Evaluation of parental knowledge, attitudes and practices regarding antibiotic use in acute upper respiratory tract infections in children under 18 years of age: a cross-sectional study in Turkey

Upper respiratory tract infections (URTIs) are common in children [1]. This is probably due to the vulnerability of children to URTIs [1, 2]. However, most URTIs have been shown to be of viral origin. In this case, the use of antibiotics is unnecessary and not suitable [3]. This unnecessary use of antibiotics is known to lead to antibiotic resistance [4, 5] The problem of unnecessary antibiotic use among children is a concern for antibiotic resistance in low- and middle-income developing countries [4‐7].

There are many reasons for inappropriate antibiotic use in children. In some cases, it may be due to the fact that families have an infection that should have used antibiotics before, and then, when a similar viral infection develops, it will not be cured without antibiotics [8]. In addition, antibiotics are started even in cases where the infection is thought to be viral due to the poor geographical conditions of the area where the physician works, lack of equipment, the fear that the patient will not be able to reach the physician easily or the sick child will not be brought to control [9‐11]. Furthermore, the indifference of parents in pediatric patients and the pressure to prescribe antibiotics on pediatrician also lead to inappropriate antibiotic use [12]. As a result, the administration of antibiotics provides minimal benefit, even harm (side effects, resistance, etc.) [13, 14].

Many studies have reported the relationship between antibiotic use and the development of resistance [15‐17]. Turkey is one of the world’s countries with the highest consumption of antibiotics is located in European regions outside the European Union [18]. The latest report from the Organisation for Economic Co-operation and Development (OECD) Health Policy Studies, in 2015, the highest rates of antimicrobial resistance (Turkey, Korea and Greece in about 35%) of the lowest rates among the member countries stated that seven times higher [19].

Turkey has two main antimicrobial stewardship program created by the Ministry of Health. The first targets the hospitals, the second the society. The antimicrobial stewardship program targeting the community includes a 4-year (2014–2017) National Action Plan for Rational Drug Use, with an emphasis on antimicrobials at the community level. The aim is to reduce antimicrobial prescriptions, especially prescriptions for acute respiratory infections, in primary care. In this plan, it is aimed to inform doctors, pharmacists and the public on rational drug use. The sale of antibiotics without a prescription is prohibited in pharmacies. Antibiotics can only be prescribed by the doctor [20, 21]. However, various studies are needed to determine whether the National Action Plan is effective or not. Among these, the knowledge, attitudes and behaviors of parents about the use of antibiotics are of great importance. There are limited studies on this subject in Turkey and is made in a limited participant [22, 23].

This study aims to evaluate the knowledge and attitudes of parents of children with upper respiratory tract infections regarding antibiotic use and their antibiotic administration practices in a tertiary care hospital in Turkey.

The questionnaires were distributed to 600 parents, but 554 parents (92.3%) responded to the questionnaire. The majority of the parents were mothers (65.5%) and the age range of the parents (60.8%) was mostly between the ages of 30–44. 25.1% of the parents were university graduates. Most of the parents (90.3%) lived in the urban areas and the income level of approximately 54.7% of them was equal to the expenditure level. Approximately half (49.5%) had a single child and 46.4% were not used antibiotics in the last year. The socio-demographic characteristics of the parents are shown in Table 1.

In our study, we assessed knowledge, attitudes and practices on antibiotic treatment of parents in Turkey. It is the most comprehensive and current study on this subject in Turkey. Our study showed that parents have a good attitude and practice in the use of antibiotics. A total of 37.7% of parents agreed to use antibiotics in any child with fever. While the rate of agreeing with this statement was 72.4% in a study conducted in Jordan [14], it was found to be lower than 10% in the study conducted in Greece [24]. In a study conducted in Italy, 92.9% of respondents knew that antibiotics did not have a direct effect on fever [25]. Parents agreed with 37% that antibiotics could be used in the treatment of infections caused by viruses. While 59% of Palestinian parents and 17.2% of Croatian parents agreed agreed with this idea, Greek parents thought that 80% of the viruses were spontaneously limited and did not use antibiotics [5, 24, 26]. Those who agreed with the statement of using antibiotics for prevention before getting sick were 7.3%. This was also a very low rate. Three times a day use was correctly defined 83.8% as “every 8 h’. On the contrary, Rowa’J et al. [27] in their study defined only 28% as “every 8 h” and 56% with “the main meals”. In our study, parents believed that the most important symptom (86.1%) to take their children to the pediatrician was fever. Parents from Jordan, Palestine and Malaysia [5, 14, 28] agreed with this view, while parents in Greece and Minnesota expected antibiotics to be prescribed for ear pain [24, 29].

In our study, we found that female gender was associated with better knowledge and practice level than male gender. However, this may be due to the fact that female gender constituted a large part of the sample.

According to the results of our study, most of the parents (73.1%) learned the data about antibiotics from the pediatricians, and very few (6.3%) put pressure on the pediatricians to prescribe antibiotics. This situation showed that the parents trusted the pediatrician.

Parents generally showed appropriate behavior in practice. 85.6% of the parents stated that they never gave antibiotics without a prescription to their children with fever. 80.9% of them stated that they never reused the old antibiotic again in the presence of a new infection. It was a very positive result compared to studies conducted in other countries [5, 14, 30]. This may be related to the increasing awareness of parents about rational antibiotic use. The impact of the national action plan on rational drug use can be great in this situation. Within the scope of this action plan, messages about rational drug use were given on television, in news programs, in social media and even in TV series. Posters about the rational use of antibiotics were hung where they could be seen by the public. This may have caused parents to use antibiotics rationally.

Most of the parents declared that (86.3%) always paid attention to the antibiotic expiration date. However, 50.5% of parents declared that they never used the antibiotic suspension until the expiration date after reconstitued it. This meant that about half of them gave the correct answer, as the antibiotic suspension should be consumed within a maximum of 10 days [27]. But Rowa’J et al. [27] showed that 98.5% of mothers applied it correctly. In our study female gender compared to male gender, high education level compared to low level, higher income level compared to low income level, using a small number of antibiotics in the last 1 year compared to using a large number of antibiotics in the last 1 year showed a better level of knowledge. In the study of Al Saleh et al. [31] female gender, high education level and surprisingly low income level were found to be associated with better knowledge level. High level of education, living in the urban areas, high level of income, low number of children, younger children were associated with better attitude level, while Al Saleh et al. [31] found higher income and better attitude levels in more than 3 children. In our study female gender compared to male gender, higher income level compared to low income level, lower number of antibiotics used in the last 1 year compared to higher number of antibiotics used in the last 1 year were associated with better practice. Hernandez et al. [32] showed in a multivariable analysis that the level of education and the low number of antibiotics used in 1 year were associated with a better level of knowledge and behavior.

According to the results of our study of parents’ lack of knowledge about antibiotics in Turkey, though generally it shows proper attitude and behavior. It shows that some of the restrictions imposed by the National Action Plan are partially working. Among these restrictions, the fact that antibiotics are prescribed only by a doctor and sold only in pharmacies limited self-use without a prescription and reduced antibiotic consumption. However, it is still necessary to keep parents, pediatricians and pharmacists informed about the use of antibiotics and to be more careful about the prescribing of antibiotics, and if necessary, sanctions should be imposed by the state to prevent unnecessary antibiotic prescriptions.