Unnecessary and irrational use of antibiotics is a major cause of bacterial resistance. Children and adolescents are the most widely users of antibiotics, whose medicines are mostly purchased by their parents, which makes parental self-medication with antibiotics much more common and accelerates the bacterial resistance. Parental self-medication with antibiotics for children exists in both developing and developed countries, with high rate in southern and eastern Europe reported repeatedly, as well as in Africa and Asia. Different from the previous studies analyzing self-medication with antibiotics designed and compared by the same demanders under the same supplier, this study aims to analyze the difference in self-medication with antibiotics of parents of different nationalities for their children under the same health service supplier in China on behalf of different demanders and the same supplier, reveal the effect of parents’ nationality on parental self-medication with antibiotics for their children under the control of health service supplier, as well as compare their differences in knowledge, attitudes and behaviors about antibiotics.
Self-medication with antibiotics of parents of different nationalities for children
Previous studies have reported that the rate of Chinese parental self-medication with antibiotics for children was 18.0-59.4%, with 25.0% in urban and18.0% in rural, and 59.4% in Hefei. Occidental parents of which was 4.0-28.0%, such as 4.0% in urban area and 12.1% in suburban area in the US, 5.0% in the UK, 22.7% in the Greece, 28.0% in the southern of Spain. As for other Asians, the rate was 39.5-59%, like 39.5% in Jordan, 57% in Syria, 46% in United Arab Emirates, 43.9% in Saudi Arabia, 40%-60% in Vietnam and 59% in the western of Nepal. In our study, 13.85% parents self-medicated with antibiotics for children in the past 6 months, while 20.10% was Chinese, 5.00% was other Asians and 2.67% was Occidental parents. The reason that the self-medication with antibiotics rates of other Asian and Occidental parents in our study are lower than the previous studies’ findings is probably that China has issued a “Restriction Order” that antibiotics should be purchased by prescriptions as early as 2004, and that all types of health institutions have been strictly required to implement antibiotics classification management and physician prescription authority management on March 3, 2017, which restricts the antibiotics purchased without prescription in China to some extent and decreases parental self-medication with antibiotics for their children in China effectively. Furthermore, we found that the self-medication with antibiotics rate of Chinese parents was the highest (20.10%), and Occidental parents lowest (2.67%). Although it is the same as the agreement that parental self-medication with antibiotics rate in China was higher than that in Occident as the studies showed before, our study is truly of great importance to reveal the essential difference of parents of different nationalities by exploring the difference in self-medication with antibiotics of parents of different nationalities on behalf of various demanders but under the same health service supplier, which means more than previous studies isolated to analyze and compare the parental self-medication with antibiotics by the same demanders (parents of the same nationality) under the same supplier (the same country or region). The results of our study reflect that Chinese parents are still more likely to self-medicate with antibiotics for their children than Occidental parents although they both are under the same background of health service supplier. What accounts for this may because that residents' antibiotic education is still insufficient in China, far from reaching the level of Occident. The government should make efforts on strengthening the publicity and education of residents' knowledge on antibiotic use and further control the irrational use of antibiotics.
Influencing factors of parental self-medication with antibiotics for children
We matched two logistic regression to analyze the effect of parents’ nationality on self-medicate with antibiotics for their children by controlling the confounders. Model 1 controlled confounders of socio-demographic characteristics of the responders and knowledge, attitudes and behaviors about antibiotics of the responders were also adjusted in model 2. Both two models steadily indicated that the difference in parents’ nationality did have an effect on parental self-medication with antibiotics, and that Chinese parents were 8.221 and 6.086 times respectively more likely to have self-medication with antibiotics for their children compared to Occidental parents. It may because of the worse knowledge and attitudes about antibiotics of Chinese parents compared to Occident and their own different traditional concepts. In Chinese society, the growth of children is paid much more attention by parents even indulged. Ailments can cause excessive sensitivity and tension in family, resulting in a common phenomenon that “people at death’s door turn in desperation to any doctor”. Many studies have identified that parents usually misuse antibiotics when children suffer the Upper Respiratory Tract Infection for symptoms such as fever, cold and cough[46-48], and overuse antibiotics for the reasons of parents’ unclear knowledge about antibiotics, medication by past experience, thinking symptoms are not severe, having leftover antibiotics at home and so on. Compared to Occidental parents’ lighter sensitivity and tension, Chinese parents are much easier to practice self-medication with antibiotics for their children. In addition, we also found that parents aged 25-34 had a higher rate of self-medication with antibiotics than parents aged 40-55, same as the related studies [34, 51]. Besides, parents considering that antibiotics should be purchased by a prescription were less likely to self-medicate with antibiotics than those don’t think so, and parents who asked for doctors to prescribe antibiotics were more prone to practice self-medication with antibiotics. In order to reduce the rate of parental self-medication with antibiotics, improve the knowledge and attitudes about antibiotics of the masses, and regulate antibiotic use to reduce the bacterial resistance, it is necessary not only for the government to further strengthen the management and supervision of antibiotic purchased by prescription, and improve the doctors’ rights of antibiotic classification and prescription, but also for the related departments in society to positively popularized health education on knowledge involved in antibiotics.
Knowledge, attitudes and behaviors about antibiotics of parents of different nationalities
Plenty of studies have indicated that controlling irrational use of antibiotics is mainly by the means of regulating the rationality of antibiotics on doctors’ prescription and improving populations' correct knowledge, attitudes and behaviors about antibiotics[52-54]. There are already many campaigns successfully held at a national or regional level in many high-income countries to educate the public appropriate use of antibiotics, including Australia, Canada, France, the UK, New Zealand and so on. China has also issued a “Restriction Order” that antibiotics should be purchased by prescriptions, restricting the behavior of antibiotics purchased without prescription in China and inappropriate antibiotic use. The results showed that parents of different nationalities living in China had different performances on knowledge, attitudes and behaviors about antibiotics. The overall accuracy of Occidental parents was higher than that of Chinese, followed by other Asians. Respondents living in Xi'an under the same supplier of health environment and norms yet presented differently on antibiotic use, which probably shows that residents in Occident are better educated on knowledge and attitudes about antibiotics than population in China area. Knowledge and attitudes are more effected by self-awareness and education popularization in the original place of residence. In Occident, educational campaigns of the rational use of antibiotics have been carried out earlier than China and other Asia countries and have already got excellent achievements, therefore Occidental parents' knowledge and attitudes about antibiotics are superior to Chinese parents and other Asians too. In the context of a consistent health service supply environment, people's behaviors are mainly determined by knowledge and attitudes, so it is reasonable that Occidental parents performs better on using antibiotics than China due to Occidental parents’ higher knowledge and attitudes about antibiotics. Health education on antibiotic-related knowledge is particularly important. Publicity and education on such related fields for residents should be paid much attention by Chinese government. Besides, the residents’ awareness of accepting education needs to be improved. With time going by, it is likely to constantly drive residents to use antibiotics appropriately and further decrease the speed of bacterial resistance by the means of reducing parental self-medication with antibiotics for their children initiatively.
Item “Repeatedly using an antibiotic is prone to have bacterial resistance” was the best acknowledge of antibiotic knowledge among three nationalities of parents, with 84.30% of Chinese parents, 76.00% of other Asians and 90.67% of Occidental parents, showing that Occidental parents had a better performance than Chinese parents, followed by other Asian parents. The results are higher than some studies in other regions [21, 57]. It may related to the fact that a series of educational activities on the rational use of antibiotics has been carried out in China since 2010, which makes residents living in China have such a better understanding of bacterial resistance. Although the education has achieved certain achievements, bacterial resistance knowledge of Chinese parents is still weaker than Occidental due to the late implementation time in China, let alone other Asia countries.
In item “Agree that antibiotics should be used immediately when your child has Upper Respiratory Tract Infections”, we found that 30.58% Chinese parents, 25.33% Occidental parents had such thought and Occidental parents performed better but both still not good enough. There are already many studies presented that Upper Respiratory Tract Infections in children are mainly caused by viral infections instead of bacteria [59, 60]. Antibiotics are targeted at infections caused by bacteria, but has little effect on killing virus. Nowadays, parents have such great expectations for the antibiotics that ignoring the fact that ailment of their children may not be microbial in origin, or it may not be bacterial in nature even if its cause is microbial. Parents should be aware of antibiotic indications and educated more on knowledge related to antibiotics, especially for Chinese parents and other Asians.
There are several limitations of this study that need to be further addressed in future studies. The study is retrospective, so recall bias on whether there was parental self-medication with antibiotics for children in the past 6 months in the survey is possible. Besides, the targeted people of this study is limited in an International Department of an International School in Xi'an, Shaanxi Province due to time, manpower and other conditions, resulting the relatively small sample size. However, considering the concentration on parents of different nationalities in school, the results of our findings can basically reflect the fact the difference in self-medication with antibiotics for children, as well as knowledge, attitudes and behaviors about antibiotics of parents of different nationalities.