A Study regarding Parental Knowledge, Attitude and Practice (KAP) among Antibiotic Use in Children in Henan Province of China

doi:10.21203/rs.3.rs-1947203/v1

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Research Article

A Study regarding Parental Knowledge, Attitude and Practice (KAP) among Antibiotic Use in Children in Henan Province of China

https://doi.org/10.21203/rs.3.rs-1947203/v1

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Aim

Inappropriate antibiotic use leads to AMR. This research targets to learn about Henan Province parental knowledge, attitude and practice regarding antibiotic use in their children.

Materials and methods

During the October through December 2020, Henan Maternal and Child Health Hospital's hospitalized parents participated in a cross-sectional questionnaire survey. The study was evaluated using logistic regression analysis.

Results

In general, parents were less knowledgeable about the following topics: antibacterial medications are not anti-inflammatory medications; scientists cannot always discover new drugs; colds and viral infections cannot be treated with antibacterial medications; and the combined effects of antibacterial medications are not always superior. The respective awareness rates were 40.83%, 28.37%, 57.09%, 39.10%, and 59.52%. For the attitude, a little of parents still had misconceptions. In total, 10.73% parents were willing to use antibiotics, 16.61% believed that expensive antibiotics would be more effective, 45.68% parents didn’t agree the doctor's treatment plan, 14.19% parents would be dissatisfied of no antibacterial drugs, 10.73% parents believed they understood antibiotics well, just only 57.79% parents were correct in their understanding of broad-spectrum antibiotics.

Conclusions

Parental knowledge of antimicrobial agents in Henan Province is good, but some problems persist. Government departments and medical institutions at all levels must continue to strengthen the conduct of antibacterial drug knowledge propaganda of parents for the prevention of bacterial drug resistance.

Henan

China

antibiotics resistance

knowledge

practice

attitude

KAP

The widening and inappropriate use, and even abuse, of antibiotics have exacerbated the problem of drug resistance, antimicrobial resistance (AMR) is considered a rapidly growing global public health emergency, to such an extent that the World Health Organization (WHO, 2019c)[1] has published a relevant action plan. Neonates and children are primary patients and at the high risk of AMR development [2].The overuse of antibiotics has particularly important implications for children[3,4]. Parents’ perceptions and practices on medicine have important effects on the management of childhood illness[5–7].According to an investigation conducted in urban China, children from eastern cities were substantially less likely than those from western cities to obtain over-the-counter antibiotics from caregivers [8]. Additionally, it was claimed that the rates of antibiotics sales in hospitals were related to regional economic statuses in China [9]. The purpose of this study was to understand the knowledge of antibiotics and the practice of using antibiotics for children in Henan Province, as well as to provide a resource for relevant government agencies developing antibiotic policy.

1.1 Subjects

Parents of pediatric inpatients in Henan Maternal and Child Health Hospital, the largest maternal and child health hospital in Henan Province, participated in the questionnaire. All respondents participated voluntarily.

1.2 Survey content

The questionnaire was developed by the team of Professor Biao Xu in the School of Public Health of Fudan University in China[10]. The questionnaire was divided into four sections: basic demographic information about parents, parents' knowledge and attitudes about antibiotic usage, and parents' conduct while giving antibiotics to their children. There were 14 questions on antibiotic usage knowledge, including three fundamental ideas of antibiotics, five features of antibiotic use, three techniques of antibiotic use, and three antimicrobial resistance and adverse responses. The answers were graded in three categories: "right," "wrong," and "unclear." There were 11 questions regarding attitudes about antibiotic usage, with answers graded as "unclear,""strongly disagree,""not very agree,""slightly agree," and "strongly agree." There were ten questions concerning antibacterial antibiotic usage behavior, and the responses were graded as "unclear,""never,""rarely,""occasionally," or "often."

1.3 Research methods

From October to December 2020, a questionnaire in the form of "Questionnaire Star" was distributed to the parents of inpatient children at Henan Maternal and Child Health Hospital. The data was compiled after the questionnaire returned.

1.4 Questionnaire evaluation criteria

The knowledge, attitude, and behavior of drug users were quantified using numbers based on the level of risk[11-12].Among them, there are 14 questions involving medication knowledge, which are assigned 3, 2, and 1 according to the risk level from low to high. All answers are correct and 42 points are awarded. If the total score is ≥ 80%, the score ≥ 33.6 is excellent, and 60% ≤ total score <80%, that is, 25.2≤total score <33.6 is good, and total score <25.2 is failed. A total of 11 questions involving attitude were assigned 5, 4, 3, 2 and 1 respectively according to the risk degree from low to high. The highest score was 55. If the total score ≥80%, the score ≥44.4 was excellent; if the 60% ≤total score < 80%, the≤33.3total score < 44.4 was good; and the total score < 33.3 was failed. A total of 10 questions involving behavior were assigned 5, 4, 3, 2 and 1 respectively according to the risk degree from low to high. The highest score was 50. If the total score ≥80%, the score ≥40 was excellent, 60%≤ the total score < 80%, 30≤ the total score < 40 was good, and the total score < 30 was failed.

1.5 Statistical analysis

SPSS21.0 software was utilized for statistical analysis after sifting through the acquired effective data. The usage rate and counting data composition ratio were described. Mean and standard deviation were used to characterize the measurement data (). In univariate analysis, if the data fulfilled both normality and variance homogeneity, a parametric test (T test, T 'test, or analysis of variance) was used for hypothesis testing; otherwise, a non-parametric test (Wilcoxon rank sum test, with test level =0.05) was employed. When doing multiple linear regression, variables were screened using the stepwise technique, with inclusion criterion =0.10 and exclusion criteria =0.15[13-14].

2.1 General characteristics of participants

A total of 289 questionnaires were gathered, all of which were legitimate, with an average response time of 10 minutes and 41 seconds. The respondents came from 16 prefectures in Henan Province, accounting for 67.82% females and 56.06% those aged 19 to 34. The general situation and KAP score of antibiotics investigated are summarized in Table 1.

Table 1 General situation and KAP score of antibiotics investigated (n=289)

2.2KAP score of antibiotics-using parents

2.2.1 Knowledge towards antibiotic use

In terms of knowledge of antibiotics, it was shown in Table 1 and Table 2.The average correct rate of basic concepts was the lowest, which was 46.48%.The average correct rate of antimicrobial resistance and adverse reactions was the highest (70.13%).On the other hand, the average correct rate of indication and method of antimicrobial use were 63.25% and 66.32% respectively. In a single question, the highest accuracy was 81.31%, and the lowest accuracy was 28.37%. Among them, the accuracy was greater than 80% for only 1 question, 70% ~ 80% for 5 questions, and less than 60% for 4 questions.

Differences in antibiotic use knowledge scores of different demographic characteristics were shown in Table1. Except for age and relationship scores with children (p>0.05), the score of female was higher than that of male, the score increased gradually with the increase of monthly income, the score from urban residents was higher than that from rural residents, the score increased with the health care status level increase, the score of employees was higher than that of retired and non-unemployed people, and the score of one-child family was higher than that of multi-child family.

Table 2 Descriptive statistics of knowledge part of respondents (n=289)

2.2.2 Attitude towards antibiotic use

As shown in Table 1 and Table 3, the overall attitude of parents towards antibiotic use was good. Among the respondents, 59.86% parents believed that antibacterial drugs were overused and misused, 85.81% parents considered that parents should get more guidance on how to use antibacterial drugs, 78.89% parents didn’t agree to give their children antibacterial drugs by themselves, and 75.09% parents won’t give antibacterial drugs to children in advance to prevent colds. 87.55% the parents approved that the cause should be identified by examination before prescribing antibiotics. Only 10.73% parents were more willing to use antibiotics when their children become sick, 16.61% the parents thought that expensive antibiotics would have better effects, and only 46.72% would follow the doctor's orders, 14.19% parents were not satisfied with no antibiotics, only 10.73% parents thought they knew enough knowledge about antibiotics, and 57.79% parents had a correct understanding of broad-spectrum antibiotics.

The differences of medication attitude scores among different demographic characteristics were shown in Table 1.Except for the fact that there was no difference in antibiotic use attitudes among different age groups (p>0.05), women were higher than men, their attitude toward the correct use of antibiotics improved with income, urban resisdents was higher than rural resisdents, and the score increased with increasing education level, the mother's attitude toward the correct use of antibiotics was better than father’ and grandparents/grandparents’, the higher the level of medical security status, the higher the score. And the score of employees was higher than that of the retired and unemployed, the one child Female-headed households outperformed multi-child households.

Table 3 Descriptive statistics of attitude part of respondents (n=289)

Questions	Strongly disagree	Not very agree	Slightly agree	Strongly agree	Unclear
01.The phenomenon of overuse of antibacterial drugs in our country	8.30%	16.96%	31.14%	28.72%	14.88%
02.Parents should get more guidance on how to use antimicrobials	2.77%	2.77%	18.34%	67.47%	8.65%
03.Prescribe antibiotics to your child according to your child's condition	45.67%	33.22%	8.65%	3.11%	9.34%
04.When you see a child around you have a cold, giving your child an antibacterial drug in advance has a preventive effect	47.75%	27.34%	8.30%	3.81%	12.80%
05.Before a doctor prescribes a prescription, the cause should be determined by examination	2.77%	2.77%	23.88%	63.67%	6.92%
06.Prefer to use antibiotic infusion if child is sick	39.10%	37.72%	7.27%	3.46%	12.46%
07.I am willing to use more expensive antibiotics	29.76%	43.25%	13.15%	3.46%	10.38%
08.Children who are sick should follow the doctor's plan and not ask the doctor	10.73%	34.95%	30.80%	15.92%	7.61%
09.I will be dissatisfied if the doctor does not prescribe antibiotics	41.52%	33.91%	10.38%	3.81%	10.38%
10.I think I know enough about antimicrobials	16.61%	39.45%	21.80%	4.84%	17.30%
11.I like to use broad spectrum antibacterials because they kill a lot of bacteria	27.34%	30.45%	11.76%	3.11%	27.34%

2.2.3 Practice of giving antibiotics to children

As shown in Table 1 and Table 4, the overall performance of antibiotics behavior was excellent. Among the respondents, 79.93% parents won’t ask doctors to prescribe antibacterial drugs to their children, 71.97% parents won’t give antibacterial drugs to their children without permission, 80.27% parents would read the drug instructions carefully before giving antibacterial drugs to their children, 78.89% parents would pay attention to the interval of using antibacterial drugs, only 48.45% parents would store antibacterial drugs at home, 7.27% parents would arbitrarily increase the dosage of antibacterial drugs for their children, 14.53% parents would arbitrarily change antibacterial drugs, 38.40% parents would voluntarily reduce the dosage of antibacterial drugs or stop taking antibiotics when condition improved, 19.72% parents added other drugs when their children took antibacterial drugs, 6.57% parents would give their children antibiotics taken by adults.

Considering the differences with the scores of antibiotic use behavior among different demographic characteristics (shown in Table 1), female were higher than male, urban was higher than rural, high education was higher than low education, and The scores increased with the medical security status increasing. There was no significant difference with the scores of antibacterial drug use behavior among other demographic characteristics (p>0.05).

Table 4 Descriptive Statistics of antibiotic use behavior of respondents (n=289)

Questions	Never	Rarely	Occasionally	Often	Unclear
01. When you take your kid to the doctor, request that the doctor prescribe antibiotics for the youngster.	51.90%	28.03%	8.65%	1.73%	9.69%
02. Self-administering antibacterial drugs to children when they are sick	49.13%	22.84%	18.34%	2.08%	7.61%
03.Read the medicine leaflet carefully before you give your child an antibacterial medicine	1.73%	10.03%	11.76%	68.51%	7.96%
04.Have antibacterials at home	12.11%	30.80%	32.53%	15.92%	8.65%
05.To improve efficacy, dosage is raised without authorisation	73.70%	12.80%	6.92%	0.35%	6.23%
06. Keep an eye on the time between antibiotics.	2.77%	3.11%	11.76%	67.13%	15.22%
07. After a few days, I feel no benefit from the drug and alter it without permission.	54.67%	21.45%	13.15%	1.38%	9.34%
08. Reduce or discontinue antibiotics once the disease improves.	29.76%	20.07%	30.10%	8.30%	11.76%
09.Taking antibiotics while adding other medicines	46.71%	21.80%	18.34%	1.38%	11.76%
10.Giving a youngster an adult antibacterial medication	74.74%	10.73%	5.88%	0.69%	7.96%

2.3 Analysis of multiple influencing factors of KAP

The parents' antibiotic knowledge, attitude, and behavior scores as dependent variables, and the parents' gender, age, monthly income, place of residence, education level, relationship with children, medical security status, work status, and number of children as independent variables, we set the unordered multi-categorical variables as dummy variables, such as relationship with children, medical security status, and work status and assigned values to the appropriate indicators (shown in Table 5), and the results of KAP multivariate analysis were shown in Table 6.

Table 5 Assignment of related indicators

Table 6 Analysis of influencing factors of medication knowledge, attitude and behavior of respondents

Variable		B	P	OR	95%CI
Knowledge
	Gender	3.006	0.000	20.206	1.733～4.279
	Education level	2.432	0.000	11.382	1.663～3.202
	Medical security status	0.722	0.039	2.059	0.189～1.255
	Number of children	-1.385	0.028	0.250	-2.622～-0.148
	Monthly income	1.623	0.000	5.068	1.050～2.196
	(Constant)	18.773	0.000
Attitude
	Monthly income	1.757	0.000	5.795	1.041～2.472
	Gender	4.805	0.000	122.119	3.221～6.389
	Education level	2.968	0.000	19.452	2.009～3.928
	Medical security status	1.514	0.000	4.545	0.850～2.178
	（Constant）	11.360	0.000
Behavior
	Education level	1.807	0.000	6.092	0.948～2.666
	Gender	4.135	0.000	62.490	2.333～5.938
	Age of groups	1.588	0.011	4.894	0.371～2.805
	Relationship with children	-1.354	0.015	0.258	-2.449～-0.260
	Medical security status	0.756	0.032	2.130	0.063～1.449
	（Constant）	24.660	0.000

2.3.1 Influencing factors of antibiotic knowledge

The results of multi-factor analysis were shown in Table 6. The factors influencing the scores of antibiotic knowledge of parents were gender, education level, medical security, number of children and monthly income (p<0.05). Female scored 3.006 points higher than male, each level of education raised the scores of antibiotic knowledge 2.432 points; each level of medical security raised the scores 0.722 points; each level of monthly income raised the scores 1.623 points; the scores of children more than two were lower 1.385 points than that one child.

2.3.2 Influencing factors of antibiotic attitude

The results of multi-factor analysis on influencing factors of parents' attitude were shown in Table 6. The factors influencing the scores of parents' antibiotic attitude consisted of monthly income, gender, education level and medical security (p<0.05). The scores of antibiotic attitude increased 1.757 points when monthly income increased with one grade; Women scored 4.805 points higher than men; the scores increased 2.968 points with each increase of education level.

2.3.3 Influencing factors of medication behavior

The results of multi-factor analysis on influencing factors of parents' antibiotic behavior were shown in Table 6. The factors influencing the score of parents' antibiotic behavior included education level, gender, age, relationship with children and medical security status (p<0.05).The scores of antibiotic using behavior increased 1.807 points with each increase of education level, Female scored 4.135 points higher than male; the scores increased 1.588 points with each grade of age, the closer the relationship with children, the scores were higher the scores increased 0.756 points for each grade of medical security.

3.1 Overall analysis of parents' cognition level of antibiotics

According to the survey, the overall cognition of parents in Henan province was good, which was closely related to the management policies adopted by the state and local governments at all levels in recent years. In order to improve public health literacy and rational use of antibiotics, the state had issued the outline of "Healthy China 2030", the National Action Plan for Curbing Bacterial Resistance (2016-2020), and the Notice of the General Office of the NHC on Further Strengthening the Management of clinical Application of Antibacterial drugs to Curb Bacterial resistance. Relevant local government departments and pharmaceutical associations in Henan Province have also taken a series of measures to improve the level of antibiotic use for the public. For example, Henan Provincial Health and Construction Commission issued the outline of "Healthy Central Plains 2030" plan, and established a popular science publicity team of "Pharmacy popularization in China, Central Plains Pharmacists in action". Leading pharmaceutical experts from medical institutions at all levels carried out a series of "Pharmaceutical science popularization Trip" activities in various forms, such as pharmaceutical lectures, pharmaceutical free diagnosis, popular science lectures, video publicity, and public account publicity, to continuously improve the ability of rational antibiotic use.

Through this investigation, it was found that there were still some problems in the cognition of antibacterial drugs among parents in Henan Province. In terms of knowledge of antibacterial drugs, parents had lower awareness rates of knowledge that antibacterial drugs were not anti-inflammatory drugs, scientists cannot always develop new antibacterial drugs, antibacterial drugs cannot treat colds, antibacterial drugs cannot treat viral infections, and the combination effect of antibacterial drugs may not be better. And the awareness rates were 40.83%, 28.37%, 57.09%, 39.10% and 59.52%, respectively, which were similar to some research results of domestic and foreign studies[15-17]. In terms of attitude towards antibacterial drugs, a few of people still had misunderstanding of antibacterial drugs, which was related to their knowledge level of antibacterial drugs, because only 10.73% parents thought they knew enough about antibacterial drugs, and similar findings had been reported [18].In the part of antibacterial behavior, 38.40% parents would stop taking antibiotics by themselves. Therefore the publicity and education of antibacterial drugs still need to be strengthened.

3.2 Analysis of influencing factors on parents' cognition of antibiotics

The factors influencing the scores of parental antibiotic knowledge were gender, education level, medical security status, number of children and monthly income. The factors influencing the scores of parental medication attitude were monthly income, gender, education level and medical security. The factors influencing the scores of parental antibiotic behavior included education level, gender, age, relationship with children and medical security. As can be seen above, the common factors affecting parental KAP scores were gender, education level and medical security status. Female parental cognition of antibiotics was better than male parental, which was consistent with the results of other scholars[7]. This matched to the fact that most sick children in Chinese families were taken care of by their mothers. The higher the parents, the better the ability to receive knowledge, the more extensive the knowledge, so the better the awareness of antibacterial drugs, which was consistent with the results of other scholars[19].The difference of medical security status was related to the nature of household registration and the importance of parents to health knowledge.

3.3 Suggestions on popularizing scientific knowledge for children's parents

Antibacterial drugs are currently only accessible via retail pharmacies and medical institutions with a doctor's prescription in order to enhance the rational use of antibacterial treatments and reduce bacterial resistance in China. And Chinese government departments have intensified the oversight of antibacterial drug usage in medical facilities. As a result, the public's sensible usage of antibacterial medicines may be enhanced by increasing antibacterial medication popularity. Based on the above factors, the government and medical institutions at all levels should adopt different strategies for different people in the process of health education knowledge popularization[20].

3.3.1 Strengthen the popularization of health education knowledge for male parents

In this survey, male parental cognition of antibiotics use was significantly lower than that female. Therefore, maternal and child health care institutions at all levels should strengthen health education for pregnant women and their spouses in the process of pre-pregnancy health education for pregnant women[21].

3.3.2 Establish a multidisciplinary health education knowledge popularization team

Health education expert teams should undertake professional integration, and set up a multi-disciplinary team of popular science propaganda including medical, medicine, and other professionals[22]. And then the teams should strengthen the spread of rational drug use knowledge for the public, especially the basic conceptual knowledge of antimicrobial agents. Therefore let the public understand the present situation of the bacterial drug resistance, regulate the behavior of irrational drug use[23].

3.3.3 Health education should form a long-term mechanism

Although the domestic government departments at all levels, the academic society organization and the medical institutions have established a multidisciplinary scientific propaganda team, the work of popular science , writing popular science articles, recording video and so on are spare time, which are unfavorable to the long-term, sustainable development for the popular science work. In order to ensure the long-term and effective continuation of popular science work, government departments should strengthen institutional reform, and establish a mechanism for popular science services or government departments to purchase services. In addition, science popularization work can also be linked to professional title promotion, and establish a mechanism to stimulate and restrain science popularization personnel [24].

Acknowledgments

Thanks to the members of the research group and the staff of the pediatric ward for their help with the questionnaire.

Author contributions

Each author has been sufficiently involved in this submission to take public responsibility for the work, meaning that each author has made substantial contributions to the conception and design of the study.

Funding

This research was financially supported by Henan Province Medical Science and Technology Research Program (Joint Co-construction) Project (Project No.: LHGJ20190406)

Ethics approval and consent to participate

This questionnaire was approved by the Ethics Committee of Henan Maternal and Child Health Hospital (batch number 2020-86). It is hereby reiterated that all methods in this study were conducted in accordance with relevant guidelines and regulations (Declaration of Helsinki), and that the informed consent was obtained from all respondents for this survey.

Consent for publication

No conflict of interest exits in the submission of this manuscript, and manuscript is approved by all authors for publication.

Competing interests

I would like to declare on behalf of my co-authors that the work described was original research that has not been published previously, and not under consideration for publication else where, in whole or in part. All the authors listed have approved the manuscript that is enclosed.

Contributor Information

Weifeng Ma, Email: [email protected]

Chunzhi Huang, Email: [email protected]

Cailian Wang, Email: [email protected]

Qinglan Liu, Email: [email protected]

Qinghe Zhao, Email: [email protected]

Yanli Ren, Email: [email protected]

Availability of Data and Materials

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request

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