Descriptive study on parents' knowledge, attitudes and practices on antibiotic use and misuse in children with upper respiratory tract infections in Cyprus.

Abstract

Upper respiratory tract infections (URTIs) are common in children and represent a significant cause of antibiotic abuse which contributes to the development of antibiotic resistance. A survey was conducted in Cyprus in 2006 to assess parents' and pediatricians' Knowledge, Attitude and Practices (KAP) concerning the role of antibiotics in children with URTIs. A school-based stratified geographic clustering sampling was used and a pre-tested KAP questionnaire was distributed. A different questionnaire was distributed to paediatricians. Demographic factors associated with antibiotic misuse were identified by backward logistic regression analysis. The parental overall response rate was 69.3%. Parents (N = 1,462) follow pediatricians advice and rarely administer antibiotics acquired over the counter. Although a third expects an antibiotic prescription for URTI symptoms, most deny pressuring their doctors. Low parental education was the most important independent risk factor positively related to antibiotic misuse (OR = 2.88, 95%CI 2.02 to 4.12, p < 0.001). Pediatricians (N = 33) denied prescribing antibiotics after parental pressure but admit that parents ask for antibiotics and believe they expect antibiotic prescriptions even when not needed. In conclusion, Cypriotic parents trust their primary care providers. Although it appears that antibiotic misuse is not driven by parental pressure, the pediatricians' view differs.

Full text

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Int. J. Environ. Res. Public Health 2011, 8, 3246-3262; doi:10.3390/ijerph8083246

International Journal of
Environmental Research and
Public Health
ISSN 1660-4601
www.mdpi.com/journal/ijerph
Article
Descriptive Study on Parents’ Knowledge, Attitudes and
Practices on Antibiotic Use and Misuse in Children with
Upper Respiratory Tract Infections in Cyprus
Andreas Rousounidis 1, Vassiliki Papaevangelou 2, Adamos Hadjipanayis 3, Sotiria Panagakou 1,
Maria Theodoridou 4, George Syrogiannopoulos 5 and Christos Hadjichristodoulou 1,*
1 Department of Hygiene and Epidemiology, Faculty of Medicine, University of Thessaly, 22
Papakyriazi street, Larissa 41222, Greece; E-Mails: rousounides@cytanet.com.cy (A.R.);
geopanagakos@yahoo.gr (S.P.)
2 Second Department of Pediatrics, P&A Kyriakou Children’s Hospital, University of Athens,
Athens 10679, Greece; E-Mail: vpapaev@med.uoa.gr
3 Department of Pediatrics, Larnaca General Hospital, Larnaca, Cyprus;
E-Mail: adahadji@cytanet.com.cy
4 First Department of Pediatrics, Aghia Sophia Children’s Hospital, University of Athens,
Athens 10679, Greece; E-Mail: alexandratheo@yahoo.gr
5 Department of Pediatrics, Faculty of Medicine, University of Thessaly, General University Hospital,
Larisa 41222, Greece; E-Mail: syrogian@otenet.gr
* Author to whom correspondence should be addressed; E-Mail: xhatzi@med.uth.gr;
Tel.: +30-2410-565007; Fax: +30-2410-565051.
Received: 5 May 2011; in revised form: 27 July 2011 / Accepted: 2 August 2011/
Published: 5 August 2011

Abstract: Upper respiratory tract infections (URTIs) are common in children and represent
a significant cause of antibiotic abuse which contributes to the development of antibiotic
resistance. A survey was conducted in Cyprus in 2006 to assess parents’ and pediatricians’
Knowledge, Attitude and Practices (KAP) concerning the role of antibiotics in children
with URTIs. A school-based stratified geographic clustering sampling was used and a
pre-tested KAP questionnaire was distributed. A different questionnaire was distributed to
paediatricians. Demographic factors associated with antibiotic misuse were identified by
backward logistic regression analysis. The parental overall response rate was 69.3%.
Parents (N = 1,462) follow pediatricians advice and rarely administer antibiotics acquired
OPEN ACCESS

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over the counter. Although a third expects an antibiotic prescription for URTI symptoms,
most deny pressuring their doctors. Low parental education was the most important
independent risk factor positively related to antibiotic misuse (OR = 2.88, 95%CI 2.02 to
4.12, p < 0.001). Pediatricians (N = 33) denied prescribing antibiotics after parental
pressure but admit that parents ask for antibiotics and believe they expect antibiotic
prescriptions even when not needed. In conclusion, Cypriotic parents trust their primary
care providers. Although it appears that antibiotic misuse is not driven by parental pressure,
the pediatricians’ view differs.
Keywords: antibiotics; bacterial resistance; KAP study; knowledge; attitudes; practices;
antibiotic overuse; antibiotic misuse; questionnaire; parents

1. Introduction
The emergence of bacterial strains resistant to antimicrobial agents presents a growing concern
worldwide [1]. The relationship between antibiotic use and resistance development is strong and
supported by several studies [2,3]. Countries with the highest per capita antibiotic consumption have
the highest prevalence of resistant pathogens [4,5]. Antibiotics are often used for the treatment of upper
respiratory tract infections, including sore throat, common cold and rhinitis, even though viruses cause
most of these illnesses [6]. Antibiotics abuse in upper respiratory tract infections (URTIs) in children is
an important factor contributing to the development of antibiotic resistance and therefore the judicious
use of antibiotics in pediatric clinical practice is crucial [7]. It has been estimated that
20–50% of all antimicrobial use is inappropriate [8]. Factors leading to antimicrobial overuse in
children are complex, involving, among other factors, parental knowledge and attitude, physician
beliefs as well as constraints of daily practice [8-11].
There is limited data regarding the use of antimicrobials and the prevalence of resistance among
respiratory pathogens in Cyprus. Recent published data revealed that overall antibiotic consumption in
Cyprus during the years 2006–2008, was higher than other EU countries (32.78 DDD/
1,000 inhabitants/day) with about 75% consumption taking place in the private sector. Beta-lactam
antibiotics represented 60% of total antibiotic consumption [12]. Although a slight decrease has been
observed on beta-lactam antibiotic consumption over the recent years, a worrisome increase in the
quinolone consumption has been recorded [12]. Preliminary results from the Antibiotic Resistance
Surveillance and Control in the Mediterranean Region (ARMed) project further supports previous
sporadic reports suggesting high antibiotic resistance in this region [13].
As no similar literature exists from this country, this study aims to explore the parental knowledge,
attitudes and practices (KAP) regarding antibiotic use for children 4–7 years old, in Cyprus. Moreover,
to investigate primary care physicians’ view on this subject, paediatricians practicing at the same areas
were asked to fill another KAP questionnaire. This survey is the first part of a national intervention
program aiming to monitor and reduce antibiotic misuse in children.

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2. Methods
2.1. Participants
The study was carried out in two districts of Cyprus, Larnaca and Limassol, between 1 February and
13 May 2006. These are two mainly urban areas with similar demographic characteristics and roughly
200,000 population each. The protocol was in accordance to the Declaration of Helsinki (1989) of the
World Medical Association and was approved by the ethics committee of the Cypriot Ministry of
Education which accepted the waiver of consent. A school based stratified geographic clustering
sampling was used to select a representative sample of children 4–7 years old. The list of all Cyprus
kindergarten and elementary schools was provided by the Ministry of Education and stratification was
conducted using the population density of the two districts of Cyprus, Larnaca and Limassol. The
schools were randomly selected, using a cross-sectional design, in order to obtain an unbiased sample
of the population in the areas studied regarding age, gender and socioeconomic status. In total, 18
kindergarten (10 in Larnaca and eight in Limassol) and 15 elementary schools (seven and eight,
respectively) were randomly selected. All parents of children attending the kindergartens and
elementary schools were asked to participate. In a second sub-study, we included all pediatricians
practicing in these two districts and asked them to complete a specially designed KAP questionnaire
addressing antibiotic consumption in children with URTIs.
2.2. Procedures
After receiving written permission from the Ministry of Education, the questionnaire was distributed
by teachers to all children attending the schools. In order to increase compliance, all teachers where
personally informed by the researcher about the study and its importance. They were asked to distribute
the questionnaires to their students, collect and mail them back to the researcher. With each
questionnaire, a formal note addressing the parents, explaining the importance of the subject and their
co-operation was handed out.
2.3. Questionnaires
A pre-tested questionnaire previously developed by our team was used in this survey [14]. The
KAP-questionnaire, included demographic data and was structured in three main sections which
displayed the Knowledge (Section A), Attitudes (Section B) and Practices (Section C) of parents
regarding antibiotics use in upper respiratory track infections (URTI) of their children.
Demographic data included age, gender, socioeconomic, educational and health insurance status.
Section A included questions regarding parental knowledge concerning antibiotics. They were asked to
mark antibiotic names out of ten commonly used medications and to answer questions relevant to
antibiotics indications, side effects and their use in viral infections. Section B studied the parental
attitudes regarding URTIs, antimicrobial agents’ use and the pediatricians’ role. Parents where asked
which symptoms and what duration would lead them to seek medical attention for their children, as
well as their expectations regarding antibiotics prescription. Other questions included reasons for
antibiotic use without medical advice (over the counter acquisition of antibiotic, use of leftover

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antibiotic from previous illness, etc.) or whether they would seek for a pediatrician who is more lenient
with antibiotic administration. Finally, section C looked into parental practices and whether the
parent-doctor relation is influenced by the latter’s attitude on antibiotic prescription. Parents were
asked whether their pediatrician spends enough time explaining the illness and suggested antibiotic
treatment for their child, whether he is influenced by their demand to prescribe antibiotics, as well as
whether their pediatrician gives them instructions over the phone (without previous examination) for
antibiotic administration to their sick child.
Each question (apart from those included in the demographic data section) was in a format of five
possible answers (accepting only one right answer), according to the 5-point Likert scale: 1 = strongly
agree, 2 = agree, 3 = uncertain, 4 = disagree and 5 = disagree strongly or 1 = always, 2 = most of the
times, 3 = often, 4 = sometimes and 5 = never.
To verify parent’s responses consistency and exclude random completion, three couples of similar
questions (where each couple included the same statement expressed in a different way) and three pairs
of contradictory questions (where each question included the reverse statement requiring the opposite
answer) were entered in the questionnaire’s structure. All these questions were randomly placed in the
questionnaire to minimize parents’ awareness. Questionnaires with discordant responses to two or
more of these paired questions were removed.
To further analyze demographic factors associated with antibiotic misuse logistic regression analysis
was applied. Six groups of questions (G1–G6), best predicting antibiotic misuse were selected as
shown in Table 1.
Table 1. Questions selected for the logistic regression analysis by section.
Section A
(knowledge)
G1 Q16) Parents who have recognized none or only 1 out of 4 common commercial names of antibiotics
G2 Q17) Antibiotic should be administered in any case, once a child has fever.
Q18) As most of the Upper Respiratory Tract Infections (like cold, flu, sore throat, ear infection) are of viral
cause, they should not be treated with antibiotics.
Q19) If a child suffers from flu or cold, resolution of symptoms will be quicker if antibiotic is given on time.
Q22) When antibiotics are administered for no special reason, their efficacy is decreased and bacteria
become more resistant.
G3

G4
G5 Q30) Would you change your pediatrician because according to your opinion he/she does not prescribe
antibiotics often enough for your child?
Q31) Would you change your pediatrician because according to your opinion he/she prescribes antibiotics
for your child very often?
Q32) Would you reuse an antibiotic which you had used in the past if your child presents similar symptoms?
Q34) Do you think that most of the Upper Respiratory Infections will be self—cured even without the use of
antibiotics?
G6 Q42) Would you be unhappy if your pediatrician does not prescribe an antibiotic for your child’s Upper
Respiratory Infection?
Q45) How often does your pediatrician recommend antibiotic therapy over the phone?
Q46) In case you strongly wish your child to receive antibiotics, how often do you directly request it?
Section B
(attitudes)
Q27) How often would you like your pediatrician to perscribe antibiotics for your child when it suffers from
cold, ear pain, sore throat, cough, vomit, fever, runny nose?
Q28) How often would you give your child antibiotics without previous pediatricians’ consult?
Section C
(practices)

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A second questionnaire, distributed to pediatricians, included nameless demographics, data
concerning the level of postgraduate studies as well as three sections referring to their Knowledge,
Attitudes and Practices regarding antibiotic prescription to children with URTIs. This questionnaire has
not been pre-tested, had similar format to the parental one but did not include similar-contradictory
questions. To increase information accuracy questionnaires were anonymous and special care was
taken during collection to prevent accidental identification.
2.4. Statistical Analysis
The data were entered in a database created by using the Epi Info software. The statistical analysis
was conducted by using the Epi Info (http://www.cdc.gov/) and SPSS software version 15.0. Parents’
answers were analyzed using the 5-point Likert scale. More specifically, the possible answers “strongly
agree” and “agree” were considered as a “positive” answer, while the possible answers “disagree” and
“strongly disagree” were considered as a “negative” answer. The possible answer “uncertain” was not
taken into consideration. Similarly, the possible answers “always”, “most of the times” were
considered as “frequently”, while the possible answers “sometimes” and “never” were considered as
“rarely”. The possible answer “often” was not taken into consideration. Univariate analysis was used to
identify risk factors associated to injudicious antibiotic use. Chi-square test or Fisher’s exact test were
used for qualitative data. Relative Risk (RR) and its 95% Confidence Interval were calculated as well.
Statistically significant factors were included in a conditional backward logistic regression model. A p-
value < 0.05 was considered statistically significant.
3. Results
Overall, 2,155 questionnaires were distributed. The overall response rate was 69.3% (1,494/2,155);
and was significantly higher in Larnaca (77.4%, 778/1,005) compared to Limassol area (62.3%,
716/1,150) (p < 0.001). Twenty five questionnaires (1.7%) were excluded from further analysis since
parents had contradictory responses to two or more of the six couples of similar-contradictive
questions. Furthermore, another seven questionnaires were excluded from further analysis
since parents did not respond to more than 50% of the questions. Therefore 1,462 questionnaires
were analyzed.
3.1. Demographic Data
Parent’s demographics are shown in Table 2. Thirty three pediatricians (33/40 enrolled, 17
pediatricians from Larnaca), returned their completed KAP questionnaires. Most pediatricians were
males (22/33), over 50 years old (18/33), general pediatricians without subspecialty (28/33) in private
practice (29/33).

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Table 2. Demogarphic characteristics of parents.
Demographic characteristics
Larnaca (N = 778)
n/Total (%)
614/778 (78.9)
36 (33–40)
463/778 (59.5)
379/463 (81.9)
285/772 (36.9)
263/756 (34.8)
667/778 (85,7)
27/778 (3.5)
531/778 (68.3)
71/774 (9.2)
72/777 (9.3)
91/778 (11.7)
733/767 (95,6)
298/775 (38.5)
Limassol (N = 716)
n/Total (%)
541/701 (77.2)
35 (32–39)
430/695 (61.9)
349/422 (82.7)
291/696 (41.8)
250/668 (37.4)
587/686 (85,6)
50/685 (7.3)
634/708 (89.5)
101/706 (14.3)
55/715 (7.7)
75/688 (10.9)
619/652 (94,9)
231/653 (35.4)
p-value
Mother responding (%)
Median age (years) (IQR)
Having insurance (%)
Having private insurance *
College/University maternal education (%)
College/University paternal education (%)
High monthly income (%) #
Foreign born (%)
Urban residence (%)
One child (%)
Single parent family (%)
Child with recurrent URI’s (%)
Good access to healthcare system (%) #
Consider pediatrician relative/friend (%) #
0.418
<0.001
0.355
0.743
0.055
0.301
0.929
0.001
<0.001
<0.001
0.276
0.631
0.578
0.230
* % among those with insurance.
# self perception of status.
3.2. Parental KAP
3.2.1. Section A (Knowledge)
Most parents (90%) affirmed that their pediatrician was the main source for information regarding
antibiotics, while television (15.3%) and newspaper (11.6%) followed. However, 3.1% of parents
declared they had never received any information. Out of ten commonly used medications, most
parents (64%) were able to identify 3/5 antibiotic names.
Although the majority of parents acknowledged that antibiotics have side effects (93%), agreed that
misuse reduces their efficiency and increases bacteria resistance (90%), that viral URTI’s are self
limited (60%) and that fever is not an indication for the administration of antibiotics (87%), many
(48.4%) believed that antibiotics may decrease duration of URTI symptoms. Interestingly, most parents
(85%) believed that scientists continuously discover new antimicrobial agents against resistant
microorganisms and that antibiotics may decrease the incidence of URTI complications (73.5%).
3.2.2. Section B (Attitudes)
Most parents stated that they would seek medical advice for their children, after 2 days of upper
respiratory tract infection symptoms. The main symptoms considered important and would drive
parents to the doctor’s office included earache (84%) and fever (81%), followed by sore throat (45%),
cough (36%) and altered behavior (33%). Many parents (33.5%) acknowledged that they expect from
their pediatrician to prescribe an antibiotic for URTI symptoms rather than nasal normal saline (30%),
mefenamic acid (11%) and paracetamol (33%). We asked parents if they believed that antibiotics were
helpful in treating a variety of symptoms. Although very few parents would ask for antibiotics for
URTI symptoms (10%), cough (13%) or vomiting (11%), many would expect their pediatrician to

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prescribe an antibiotic if their child had earache (51%), fever (41%), or sore throat (27%). Interestingly,
parents denied that they would purchase antibiotics over the counter without consulting the pediatrician
but 6% admitted they would do so if their doctor had previously prescribed an antibiotic for similar
symptoms.
The majority of parents (81%) concurred that antibiotics are excessively used without appropriate
indications and declared that they would not change pediatrician if he/she didn’t prescribe easily
antibiotics (95.5%), while they affirmed they would change their doctor because she/he prescribed
easily antibiotics (66.5%).
According to 88% of parents, their concern regarding secondary complications of upper respiratory
tract infections would lead them to seek medical advice, while 60% agree that it is best to avoid the use
of antibiotics for uncomplicated URTIs. Finally, the vast majority of parents (98%) agree that
education of both parents and pediatricians on the judicious use of antibiotics is necessary.
3.2.3. Section C (Practices)
Few parents (9%) admitted that they were left discontent from their pediatrician whenever he/she
didn’t prescribe antibiotics. However, only 59% would query their pediatrician whether it was really
necessary in case he/she would give them a prescription or would praise their doctor when he/she
elected not to administer antibiotics. In another question, the majority of parents (90%) stated that the
side effects of antimicrobial use are important. Very few parents admitted that they would request
antibiotics openly (8.5%) or when diagnosis is not certain (6.5%) or over the phone without a
preceding office visit (9%), while very few (4.5%) believe that their pediatrician prescribed antibiotics
just because parents asked for them. A significant proportion of parents (90%) believe they have been
well informed on the judicious use of antibiotics, admit their doctor has spent time explaining the
child’s disease and whether he should or not administer antibiotics and more importantly, 97% stated
they precisely follow pediatricians’ instructions.
3.3. Demographic Factors Associated with Parental KAP
Residence area, ethnicity, parental age, sex and educational level were identified as significant
factors associated with knowledge, attitudes and practices of parents concerning judicious antibiotic
use for URTI’s. Table 3 depicts most identified associations. Furthermore, parents identifying their
doctor as their friend/relative (rather than having a strictly professional relationship with him/her) were
more satisfied in reference to the amount of information provided concerning antibiotic use
(RR = 1.06, 95%CI 1.03–1.10) and were more likely to praise their pediatrician for withholding
antibiotic administration (RR = 1.21, 95%CI 1.11–1.33). Parents with a single child were more likely
to feel they have inadequate information considering the judicious use of antibiotics (RR = 0.92,
95%CI 0.86–0.99) and admit they worry more than other parents (RR = 1.33, 95%CI 1.12–1.59).
Finally, parents that have good access to the health system consider themselves to be less anxious
about their child’s health (RR = 0.75, 95%CI 0.59–0.97).

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Table 3. Demographic factors associated with parental KAP.
Factor
Residence
area
(Larnaca
versus
Limassol)

Question
Q15_7. I have not had any information concerning judicious antibiotic use
RR* (95%CI)
2.17
(1.15–4.12)
P-value
0.014
Q30. Would you change pediatrician because he administers antibiotics too
often?
Q46. How often would you directly ask from your pediatrician to prescribe
antibiotics?
Q50. How often do you believe that your pediatrician administered antibiotics
because you requested it?
Q15_2. I have had been informed by TV concerning judicious antibiotic use
0.59
(0.36–0.97)
1.61
(1.12–2.30)
1.74
(1.05–2.89)
1.49
(1.16–1.92)
0.036
0.008
0.028
Parental age
(>35years
versus
≤35 years)
Parental sex
(father versus
mother)

0.002
Q15_4. I have had been informed by the newspapers concerning judicious
antibiotic use
Q18. Most URTI’s are self limited
1.78
(1.31–2.42)
1.16
(1.05–1.28)
1.25
(1.08–1.46)
1.20
(1.08–1.34)
0.72
(0.57–0.92)
1.04
(1.01–1.08)
1.05
(1.01–1.08)
0.72
(0.52–0.99)
2.29
(1.26–4.16)
1.24
(1.09–1.40)
1.61
(1.02–2.53)
1.81
(1.30–2.52)
1.56
(1.16–2.10)
2.06
(1.51–2.82)
1.96
(1.01–3.81)
0.63
(0.40–0.99)
<0.001
0.004
Q26_7. Altered behavior would lead me at the pediatricians office for advise 0.003
Q34. Do you believe it is better to follow a child with URTI rather than
prescribing antibiotics?
Q35. Would you be more prone to ask for antibiotics if your child had often
URI’s
Q39. How much information on the judicious antibiotic use have you had?
0.001
0.008
0.019
Q41. Are you concerned about antibiotic side effects? 0.010
Q15_2. I have had been informed by TV concerning judicious antibiotic use. 0.042
Q15_7. I have not had any information concerning judicious antibiotic use 0.006
Q19. Antibiotics shorten URTI duration 0.002
Q21. Antibiotics do not have side effects 0.040

Q27_1. How often would you want your pediatrician prescribe antibiotics for a
common cold.
Q27_4. How often would you want your pediatrician prescribe antibiotics for
cough.
Q27_5. How often would you want your pediatrician prescribe antibiotics for
vomiting.
Q32. Would you ever use left over antibiotic for a new episode of URI or sore
throat?
Q42. Do you agree you would be left discontent if your pediatrician did not
prescribe antibiotics?
0.001
0.004
<0.001
0.043
0.045

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Table 3. Cont.
Parental
educational
level
(At least one
parent
with
education
versus parents
with up
secondary
school)

college
to
Q15_4. I have had been informed by the newspapers concerning judicious
antibiotic use
0.50
(0.37–0.67)
<0.001
Q17. When your child has fever, does he always needs antibiotics? 2.31
(1.67–3.19)
0.75
(0.68–0.82)
1.73
(1.52–1.97)
2.23
(1.42–3.51)
0.92
(0.88–0.95)
1.79
(1.27–2.53)
3.90
(2.04–7.45)
<0.001
Q18. Most URTI’s are self limited <0.001
Q19. Antibiotics shorten URTI duration <0.001
Q21. Antibiotics have no side effects <0.001
Q22. Antibiotic misuse increases antibiotic resistance. <0.001
Q26_3. Nasal congestion would lead me at the pediatricians office for advise. 0.001
Q27_2. How often would you want your pediatrician to prescribe antibiotics
for
nasal congestion?
Q27_4. How often would you want your pediatrician to prescribe antibiotics
for cough?
Q28_1. How often would you administer antibiotics to your child over the
counter because of reduced time or to avoid visit expenses?
Q28_2. How often would you administer antibiotics to your child over the
counter because you considered disease mild?
Q28_3. How often would you administer antibiotics to your child over the
counter because he had previously prescribed one for similar symptoms?
Q34. Do you believe it is better to follow a child with URTI rather than
prescribing antibiotics?
Q42. Do you agree you would be left discontent when your pediatrician did
not prescribe antibiotics?
Q45. How often do you get instructions concerning antibiotic administration
over the phone?
<0.001
2.33
(1.70–3.18)
3.17
(1.38–7.28)
3.26
(1.74–6.12)
1.88
(1.20–2.94)
0.68
(0.61–0.76)
1.47
(1.05–2.07)
1.46
(1.04–2.04)
<0.001
0.004
<0.001
0.005
<0.001
0.024
0.027

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Table 3. Cont.
Parental
Ethnicity
(Immigrant
versus
Cypriotic
Ethnicity)

Q15_6. I have had been informed concerning judicious antibiotic use by
relative
2.86
(1.25–6.54)
0.024
Q26_2. Fever would lead me at the pediatricians office for advise 0.72
(0.59–0.87)
0.82
(0.71–0.96)
3.61
(1.84–7.07)
3.51
(1.81–6.83)
4.38
(2.01–9.56)
2.63
(1.65–4.19)
<0.001
Q26_4. Ear ache would lead me at the pediatricians office for advise 0.001
Q28_2. How often would you administer antibiotics to your child over the
counter because you considered disease mild?
Q30. Would you change pediatrician because he does not administer
antibiotics easily?
Q32. Would you ever use left over antibiotic for a new episode of URI or sore
throat?
Q42. Do you agree you would be left discontent when your pediatrician did not
prescribe antibiotics?
0.001
0.002
0.002

<0.001
* RR = refers to what is the relative risk of parents answering correctly to each question according to their
demographic factor examined.
3.4. Logistic Regression Analysis
Possible association of demographic factors with antibiotic misuse was further assessed by applying
logistic regression analysis. According to the answers given to the six groups of questions formed for
this purpose (Table 1), parents were divided into those with and without antibiotic misuse. Association
of demographic factors with knowledge, attitudes and practices concerning antibiotic misuse in
children with URI’s are shown in Table 4. Parents’ educational level remained into the model in all six
groups of questions.
Table 4. Logistic regression analysis on factors associated with misuse of antibiotics.
Questions
Group 1
Demographic factor
Parents’ educational level *
Having Insurance (No/Yes)
Immigrant (Yes/No)
Sex (Father/Mother)
Income (high/low)
No of children (1 versus ≥2)
Frequent URI’s (No/Yes)
Parents’ educational level *
Immigrant (Yes/No)
Parents’ educational level *
Sex (Father/Mother)
Parents’ educational level *
Immigrant (Yes/No)
OR
1.58
1.49
2.21
2.24
0.52
3.19
2.23
7.44
6.00
2.45
3.57
2.19
2.22
95% CI
1.11–2.26
1.04–2.13
1.19–4.10
1.54–3.26
0.34–0.79
2.11–4.83
1.16–4.29
0.93–59.84
1.21–29.77
1.08–5.60
1.70–7.50
1.45–3.32
1.09–4.51
p-value
0.011
0.031
0.012
<0.001
0.002
<0.001
0.016
0.059
0.028
0.033
0.001
<0.001
0.028
Group 2
Group 3
Group 4

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Table 4. Cont.
Group 5 Parental Age
(>35year versus ≤35year)
Parents’ educational level *
Income (high/low)
Parents’ educational level *
Residence (urban/rural )
0.69
2.88
0.50–0.95
2.02–4.12
0.021
<0.001
0.59
2.47
0.56
0.40–0.87
1.38–4.44
0.32–0.95
0.008
0.002
0.032
Group 6
* Parents’ educational level = Up to secondary school versus at least one parent College/University.
3.5. Pediatricians’ View
Although most pediatricians (>97%) agreed that URTIs are self limited and antibiotic misuse
increases antibiotic resistance, 60% agreed that most pediatricians would administer antibiotics for
URTIs under parental pressure. Furthermore, although most pediatricians denied they would ever
prescribe antibiotics to please the parents, to avoid parents seeking medical help from another
pediatrician or because parents insisted, almost 25% would prescribe antibiotics whenever fever
persisted for more than 3 days and 15% would do so if the family was leaving on vacation. While all
denied administration of antibiotics for common cold or runny nose, 18% and 49% would prescribe
antibiotics for croup and otitis with effusion, respectively. While less than 40% reported they believe
that parents would appreciate their withholding antibiotics for URTI, more than two thirds reported
that they feel that parents want them to administer antibiotics even when their use is not medically
necessary. Finally more than 60% reported that parents regularly ask for antibiotics for URTIs.
Comparing the answers given by the pediatricians from Larnaca and Limassol it is worth noticing
that pediatricians practicing in Larnaca were more likely to administer antibiotics in cases were fever
lasted for more than 3 days (RR = 6.59; 95%CI 0.91–47.76, p = 0.039) and believed that parents expect
them to prescribe antibiotics for URTI’s (RR = 2.51; 95%CI 1.32–4.78, p = 0.001) while they were less
likely to be praised by parents when withholding antibiotics (RR = 0.28; 95%CI 0.09–0.84,
p = 0.008).
4. Discussion
This is the first study on KAP from parents in Cyprus concerning antibiotic use in young children
with URTI’s. This is a cross-sectional study that included a large number of parents sampled by a
stratified geographic clustering methodology. The overall response rate was 69.3%. Although this is
lower than that reported in other KAP studies where face-to-face or telephone interviews are used,
our methodology using self-answered questionnaires increases the precision of information
obtained [15,16]. This methodology was preferred since direct parental interviewing might both
involve interviewees’ influence as well as interviewers’ bias in the interpretation of parental answer.
Moreover, the probability of the responders’ embarrassment towards the interviewer would affect the
quality of their answers [17]. Additionally, in order to interview a large cohort of parents, a large
number of interviewers would have to be trained to be sent to interview the parents, which was
impractical. Finally, the variability among the interviewers could not be excluded. Using the
self-answered methodology however, each responder received the same set of questions phrased in

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exactly the same way, so the answers were derived in a more objective way. Distribution of the
questionnaires by teachers and including a letter explaining the importance of the study probably
increased parents’ compliance. This study indicates that school based sampling is helpful and achieves
high response rates when compared to randomly sending questionnaires to parents by mail [18].
The response rate was significantly higher in Larnaca compared to Limassol (p ≤ 0.001).
Differences in response rates between different geographic areas have been reported and may be
explained by differences among the demographic characteristics of parents [14]. Parents from Larnaca
had a higher median age and were less likely to be immigrants (Table 2). However, in contrast to
previous published studies, parents from Limassol, the area with lower response rate, had a higher
education (although not at a significant different level) and had a higher percentage of urban residence
when compared to parents from Larnaca [14]. Other factors including idiosyncrasy and perception of
importance of health issues may indeed influence response rates in such studies [19]. Interestingly,
pediatricians practicing in Larnaca seemed to be more “pressured” by parents to prescribe antibiotics
when compared to those from Limassol, suggesting that people residing in Larnaca are more concerned
about febrile URTIs.
Six couples of repetitive or contradictory questions were included in order to exclude questionnaires
filled in randomly or incoherently. Overall 1.7% questionnaires were not further analyzed. This is a
similar percentage as compared to previous studies [14]. As expected, low parental educational level
was strongly associated with exclusion of questionnaire due to inconsistency.
In Cyprus, as in Greece and other Mediterranean countries, children’s primary care is provided by
private pediatricians. In Cyprus, most have been trained in Greece and Great Britain. Overall parents
appeared to have a trusting relationship with their private pediatrician, most (97.5%) declared they
follow their exact recommendations, two thirds of parents were happy with their access to the
healthcare system and more than a third declared that they had an intimate relationship with their
child’s pediatrician. Most parents identified their pediatrician as the major source of information
regarding use and misuse of antibiotics whereas in other KAP studies television has been identified as
the preferred source of information [20]. Although parents were overall knowledgeable in regard to
antibiotic administration during children’s URTIs and their side effects, it is worth noticing that most
parents believe that scientists continuously discover new antimicrobials and therefore do not realize the
problems faced by the scientific society with shortage of new antimicrobials in the production pipeline
[5]. Furthermore, although they are able to recognize that URTIs are usually viral and that fever should
not be treated with antibiotics, many
or complications.
Most parents’ expectation for antibiotic prescription is high, therefore, further parental education is
needed concerning when to visit a doctor during uncomplicated URTIs, as well as on the recent
guidelines for the symptomatic treatment of otitis media in children over 2 years old [21].
In a recent Greek study, it was shown that a significant proportion of antibiotic outpatient
consumption is secondary to over the counter purchase, while in another study involving pharmacists it
was depicted that over the counter purchase of antibiotics is easy [22,23]. In contrast, in a study from
the University of Thessaly Greece, referring to parents alone, it was revealed that although parents have
the opportunity to purchase antibiotics over the counter, less than 10% of parents would consider doing
believe that antibiotics decrease duration

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so [24]. In our study, very few parents admitted administering antibiotics to their children suffering
from URTIs without first consulting their pediatrician, indicating that parents follow their doctors
advice. This is in accordance with a recent study indicating that Cyprus has the lowest over the counter
consumption among several other South Mediterranean countries [25].
Clearly demographic factors such as residence area, ethnicity, parental age, sex and educational
level are associated with knowledge, attitudes and practices concerning judicious use of
antibiotics (Table 3). Older parental age and higher educational level were clearly associated with
better knowledge (Table 3). While younger parents were worried about fever, older parents were more
likely to worry by the altered behavior of their child during a URTI, acknowledge that antibiotics are
overused, that it is better to watch a child with URTI rather than administer antibiotics and declared
concern over the side effects of antibiotic treatment. Immigrant parents declared they would be
unsatisfied if antibiotics were not prescribed and would change pediatrician if he/she did not prescribe
antibiotics easily. When logistic regression was applied the most important factor associated with
correct parental knowledge, attitudes and practices on judicious use of antibiotics during childhood
URTI’s was parental educational level (Table 4). Ethnicity was also related to knowledge concerning
antibiotic use while immigrants were more likely to purchase antibiotics over the counter.
Parental demographics such as age, educational level, ethnicity and income have been
previously been identified by others as important factors explaining KAPs related to antibiotic
consumption [9-11,26-28].
Overall, it appears that the over consumption of antibiotics in Cyprus is not overtly driven by
parental pressure. Moreover, parents identifying their pediatrician as a relative/friend are content with
received education and more likely to even praise them for not prescribing antibiotics. These findings
are supported by others, since parents’ satisfaction is shown to be related to the time spent with the
doctor rather than the recommended treatment [9]. Therefore, it appears that pediatricians in Cyprus
have made a significant effort over the years to build a trusted relationship and educate parents on the
use of antibiotics in children with URTI’s. These findings are in accordance with recent data from the
Armed project that suggest that in Cyprus self-medication rates are low while the prevalence of E. coli
and Streptococcus pneumoniae resistance is low when compared to other countries in the
Euro-Mediterranean area [23,29,30]. However, increased prevalence of methicillin-resistant
Staphylococcus aureus (MRSA) in invasive isolates has been recently reported [31]. Moreover,
outpatient antibiotic consumption in Cyprus is high when compared to other EU countries [12]. It is
possible therefore that as described in other European countries primary care physicians consistently
prescribe antibiotics for URTIs despite current existing evidence of little benefit and universal pressure
for minimizing antibiotic use [32]. This is supported by our finding that about 40% of parents have
received telephone instructions for antibiotic administration as well as the recognition from over a
quarter of parents (28%) that they have directly asked their pediatrician to prescribe antibiotic
treatment. However, in contrast to parents, pediatricians reported that 60% of parents directly ask for
antibiotics. So, although the parents’ view supports that antibiotic prescription is not parental driven,
the small sub-study on pediatricians view showed that pediatricians (66%) feel that indeed parents
expect them to administer antibiotics.

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5. Limitations
The main limitation of this study is that the data provided is of local interest. However, the
conclusions could also refer to other countries where private pediatric service predominates or other
countries with similar culture such as Greece or other countries in the Mediterranean area.
The response rate of <70% is considered low when compared to other studies using different
methodology [15,16]. On the other hand, using self-answered questionnaires possibly increases the
proportion of honesty in the given answers. A major limitation of the study is the small number of
pediatricians interviewed. However, statistical significant results depict the existing gap
between parents and pediatricians and may clarify the ways to go further towards the reduction of
antibiotic consumption.
6. Conclusions
This study indicates that in Cyprus, parents are satisfied by the care provided and recognize their
pediatricians as their main source of information. Although, it appears that antibiotic misuse is not
driven by parental pressure, pediatricians’ view implies that medical doctors feel that the majority of
parents wish for antibiotic administration for their children’s URTIs. It is therefore concluded that
simultaneous well structured interventions towards both pediatricians and parents are needed to
improve antibiotic consumption.
Acknowledgments
We would like to thank all pediatricians and parents who participated in the survey filling in the
questionnaires. Moreover, we would like to thank the ex-president of Cyprus Paediatric Association
Persianis Nikos for his contribution in conducting the survey. The survey was funded by Research
Promotion Foundation of Cyprus. The foundation had no role in study design, data collection and
analysis, decision to publish, or preparation of the manuscript.
Conflict of interest
The authors declare no conflict of interest.
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