A systematic review of parent and clinician views and perceptions that influence prescribing decisions in relation to acute childhood infections in primary care

Figures & data

Figure 1. Flow chart of inclusion. Literature search and study descriptions.

Table I. Description of included studies (in date order).

First author, date	Focus on antibiotic prescribing	Location	Parent sample	Clinician sample	Illness	Study focus
Clarke 1989 [20]	No	Leeds, UK Urban	Families	None	RTI & febrile illness	To investigate how parents from different ethnic groups manage their children's RTIs & fevers & their consultation with GPs. Face-to-face interviews
Butler 1998 [21]	Yes	Cardiff, UK	5 mothers	21 GPs [1–28 years as principles]	Sore throat	To better understand reasons antibiotics are prescribed for sore throats. Face-to-face interviews
Barden 1998 [29]	Yes, and in context of overuse	Atlanta, USA Urban	29 parents	22 physicians	URTI	To assess the attitudes and assumptions of physicians and parents regarding antimicrobial use and misuse. Focus groups
Elwyn 1999 [22]	Yes, and in context of overuse	Cardiff, UK Urban	2 mothers 1 father	1 GP	Tonsillitis	To examine the “shared-decision-making” model in situations of conflict over preferred treatments. Discourse analysis of recorded consultations
Arrol 2002 [33]	Yes, and in context of overuse	Auckland, New Zealand Urban	Parents consulting for children	13 physicians	General	To explore issues and attitudes regarding delayed prescription use from the perspectives of family physicians and patients. Face-to-face interviews
Bjornsdottir 2002 [26]	Yes	Iceland Urban & rural	None	10 GPs	General	This study aims at understanding GPs’ decision-making when deciding whether or not to prescribe antibiotics. Face-to-face interviews
Jonsson 2002 [28]	No	Iceland Urban	17 mothers, 6 fathers	None	Otitis media	To explore the views and feelings of parents of pre-school children with newly diagnosed acute otitis media towards the disease and its diagnosis and treatment. Face-to-face interviews
Pradier 2003 [31]	Yes, and in context of overuse	France	8 groups of parents	2 groups of GPs 1 group of paediatricians 2 groups of pharmacists	Feverish nasopharyngitis	To explore ways of modifying attitudes and behaviours of doctors (GPs and paediatricians), parents, and pharmacists towards the over-prescription of antibiotics. Focus groups
Everitt 2003 [23]	Yes	UK	11 mothers	None	Conjunctivitis	To explore patients’ understanding of conjunctivitis and its management. Face-to-face interviews
Petursson 2005 [27]	Yes, and in context of overuse	Iceland Urban & rural	None	16 GPs	General	To explore reasons given by Icelandic GPs for non-pharmacological prescribing. Face-to-face interviews
Larson 2006 [30]	Yes	New York, USA Urban	25 mothers	3 health care professionals 2 pharmacy employees	General	To describe the knowledge, attitudes, beliefs, and practices of Latino community members regarding the use of antibiotics. Focus groups
Rose 2006 [24]	Yes, and in context of overuse	Sheffield & Berkshire, UK	None	39 GPs	Conjunctivitis	To investigate the non-clinical determinants of the management of acute infective conjunctivitis in children. Telephone interviews
Hawkings 2008[25]	Yes	South Wales, UK	Adults, of whom 9 were mothers	None	General	To achieve a deeper understanding of the use of antibiotics in the community. Face-to-face interviews
Hoye 2010 [32]	Yes, and in context of overuse	Norway	None	33 GPs	RTIs	To explore Norwegian GPs’ views and experiences of delayed antibiotic prescribing in patients with URTIs. Focus groups
Tonkin-Crine 2011 [14]	Yes, and in context of overuse	UK, France, Poland, Spain, Belgium	None	52 GPs	RTIs	To elicit GPs’ views on strategies for antibiotic prescribing. Face-to-face and telephone interviews

Table II. Study appraisal.

First author, date	Primary marker: Is the aim of the research to explore subjective meanings of experience?	Context sensitivity: Is the research design sensitive to the context in which study takes place?	Sampling strategy: Is the sampling strategy described appropriate and informed by theory or context?	Data quality: Are different sources of knowledge/understanding compared?	Theoretical adequacy: Is process from theory to interpretation explicit?	Generalizability and typicality: What claims are being made, and do they follow from the data?
Clarke 1989 [20]	Partly satisfied	Partly satisfied	Unclear	Partly satisfied	Satisfied	Satisfied
Butler 1998 [21]	Satisfied	Unclear	Satisfied	Satisfied	Satisfied	Satisfied
Barden 1998 [29]	Satisfied	Unclear	Unclear	Satisfied	Not satisfied	No claims
Elwyn 1999 [22]	Partly satisfied	Unclear	Satisfied	Partly satisfied	Satisfied	No claims
Arrol 2002 [33]	Satisfied	Unclear	Satisfied	Satisfied	?	No claims
Bjornsdottir 2002 [26]	Satisfied	Unclear	Unclear	Satisfied	Satisfied	Satisfied
Jonsson 2002 [28]	Satisfied	Unclear	Satisfied	Satisfied	Satisfied	Unclear
Pradier 2003 [31]	?	Unclear	Unclear	Satisfied	Not satisfied	Unclear
Everitt 2003 [23]	Satisfied	Unclear	Satisfied	Partly satisfied	Not satisfied	Satisfied
Petursson 2005 [27]	Satisfied	Unclear	Satisfied	Partly satisfied	Satisfied	No claims
Larson 2006 [30]	Satisfied	Unclear	Satisfied	Satisfied	Satisfied	Satisfied
Rose 2006 [24]	Partially satisfied	Unclear	Satisfied	Satisfied	Unclear	Not satisfied
Hawkings 2008 [25]	Satisfied	Satisfied	Satisfied	Unclear	Satisfied	Satisfied
Hoye 2010 [32]	Satisfied	Unclear	Unclear	Satisfied	Unclear	Satisfied
Tonkin-Crine 2011 [14]	Satisfied	?	Satisfied	Satisfied	Not satisfied	Satisfied

Figure 2. Examples of third-order development.

Table III. Factors influencing prescription decision (third-order constructs).

Influence on	Third order construct	Supporting sub themes
Clinician factors supporting decisions to prescribe	Just in case	Non-treatment is too risky where there is uncertainty about the consequences of not prescribing, uncertainty about a parent’s ability to cope, uncertainty about diagnosis [24,27]
	Pressures from outside the consulting room	US based clinicians said incentives & free samples from pharmaceutical industry encouraged prescription [29] Requirement to end consultation quickly [26,29] Pressure to give antibiotics to allow return to work or daycare [24,26] Clinicians believed that use of day care and other group exposures were a major cause of antibiotic overuse because it led to frequent infections [29]
	Clinically indicated	A green nasal discharge indicated antibiotics were needed [29] Antibiotic prescription can reduce parental anxiety [24,27,28,33]
	Perceived pressure from parents	Potential for litigation, repeat consultations, visits to other doctors, late night calls, [14,29,31] To increase patient satisfaction and reinforce the doctor-patient relationship [29,31,14] Prescribing was ‘less stressful’ for the clinician than an ‘anxious and angry’ parent. [28, 33, 24, 27] Potential for litigation, repeat consultations, visits to other doctors, late night calls, [14, 29, 31] Clinicians felt that parental expectations for antibiotics was the principle factor that influenced them to prescribe antibiotics when not needed [27, 29]
Parent factors supporting decisions to prescribe	Prescription is needed	A minority of parents believed antibiotics would resolve symptoms and avoid repeat consultations and that they were needed when home management failed [21, 22, 29, 23, 24, 28] Because the current illness is bacterial [29]
	External pressures	From day care providers/school or employment demands [22,23,29]
Clinicians factors supporting decisions not to prescribe	Concern about adverse outcomes	Concern about adverse outcomes [22]
	Lack of pressure to prescribe	Lack of perceived parental pressure [26,29,32]
	Certainty a prescription not needed	Near patient tests provided certainty a prescription is not needed [14]
	Concern about over prescription	Belief that they or their practice colleagues already overprescribe [29,31]
Parent factors supporting decisions not to prescribe	No-intervention preference	Preference for a no-intervention approach [21,23,25,30]
	Concern about side effects	Concern about adverse outcomes [22,23,25,28,29]
	Do not believe will be helpful	Belief the prescription will not improve symptoms [20,21]
Clinician consultation needs	A good consultation	A good consultation is one which is quickly completed, and both parents and clinician are satisfied [24,29]
	Parent education	To educate parents about illness/treatment [21, 29]
Parent consultation needs	A medical assessment	A medical evaluation and medical information [20,23,28,29,31]
	A necessary appointment	Don't want to “bother” the doctor unnecessarily [22]
	“Appropriate“ treatment	To receive “appropriate” treatment as recommended by a doctor [20–23,29,31]
	A medical decision	A medical decision (which could be that no treatment was necessary) [21,23,29,20,21,33]

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