Article

Educational Posters to Reduce Antibiotic Use

Department of Pediatrics, New York Medical College, Valhalla, NY, USA.
Journal of Pediatric Health Care (Impact Factor: 1.44). 05/2006; 20(3):192-7. DOI: 10.1016/j.pedhc.2005.12.017
Source: PubMed
ABSTRACT
Antibiotic overuse promotes resistant strains of bacteria and puts patients at risk for adverse reactions. Given the use of educational posters in government-sponsored public health campaigns, this study examined the effectiveness of a waiting room poster in reducing excessive antibiotic use in clinical practice.
Investigators conducted a 1-month trial of an educational poster with historical controls using three private pediatric group practices in Westchester County, New York. Children between the ages of 6 months and 10 years at the time of a visit to diagnose and treat symptoms of respiratory illness were enrolled as subjects. Antibiotic prescriptions for children with respiratory illnesses seen during the poster month were compared with prescriptions written during three 1-month historical control periods. The proportion of visits that resulted in a prescription for an antibiotic served as the outcome measure.
Overall, 326 of the 720 patients (45.2%) enrolled in the study were treated with an antibiotic. Multiple logistic regression analysis revealed no statistically significant difference in the proportion of visits resulting in an antibiotic prescription among the 4 study months (P = .79), indicating that the educational poster had no effect on antibiotic use.
Public education in the form of a waiting room poster was not sufficient to decrease antibiotic prescriptions. This finding has implications for current large-scale programs and for health care providers as they continue to attempt to educate patients on the appropriate use of antibiotics.

Full-text

Available from: Patricia A Patrick, Jul 28, 2015
Educational Posters
to Reduce
Antibiotic Use
David Ashe, MD, Patricia A. Patrick, MPH,
Michelle M. Stempel, MPH, Qiuhu Shi, PhD, &
Donald A. Brand, PhD
ABSTRACT
Introduction: Antibiotic overuse promotes resistant strains of bacteria and puts
patients at risk for adverse reactions. Given the use of educational posters in
government-sponsored public health campaigns, this study examined the ef-
fectiveness of a waiting room poster in reducing excessive antibiotic use in
clinical practice.
Methods: Investigators conducted a 1-month trial of an educational poster with
historical controls using three private pediatric group practices in Westchester
County, New York. Children between the ages of 6 months and 10 years at the
time of a visit to diagnose and treat symptoms of respiratory illness were
enrolled as subjects. Antibiotic prescriptions for children with respiratory
illnesses seen during the poster month were compared with prescriptions
written during three 1-month historical control periods. The proportion of visits
that resulted in a prescription for an antibiotic served as the outcome measure.
Results: Overall, 326 of the 720 patients (45.2%) enrolled in the study were
treated with an antibiotic. Multiple logistic regression analysis revealed no
statistically significant difference in
the proportion of visits resulting in
an antibiotic prescription among the
4 study months (P .79), indicating
that the educational poster had no
effect on antibiotic use.
Discussion: Public education in the
form of a waiting room poster was
not sufficient to decrease antibiotic
prescriptions. This finding has impli-
cations for current large-scale pro-
grams and for health care providers
as they continue to attempt to edu-
cate patients on the appropriate
use of antibiotics. J Pediatr Health
Care. (2006) 20, 192-197.
According to recent estimates,
10% to 22% of children younger
than 18 years diagnosed with
common colds or upper respira-
tory tract infections receive anti-
biotics from their health care pro-
viders (Finkelstein et al., 2000;
Finkelstein et al., 2003; Mainous,
Hueston, Davis, & Pearson, 2003;
McCaig, Besser, & Hughes, 2002).
Based on these trends in antibi-
otic use and bacterial resistance,
there is “room for improvement”
in appropriate antibiotic pre-
scribing (Watson et al., 1999). Re-
ducing inappropriate antibiotic
use is a challenging task, in part
because of parental expectations
and demands for antibiotics
(Bauchner, Pelton, & Klein, 1999;
Mangione-Smith, McGlynn, El-
liott, Krogstad, & Brook, 1999).
Government-sponsored cam-
paigns have been launched to
help reduce over-prescribing of
antibiotics by promoting inter-
ventions such as educational
posters and brochures, which can
be incorporated easily and inex-
pensively into clinical practice.
Successful interventions in
promoting judicious antibiotic
use typically have involved mul-
tiple time-consuming and labor-
intensive steps and have used pa-
rental knowledge, attitudes, and
behaviors as outcome measures
(Bauchner, Osganian, Smith, &
David Ashe is Assistant Professor, Department of Pediatrics, New York Medical
College, Valhalla, NY.
Patricia A. Patrick is Instructor, Department of Medicine, New York Medical College,
Valhalla, NY.
Michelle M. Stempel is Clinical Research Assistant, Memorial Sloan-Kettering Cancer
Center, New York, NY.
Qiuhu Shi is Associate Professor, School of Public Health, New York Medical College,
Valhalla, NY.
Donald A. Brand is Professor, Department of Medicine and Department of Pediatrics,
New York Medical College, Valhalla, NY.
This study was supported by Award 2D54HP00022 from the Health Resources and
Services Administration.
Reprint requests: David Ashe, MD, 106 Washington Ave, Pleasantville, NY 10570;
e-mail: davidashe@aol.com
0891-5245/$32.00
Copyright © 2006 by the National Association of Pediatric Nurse Practitioners.
doi:10.1016/j.pedhc.2005.12.017
192 Volume 20 Number 3 Journal of Pediatric Health Care
Original Article
www.jpedhc.org
Page 1
Triant, 2001; Collett, Pappas,
Evans, & Hayden, 1999; Stivers,
Mangione-Smith, Elliott, Mc-
Donald, & Heritage, 2003; Taylor,
Kwan-Gett, & McMahon, 2003;
Trepka, Belongia, Chyou, David,
& Schwartz, 2001; Wheeler et al.,
2001). These multidimensional
approaches involve combina-
tions of clinician, patient, and
community-wide educational in-
terventions. Clinician-oriented
activities include educational
presentations and group meet-
ings, coupled with the distribu-
tion of written materials on judi-
cious antibiotic use to parents.
While these approaches have
proven successful, such complex
interventions may not be sensible
on a large scale.
The efficacy of educational
posters as a single intervention,
with antibiotic use as the primary
outcome measure, has not been
studied previously. Because re-
searchers have shown that many
parents notice and read health
promotion posters (Ward & Haw-
thorne, 1994), the purpose of the
present study was to evaluate
whether an educational poster
located in the reception area of a
clinician’s office would lead to a
reduction in the frequency of an-
tibiotic prescriptions for children
with symptoms of respiratory ill-
ness. The study hypothesis was
that educating parents about the
judicious use of antibiotics would
curtail parental demands for anti-
biotics for children with viral re-
spiratory illnesses, which, in turn,
would decrease the frequency of
prescriptions. Our rationale for
evaluating this specific interven-
tion is that many government-
sponsored campaigns rely on sin-
gle educational interventions,
such as posters, as educational
tools to reduce the overprescrib-
ing of antibiotics (Centers for Dis-
ease Control and Prevention
[CDC], 2005a). The effectiveness of
such interventions is uncertain.
METHODS
Setting
Three private pediatric group
practices belonging to a network
of office practices in Westchester
County, New York, served as study
sites. The practices serve a patient
population that is 80% White, 10%
Latino, 5% Asian, and 5% African-
American. Approximately 5% of
families are Spanish-speaking, and
nearly all of them have private in-
surance. Seven of 10 clinicians at
these sites volunteered to partici-
pate in the study by allowing in-
vestigators to review medical
records of their patients presenting
with respiratory illnesses during
the study months.
Study Design
A 1-month trial of an educa-
tional poster was carried out at the
three sites. Posters were placed in
the reception area of each practice
on December 1, 2001. Antibiotic
prescriptions for children with re-
spiratory illnesses seen during the
ensuing month were compared
with prescriptions written during
three 1-month historical control
periods: November 2000, Decem-
ber 2000, and November 2001. The
proportion of these visits that re-
sulted in a prescription for an an-
tibiotic served as the outcome
measure.
The 16⬙⫻22 poster (Figure)
provided brief answers to the fol-
lowing questions: What causes a
runny nose during a cold? How is a
viral respiratory infection treated?
What are antibiotics, and when are
they needed? Why not take antibi-
otics now? Our poster was similar
in size to those provided by the
CDC but provided additional de-
tails derived from their educational
brochures (CDC, 2005b).
Power calculations determined
that a sample of 60 visits for respi-
ratory illnesses in each practice
during the 1-month trial and dur-
ing each control month would be
sufficient to detect a difference of
15 percentage points in the pro-
portion of visits resulting in an an-
tibiotic prescription with 80%
power and a significance level of
0.05. Random sampling was used
to select 60 patient visits from each
practice during each month of the
study. Details are given later in this
article.
As an outcome measure, the pro-
portion of visits for which treatment
was consistent with the diagnosis
would, in theory, be preferable to
the proportion of visits that resulted
in a prescription for an antibiotic.
The former measure would consider
appropriateness, not simply fre-
quency of administration of antibiot-
ics. Clinicians may consciously or
unconsciously tend to record diag-
noses that justify their treatments;
therefore, it is unlikely that a chart
review would offer an accurate as-
sessment of the appropriateness of
individual antibiotic prescriptions.
To avoid this type of documentation
bias, which probably is inherent in
most chart-based appropriateness-
of-care studies, we simply measured
the proportion of visits that resulted
in a prescription for an antibiotic.
This approach assumes implicitly
that the prevalence of bacterial in-
fections of the respiratory tract in a
given month should remain roughly
constant from one year to the next.
In that case, an intervention leading
to a reduction in the frequency of
antibiotic use would suggest more
judicious use of these drugs.
Data Collection
Staff at the office practices pro-
vided investigators with lists of
dates when patient appointments
were scheduled during each of
the 4 study months. After shuf-
fling each list with a random
number generator, we chose
dates from the top of the list, and
office staff provided the names of
patients seen for acute illnesses
on each of the chosen dates. We
reviewed their medical records to
determine eligibility for inclusion
in the study based on the follow-
ing criteria:
193Journal of Pediatric Health Care May/June 2006
Page 2
The child was between 6
months and 10 years old at time
of the visit.
The purpose of the visit was to
diagnose and treat an acute
illness.
The child or guardian reported
symptoms of respiratory illness,
as indicated by the presence of
one or more of the words indi-
cated in the Box or phrases (or
their equivalents) in the medical
record entry for the visit.
This group of patients would be
expected to include children with
viral respiratory illnesses and chil-
dren with bacterial infections for
which antibiotic treatment would
be indicated. If a patient met the
eligibility criteria, his or her age,
sex, symptoms, diagnoses, and
prescriptions were recorded. Data
collection continued until 60 pa-
tient visits for acute respiratory ill-
nesses were included from each
month at each site.
The study was approved by the
institutional review board of New
York Medical College.
Analysis
Multiple logistic regression
analysis was used to compare the
intervention and control months
with respect to the percentage of
visits resulting in a prescription for
an antibiotic. In addition to month
and year, the regression model in-
cluded a year-by-month interac-
tion term and a study site indicator
variable. A significant non-zero in-
teraction term would demonstrate
that the intervention had an effect.
Including data from November
2000 and November 2001 enabled
us to consider and control for the
possibility of a year-to-year change
in prescribing patterns caused by
extrinsic factors unrelated to the
intervention. Study site was in-
cluded as a control factor to allow
for possible inter-site differences.
RESULTS
Study patients comprised 369
boys (51.3%) and 351 girls (48.8%)
with an average age of 4.2 years.
The patients’ diagnoses are shown
in Table 1.
Overall, 326 of the 720 patients
(45.2%) were treated with an anti-
biotic. The analysis revealed no
statistically significant differences
FIGURE. 16 22 waiting room poster.
194 Volume 20 Number 3 Journal of Pediatric Health Care
Page 3
among study sites, so this term was
dropped from the logistic regres-
sion model. The final analysis
demonstrated that the proportion
of visits resulting in a prescription
for an antibiotic did not differ sig-
nificantly among the 4 study
months (P .79) (Table 2). This
result indicates that the educa-
tional poster had no effect on an-
tibiotic use.
DISCUSSION
This study showed that a wait-
ing room poster aimed at educat-
ing parents about appropriate an-
tibiotic use was ineffective in
reducing pediatric antibiotic pre-
scriptions, but the study does have
limitations. While our poster con-
tained more detailed information
than similar, government-spon-
sored educational posters, we do
not know whether parents noticed
the poster or understood the infor-
mation. Possible strategies to en-
hance the efficacy of the educa-
tional campaign include measures
to improve parents’ interaction
with the poster, narrow the educa-
tional message, or incorporate ad-
ditional vehicles of dissemination.
Of these strategies, only the first
two permit practical wide-scale
use. For example, placing posters
in an examination room rather
than a waiting room may increase
the prestige of such devices and
also encourage communication
about the subject between parent
and clinician.
For a waiting room poster to
influence antibiotic prescribing, a
sequence of events must take
place. Parents must (a) notice the
poster, (b) be interested enough in
the topic to want to learn about it,
(c) read and understand the mes-
sage, (d) decide that it is relevant
to their child’s current illness, and
(e) alter their expectations and
usual communication with their
health care provider based on the
knowledge gained. In addition, the
health care provider must (f) deter-
mine that the patient has a viral
illness, (g) be expected to pre-
scribe an antibiotic in response to
parental expectations or overt
pressure, but (h) respond to al-
tered signals from the parent by
refraining from prescribing an an-
tibiotic that would otherwise have
been prescribed. A failure of any
link in this chain would preclude
an effect on the final outcome of
interest.
Because the success of an ed-
ucational intervention first de-
pends on its ability to be recog-
nized and realized by the
targeted population, it must be
tailored to the specific literacy
level and language skills of the
patient community (Harris et al.,
2003). An educational interven-
tion targeting a specific symptom
or diagnosis also may increase its
likelihood of being noticed as rel-
evant and affect communication.
One study showed that a simple
educational intervention—pam-
phlet and video—was successful
in altering parental attitudes re-
garding the use of antibiotics in
their children for specific condi-
tions, for example, nasal dis-
charge (Bauchner et al., 2001).
Another study indicated that
health care providers could elim-
inate up to 8 million unnecessary
courses of antibiotics per year if
they were more diligent in distin-
guishing acute otitis media from
otitis media with effusion and de-
ferred antibiotics for the latter
(Dowell, Marcy, Phillips, Gerber,
& Schwartz, 1998a). As such,
TABLE 1. Diagnoses of
720 patients with
respiratory illnesses as
indicated in the patients’
medical records
Diagnosis No. (%)
Upper respiratory infection 257 (35.7)
Otitis media, acute 154 (21.4)
Pharyngitis 112 (15.5)
Sinusitis 71 (10.0)
Viral syndrome 26 (3.6)
Bronchiolitis 24 (3.3)
Pneumonia 18 (2.5)
Rhinitis 11 (1.5)
Asthma 10 (1.4)
Otitis media with effusion 10 (1.4)
Upper respiratory infection,
bacterial
6 (0.8)
Congestion 3 (0.4)
Chronic cough 3 (0.4)
Croup 3 (0.4)
Otalgia 3 (0.4)
Bronchitis 2 (0.3)
Impacted cecum 2 (0.3)
Laryngitis 2 (0.3)
Allergic rhinitis 1 (0.1)
Febrile illness 1 (0.1)
Impetigo strep 1 (0.1)
TABLE 2. Percent of
visits for respiratory
illnesses that resulted in
an antibiotic prescription
during each of the four
study months (boldface
identifies the month of
the intervention)
November December
2000 81/180* (45.0%) 94/180 (52.2%)
2001 64/180 (35.6%) 87/180 (48.3%)
*The numerator gives the number of an-
tibiotic prescriptions, and the denomina-
tor gives the total number of respiratory
illness visits.
BOX. Symptoms of
respiratory illness, as
reported by child or
guardian, that serve as
inclusion criteria
Congestion
Coryza
Cough
Earache
Ear pain
Holding ears
Mucorrhea
Nasal discharge
Nasal mucus
Otalgia
Rhinomucorrhea
Rhinorrhea
Ringing ears
Runny nose
Scratchy throat
Sore throat
Stuffy nose
Throat pain
195Journal of Pediatric Health Care May/June 2006
Page 4
posters targeting only appropri-
ate prescribing for otitis media
may meet with greater success
than did our poster.
Ineffective communication be-
tween parents and clinicians has
been shown to interfere with pru-
dent antibiotic treatment. Some cli-
nicians justify the prescription of
antibiotics when they are medi-
cally unnecessary by citing paren-
tal pressure and expectations
(Bauchner et al., 1999; Bauchner et
al., 2001; Mangione-Smith et al.,
2001; Wheeler et al., 2001). In one
study, 48% of clinicians reported
that they believed this type of pa-
rental pressure was exerted fre-
quently (Bauchner et al., 1999). In
another study, instead of prescrib-
ing their initial antibiotic recom-
mendation, 30% of clinicians cus-
tomarily honored a parent’s
preference for a particular antibi-
otic (Palmer & Bauchner, 1997).
Clinicians are more likely to over-
prescribe antibiotics if parents be-
gan a discussion on the subject or
even when parental expectations
are inferred but not directly verbal-
ized (Mangione-Smith et al., 2001).
They also are much more likely to
prescribe antibiotics when parents
volunteer their own opinions re-
garding their children’s diagnoses
or when they are not receptive to a
diagnosis of viral illness (Stivers et
al., 2003). Clinicians may fear that
failure to provide an antibiotic will
cause parents to leave their prac-
tice; however, parents who expect
an antibiotic but are instead of-
fered a contingency plan for treat-
ment have higher satisfaction
scores than do parents who do not
receive a contingency plan (Collett
et al., 1999; Mangione-Smith et al.,
2001). Clinicians must not only ac-
ademically acknowledge the cor-
rectness of decreased antibiotic
use but also actively support such
a stance and provide alternatives
(Dowell, Marcy, Phillips, Gerber, &
Schwartz, 1998b; Kuzujanakis,
Kleinman, Rifas-Shiman, & Finkel-
stein, 2003).
We were hopeful that the edu-
cational material displayed by our
poster would change misconcep-
tions held by parents and lead to a
reduction in the overuse of antibi-
otics. Theoretically, such a change
would help curtail the spread of
antibiotic-resistant bacteria. Unfor-
tunately, the intervention did not
have the desired effect, suggesting
that this type of public health cam-
paign may not be sufficient to ed-
ucate parents on the appropriate
use of antibiotics. In addition to
modifications previously sug-
gested, if we want to practically
promote wide-scale judicious anti-
biotic use, we may need to recon-
sider how our educational efforts
can be most efficiently used. While
parents are quite interested in
learning facts that have a direct
bearing on the diagnosis and treat-
ment of their children’s illnesses—
illnesses that often generate a cer-
tain degree of apprehension—final
trust lies with health care provid-
ers, who must find new ways to
satisfy old demands. New tech-
niques to enhance communication
skills of both clinicians in training
and in practice ultimately may
prove to be more efficacious than
elaborate attempts to educate the
public.
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  • Source
    • "Of these, 25 studies did not fulfil the eligibility criteria, for the following reasons: no data on children (í µí±› = 7 studies), other country than in this study (í µí±› = 12), no data on diagnoses of this study (í µí±› = 4), no data on antibiotic prescription rates (í µí±› = 2). Eleven studies [2, 7, 8,7576777879808182 with a total of 16 diagnosis groups (cough/tracheitis/bronchitis: í µí±› = 2, sore throat/pharyngitis: í µí±› = 2, ear pain/otitis: í µí±› = 6, Upper RTI/RTI: í µí±› = 6) were eligible for comparisons (further data inTable 5 ). All 16 comparison groups had higher antibiotic prescription rates than the corresponding C-, and A-groups of this study (Figure 1). "
    [Show abstract] [Hide abstract] ABSTRACT: Children with acute respiratory or ear infections (RTI/OM) are often unnecessarily prescribed antibiotics. Antibiotic resistance is a major public health problem and antibiotic prescription for RTI/OM should be reduced. Anthroposophic treatment of RTI/OM includes anthroposophic medications, nonmedication therapy and if necessary also antibiotics. This secondary analysis from an observational study comprised 529 children <18 years from Europe (AT, DE, NL, and UK) or USA, whose caregivers had chosen to consult physicians offering anthroposophic (A-) or conventional (C-) treatment for RTI/OM. During the 28-day follow-up antibiotics were prescribed to 5.5% of A-patients and 25.6% of C-patients ( P < 0.001 ); unadjusted odds ratio for nonprescription in A- versus C-patients 6.58 (95%-CI 3.45–12.56); after adjustment for demographics and morbidity 6.33 (3.17–12.64). Antibiotic prescription rates in recent observational studies with similar patients in similar settings, ranged from 31.0% to 84.1%. Compared to C-patients, A-patients also had much lower use of analgesics, somewhat quicker symptom resolution, and higher caregiver satisfaction. Adverse drug reactions were infrequent (2.3% in both groups) and not serious. Limitation was that results apply to children of caregivers who consult A-physicians. One cannot infer to what extent antibiotics might be avoided in children who usually receive C-treatment, if they were offered A-treatment.
    Full-text · Article · Nov 2014 · Evidence-based Complementary and Alternative Medicine
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    • "Although posters can increase awareness of health promotion issues, [6] their messages are not necessarily effective in changing patients' behaviour and lifestyles. Ashe et al. showed that public education in the form of waiting room posters was not sufficient to decrease antibiotic prescriptions [14]. However, other authors have shown that it may be relevant to make waiting room media part of an active health education strategy [15] . "
    [Show abstract] [Hide abstract] ABSTRACT: Background General practitioners (GPs) play a central role in disseminating information and most health policies are tending to develop this pivotal role of GPs in dissemination of health-related information to the public. The objective of this study was to evaluate use of the waiting room by GPs as a vector for health promotion. Results A cross-sectional study was conducted on a representative sample of GPs using semi-structured, face-to-face interviews. A structured grid was used to describe the documents. Quantitative and qualitative analysis was performed. Sixty GPs participated in the study. They stated that a waiting room had to be pleasant, but agreed that it was a useful vector for providing health information. The GPs stated that they distributed documents designed to improve patient care by encouraging screening, providing health education information and addressing delicate subjects more easily. However, some physicians believed that this information can sometimes make patients more anxious. A large number of documents were often available, covering a variety of topics. Conclusion General practitioners intentionally use their waiting rooms to disseminate a broad range of health-related information, but without developing a clearly defined strategy. It would be interesting to correlate the topics addressed by waiting room documents with prevention practices introduced during the visit.
    Full-text · Article · Sep 2012 · BMC Research Notes
  • [Show abstract] [Hide abstract] ABSTRACT: Vanderbilt University Medical Center is implementing a DNA Databank to facilitate genomic research. This study describes the use of informational posters to communicate to patients about the Databank and their option to not participate. Informational posters were displayed in two phlebotomy areas prior to the implementation of the DNA Databank project. Patients leaving the phlebotomy areas were interviewed by non-medical personnel about the posters and the Databank using a structured interview guide. Completed interviews with patients (n = 192) show that only 32% recalled seeing the posters (memory of the image only, or of the image and the content of the text). The majority of participants (93%) either recalled the poster or reported that they were comfortable with the DNA Databank concept after they had been read a brief statement about the program. A significant relationship (p = 0.001) appeared between respondents' awareness of research practices concerning anonymous discarded tissues and their level of comfort with the DNA Databank. Individuals who report feeling uncomfortable with the Databank are an important population to inform about the Databank and opting out. Since there were no statistically significant demographic differences between those who recalled the poster and those who did not, there is no way to prospectively identify which patients will not be reached by the posters or who may feel uncomfortable with the program. Additional mechanisms to promote widespread notification are needed.
    No preview · Article · Feb 2007 · Cell and Tissue Banking
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