6 months (AOM-experienced group; N = 1438) or had never experienced any professionally diagnosed AOM episode (non AOM-experienced group; N = 1429). The interviews consisted of questions with multiple-choice, five-point scaled or free-text answers. Answers to multiple-choice questions were presented as frequencies of particular responses and those to scaled questions as mean values or percentages of parents considering each aspect as applicable. Results: Parents considered that the main AOM burdens for affected children were pain (mean values on five-point scales: 4.4 and 4.5), disturbed sleep (4.3 and 4.3) and irritability (4.2 and 4.0) and for their families, sleepless nights (4.2 and 3.8) and worries about the child’s recovery (4.1 and 4.3) and about potential long-term implications (4.0 and 4.3) in the AOM-experienced and non AOM-experienced groups, respectively. During their child’s most recent AOM episode, 95% of parents in the AOMexperienced group used antibiotics, 76% reported that their doctors prescribed antibiotics for immediate use, 13% were advised to return for antibiotic prescription if symptoms did not abate and 9% received a prescription for antibiotics to use if symptoms did not improve. Both reported prescription and usage rates for antibiotics were higher than expected. When their child had AOM, 73% of parents had to be absent from work or rearrange their working hours. Among those who took leave from work, 67% stayed at home for 2–7 days. Conclusions: Parents perceive AOM to be a burden for their child and families, particularly the pain and disturbed sleep due to AOM, and this disease had a significant effect on parents’ ability to attend work. Given how common AOM is, this loss of workdays may lead to substantial financial burden for families and the society. Antibiotics were almost invariably used in all countries despite current guidelines. ß 2013 Elsevier Ireland Ltd. All rights reserved.
Keywords: Acute otitis media Children Survey Burden Awareness Family
1. Introduction Most episodes of acute otitis media (AOM) in children are caused by bacteria, of which the three most frequently identified are Streptococcus pneumoniae, non-typeable Haemophilus influenzae, and Moraxella catarrhalis [1–6]. AOM is one of the most
Abbreviations: AOM, acute otitis media; EAR, Ear infections Attitudes Research. * Corresponding author at: 160 Gillies Avenue, Auckland, New Zealand. Tel.: +64 96311970. E-mail addresses: [email protected] (C. Barber), [email protected] (S. Ille), [email protected] (A. Vergison), [email protected] (H. Coates). 0165-5876/$ – see front matter ß 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijporl.2013.11.030
frequent bacterial infections for which medical advice is sought and represents the most common reason for antibiotic prescription in children younger than five years of age [2,7]. Guidelines on the clinical management of AOM in children have been developed and various countries recommend a ‘‘watch-and-wait’’ policy before starting treatment of AOM with antibiotics, but adherence to these guidelines is poor and early and frequent use of antibiotics continues [1,3,8–11]. Currently, the knowledge of parents’ perceptions and attitudes regarding AOM is limited and additional studies are needed to better understand the situation of children with this disease and to determine priorities in targeting educational interventions. In previous studies, parents reported that AOM had an important
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burden on the affected child, themselves and their family and that this disease resulted in substantial use of medical services and loss of workdays [12,13]. However, parental knowledge about AOM may be inaccurate; parents seem to underestimate the actual risk of their child experiencing an AOM episode and the majority of parents consider that antibiotics are always useful to treat this disease [14,15]. Here, we present the results of the Ear infections Attitudes Research (EAR) survey, which is the largest study that has currently been conducted on a global level to investigate parental attitudes and awareness towards AOM in young children.
parents whose child/children had experienced at least one professionally diagnosed episode of AOM in the last six months (AOM-experienced group) and parents whose child/children had never experienced any professionally diagnosed episode of AOM (non AOM-experienced group). During the recruitment process, panel members received an invitation to take part in the survey and were asked questions to make sure that they were eligible; those who met the criteria were admitted to the survey.
2. Methods
Answers to multiple-choice questions were analysed by considering the frequency of particular responses. Answers to the five-point scaled questions were presented as mean values or as percentages of parents who considered each aspect to be applicable (the two highest values on the scale). Statistical analyses were done with SPSS1 and QuantumTM (IBM Software).
2.1. Study design The EAR study was conducted in October and November 2010 via online interviews by the Health division of GfK SE, Germany, which is a global independent market research company. The survey was sponsored by GlaxoSmithKline Biologicals SA and was overseen by a multi-disciplinary steering committee, the Global Otitis Media Prevention Panel, which provided independent and multi-disciplinary guidance and perspective on the survey design. The research included respondents from 12 countries across the world (Great Britain, Germany, Spain, Poland, Canada, Mexico, South Africa, Australia, New Zealand, Taiwan, the Philippines, and Japan). The healthcare systems of the participating countries, which varied substantially, consisted of a mix of public and private financing and organisation. The online interviews were designed to have durations of 20 min and consisted of multiple-choice, five-point scaled, or freetext questions. The questions focused on the respondents’ perception of the burden of AOM on their child and family and of the impact of AOM on their work and income, on the respondents’ understanding of the connection between antibiotic prescribing and resistance, and on the most common AOM treatment strategies used in reality. 2.2. Study participants Participants were the main caregivers of children under three and a half years old. In this study, 98% of the caregivers were parents and the term ‘‘parent’’ was used when referring to the main caregiver throughout this manuscript. Parents were mostly recruited through a global network of market research online panels of respondents, except in the Philippines where some participants were recruited via physicians’ clinics. Respondents were divided (1:1) into two groups:
2.3. Statistical analyses
3. Results 3.1. Survey population The survey included responses from 2867 parents; 1438 in the AOM-experienced group and 1429 in the non AOM-experienced group (Table 1). There were approximately 250 respondents from each country, except from the Philippines where 100 questionnaires were completed. The mean age of the children who had experienced an episode of AOM was 21.8 8.9 months. Parents in the AOM-experienced group reported that their child/children under three and a half years old had suffered on average 1.5 professionally diagnosed AOM episodes in the past six months (median: 1 episode). The mean duration of the AOM episodes reported by the parents was 8.8 days (median: 7 days). 3.2. Burden of AOM and other typical illnesses for the affected child The aspects that surveyed parents strongly considered to be a burden of AOM for the affected child were pain (mean values on a five-point scale: 4.4 and 4.5), disturbed sleep (both mean values: 4.3), and irritability (mean values: 4.2 and 4.0) in the AOMexperienced and the non AOM-experienced groups, respectively (Fig. 1). Parents in both groups also considered the use of antibiotics as a burden of AOM, albeit to a lesser extent (mean values: 3.8 and 3.5). Only 10% of surveyed parents in the AOMexperienced group took AOM more lightly after having seen their
Table 1 Number of surveyed parents per country. Macro-area
Country
AOM-experienced (N = 1438)
Non AOM-experienced (N = 1429)
Total (N = 2867)
Europe
Great Britain Germany Spain Poland
136 135 123 113
114 116 127 137
250 251 250 250
Northern America
Canada Mexico
125 125
126 125
251 250
Emerging Markets
South Africa
126
126
252
Asia-Pacific
Australia New Zealand Taiwan Philippines
128 125 126 50
129 129 126 50
257 254 252 100
Japan
Japan
126
124
250
Note: AOM-experienced group = parents who have at least one child under three and a half years old who had experienced a professionally diagnosed episode of AOM within the last six months. Non AOM-experienced group = parents who have at least one child under three and a half years old who had never experienced any professionally diagnosed episode of AOM. N = number of parents in the survey.
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non AOM-experienced AOM-experienced Pain Surgery Pneumonia Meningitis Long-term hearing difficulties Recurrent AOM episodes Delayed speech development Temporary hearing difficulties Disturbed sleep Irritability Use of antibiotics Use of pain relief medication Day-care absence Family activities missed out 0
1
2
3
4
5
Mean values Fig. 1. Extent to which parents perceived that different AOM symptoms (A) or potential consequences (B) were a burden for the affected child. Note: AOM-experienced group = parents (N = 1438) who have at least one child under three and a half years old who had experienced a professionally diagnosed episode of AOM within the last six months. Non AOM-experienced group = parents (N = 1429) who have at least one child under three and a half years old who had never experienced any professionally diagnosed episode of AOM. The mean values were taken from a five-point scale, where 1 = ‘‘no strain at all’’ and 5 = ‘‘very significant strain’’. Please note that some of the consequences mentioned in this figure are rare.
child suffering from it, while more than half of them (52%) took AOM more seriously afterwards. Parents in the non AOM-experienced group expected a greater burden of AOM for the affected child than parents in the AOMexperienced group in terms of complications or less widespread consequences of the disease, such as meningitis (mean values: 4.5 and 3.8), long-term hearing difficulties (mean values: 4.5 and 3.8), and recurring AOM episodes (mean values: 4.4 and 3.9). Most surveyed parents across both groups were aware of the following AOM-related consequences: intense ear pain (87%), fever (73%), temporary hearing impairment (70%), and headache (62%). In contrast, surveyed parents were less often aware of other potential consequences of AOM, such as sepsis (translated to infection of the blood in the parents’ questionnaire; 10%), meningitis (17%), and mastoiditis (17%). Parents in the AOM-experienced and non AOM-experienced groups considered that AOM and gastroenteritis (translated to stomach flu in the parents’ questionnaire) involved a burden for the affected child (mean values for both diseases: 4.3 and 4.4) that was lower than pneumonia (mean values: 4.5 and 4.6) but heavier than chicken pox (mean values: 4.0 and 4.1). However, some exceptions were observed: the burden of AOM for the affected child was considered similar to that of pneumonia by parents across both groups in Poland (both mean values: 4.6), South Africa (both mean values: 4.5), Taiwan (mean values: 4.5 and 4.6), and the Philippines (mean values: 4.9 and 5.0), similar to that of chicken pox by parents in Taiwan (mean values: 4.5 and 4.4) and Japan (mean values: 4.2 and 4.1), and lower than that of gastroenteritis by parents in Japan (mean values: 4.2 and 4.4). The percentage of respondents who were concerned about AOM (78%) was lower than pneumonia (92%), but similar to gastroenteritis (75%) and higher than chicken pox (62%). Parents reported that their level of concern would be lower if their child experienced an episode of AOM (mean value: 4.2) than an episode of pneumonia (mean value: 4.7), except in Poland (both mean values: 4.8), South Africa (mean values: 4.4 and 4.5), and the Philippines (mean values: 4.8 and 4.9) where it was similar.
Parents reported that their level of concern would be similar if their child experienced an episode of AOM (mean value: 4.2) or gastroenteritis (mean value: 4.1), except in Spain (mean values: 4.0 and 3.7) and Poland (4.8 and 4.5). The level of concern of parents from all the surveyed countries would be higher if their child experienced an episode of AOM (mean value: 4.2) than an episode of chicken pox (mean value 3.8). 3.3. Burden of AOM for the caregiver and family Heavy burdens of AOM for the caregiver and family perceived by the AOM-experienced and non AOM-experienced parents were worries about the child’s recovery (mean values: 4.1 and 4.3), worries about potential long-term implications (mean values: 4.0 and 4.3), suffering with the child (both mean values: 4.0), and feeling helpless (both mean values: 4.0) (Fig. 2). Some burdens were perceived more strongly by parents in the AOM-experienced group compared with the non AOM-experienced group, including sleepless nights (mean values: 4.2 and 3.8) and the negative impact on their daily performance at work or as a home maker (mean values: 3.8 and 3.5). When AOM was compared with three other typical children’s illnesses (pneumonia, gastroenteritis, and chicken pox), AOM was perceived as involving a mean burden for the entire family of 4.0 in the AOM-experienced group and 4.1 in the non AOM-experienced group, which is lower than pneumonia (mean value in both groups: 4.4) and gastroenteritis (mean value in both groups: 4.2), but heavier than chicken pox (mean value in both groups: 3.9). Exceptions were observed for parents across both groups in Poland (mean values: 4.3 and 4.4) and the Philippines (mean values: 4.9 and 5.0), whereby the burden of AOM for the entire family was considered similar to that of pneumonia. 3.4. Financial and work-related burden of AOM Among the parents in the AOM-experienced group (N = 1438), 52% stated that they (the respondent or their partner) had to be
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non AOM-experienced AOM-experienced
Anxious about immediate health of the child Worried about potential long-term implications Feeling helpless Suffered with the child Sleepless nights Negative impact on daytime performance Rearrangements of child care Rearrangement of family plans Holiday cancelled 0
1
2
3
4
5
Mean value Fig. 2. Extent to which different AOM symptoms or consequences were perceived to be a burden for the parents or the family of children with this disease. Note: AOMexperienced group = parents (N = 1438) who have at least one child under three and a half years old who had experienced a professionally diagnosed episode of AOM within the last six months. Non AOM-experienced group = parents (N = 1429) who have at least one child under three and a half years old who had never experienced any professionally diagnosed episode of AOM. The mean values were taken from a five-point scale, where 1 = ‘‘no strain at all’’ and 5 = ‘‘very significant strain’’.
absent from work when their child had AOM, 21% had to rearrange their working hours, and 27% attended work as usual (Fig. 3). The surveyed parents who took leave from work (N = 743) reported that had to stay at home for 1 day (24%), 2–3 days (44%), 4–7 days (23%), or at least 8 days (9%). The work-related burden differed widely between the countries; in particular, 29% of surveyed parents who took leave from work in Poland, but 0% in New Zealand, reported that they had to be absent for 8 days or more when their child was suffering from an AOM episode. From a choice of responses, 44% of surveyed parents who took leave from work (N = 743) indicated that consequences of their unexpected absence included the use of some of their annual holiday or leave allowance, 37% indicated a reduction of the money earned by the family, 12% indicated problems at work for themselves or their partners, and 11% indicated problems at work for their colleagues. Of note, 19% of surveyed parents did not report that they had experienced any of the above listed consequences of their absence from work.
3.5. Usage of antibiotics Parents in the AOM-experienced group reported that, during the most recent episode of AOM of their child, their doctor prescribed antibiotics for immediate use (76%), told them to return for prescription of antibiotics if the symptoms did not improve (13%), prescribed antibiotics to be taken after a few days if the symptoms did not improve (9%), or did not prescribe antibiotics (2%) (Fig. 4). The highest percentage of respondents reporting that their doctors did not prescribe antibiotics was in Germany (6%). The percentages of respondents whose doctors prescribed antibiotics for immediate use varied between 30% (Taiwan; statistically significantly different from all the other countries) and 100% (the Philippines; statistically significantly different from all the Prescription for immediate antibiotic use Prescription for use if no improvement Return to the doctor if no improvement No prescription
100
50
2-3 days
4-7 days
At least 8 days
Fig. 3. Duration of parents’ absence from work when their child experienced the most recent episode of AOM infection (based on the answers of those 52% [N = 743] of parents from the AOM-experienced group who took leave from work).
Total
Japan
Taiwan
Philippines
1 day
New Zealand
0
Australia
0
Mexico
10
South Africa
20
Canada
20
Poland
40
Spain
30
60
G re at Britain
Percentage of parents
40
Germany
Pe rce ntage of pare nts
80
Fig. 4. Doctors’ advice to parents concerning the use of antibiotics during the most recent episode of AOM of their child (AOM-experienced group [N = 1438]).
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other countries). In Taiwan, the majority of surveyed parents were told to wait and see if symptoms improved before giving the antibiotics: 44% of Taiwanese parents were told to return to the doctor later to receive the prescription if needed and 22% had received the prescription directly but were asked to wait before giving the antibiotics. In the AOM-experienced group, the majority of parents (76%) reported that they had immediately used antibiotics during the most recent episode of AOM of their child; 18% of parents waited to see if the child’s symptoms improved before giving antibiotics; 1% went to another doctor to receive an antibiotic prescription since their doctor did not prescribe antibiotics; and 5% did not use antibiotics (Fig. 5). The highest percentages of surveyed parents who did not use antibiotics were reported in Germany and Taiwan (12% and 10%; both statistically significantly different from Poland, South Africa, Mexico, and the Philippines). The percentage of surveyed parents who reported immediate antibiotic use varied between 37% (Taiwan; statistically significantly different from all the other countries) and 100% (the Philippines; statistically significantly different from all the other countries). In Taiwan, 49% of surveyed parents first waited to see if their child’s symptoms improved before giving antibiotics. 3.6. Attitudes towards antibiotic prescription The proportion of respondents across both groups (N = 2867) who stated that doctors prescribe antibiotics appropriately was 45%, that they prescribe too many antibiotics 23%, and that they do not prescribe enough antibiotics 6%. Moreover, 26% of surveyed parents thought that antibiotics should be used only for severe infections and 9% declared that they could not give an answer because they did not have the scientific knowledge to have an opinion on antibiotic usage. Across both groups, 32% of parents were able to identify a correct definition of antibiotic resistance (antibiotics can become less effective the more they are used across the population as bacteria become resistant to them), while 57% thought that antibiotic resistance meant that the body gets used to antibiotics and they become ineffective. A minority of surveyed parents thought that antibiotic resistance meant that antibiotics can Immediate antibiotic use Antibiotic use after visit to another doctor Wait and see before antibiotic use No antibiotic use
100
Pe rce ntage s of pare nts
80
60
40
20
Total
Japan
Philippines
Taiwan
New Zealand
Australia
Mexico
South-Africa
Canada
Poland
Spain
Germany
G re at B ritain
0
Fig. 5. Usage of antibiotics by the parents for treating the most recent episode of AOM of their child (AOM-experienced group [N = 1438]).
become more effective the more they are used across the population (5%) or that antibiotics can have side-effects like diarrhoea (5%). When surveyed parents were asked to evaluate what is generally happening with most common antibiotics, the majority of them (74%) correctly assumed that antibiotics were becoming less effective. After having been told the correct definition of antibiotic resistance, 73% of surveyed parents stated that they were concerned about a rise in antibiotic resistance. 3.7. Measures to prevent AOM Canada and South Africa were not included in these analyses because AOM indications were not comprised in the license of pneumococcal vaccines in these countries. According to the surveyed parents (N = 2364), measures that could be taken to prevent AOM included vaccination (23%), taking medication to prevent an infection elsewhere spreading to the ear (25%), and keeping the child warm on cold days (41%). More than half (57%) of respondents would likely consider vaccinating their child against AOM if they knew that a vaccine was available, 13% would not consider vaccination against AOM, and the remaining respondents were undecided. The likelihood of a parent considering vaccination of their children against AOM was similar in the AOM-experienced and the non AOM-experienced groups. 4. Discussion 4.1. Burden of AOM The EAR study directly consulted almost 3000 parents from around the world about the impact that AOM had on their child, themselves, and their family. Parents whose children had experienced AOM in the last six months (N = 1438) considered that the main burdens of this disease for the affected child were pain, disturbed sleep and irritability, which is consistent with previous observations [13,16]. These results support the important role of symptomatic drugs (e.g. analgesics) for the treatment of AOM and may explain why the majority of the surveyed parents took AOM more seriously after having seen their child suffering from it. Parents declared that AOM affected themselves and their whole family mainly due to sleepless nights and worry about the child’s recovery. More than half of the surveyed parents in the AOM-experienced group stated that they had to be absent from work when their child last had AOM, which is a higher proportion than that reported previously by European caregivers, who declared that they had to take time off from a paid job in about 20% of physician-confirmed AOM episodes [17]. A potential explanation for this difference could be that the previous study referred to children under 5 years of age, while the present study is based on children younger than three and a half years old. Moreover, the percentage of 20% reported in the previous study was based on absence from a paid job, while this was not a criterion in the present study. This loss of working days may lead to a reduction of the money earned by the family, especially in developing countries where sick leave is less formalised. Moreover, previous studies have shown that AOM also reduces the family income due to indirect costs and that this common disease has a significant economic impact for society overall [13,17,18]. In our survey, the overall reported burden for the affected child and their family and the level of concern for AOM were higher than those for chicken pox, similar to those for gastroenteritis and lower than those for pneumonia. However, some differences were observed between countries, such as parents in Poland, South Africa, Taiwan, and the Philippines who estimated that, for the
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affected child, the burden of pneumonia was similar to that of AOM or parents in Japan who estimated that the burden of AOM was lower than that of gastroenteritis. In a previous study conducted in nine countries, of which five countries were also included in the present study, physicians considered that AOM was a more severe disease than chicken pox, but a less severe disease than pneumonia and gastroenteritis [19]. In the present study, the majority of parents were unaware of serious consequences that AOM can have for a child, such as sepsis and meningitis [20]. This finding was expected since the majority of doctors do not routinely inform parents about the complications associated with AOM because the incidence of serious consequences of this disease has become extremely low, especially in developed countries [21–24]. 4.2. Attitudes towards antibiotics and AOM prevention Respondents from most countries reported that antibiotics to be taken immediately were frequently prescribed by physicians for treating AOM. These results are in line with findings from previous studies showing that the vast majority of patients with AOM were treated with antibiotics [12,19,25,26]. The high prescription rates of antibiotics for immediate use that was reported by surveyed parents in Australia (81%) and Great Britain (75%) were surprising because national guidelines in both countries advise physicians to delay the prescription of antibiotics for children with AOM [8,9]. The high prescription rates of antibiotics for immediate use reported by surveyed parents in Germany (76%) contrasts with results of previous studies, in which only 40% of German paediatricians reported that they used antibiotics as first line treatment for AOM [19] and 60.8% of German parents declared that antibiotics were prescribed to their children during their last physician-confirmed AOM episode [17]. Although further investigations would be needed to explain these discrepancies between studies, potential explanations included the facts that paediatricians only reported antibiotic use as first line treatment, while parents in the present study did not specify whether the antibiotics were prescribed at the first visit or later, and that both previous studies referred to children younger than five years of age. The low antibiotic prescription rate reported by Taiwanese parents suggests that the paediatricians follow the new antibiotic use payment regulation implemented by the National Health Insurance Drug Payment Regulations in 2001 in Taiwan, which mentions that there should be clinical evidence of bacterial infection, such as bacterial otitis media, before antibiotics may be used [27]. Although parents were somewhat more critical about the use of antibiotics in some countries, the vast majority of them were compliant and gave the prescribed antibiotics to their child immediately. The majority of parents were aware that the most common antibiotics are generally becoming less effective, but they were not aware of the true reason for the development of antibiotic resistance (they incorrectly assumed that the body, rather than bacteria, becomes resistant to antibiotics). They declared that they were concerned about the rise in antibiotic resistance, which is in line with findings from a previous study conducted in Finland and the Netherlands [15]. In all the countries, except Taiwan, the implementation of a ‘‘watch-and-wait’’ strategy before giving antibiotics to children with AOM seemed challenging and had a limited impact on the use of antibiotics. This observation is in line with previous studies showing that adherence of physicians to the AOM guidelines was poor [3]. These findings suggest that further education is needed to support better understanding of the connection between antibiotic prescribing and resistance and to emphasise the role that frequent childhood diseases, such as AOM, have in the rise in antibiotic resistance.
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The results of our study raised questions as to whether new preventative approaches for AOM were needed. Although most surveyed parents were not aware of the availability of a vaccine against AOM, more than half of them stated that they would consider getting their child vaccinated against this disease, which is in line with the results of a previous study conducted in Canada [14]. In contrast with what was reported in the previous Canadian study, parents in our study were not more likely to consider vaccination if their child had experienced AOM than if their child did not experience the disease [14]. 4.3. Study strengths and limitations The strengths of this study included the high number of respondents, who were enrolled in 12 countries across the world. The questions were directly addressed to parents and closely reflected their perceptions about AOM, its consequences, and medical practices. This is the largest survey to date that investigated parental attitudes towards AOM and gives a snapshot of the global situation. Limitations of this study, which might lead to potential selection biases, included the use of online interviews and the limited number of respondents per country, who might not be representative of the population of parents in each country. Moreover, the list of questions that was sent to the parents varied between countries, and therefore between countries comparisons should be interpreted cautiously. Other limitations include the lack of information on the sex and the health status of the affected children, and the absence of stratification by age. 4.4. Study conclusions In the 12 countries included in this study, parents perceived the effects of AOM to be a burden for their children and families, particularly pain and disturbed sleep, and they reported that AOM had a significant effect on their ability to attend work. Parents mostly seemed to trust their doctors, but they were not well informed on why rational use of antibiotics was mandatory. Alongside parental misbeliefs on antibiotic actions, physicians might not be fully aware of AOM treatment recommendations and prevention opportunities. Conflict of interest The institution of SI received money from GlaxoSmithKline group of companies for conducting and analysing the survey. AV and CB declare that they received payment for advisory board membership and meeting attendance from GlaxoSmithKline group of companies. HC declares he received payment for consultancy and meeting attendance from GlaxoSmithKline group of companies. Authors’ contributions SI was involved in the plan, design, and review of the reported study, the collection of the data, the interpretation of the results, and the coordination of the study. AV participated to the study design and the interpretation of the data. HC was involved in the review of the reported study and the interpretation and comments on the results. CB was involved in the plan design and review of the reported study and the interpretation of the data. Funding source GlaxoSmithKline Biologicals SA was the funding source and was involved in all stages of the study conduct and analysis.
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GlaxoSmithKline Biologicals SA also funded all costs associated with the development and the publishing of the present manuscript. Acknowledgements The authors thank the parents who participated in the study and the members of the Global Otitis Media Prevention Panel for their contribution to the survey. We thank Claire Verbelen (XPE Pharma & Science) for scientific writing support and Bart van Heertum (XPE Pharma & Science c/o GlaxoSmithKline Vaccines) for editorial support and manuscript coordination. References [1] A.S. Lieberthal, A.E. Carroll, T. Chonmaitree, T.G. Ganiats, A. Hoberman, M.A. Jackson, et al., The diagnosis and management of acute otitis media, Pediatrics 131 (2013) e964–e999. [2] A.W. Cripps, D.C. Otczyk, J.M. Kyd, Bacterial otitis media: a vaccine preventable disease? Vaccine 23 (2005) 2304–2310. [3] A. Vergison, R. Dagan, A. Arguedas, J. Bonhoeffer, R. Cohen, I. Dhooge, et al., Otitis media and its consequences: beyond the earache, Lancet Infect. Dis. 10 (2010) 195–203. [4] L. Corbeel, What is new in otitis media? Eur. J. Pediatr. 166 (2007) 511–519. [5] E. Leibovitz, Acute otitis media in pediatric medicine: current issues in epidemiology, diagnosis, and management, Paediatr. Drugs 5 (Suppl. 1) (2003) 1–12. [6] M.E. Pichichero, Evolving shifts in otitis media pathogens: relevance to a managed care organization, Am. J. Manag. Care 1 (Suppl. 6) (2005) S192–S201, 1. [7] J.O. Klein, media. Otitis, Clin. Infect. Dis. 19 (1994) 823–833. [8] P. Little, Delayed prescribing—a sensible approach to the management of acute otitis media, JAMA 296 (2006) 1290–1291. [9] NSW Department of Health, Children and Infants with Otitis media – Acute management, 2004 Available at: http://www.health.nsw.gov.au/policies/PD/ 2005/pdf/PD2005_385.pdf (last accessed 31.08.12). [10] C.L.M. Appelman, P. Bossen, J. Dunk, E. Lisdonk, R.A. de Melker, H. van Weert, NHG Standard otitis media acuta – guideline on acute otitis media of the Dutch College of General Practitioners, Huisarts Wet 33 (1990) 242–245. [11] M. Haggard, Poor adherence to antibiotic prescribing guidelines in acute otitis media – obstacles, implications, and possible solutions, Eur. J. Pediatr. 170 (2011) 323–332.
[12] E. Dube, P. De Wals, V. Gilca, N. Boulianne, M. Ouakki, F. Lavoie, et al., Burden of acute otitis media on Canadian families, Can. Fam. Physician 57 (2011) 60–65. [13] D. Greenberg, N. Bilenko, Z. Liss, T. Shagan, O. Zamir, R. Dagan, The burden of acute otitis media on the patient and the family, Eur. J. Pediatr. 162 (2003) 576–581. [14] E. Dube, P. De Wals, V. Gilca, N. Boulianne, M. Ouakki, F. Lavoie, et al., New vaccines offering a larger spectrum of protection against acute otitis media: will parents be willing to have their children immunized? Int. J. Pediatr. Otorhinolaryngol. 73 (2009) 987–991. [15] P.A. Tahtinen, C.W. Boonacker, M.M. Rovers, A.G. Schilder, P. Huovinen, P.R. Liuksila, et al., Parental experiences and attitudes regarding the management of acute otitis media-a comparative questionnaire between Finland and The Netherlands, Fam. Pract. 26 (2009) 488–492. [16] S. Berman, Otitis media in children, N. Engl. J. Med. 332 (1995) 1560–1565. [17] J.H. Wolleswinkel-van den Bosch, E.A. Stolk, M. Francois, R. Gasparini, M. Brosa, The health care burden and societal impact of acute otitis media in seven European countries: results of an Internet survey, Vaccine 28 (Suppl. 6) (2010) G39–G52. [18] M. Niemela, M. Uhari, M. Mottonen, T. Pokka, Costs arising from otitis media, Acta Paediatr. 88 (1999) 553–556. [19] A. Arguedas, K. Kvaerner, J. Liese, A.G. Schilder, S.I. Pelton, Otitis media across nine countries: disease burden and management, Int. J. Pediatr. Otorhinolaryngol. 74 (2010) 1419–1424. [20] L. Monasta, L. Ronfani, F. Marchetti, M. Montico, L. Vecchi Brumatti, A. Bavcar, et al., Burden of disease caused by otitis media: systematic review and global estimates, PLoS One 7 (2012) e36226. [21] I. Petersen, A.M. Johnson, A. Islam, G. Duckworth, D.M. Livermore, A.C. Hayward, Protective effect of antibiotics against serious complications of common respiratory tract infections: retrospective cohort study with the UK General Practice Research Database, BMJ 335 (2007) 982. [22] S. Berman, Otitis media in developing countries, Pediatrics 96 (1995) 126–131. [23] K. Leskinen, J. Jero, Complications of acute otitis media in children in southern Finland, Int. J. Pediatr. Otorhinolaryngol. 68 (2004) 317–324. [24] D.A. Van Zuijlen, A.G. Schilder, F.A. Van Balen, A.W. Hoes, National differences in incidence of acute mastoiditis: relationship to prescribing patterns of antibiotics for acute otitis media? Pediatr. Infect. Dis. J. 20 (2001) 140–144. [25] L. Vernacchio, R.M. Vezina, A.A. Mitchell, Management of acute otitis media by primary care physicians: trends since the release of the 2004 American Academy of Pediatrics/American Academy of Family Physicians clinical practice guideline, Pediatrics 120 (2007) 281–287. [26] M.P. Hansen, D.E. Jarbol, B. Gahrn-Hansen, R. Depont Christensen, A. Munck, C. Ellegaard Trankjaer Ryborg, et al., Treatment of acute otitis media in general practice: quality variations across countries, Fam. Pract. 29 (2012) 63–68. [27] K. Ying-tiao, Antibiotics in a patient with upper respiratory tract infection and otitis media, Med. Dispute Mediat. Rep. 37 (2008) 32–37.
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Acute otitis media in young children – What do parents say? Colin Barber a,*, Susanne Ille b, Anne Vergison c, Harvey Coates d a
Department of Paediatric Otolaryngology, Starship Hospital, 2 Park Road, Grafton, Auckland 1023, New Zealand GfK SE, Nordwestring 101, Nu¨rnberg, Germany c Department of Paediatric Infectious Diseases, Infection Control and Epidemiology Unit, ULB-Hopital Universitaire Des Enfants, J.J. Crocq 15, 1020 Brussels (Laken), Belgium d School of Paediatrics and Child Health, The University of Western Australia, Perth, 208 Hampden Road, Nedlands, Western Australia 6009, Australia b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 6 August 2013 Received in revised form 21 November 2013 Accepted 24 November 2013 Available online 3 December 2013
Objectives: The Ear infections Attitudes Research study investigated parental attitudes and awareness towards acute otitis media (AOM) and evaluated the burden of AOM for affected children, their families, and parental work capabilities. Methods: This study, conducted via online interviews in October–November 2010, included parents (N = 2867) from 12 countries, whose children aged 3.5 years had experienced 1 professionally diagnosed AOM episode in the last 6 months (AOM-experienced group; N = 1438) or had never experienced any professionally diagnosed AOM episode (non AOM-experienced group; N = 1429). The interviews consisted of questions with multiple-choice, five-point scaled or free-text answers. Answers to multiple-choice questions were presented as frequencies of particular responses and those to scaled questions as mean values or percentages of parents considering each aspect as applicable. Results: Parents considered that the main AOM burdens for affected children were pain (mean values on five-point scales: 4.4 and 4.5), disturbed sleep (4.3 and 4.3) and irritability (4.2 and 4.0) and for their families, sleepless nights (4.2 and 3.8) and worries about the child’s recovery (4.1 and 4.3) and about potential long-term implications (4.0 and 4.3) in the AOM-experienced and non AOM-experienced groups, respectively. During their child’s most recent AOM episode, 95% of parents in the AOMexperienced group used antibiotics, 76% reported that their doctors prescribed antibiotics for immediate use, 13% were advised to return for antibiotic prescription if symptoms did not abate and 9% received a prescription for antibiotics to use if symptoms did not improve. Both reported prescription and usage rates for antibiotics were higher than expected. When their child had AOM, 73% of parents had to be absent from work or rearrange their working hours. Among those who took leave from work, 67% stayed at home for 2–7 days. Conclusions: Parents perceive AOM to be a burden for their child and families, particularly the pain and disturbed sleep due to AOM, and this disease had a significant effect on parents’ ability to attend work. Given how common AOM is, this loss of workdays may lead to substantial financial burden for families and the society. Antibiotics were almost invariably used in all countries despite current guidelines. ß 2013 Elsevier Ireland Ltd. All rights reserved.
Keywords: Acute otitis media Children Survey Burden Awareness Family
1. Introduction Most episodes of acute otitis media (AOM) in children are caused by bacteria, of which the three most frequently identified are Streptococcus pneumoniae, non-typeable Haemophilus influenzae, and Moraxella catarrhalis [1–6]. AOM is one of the most
Abbreviations: AOM, acute otitis media; EAR, Ear infections Attitudes Research. * Corresponding author at: 160 Gillies Avenue, Auckland, New Zealand. Tel.: +64 96311970. E-mail addresses: [email protected] (C. Barber), [email protected] (S. Ille), [email protected] (A. Vergison), [email protected] (H. Coates). 0165-5876/$ – see front matter ß 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijporl.2013.11.030
frequent bacterial infections for which medical advice is sought and represents the most common reason for antibiotic prescription in children younger than five years of age [2,7]. Guidelines on the clinical management of AOM in children have been developed and various countries recommend a ‘‘watch-and-wait’’ policy before starting treatment of AOM with antibiotics, but adherence to these guidelines is poor and early and frequent use of antibiotics continues [1,3,8–11]. Currently, the knowledge of parents’ perceptions and attitudes regarding AOM is limited and additional studies are needed to better understand the situation of children with this disease and to determine priorities in targeting educational interventions. In previous studies, parents reported that AOM had an important
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burden on the affected child, themselves and their family and that this disease resulted in substantial use of medical services and loss of workdays [12,13]. However, parental knowledge about AOM may be inaccurate; parents seem to underestimate the actual risk of their child experiencing an AOM episode and the majority of parents consider that antibiotics are always useful to treat this disease [14,15]. Here, we present the results of the Ear infections Attitudes Research (EAR) survey, which is the largest study that has currently been conducted on a global level to investigate parental attitudes and awareness towards AOM in young children.
parents whose child/children had experienced at least one professionally diagnosed episode of AOM in the last six months (AOM-experienced group) and parents whose child/children had never experienced any professionally diagnosed episode of AOM (non AOM-experienced group). During the recruitment process, panel members received an invitation to take part in the survey and were asked questions to make sure that they were eligible; those who met the criteria were admitted to the survey.
2. Methods
Answers to multiple-choice questions were analysed by considering the frequency of particular responses. Answers to the five-point scaled questions were presented as mean values or as percentages of parents who considered each aspect to be applicable (the two highest values on the scale). Statistical analyses were done with SPSS1 and QuantumTM (IBM Software).
2.1. Study design The EAR study was conducted in October and November 2010 via online interviews by the Health division of GfK SE, Germany, which is a global independent market research company. The survey was sponsored by GlaxoSmithKline Biologicals SA and was overseen by a multi-disciplinary steering committee, the Global Otitis Media Prevention Panel, which provided independent and multi-disciplinary guidance and perspective on the survey design. The research included respondents from 12 countries across the world (Great Britain, Germany, Spain, Poland, Canada, Mexico, South Africa, Australia, New Zealand, Taiwan, the Philippines, and Japan). The healthcare systems of the participating countries, which varied substantially, consisted of a mix of public and private financing and organisation. The online interviews were designed to have durations of 20 min and consisted of multiple-choice, five-point scaled, or freetext questions. The questions focused on the respondents’ perception of the burden of AOM on their child and family and of the impact of AOM on their work and income, on the respondents’ understanding of the connection between antibiotic prescribing and resistance, and on the most common AOM treatment strategies used in reality. 2.2. Study participants Participants were the main caregivers of children under three and a half years old. In this study, 98% of the caregivers were parents and the term ‘‘parent’’ was used when referring to the main caregiver throughout this manuscript. Parents were mostly recruited through a global network of market research online panels of respondents, except in the Philippines where some participants were recruited via physicians’ clinics. Respondents were divided (1:1) into two groups:
2.3. Statistical analyses
3. Results 3.1. Survey population The survey included responses from 2867 parents; 1438 in the AOM-experienced group and 1429 in the non AOM-experienced group (Table 1). There were approximately 250 respondents from each country, except from the Philippines where 100 questionnaires were completed. The mean age of the children who had experienced an episode of AOM was 21.8 8.9 months. Parents in the AOM-experienced group reported that their child/children under three and a half years old had suffered on average 1.5 professionally diagnosed AOM episodes in the past six months (median: 1 episode). The mean duration of the AOM episodes reported by the parents was 8.8 days (median: 7 days). 3.2. Burden of AOM and other typical illnesses for the affected child The aspects that surveyed parents strongly considered to be a burden of AOM for the affected child were pain (mean values on a five-point scale: 4.4 and 4.5), disturbed sleep (both mean values: 4.3), and irritability (mean values: 4.2 and 4.0) in the AOMexperienced and the non AOM-experienced groups, respectively (Fig. 1). Parents in both groups also considered the use of antibiotics as a burden of AOM, albeit to a lesser extent (mean values: 3.8 and 3.5). Only 10% of surveyed parents in the AOMexperienced group took AOM more lightly after having seen their
Table 1 Number of surveyed parents per country. Macro-area
Country
AOM-experienced (N = 1438)
Non AOM-experienced (N = 1429)
Total (N = 2867)
Europe
Great Britain Germany Spain Poland
136 135 123 113
114 116 127 137
250 251 250 250
Northern America
Canada Mexico
125 125
126 125
251 250
Emerging Markets
South Africa
126
126
252
Asia-Pacific
Australia New Zealand Taiwan Philippines
128 125 126 50
129 129 126 50
257 254 252 100
Japan
Japan
126
124
250
Note: AOM-experienced group = parents who have at least one child under three and a half years old who had experienced a professionally diagnosed episode of AOM within the last six months. Non AOM-experienced group = parents who have at least one child under three and a half years old who had never experienced any professionally diagnosed episode of AOM. N = number of parents in the survey.
302
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non AOM-experienced AOM-experienced Pain Surgery Pneumonia Meningitis Long-term hearing difficulties Recurrent AOM episodes Delayed speech development Temporary hearing difficulties Disturbed sleep Irritability Use of antibiotics Use of pain relief medication Day-care absence Family activities missed out 0
1
2
3
4
5
Mean values Fig. 1. Extent to which parents perceived that different AOM symptoms (A) or potential consequences (B) were a burden for the affected child. Note: AOM-experienced group = parents (N = 1438) who have at least one child under three and a half years old who had experienced a professionally diagnosed episode of AOM within the last six months. Non AOM-experienced group = parents (N = 1429) who have at least one child under three and a half years old who had never experienced any professionally diagnosed episode of AOM. The mean values were taken from a five-point scale, where 1 = ‘‘no strain at all’’ and 5 = ‘‘very significant strain’’. Please note that some of the consequences mentioned in this figure are rare.
child suffering from it, while more than half of them (52%) took AOM more seriously afterwards. Parents in the non AOM-experienced group expected a greater burden of AOM for the affected child than parents in the AOMexperienced group in terms of complications or less widespread consequences of the disease, such as meningitis (mean values: 4.5 and 3.8), long-term hearing difficulties (mean values: 4.5 and 3.8), and recurring AOM episodes (mean values: 4.4 and 3.9). Most surveyed parents across both groups were aware of the following AOM-related consequences: intense ear pain (87%), fever (73%), temporary hearing impairment (70%), and headache (62%). In contrast, surveyed parents were less often aware of other potential consequences of AOM, such as sepsis (translated to infection of the blood in the parents’ questionnaire; 10%), meningitis (17%), and mastoiditis (17%). Parents in the AOM-experienced and non AOM-experienced groups considered that AOM and gastroenteritis (translated to stomach flu in the parents’ questionnaire) involved a burden for the affected child (mean values for both diseases: 4.3 and 4.4) that was lower than pneumonia (mean values: 4.5 and 4.6) but heavier than chicken pox (mean values: 4.0 and 4.1). However, some exceptions were observed: the burden of AOM for the affected child was considered similar to that of pneumonia by parents across both groups in Poland (both mean values: 4.6), South Africa (both mean values: 4.5), Taiwan (mean values: 4.5 and 4.6), and the Philippines (mean values: 4.9 and 5.0), similar to that of chicken pox by parents in Taiwan (mean values: 4.5 and 4.4) and Japan (mean values: 4.2 and 4.1), and lower than that of gastroenteritis by parents in Japan (mean values: 4.2 and 4.4). The percentage of respondents who were concerned about AOM (78%) was lower than pneumonia (92%), but similar to gastroenteritis (75%) and higher than chicken pox (62%). Parents reported that their level of concern would be lower if their child experienced an episode of AOM (mean value: 4.2) than an episode of pneumonia (mean value: 4.7), except in Poland (both mean values: 4.8), South Africa (mean values: 4.4 and 4.5), and the Philippines (mean values: 4.8 and 4.9) where it was similar.
Parents reported that their level of concern would be similar if their child experienced an episode of AOM (mean value: 4.2) or gastroenteritis (mean value: 4.1), except in Spain (mean values: 4.0 and 3.7) and Poland (4.8 and 4.5). The level of concern of parents from all the surveyed countries would be higher if their child experienced an episode of AOM (mean value: 4.2) than an episode of chicken pox (mean value 3.8). 3.3. Burden of AOM for the caregiver and family Heavy burdens of AOM for the caregiver and family perceived by the AOM-experienced and non AOM-experienced parents were worries about the child’s recovery (mean values: 4.1 and 4.3), worries about potential long-term implications (mean values: 4.0 and 4.3), suffering with the child (both mean values: 4.0), and feeling helpless (both mean values: 4.0) (Fig. 2). Some burdens were perceived more strongly by parents in the AOM-experienced group compared with the non AOM-experienced group, including sleepless nights (mean values: 4.2 and 3.8) and the negative impact on their daily performance at work or as a home maker (mean values: 3.8 and 3.5). When AOM was compared with three other typical children’s illnesses (pneumonia, gastroenteritis, and chicken pox), AOM was perceived as involving a mean burden for the entire family of 4.0 in the AOM-experienced group and 4.1 in the non AOM-experienced group, which is lower than pneumonia (mean value in both groups: 4.4) and gastroenteritis (mean value in both groups: 4.2), but heavier than chicken pox (mean value in both groups: 3.9). Exceptions were observed for parents across both groups in Poland (mean values: 4.3 and 4.4) and the Philippines (mean values: 4.9 and 5.0), whereby the burden of AOM for the entire family was considered similar to that of pneumonia. 3.4. Financial and work-related burden of AOM Among the parents in the AOM-experienced group (N = 1438), 52% stated that they (the respondent or their partner) had to be
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non AOM-experienced AOM-experienced
Anxious about immediate health of the child Worried about potential long-term implications Feeling helpless Suffered with the child Sleepless nights Negative impact on daytime performance Rearrangements of child care Rearrangement of family plans Holiday cancelled 0
1
2
3
4
5
Mean value Fig. 2. Extent to which different AOM symptoms or consequences were perceived to be a burden for the parents or the family of children with this disease. Note: AOMexperienced group = parents (N = 1438) who have at least one child under three and a half years old who had experienced a professionally diagnosed episode of AOM within the last six months. Non AOM-experienced group = parents (N = 1429) who have at least one child under three and a half years old who had never experienced any professionally diagnosed episode of AOM. The mean values were taken from a five-point scale, where 1 = ‘‘no strain at all’’ and 5 = ‘‘very significant strain’’.
absent from work when their child had AOM, 21% had to rearrange their working hours, and 27% attended work as usual (Fig. 3). The surveyed parents who took leave from work (N = 743) reported that had to stay at home for 1 day (24%), 2–3 days (44%), 4–7 days (23%), or at least 8 days (9%). The work-related burden differed widely between the countries; in particular, 29% of surveyed parents who took leave from work in Poland, but 0% in New Zealand, reported that they had to be absent for 8 days or more when their child was suffering from an AOM episode. From a choice of responses, 44% of surveyed parents who took leave from work (N = 743) indicated that consequences of their unexpected absence included the use of some of their annual holiday or leave allowance, 37% indicated a reduction of the money earned by the family, 12% indicated problems at work for themselves or their partners, and 11% indicated problems at work for their colleagues. Of note, 19% of surveyed parents did not report that they had experienced any of the above listed consequences of their absence from work.
3.5. Usage of antibiotics Parents in the AOM-experienced group reported that, during the most recent episode of AOM of their child, their doctor prescribed antibiotics for immediate use (76%), told them to return for prescription of antibiotics if the symptoms did not improve (13%), prescribed antibiotics to be taken after a few days if the symptoms did not improve (9%), or did not prescribe antibiotics (2%) (Fig. 4). The highest percentage of respondents reporting that their doctors did not prescribe antibiotics was in Germany (6%). The percentages of respondents whose doctors prescribed antibiotics for immediate use varied between 30% (Taiwan; statistically significantly different from all the other countries) and 100% (the Philippines; statistically significantly different from all the Prescription for immediate antibiotic use Prescription for use if no improvement Return to the doctor if no improvement No prescription
100
50
2-3 days
4-7 days
At least 8 days
Fig. 3. Duration of parents’ absence from work when their child experienced the most recent episode of AOM infection (based on the answers of those 52% [N = 743] of parents from the AOM-experienced group who took leave from work).
Total
Japan
Taiwan
Philippines
1 day
New Zealand
0
Australia
0
Mexico
10
South Africa
20
Canada
20
Poland
40
Spain
30
60
G re at Britain
Percentage of parents
40
Germany
Pe rce ntage of pare nts
80
Fig. 4. Doctors’ advice to parents concerning the use of antibiotics during the most recent episode of AOM of their child (AOM-experienced group [N = 1438]).
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other countries). In Taiwan, the majority of surveyed parents were told to wait and see if symptoms improved before giving the antibiotics: 44% of Taiwanese parents were told to return to the doctor later to receive the prescription if needed and 22% had received the prescription directly but were asked to wait before giving the antibiotics. In the AOM-experienced group, the majority of parents (76%) reported that they had immediately used antibiotics during the most recent episode of AOM of their child; 18% of parents waited to see if the child’s symptoms improved before giving antibiotics; 1% went to another doctor to receive an antibiotic prescription since their doctor did not prescribe antibiotics; and 5% did not use antibiotics (Fig. 5). The highest percentages of surveyed parents who did not use antibiotics were reported in Germany and Taiwan (12% and 10%; both statistically significantly different from Poland, South Africa, Mexico, and the Philippines). The percentage of surveyed parents who reported immediate antibiotic use varied between 37% (Taiwan; statistically significantly different from all the other countries) and 100% (the Philippines; statistically significantly different from all the other countries). In Taiwan, 49% of surveyed parents first waited to see if their child’s symptoms improved before giving antibiotics. 3.6. Attitudes towards antibiotic prescription The proportion of respondents across both groups (N = 2867) who stated that doctors prescribe antibiotics appropriately was 45%, that they prescribe too many antibiotics 23%, and that they do not prescribe enough antibiotics 6%. Moreover, 26% of surveyed parents thought that antibiotics should be used only for severe infections and 9% declared that they could not give an answer because they did not have the scientific knowledge to have an opinion on antibiotic usage. Across both groups, 32% of parents were able to identify a correct definition of antibiotic resistance (antibiotics can become less effective the more they are used across the population as bacteria become resistant to them), while 57% thought that antibiotic resistance meant that the body gets used to antibiotics and they become ineffective. A minority of surveyed parents thought that antibiotic resistance meant that antibiotics can Immediate antibiotic use Antibiotic use after visit to another doctor Wait and see before antibiotic use No antibiotic use
100
Pe rce ntage s of pare nts
80
60
40
20
Total
Japan
Philippines
Taiwan
New Zealand
Australia
Mexico
South-Africa
Canada
Poland
Spain
Germany
G re at B ritain
0
Fig. 5. Usage of antibiotics by the parents for treating the most recent episode of AOM of their child (AOM-experienced group [N = 1438]).
become more effective the more they are used across the population (5%) or that antibiotics can have side-effects like diarrhoea (5%). When surveyed parents were asked to evaluate what is generally happening with most common antibiotics, the majority of them (74%) correctly assumed that antibiotics were becoming less effective. After having been told the correct definition of antibiotic resistance, 73% of surveyed parents stated that they were concerned about a rise in antibiotic resistance. 3.7. Measures to prevent AOM Canada and South Africa were not included in these analyses because AOM indications were not comprised in the license of pneumococcal vaccines in these countries. According to the surveyed parents (N = 2364), measures that could be taken to prevent AOM included vaccination (23%), taking medication to prevent an infection elsewhere spreading to the ear (25%), and keeping the child warm on cold days (41%). More than half (57%) of respondents would likely consider vaccinating their child against AOM if they knew that a vaccine was available, 13% would not consider vaccination against AOM, and the remaining respondents were undecided. The likelihood of a parent considering vaccination of their children against AOM was similar in the AOM-experienced and the non AOM-experienced groups. 4. Discussion 4.1. Burden of AOM The EAR study directly consulted almost 3000 parents from around the world about the impact that AOM had on their child, themselves, and their family. Parents whose children had experienced AOM in the last six months (N = 1438) considered that the main burdens of this disease for the affected child were pain, disturbed sleep and irritability, which is consistent with previous observations [13,16]. These results support the important role of symptomatic drugs (e.g. analgesics) for the treatment of AOM and may explain why the majority of the surveyed parents took AOM more seriously after having seen their child suffering from it. Parents declared that AOM affected themselves and their whole family mainly due to sleepless nights and worry about the child’s recovery. More than half of the surveyed parents in the AOM-experienced group stated that they had to be absent from work when their child last had AOM, which is a higher proportion than that reported previously by European caregivers, who declared that they had to take time off from a paid job in about 20% of physician-confirmed AOM episodes [17]. A potential explanation for this difference could be that the previous study referred to children under 5 years of age, while the present study is based on children younger than three and a half years old. Moreover, the percentage of 20% reported in the previous study was based on absence from a paid job, while this was not a criterion in the present study. This loss of working days may lead to a reduction of the money earned by the family, especially in developing countries where sick leave is less formalised. Moreover, previous studies have shown that AOM also reduces the family income due to indirect costs and that this common disease has a significant economic impact for society overall [13,17,18]. In our survey, the overall reported burden for the affected child and their family and the level of concern for AOM were higher than those for chicken pox, similar to those for gastroenteritis and lower than those for pneumonia. However, some differences were observed between countries, such as parents in Poland, South Africa, Taiwan, and the Philippines who estimated that, for the
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affected child, the burden of pneumonia was similar to that of AOM or parents in Japan who estimated that the burden of AOM was lower than that of gastroenteritis. In a previous study conducted in nine countries, of which five countries were also included in the present study, physicians considered that AOM was a more severe disease than chicken pox, but a less severe disease than pneumonia and gastroenteritis [19]. In the present study, the majority of parents were unaware of serious consequences that AOM can have for a child, such as sepsis and meningitis [20]. This finding was expected since the majority of doctors do not routinely inform parents about the complications associated with AOM because the incidence of serious consequences of this disease has become extremely low, especially in developed countries [21–24]. 4.2. Attitudes towards antibiotics and AOM prevention Respondents from most countries reported that antibiotics to be taken immediately were frequently prescribed by physicians for treating AOM. These results are in line with findings from previous studies showing that the vast majority of patients with AOM were treated with antibiotics [12,19,25,26]. The high prescription rates of antibiotics for immediate use that was reported by surveyed parents in Australia (81%) and Great Britain (75%) were surprising because national guidelines in both countries advise physicians to delay the prescription of antibiotics for children with AOM [8,9]. The high prescription rates of antibiotics for immediate use reported by surveyed parents in Germany (76%) contrasts with results of previous studies, in which only 40% of German paediatricians reported that they used antibiotics as first line treatment for AOM [19] and 60.8% of German parents declared that antibiotics were prescribed to their children during their last physician-confirmed AOM episode [17]. Although further investigations would be needed to explain these discrepancies between studies, potential explanations included the facts that paediatricians only reported antibiotic use as first line treatment, while parents in the present study did not specify whether the antibiotics were prescribed at the first visit or later, and that both previous studies referred to children younger than five years of age. The low antibiotic prescription rate reported by Taiwanese parents suggests that the paediatricians follow the new antibiotic use payment regulation implemented by the National Health Insurance Drug Payment Regulations in 2001 in Taiwan, which mentions that there should be clinical evidence of bacterial infection, such as bacterial otitis media, before antibiotics may be used [27]. Although parents were somewhat more critical about the use of antibiotics in some countries, the vast majority of them were compliant and gave the prescribed antibiotics to their child immediately. The majority of parents were aware that the most common antibiotics are generally becoming less effective, but they were not aware of the true reason for the development of antibiotic resistance (they incorrectly assumed that the body, rather than bacteria, becomes resistant to antibiotics). They declared that they were concerned about the rise in antibiotic resistance, which is in line with findings from a previous study conducted in Finland and the Netherlands [15]. In all the countries, except Taiwan, the implementation of a ‘‘watch-and-wait’’ strategy before giving antibiotics to children with AOM seemed challenging and had a limited impact on the use of antibiotics. This observation is in line with previous studies showing that adherence of physicians to the AOM guidelines was poor [3]. These findings suggest that further education is needed to support better understanding of the connection between antibiotic prescribing and resistance and to emphasise the role that frequent childhood diseases, such as AOM, have in the rise in antibiotic resistance.
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The results of our study raised questions as to whether new preventative approaches for AOM were needed. Although most surveyed parents were not aware of the availability of a vaccine against AOM, more than half of them stated that they would consider getting their child vaccinated against this disease, which is in line with the results of a previous study conducted in Canada [14]. In contrast with what was reported in the previous Canadian study, parents in our study were not more likely to consider vaccination if their child had experienced AOM than if their child did not experience the disease [14]. 4.3. Study strengths and limitations The strengths of this study included the high number of respondents, who were enrolled in 12 countries across the world. The questions were directly addressed to parents and closely reflected their perceptions about AOM, its consequences, and medical practices. This is the largest survey to date that investigated parental attitudes towards AOM and gives a snapshot of the global situation. Limitations of this study, which might lead to potential selection biases, included the use of online interviews and the limited number of respondents per country, who might not be representative of the population of parents in each country. Moreover, the list of questions that was sent to the parents varied between countries, and therefore between countries comparisons should be interpreted cautiously. Other limitations include the lack of information on the sex and the health status of the affected children, and the absence of stratification by age. 4.4. Study conclusions In the 12 countries included in this study, parents perceived the effects of AOM to be a burden for their children and families, particularly pain and disturbed sleep, and they reported that AOM had a significant effect on their ability to attend work. Parents mostly seemed to trust their doctors, but they were not well informed on why rational use of antibiotics was mandatory. Alongside parental misbeliefs on antibiotic actions, physicians might not be fully aware of AOM treatment recommendations and prevention opportunities. Conflict of interest The institution of SI received money from GlaxoSmithKline group of companies for conducting and analysing the survey. AV and CB declare that they received payment for advisory board membership and meeting attendance from GlaxoSmithKline group of companies. HC declares he received payment for consultancy and meeting attendance from GlaxoSmithKline group of companies. Authors’ contributions SI was involved in the plan, design, and review of the reported study, the collection of the data, the interpretation of the results, and the coordination of the study. AV participated to the study design and the interpretation of the data. HC was involved in the review of the reported study and the interpretation and comments on the results. CB was involved in the plan design and review of the reported study and the interpretation of the data. Funding source GlaxoSmithKline Biologicals SA was the funding source and was involved in all stages of the study conduct and analysis.
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GlaxoSmithKline Biologicals SA also funded all costs associated with the development and the publishing of the present manuscript. Acknowledgements The authors thank the parents who participated in the study and the members of the Global Otitis Media Prevention Panel for their contribution to the survey. We thank Claire Verbelen (XPE Pharma & Science) for scientific writing support and Bart van Heertum (XPE Pharma & Science c/o GlaxoSmithKline Vaccines) for editorial support and manuscript coordination. References [1] A.S. Lieberthal, A.E. Carroll, T. Chonmaitree, T.G. Ganiats, A. Hoberman, M.A. Jackson, et al., The diagnosis and management of acute otitis media, Pediatrics 131 (2013) e964–e999. [2] A.W. Cripps, D.C. Otczyk, J.M. Kyd, Bacterial otitis media: a vaccine preventable disease? Vaccine 23 (2005) 2304–2310. [3] A. Vergison, R. Dagan, A. Arguedas, J. Bonhoeffer, R. Cohen, I. Dhooge, et al., Otitis media and its consequences: beyond the earache, Lancet Infect. Dis. 10 (2010) 195–203. [4] L. Corbeel, What is new in otitis media? Eur. J. Pediatr. 166 (2007) 511–519. [5] E. Leibovitz, Acute otitis media in pediatric medicine: current issues in epidemiology, diagnosis, and management, Paediatr. Drugs 5 (Suppl. 1) (2003) 1–12. [6] M.E. Pichichero, Evolving shifts in otitis media pathogens: relevance to a managed care organization, Am. J. Manag. Care 1 (Suppl. 6) (2005) S192–S201, 1. [7] J.O. Klein, media. Otitis, Clin. Infect. Dis. 19 (1994) 823–833. [8] P. Little, Delayed prescribing—a sensible approach to the management of acute otitis media, JAMA 296 (2006) 1290–1291. [9] NSW Department of Health, Children and Infants with Otitis media – Acute management, 2004 Available at: http://www.health.nsw.gov.au/policies/PD/ 2005/pdf/PD2005_385.pdf (last accessed 31.08.12). [10] C.L.M. Appelman, P. Bossen, J. Dunk, E. Lisdonk, R.A. de Melker, H. van Weert, NHG Standard otitis media acuta – guideline on acute otitis media of the Dutch College of General Practitioners, Huisarts Wet 33 (1990) 242–245. [11] M. Haggard, Poor adherence to antibiotic prescribing guidelines in acute otitis media – obstacles, implications, and possible solutions, Eur. J. Pediatr. 170 (2011) 323–332.
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