ORIGINAL RESEARCH
Rural parent behaviors and expectations when caring for children with acute respiratory infections Ann Marie Hart, PhD, FNP-BC (Associate Professor)1 , Kari M. Morgan, PhD (Associate Professor)2 , & Gina M. Casper, MS (Graduate Student)2 1 2
Fay W. Whitney School of Nursing, University of Wyoming, Laramie, Wyoming Family and Consumer Sciences, University of Wyoming, Laramie, Wyoming
Keywords Primary care; rural; parenting; upper respiratory infection (URI). Correspondence Ann Marie Hart, PhD, FNP-BC, Fay W. Whitney School of Nursing, University of Wyoming, Dept. 3065, 1000 E. University Avenue, Laramie, WY 82071. Tel: 307-766-6564; Fax: 307-766-4294; E-mail: [email protected] Received: April 2011; accepted: August 2011 doi: 10.1111/j.1745-7599.2012.00802.x
Abstract Purpose: To explore rural parents’ behaviors and expectations regarding acute respiratory infections (ARIs) in children. Data sources: A random digit dial telephone survey administered to 655 rural adults; 176 answered questions regarding care of their children. Conclusions: Increasing fluid intake was the action most parents reported “always” taking when caring for a child with an ARI. Parents take their child to see a provider when they “just know” their child will not get better or when the child has discolored phlegm or discharge. Most reported reasons for not taking child to a provider were because the child got better on their own and they knew how to treat their child on their own. When seeing a provider for an ARI, parents considered it very important that the provider listen to the child’s symptoms, examine their child for the cause of their symptoms, and provide symptom management advice. Parents expect providers to treat the ARI in one visit and allow for follow-up by phone or e-mail. Implications for practice: Nurse practitioners (NPs) in rural communities should be aware of the behaviors and expectations of parents in their practice. Awareness of these potentially unique issues will allow NPs to work with rural patients more effectively.
Effective nurse practitioner (NP) practice requires an appreciation of the unique nature of individuals and families (Dunphy & Winland-Brown, 2007). Possessing awareness and understanding of the behaviors and expectations of individuals and families, as well as their underlying values and beliefs, is a key component of evidence-based practice and quality care (Strauss, Richardson, Glaszious, & Haynes, 2005). When NPs see children for acute respiratory infections (ARIs; i.e., common colds, pharyngitis, acute bronchitis, acute otitis media, acute sinusitis), understanding parental values, beliefs, and expectations is critical, particularly as NPs educate parents regarding effective ARI treatment, including the appropriate use of antibiotics. With a few exceptions, including acute otitis media, Group A Streptococcus pharyngitis, and cough illness stemming from Bordetella pertussis, antibiotics are not recommended as first-line treatment for ARIs experienced in
children (Coker et al., 2010; Dowell, Marcy, Phillips, Gerber, & Schwartz, 1998; O’Brien et al., 1998a, 1998b; Rosenstein et al., 1998; Schwartz, Marcy, Phillips, Gerber, & Dowell, 1998), yet they are frequently prescribed by NPs and other healthcare providers (HCPs; Goolsby, 2007; Ladd, 2005; Roumie et al., 2005). Inappropriate antibiotic use is believed to be a primary contributor to antibiotic resistance, which is one of the most significant public health challenges facing the United States and world today (Centers for Disease Control and Prevention, 2011; Friedman & Whitney, 2008). Thus, it is essential that NPs and other HCPs working with children make judicious antibiotic prescribing decisions based upon current, evidence-based guidelines and information (American Academy of Microbiology, 2009). Current national data indicate that although inappropriate antibiotic prescribing rates for pediatric ARIs are declining, rates are still higher than desired at 23%–48%
C 2012 The Author(s) Journal of the American Association of Nurse Practitioners 25 (2013) 431–439
C 2012 American Association of Nurse Practitioners
431
Rural parent behaviors and expectations
(Grijalva, Nuorti, & Griffin, 2009). Factors that may contribute to inappropriate antibiotic prescribing in pediatric ARIs include perceptions that parents desire antibiotics (Barden, Dowell, Schwartz, & Lackey, 1998; Ciofi degli Atti et al., 2006; Mangione-Smith, McGlynn, Elliott, Krogstad, & Brook, 1999), parental misconceptions regarding appropriate antibiotic use (Belongia, Naimi, Gal, & Besser, 2002; Lee, Friedman, Ross-Degnan, Hibberd, & Goldmann, 2003), and parental pressure for antibiotics (Bauchner, Pelton, & Klein, 1999). Research has also shown that HCPs often misread parental communication regarding visit expectations (Stivers, Mangione-Smith, Elliott, McDonald, & Heritage, 2003), which in turn may lead to inappropriate antibiotic prescribing. Thus a better understanding of parental expectations and behaviors regarding children’s ARI management and ARI-related HCP visits may assist NPs to both better address parental expectations and decrease inappropriate antibiotic use. At present, the research related to behaviors and expectations for pediatric ARI management has been limited to parents residing in urban and suburban communities. No similar research has been conducted with the 21% of the U.S. population who reside in rural communities (United States Census Bureau, 2011). Despite this, the rural health literature indicates that rural inhabitants experience unique health-related challenges, which could impact their behaviors and expectations related to ARI management. Studies indicate that rural inhabitants frequently experience decreased access to a variety of healthcare services, including mental and behavioral illness (Sawyer, Gale, & Lambert, 2006), specialty care (Baldwin et al., 2008; Cook et al., 2007), preventive care (Casey, Call, & Klingner, 2001; Krishna, Gillespie, & McBride, 2010; McCall-Hosenfeld & Weisman, 2011), and oral health care (Ahn, Burdine, Smith, Ory, & Phillips, 2011; Allison & Manski, 2007). Barriers to rural healthcare access are multiple, including but not limited to availability of HCPs, long travel distances, inclement weather and poor road conditions, lack of public transportation, and inadequate or no healthcare coverage (Bushy, 2011). Even if healthcare services are available and accessible to rural communities, there is no guarantee that these services will be accepted or utilized. Healthcare utilization by rural populations is influenced by a number of factors including cultural beliefs and traditions (e.g., health-illness beliefs, self-reliance, illness care practices, etc.), community support, trust in the HCPs, and concerns regarding confidentiality and anonymity (Brems & Johnson, 2007; Bushy, 2011). NPs play a key role in the healthcare network of rural communities (Cipher, Hooker, & Guerra, 2006; Everett, Schumacher, Wright, & Smith 2009). Thus, it is essential that NPs who work with rural families appreciate how 432
A. M. Hart et al.
these families approach ARI management, their beliefs and values regarding ARI management, and their expectations for ARI-related HCP visits, including but not limited to the prescribing of antibiotics. This article reports on findings from a larger study conducted to assess patient values, beliefs, behaviors, and expectations regarding ARI management and care (Hart & Morgan, 2008). Specifically, the purpose of this study was to explore rural parents’ values and beliefs regarding ARI management, as well as their behaviors and expectations for management of their children’s ARIs, including the use of antibiotics.
Methods A random digit dial telephone survey was administered to English-speaking adults (18 years of age or older) in Wyoming. The survey contained 53 items (excluding demographic items), which were developed from previously collected focus group data regarding ARI management (Morgan & Hart, 2009). ARIs were defined as a “cold” or any other illness where nasal congestion, sinus pain, nasal discharge, cough, or sore throat is experienced, and did not include ear pain. Survey items covered the following general topic areas: (a) initial symptom management, (b) when professional care is typically sought for an ARI, (c) why professional care would not be sought for an ARI, (d) expectations for ARI management from HCPs, and (e) informational resources for ARI management. For each general topic, respondents were asked more detailed questions, to which they were able to respond “always,” “sometimes,” “never,” or “don’t know/not sure” or “very important,” “quite important,” “not important,” or “don’t know/not sure.” For example, under the general topic of initial ARI management, participants were asked, “When you begin noticing that you have symptoms of a respiratory infection, do you ——?” (stay at home and rest, increase the intake of fluids, take herbal and natural remedies, etc.). Under the general topic of expectations from an HCP, respondents were asked “How important is it for the HCP to ——?” (e.g., give you advice about managing your symptoms, explain different treatment options, provide you with an antibiotic script, etc.). Data were analyzed by the Wyoming Survey & Analysis Center using version 15 of the Statistical Package for the Social Sciences. The study was approved by the University of Wyoming’s Human Subjects Review Board and was conducted by a University affiliated survey research center. Before beginning the survey, participants were informed of the nature of the study, the associated risks and benefits, and their right to refuse or stop participating.
Rural parent behaviors and expectations
A. M. Hart et al.
Figure 1 Age of respondents.
Figure 2 Educational level of respondents.
Results
Table 1 Age distribution of children
Demographics
Age range
n
All participants resided in Wyoming, which is the least populated state in the United States with a little over 500,000 inhabitants, 70% of whom are classified as rural (United States Department of Agriculture, 2011) and 94% of whom are classified as Caucasian, non-Hispanic (Wyoming Department of Administration and Information, 2010). The survey was administered to 655 Englishspeaking adults (≥18 years), 233 (35%) of whom reported having one or more child (≤18 years) living in their home. Of these, 176 (76%) agreed to answer a series of child-related question. Sixty-six percent (66%) of the respondents were female and most were over the age of 45 years and had completed high school or General
0–2 years 3–6 years 7–10 years 11–14 years 15–18 years
18 37 30 43 48
Education Development (GED) equivalent (see Figures 1 and 2 for breakdown of respondents’ age ranges and educational levels). Respondents with more than one child were asked to answer for their child with the most recent birthday. See Table 1 for the age distribution of the children; 57% of the children were male and 43% were 433
Rural parent behaviors and expectations
A. M. Hart et al.
Table 2 Actions taken when caring for a child with ARI symptoms
Table 3 Rationale for seeing an HCP regarding child’s ARI symptoms
Item
Always, % Sometimes, % Never, %
Item
Always, %
Sometimes, %
Never, %
Increase child’s intake of fluids.
80.3 (n = 139) 65.7 (n = 115) 48.6 (n = 85) 36.0 (n = 63)
14.5 (n = 25) 25.7 (n = 45) 37.7 (n = 66) 53.7 (n = 94)
5.2 (n = 9) 8.6 (n = 15) 13.7 (n = 24) 10.3 (n = 18)
When you “just know” child won’t get better without something from their HCP. When child is coughing up discolored phlegm. When child’s nasal discharge is discolored. When child runs a fever.
74.8 (n = 119)
19.5 (n = 31)
5.7 (n = 9)
33.3 (n = 58) 27.8 (n = 49) 24.9 (n = 42) 22.7 (n = 40) 18.2 (n = 32)
55.7 (n = 97) 62.5 (n = 110) 28.4 (n = 48) 43.8 (n = 77) 27.3 (n = 48)
10.9 (n = 19) 9.7 (n = 17) 46.7 (n = 79) 33.5 (n = 59) 54.5 (n = 96)
When you’ve waited for a week or so and child’s symptoms get worse When you hear that others who have the same symptoms as child have gone to an HCP and received a prescription. Go in at first sign of a respiratory infection. Go in no matter what.
55.9 (n = 85) 43.9 (n = 68) 35.7 (n = 56) 33.8 (n = 53)
36.2 (n = 55) 42.6 (n = 66) 51.6 (n = 81) 36.3 (n = 57)
7.9 (n = 12) 13.5 (n = 21) 12.7 (n = 20) 29.9 (n = 47)
15.1 (n = 24)
41.5 (n = 66)
43.4 (n = 69)
12.5 (n = 20) 6.3 (n = 10) 4.5 (n = 7) 3.1 (n = 5) 1.3 (n = 2)
35.6 (n = 57) 32.5 (n = 52) 58.6 (n = 92) 22.6 (n = 36) 16.9 (n = 27)
51.9 (n = 83) 61.3 (n = 98) 36.9 (n = 58) 74.2 (n = 118) 81.9 (n = 131)
Talk to others in their family about child’s symptoms. Have child stay away from others to keep them from getting sick. Have child take medicines they can buy at the store over the counter. Stay home and rest Have child seen by an HCP. Act the same as when child does not have any symptoms. Talk to others in their community about child’s symptoms. Have child take herbal and natural remedies.
female. Most (88.7%) of respondents reported that their child had healthcare coverage and 95% reported that their child had an HCP. Data were not collected regarding race/ethnicity or primary language of the participants. In addition, data were not collected regarding type of child’s healthcare coverage.
When child is coughing up any phlegm at all. Because someone (else) in their family wants them to. Because someone outside of their family (i.e., a friend or co-worker) wants them to.
Caring for a child with an ARI When caring for a child with an ARI, parents indicated that they “always” or “sometimes” (reported respectively) increased their child’s intake of fluids (80.3%, 14.5%), talked to others in their family about their child’s symptoms (65.7%, 25.7%), and had their child stay away from others to keep them from getting sick (48.6%, 37.7%). They also reported giving their child over the counter medicines (36.0%, 53.7%) and having their child stay home and rest (33.3%, 55.7%). The action they were least likely to take was having their child take herbal or natural remedies (18.2%, 27.3%). See Table 2 for a complete listing of responses.
Rationale for seeing an HCP for a child’s ARI symptoms When asked about their rationale for seeing an HCP when their child is experiencing an ARI, the vast majority of parents reported that “always” or sometimes” (reported respectively) went to see an HCP when they “just knew” that their child would not get better without something from their HCP (74.8%, 19.5%). They 434
also reported that specific symptoms such as discolored phlegm (55.9%, 36.2%), discolored nasal discharge (43.9%, 42.6%), or fever (35.7%, 51.6%) were reasons that they would take their child to see an HCP. Few parents reported that they would see an HCP “no matter what” (6.3%, 32.5%) or at the first sign of an ARI (12.5%, 35.6%). Rather, most parents reported that they would wait a week to see if symptoms worsened prior to seeking help from an HCP (33.8%, 36.3%). See Table 3 for a complete listing of responses.
Rationale for not seeking treatment from an HCP for a child’s ARI Two primary reasons for not seeking treatment for a child’s ARI were: “waited it out and the child got better on their own” (97.1%) and that they “knew how to treat the child without consulting a HCP” (96.2%). Many parents also agreed with the statement that “HCPs can’t do much for a cold” (58.1%). Additionally, a few indicated that HCPs are not much help when dealing with
Rural parent behaviors and expectations
A. M. Hart et al.
Table 4 Reasons for not seeing an HCP regarding child’s ARI symptoms Item Waited it out and child got better on his/her own. Knew how to treat child without consulting an HCP. HCPs can’t do much for a cold. HCPs aren’t much help. Bad weather. Costs too much money. Couldn’t get child in soon enough. HCP doesn’t listen or respect parental knowledge of child. Too hard to get away from family or work commitments. Child’s HCP too far away. Didn’t have time to go in. Child did not have an HCP to see. No transportation. HCP won’t give child an antibiotic. Other.
All respondents, %
n
97.1
102
96.2
101
58.1 16.2 15.2 15.2 14.3 11.4
61 17 16 16 15 12
9.5
10
7.6 7.6 5.7 2.9 2.9 11.4
8 8 6 3 3 12
ARI symptoms (16.2%). See Table 4 for a complete listing of responses.
Desired behaviors when seeking help from an HCP When parents chose to seek help from an HCP for their child’s ARI symptoms, they indicated that it was “very important” or “quite important” (reported respectively) for the HCP to listen to their child’s symptoms (89.3%, 10.2%), examine the child for the cause of the symptoms (83%, 11%), and give advice based on these symptoms (83%, 14%). They also wanted the HCP to talk to them about their worries and concerns (80.2%, 19.8%) and explain the severity the child’s symptoms (80.2%, 17.5%). See Table 5 for a complete listing of responses.
Expectations regarding treatment of a child with an ARI Parents indicated that it was “very” or “quite” important (reported respectively) that their child’s ARI be handled in one visit (51.1%, 44.3%). If parents had additional questions, they wanted to be able to talk with the child’s HCP by phone or e-mail (48%, 40.1%). A small percentage of parents reported that it was “very important” to receive a prescription for symptom management (28.3%) or an antibiotic (21.1%), however, the majority felt it was “quite” important” to receive a prescription for symptom management (65.9%) or an antibiotic (70.2%). Additionally, almost half of the parents indicated that it was important to receive a prescription for other family members who were experiencing the same symptoms as
the sick child (13.6%, 34.5%). See Table 6 for additional details on these responses.
Discussion and implications for practice The purpose of this study was to explore rural parents’ values and beliefs regarding ARI management, as well as their behaviors and expectations for management of their children’s ARIs, including the use of antibiotics. The results of this study have implications for NPs who are attempting to engage in evidence-based antibiotic prescribing for rural children experiencing ARIs. Although the literature indicates that antibiotics are typically ineffective for the treatment of most pediatric ARIs (Coker et al. 2010; Dowell et al., 1998; O’Brien et al., 1998a, 1998b; Rosenstein et al., 1998; Schwartz et al., 1998) and that most parents are satisfied even when antibiotics are not prescribed for their child’s ARIs (Welschen, Kuyvenhoven, Hoes, & Verheij, 2004; White, Moir, Zweifler, & Hughes, 2010), it is often difficult to put this “evidence into practice” when the NP is engaged in a real life encounter with a sick child and a concerned parent. At times, NPs may feel like they are “hitting the wall” in their attempts to work with parents to appropriately prescribe antibiotics for their children. However, it may be that by trying to understand parents’ underlying expectations, NPs may be better equipped to explain why antibiotics are not appropriate and to develop an alternative plan of care. Findings from our study support the notion that rural parents want to be listened to and desire to discuss their child’s symptoms. Although most of the parents in our study expressed interest in and/or indicated an expectation for antibiotics, they primarily reported desiring to discuss their child’s symptoms with an HCP, as well as their own worries and concerns. This finding confirms results from a study in the UK and the Netherlands that found that parents sought medical advice when they were worried about their child and their ability to care for their child (Hugenholtz, Broer, & van Daalen, 2009). NPs may find that parents send mixed messages about their desires for antibiotics. Parental communication patterns may be to blame for this misunderstanding. For example, a study conducted in the United States found that parental use of “candidate diagnoses” (e.g., “I think he has strep”) and parental resistance to viral diagnoses were related to physicians’ beliefs that the parents expected antibiotics (Stivers et al., 2003). However, when parents were probed regarding their expectations for antibiotics, they denied having such expectations. Stivers et al. suggested that parents may be using “candidate diagnoses” and resisting “viral” diagnoses because they are concerned that their child has something more 435
Rural parent behaviors and expectations
A. M. Hart et al.
Table 5 Parental expectations for HCPs’ behaviors when child is being seen for ARI symptoms
Item HCP talks to parents about their worries and concerns HCP listens to child’s symptoms HCP gives advice about managing child’s symptoms HCP examines child for cause of their symptoms HCP explains severity of child’s symptoms HCP is aware of child’s personal health history HCP explains different treatment options HCP provides recommendations based on current scientific knowledge HCP respects that they know child and know what child needs to get better HCP provides information on how child’s illness may affect other members of their family HCP is aware of family’s health history HCP does something so child does not spread the infection to others HCP explains how child’s symptoms may change in the next few days or weeks HCP discusses how soon child will be well HCP provides treatment the parent requests Child receives prescription to manage symptoms HCP provides child with the same treatment as other children parents know who have same symptoms Child receives a note for sick leave from school or work Child is prescribed an antibiotic HCP is aware of their financial circumstances HCP is aware of how difficult it is for parents to get to a store or pharmacy HCP is aware of how far they have traveled for appointment
significant or are simply wanting validation for being seen by an HCP. NPs may find it useful to reflect on the messages that rural parents are sending regarding antibiotic use, and specifically address these messages with parents as a means of opening the door for discussion of antibiotic use and how to best address parents’ actual concerns and worries regarding their child. Parents in our study 436
Very important, %
Quite important, %
Not very important, %
Not important at all, %
80.2 (n = 142) 89.3 (n = 158) 83 (n = 147) 83 (n = 146) 80.2 (n = 142) 79.5 (n = 140) 72.6 (n = 127) 70.3 (n = 123) 65.3 (n = 115) 63.4 (n = 111) 55.7 (n = 97) 54.3 (n = 95) 47% (n = 135) 46.6 (n = 82) 43.9 (n = 75) 40.4 (n = 69) 39.3 (n = 68) 35.7 (n = 61) 25.6 (n = 42) 22.3 (n = 39) 19.4 (n = 34) 17.7 (n = 31)
19.8 (n = 35) 10.2 (n = 18) 14 (n = 25) 11 (n = 20) 17.5 (n = 31) 19.3 (n = 34) 24.6 (n = 43) 26.3 (n = 46) 22.2 (n = 39) 32.6 (n = 57) 35.1 (n = 61) 29.7 (n = 52) 33 (n = 33) 33.0 (n = 58) 24.6 (n = 42) 29.8 (n = 51) 23.1 (n = 40) 27.5 (n = 47) 33.5 (n = 55) 26.3 (n = 46) 17.7 (n = 31) 18.9 (n = 33)
0.0 (n = 0) 0.0% (n = 0) 3 (n = 5) 5 (n = 8) 1.7 (n = 3) 1.1 (n = 2) 2.9 (n = 5) 2.3 (n = 4) 10.2 (n = 18) 3.4 (n = 6) 8.0 (n = 14) 10.3 (n = 18) 18 (n = 6) 17.6 (n = 31) 21.6 (n = 37) 25.1 (n = 43) 23.7 (n = 41) 22.8 (n = 39) 32.9 (n = 54) 30.3 (n = 53) 37.1 (n = 65) 34.9 (n = 61)
0.0 (n = 0) 0.6 (n = 1) 0.0 0.6 (n = 1) 0.6 (n = 1) 0.0 (n = 0) 0.0 (n = 0) 1.1 (n = 2) 2.3 (n = 4) 0.6 (n = 1) 1.1 (n = 2) 5.7 (n = 10) 3 (n = 2) 2.8 (n = 5) 9.9 (n = 17) 4.7 (n = 8) 13.9 (n = 24) 14.0 (n = 24) 7.9 (n = 13) 21.1 (n = 37) 25.7 (n = 45) 28.6 (n = 50)
wanted to talk about their worries and concerns, so perhaps by creating a relaxed environment where parents can truly express their worries and desires, antibiotic use can be minimized. Because parents also reported that they wanted recommendations based on current scientific knowledge (i.e., 70.3% said that this was very important; 26.3% said that this was quite important), there is reason to believe that parents want to know what is
Rural parent behaviors and expectations
A. M. Hart et al.
Table 6 Parental expectations when consulting with HCP regarding child’s ARI symptoms
Item ARI handled in one visit. Able to follow up with HCP regarding child’s ARI by phone or e-mail. Receive a prescription for symptoms of child’s ARI. Receive an antibiotic prescription for child’s ARI. Answer parental questions over the phone without an appointment. Provide advice outside of the office. Provide prescriptions for other members in the family who have the same symptoms without first seeing them.
Very Quite Not very important, % important, % important, % 51.1 (n = 90) 48.0 (n = 85)
44.3 (n = 78) 40.1 (n = 71)
4.5 (n = 8) 11.9 (n = 21)
28.3 (n = 49) 21.1 (n = 36)
65.9 (n = 114) 70.2 (n = 120)
5.8 (n = 10) 8.8 (n = 15)
28.2 (n = 50)
52.5 (n = 93)
19.2 (n = 34)
16.4 (n = 29) 13.6 (n = 24)
40.1 (n = 71) 34.5 (n = 61)
43.5 (n = 77) 52.0 (n = 92)
best for the care of their children and may be receptive to current, research-based information on why or why not to use antibiotics. Our study also support findings from another study that found parents use a variety of criteria to assess their children’s conditions prior to seeking medical advice, although, their understanding of the particular phenomena their child is experiencing may be limited or even faulty (Saunders, Tennis, Jacobson, Gans, & Dick, 2003). Specifically, parents in our study appeared to have misinformation regarding ARI symptoms and how to interpret these symptoms. For example, discolored phlegm, discolored nasal discharge, and fever were cited by a majority of parents as reasons to see an HCP. Current best practice recommendations do not warrant antibiotics for mucopurulent rhinitis until they have been present for 10–14 days (Rosenstein et al., 1998), and fevers are also commonly misunderstood and feared by parents (Saunders et al., 2003). Based on the findings from our study indicating that parents would like to discuss symptoms and have their child examined for the cause of the symptoms more than they would like to receive antibiotics, it may be an opportunity for discussion of symptom management (e.g., saline rinse, fever reduction, etc.), and phone or e-mail follow up if symptoms persist. Others have confirmed the potential value in educating parents regarding the interpretation of symptoms, including fevers (Saunders et al., 2003). Again, our study indicates that parents
are interested in receiving current, research-based information regarding the health of their children, and thus, efforts to educate rural parents on current knowledge of symptoms may be well received. Our finding that 91% of the parents in our study agreed that it was either “very” or “quite” important for an HCP to prescribe an antibiotic for their child’s ARI is not dissimilar from results of studies conducted with parents primarily living in urban and suburban areas (Cho, Hong, & Park, 2004; Lee, Friedman, Ross-Degnan, Hibberd, & Goldmann, 2003). Both of these studies found that although most parents reported knowing that colds were viral in nature, many also believed that antibiotics could either shorten the duration of symptoms or prevent ARI-related complications. Although our study did not inquire about parental beliefs regarding the etiology of ARIs or how antibiotics might help ARIs, it may be that rural parents have similar beliefs regarding ARIs and antibiotics. The aforementioned implications for practice might also apply to NPs working in urban or suburban settings. However, travel distances to an HCP or pharmacy are two items that may be unique to rural settings. For example, 36.6% of the parents in our study reported that they wanted their HCP to be aware of how far they traveled to come to this appointment, and 37.1% indicated that it was “very” or “quite” important for their child’s HCP to be aware of how difficult it is to get to a store or pharmacy. It is tempting to think that these expectations mean that parents will not be satisfied without receiving an antibiotic, or that they may have antibiotics on hand at home that they will use regardless of advice that is provided. However, NPs should resist the temptation to prescribe based on assumptions or perceived parental pressure, rather, it is essential to discuss appropriate antibiotic use with parents and to develop a treatment plan that acknowledges the family’s distance from a pharmacy or HCP. In addition, previous research conducted with rural families did not indicate that families in this state keep antibiotics on hand for “just in case” situations (Morgan & Hart, 2009). Awareness of these and other potentially unique issues will allow NPs to work more efficiently with rural families in their practice and better provide appropriate education and anticipatory guidance for rural patients. In addition to eliciting parents’ specific expectations and concerns, NPs may also be wise to develop different models of care for children experiencing ARIs. Parents in our study indicated they would appreciate being able to consult with HCPs over the phone, and several studies support protocol-based telephone consultations for ARI management (Chaudhry et al., 2006; McConnochie et al., 2006). Thus, NPs who care for children should consider 437
Rural parent behaviors and expectations
developing a protocol or mechanism to accommodate this patient need.
Limitations There were several limitations to this study that should be noted. First, this survey was conducted during the summer, when individuals are least likely to experience ARIs. Because the respondents and their children were most likely not experiencing ARIs during the survey’s administration, they may have had difficulty accurately recalling behaviors that they typically engage in when their children experience ARI symptoms. Second, respondents may have answered survey items in a manner they perceived as socially desirable or politically correct (Macnee & McCabe, 2008). Third, the interviews were conducted in a large, sparsely populated, rural state and results may not be generalizable to nonrural populations or rural populations in more densely populated regions or other regions of the United States. Lastly, because it is likely that the majority of our participants were Caucasian and nonHispanic, our results may not be applicable to other racial or ethnic populations.
Conclusion Our study is one of the first to address rural parents’ behaviors and expectations for managing their children’s ARIs. Although some of our results are similar to those conducted with families residing in urban and suburban communities (i.e., expectations for antibiotics and concerns regarding discolored phlegm and nasal discharge), some were unique, such as expecting that the HCP be aware of distance traveled for the appointment and distance to a pharmacy. In summary, our results suggest that by better understanding expectations and behaviors of rural parents, NPs can develop better strategies for providing evidencebased care for patients (both children and adults) who present with ARIs and other common concerns. NPs play a key role in many rural communities (Cipher, Hooker, & Guerra, 2006; Everett, Schumacher, Wright, & Smith 2009) and are uniquely positioned to educate parents regarding ARI symptom management and appropriate antibiotic use by developing relationships based on knowledge of rural families’ expectations and behaviors.
Acknowledgments This study was funded by an Agricultural Experiment Station grant through the University of Wyoming College of Agriculture and Natural Resources. 438
A. M. Hart et al.
References Ahn, S., Burdine, J. N., Smith, M. L., Ory, M. G., & Phillips, C. D. (2011). Residential rurality and oral health disparities: influences of contextual and individual factors. Journal of Primary Prevention, 32, 29–41. Allison, R. A., & Manski, R. J. (2007). The supply of dentists and access to care in rural Kansas. Journal of Rural Health, 23, 198–206. American Academy of Microbiology (2009). Antibiotic resistance: An ecological perspective on an old problem. Retrieved from http://academy.asm.org/ images/stories/documents/ antibioticresistance.pdf Baldwin, L. M., Hollow, W. B., Casey, S., Hart, L. G., Larson, E. H., Moore, K., . . . Grossman, D. C. (2008). Access to specialty health care for rural American Indians in two states. Journal of Rural Health, 24, 269–278. Barden, L. S., Dowell, S. F., Schwartz, B., & Lackey, C. (1998). Current attitudes regarding use of antimicrobial agents: Results from physicians’ and parents’ focus group discussions. Clinical Pediatrics, 37, 665–671. Bauchner, H., Pelton, S. I., & Klein, J. O. (1999). Parents, physicians, and antibiotic use. Pediatrics, 103, 395–401. Belongia, E. A., Naimi, T. S., Gale, C. M., & Besser, R. E. (2002). Antibiotic use and upper respiratory infections: A survey of knowledge, attitudes, and experience in Wisconsin and Minnesota. Preventive Medicine, 34, 346–352. Brems, C., & Johnson, M. (2007). Challenges and uniqueness of rural and frontier services in the United States. Journal of Psychological Practice, 14, 93–122. Bushy, A. (2011). Rural nursing: Practice and issues. American Nurses Association Continuing Education Program. Washington, DC: American Nurses Association. Casey, M. M., Call, K. T., & Klingner, J. M. (2001). Are rural residents less likely to obtain recommended preventive healthcare services? American Journal of Preventive Medicine, 21, 182–188. Centers for Disease Control (2011). Fast facts about antibiotic resistance. Retrieved from http://www.cdc.gov/getsmart/antibiotic-use/anitbiotic-resistancefaqs.html#d Chaudhry, R., Stroebel, R. J., McLeod, T. G., Van Houten, H. K., Naessens, J. M., Jaeger, T. M., . . .Scheitel, S. M. (2006). Nurse-based telephone protocol versus usual care for management of URI and acute sinusitis: A controlled trial. Managed Care Interface, 19, 26–31. Cho, H., Hong, S., & Park, S. (2004). Knowledge and beliefs of primary care physicians, pharmacists, and parents on antibiotic use for the pediatric common cold. Social Science and Medicine, 58, 623–629. Ciofi detli Atti, M. L., Massari, M., Bella, A., Boccia, D., Filia, A., & Salmaso, S. (2006). Clinical, social, and relational determinants of paediatric ambulatory drug prescriptions due to respiratory tract infections in Italy. European Journal of Clinical Pharmacology, 62, 1055–1064. Cipher, D. J., Hooker, R. S., & Guerra, P. (2006). Prescribing trends by nurse practitioners and physician assistants in the United States. Journal of the American Academy of Nurse Practitioners, 18, 291–296. Coker, T. R., Chan, L. S., Newberry, S. J., Limbos, S. A., Suttorp, M. J., Shekelle, P. G., & Takata, G. S. (2010). Diagnosis, microbial epidemiology, and antibiotic treatment of acute otitis media in children. Journal of the American Medical Association, 304, 2161–2169. Cook, N. L., Hicks, L. S., O’Malley, A. J., Keegan, T., Guadagnoli, E., & Landon, B. E. (2007). Access to specialty care and medical services in community health centers. Health Affairs, 26, 1459–1468. Dowell, S. F., Marcy, S. M., Phillips, W. R., Gerber, M. A., & Schwartz, B. (1998). Principles of judicious use of antimicrobial agents for pediatric upper respiratory tract infections. Pediatrics, 101, 163–165. Dunphy, L. M., & Winland-Brown, J. E. (2007). Advanced practice nursing in the twenty-first century: A circle of caring. In L. M. Dunphy & J. E. Winland-Brown (Eds.), Primary care: The art and science of advanced practice nursing (2nd ed., pp. 3–18). Philadelphia: F.A. Davis. Everett, C. M., Schumacher, J. M., Wright, A., & Smith, M. A. (2009). Physician assistants and nurse practitioners as a usual source of care. Journal of Rural Health, 25, 407–414. Friedman, C. R., & Whitney, G. C. (2008). It’s time for a change in practice: Reducing antibiotic use can alter antibiotic resistance. Journal of Infectious Diseases, 197, 1082–1083.
A. M. Hart et al.
Goolsby, M. J. (2007). Antibiotic prescribing habits of nurse practitioners treating pediatric patients: AntiBUGS pediatrics. Journal of the American Academy of Nurse Practitioners, 19, 332–334. Grijalva, C. G., Nuorti, J. P., & Griffin, M. R. (2009). Antibiotic prescription rates for acute respiratory tract infections in U.S. ambulatory settings. American Medical Association, 302, 758–766. Hart, A. M., & Morgan, K. (2008). Integrating patient values into evidencebased practice (EBP): How individuals and families manage acute respiratory infections (ARIs). Poster presented at the 34th Annual Meeting of the National Organization for Nurse Practitioner Faculties (NONPF), Louisville, KY. Hugenholtz, M., Broer, C., & van Daalen, R. (2009). Apprehensive parents: A qualitative study of parents seeking immediate primary care for their children. British Journal of General Practice, 59, 173–179. Krishna, S., Gillespie, K. N., & McBride, T. M. (2010). Diabetes burden and access to preventive care in the rural United States. Journal of Rural Health Care, 26, 3–11. Ladd, E. (2005). The use of antibiotics for viral upper respiratory tract infections: An analysis of nurse practitioner and physician prescribing practices in ambulatory care, 1997–2001. Journal of the American Academy of Nurse Practitioners, 17, 416–424. Lee, G. M., Friedman, J. F., Ross-Degnan, D., Hibberd, P. L., & Goldmann, D. A. (2003). Misconceptions about colds and predictors of health service utilization. Pediatrics, 111, 231–237. Macnee, C. L., & McCabe, S. (2008). Understanding nursing research: Reading and using research in evidence-based practice (2nd ed.). Philadelphia: Lippincott, Williams, & Wilkins. Mangione-Smith, R., McGlynn, E. A., Elliott, M. N., Krogstad, P., & Brook, R. H. (1999). The relationship between perceived parental expectations and pediatrician antimicrobial prescribing behavior. Pediatrics, 103, 711–718. McCall-Hosenfeld, J. S., & Weisman, C. S. (2011). Receipt of preventive counseling among reproductive-aged women in rural and urban communities. Rural and Remote Health, 11, Article No. 1617. McConnochie, K. M., Conners, G. P., Brayer, A. F., Goepp, J., Herendeen, N. E., Wood, N. E., et al. (2006). Differences in diagnosis and treatment using telemedicine versus in-person evaluation of acute illness. Ambulatory Pediatrics, 6, 187–195. Morgan, K., & Hart, A. M. (2009). Families in rural settings: Values regarding acute respiratory infections. Families, Systems, and Health, 27, 85–97.
Rural parent behaviors and expectations
O’Brien, K. L., Dowell, S. F., Schwartz, B., Marcy, S. M., Phillips, W. R., & Gerber, M. A. (1998a). Acute sinusitis—Principles of judicious use of antimicrobial agents. Pediatrics, 101, 174–177. O’Brien, K. L., Dowell, S. F., Schwartz, B., Marcy, S. M., Phillips, W. R., & Gerber, M. A. (1998b). Cough illness/bronchitis—Principles of judicious use of antimicrobial agents. Pediatrics, 101, 178–181. Rosenstein, N. Phillips, W. R., Gerber, M. A., Marcy, S. M., Schwartz, B., & Dowell, S. F. (1998). The common cold—Principles of judicious use of antimicrobial agents. Pediatrics, 101, 181–184. Roumie, C. L., Halasa, N. B., Grijalva, C. G., Edwards, K. M., Zhu, Y., Dittus, R. S. et al. (2005). Trends in antibiotic prescribing for adults in the United States—1995 to 2002. Journal of General Internal Medicine, 20, 697–702. Saunders, N. R., Tennis, O., Jacobson, S., Gans, M., & Dick, P. T. (2003). Parents’ responses to symptoms or respiratory tract infections in their children. Canadian Medical Association Journal, 168, 26–31. Sawyer, D., Gale, J., & Lambert, D. (2006). Rural and frontier mental and behavioral health care: Barriers, effective policy strategies, best practices. National Association for Rural Mental Health (NARMH). Retrieved from http://www.narmh.org/publications/archives/ rural˙frontier.pdf Schwartz, B., Marcy, S. M., Phillips, W. R., Gerber, M. A., & Dowell, S. F. (1998). Pharyngitis—Principles of judicious use of antimicrobial agents. Pediatrics, 101, 171–174. Stivers, T., Mangione-Smith, R., Elliott, M. N., McDonald, L., & Heritage, J. (2003). Why do physicians think parents expect antibiotics? What parents report vs what physicians believe. Journal of Family Practice, 52, 140–148. Strauss, S. E., Richardson, W. S., Glaszious, P., & Haynes, R. B. (2005). Evidence-based medicine: How to practice and teach evidence-based medicine (3rd ed.). Edinburgh: Elsevier. United States Census Bureau (2011). The 2011 statistical abstract: The national databook. Retrieved from http://www.census.gov/compendia/statab/ cats/population.html United States Department of Agriculture (2011). State Fact Sheet: Wyoming. Retrieved from http://www.ers.usda.gov/statefacts/WY.htm Welschen, I., Kuyvenhoven, M., Hoes, A., & Verheij, T. (2004). Antibiotics for acute respiratory tract symptoms: patients’ expectations, GPs’ management and patient satisfaction. Family Practice, 21, 234–237. White, D., Moir, A., Zweifler, J., & Hughes, S. (2010). Parental satisfaction without antibiotics. Nurse Practitioner, 35, 40–42. Wyoming Department of Administration and Information (2010). Wyoming population estimates and forecasts. Retrieved from http://eadiv.state.wy.us/pop/CO Minority09.htm
439
Rural parent behaviors and expectations when caring for children with acute respiratory infections Ann Marie Hart, PhD, FNP-BC (Associate Professor)1 , Kari M. Morgan, PhD (Associate Professor)2 , & Gina M. Casper, MS (Graduate Student)2 1 2
Fay W. Whitney School of Nursing, University of Wyoming, Laramie, Wyoming Family and Consumer Sciences, University of Wyoming, Laramie, Wyoming
Keywords Primary care; rural; parenting; upper respiratory infection (URI). Correspondence Ann Marie Hart, PhD, FNP-BC, Fay W. Whitney School of Nursing, University of Wyoming, Dept. 3065, 1000 E. University Avenue, Laramie, WY 82071. Tel: 307-766-6564; Fax: 307-766-4294; E-mail: [email protected] Received: April 2011; accepted: August 2011 doi: 10.1111/j.1745-7599.2012.00802.x
Abstract Purpose: To explore rural parents’ behaviors and expectations regarding acute respiratory infections (ARIs) in children. Data sources: A random digit dial telephone survey administered to 655 rural adults; 176 answered questions regarding care of their children. Conclusions: Increasing fluid intake was the action most parents reported “always” taking when caring for a child with an ARI. Parents take their child to see a provider when they “just know” their child will not get better or when the child has discolored phlegm or discharge. Most reported reasons for not taking child to a provider were because the child got better on their own and they knew how to treat their child on their own. When seeing a provider for an ARI, parents considered it very important that the provider listen to the child’s symptoms, examine their child for the cause of their symptoms, and provide symptom management advice. Parents expect providers to treat the ARI in one visit and allow for follow-up by phone or e-mail. Implications for practice: Nurse practitioners (NPs) in rural communities should be aware of the behaviors and expectations of parents in their practice. Awareness of these potentially unique issues will allow NPs to work with rural patients more effectively.
Effective nurse practitioner (NP) practice requires an appreciation of the unique nature of individuals and families (Dunphy & Winland-Brown, 2007). Possessing awareness and understanding of the behaviors and expectations of individuals and families, as well as their underlying values and beliefs, is a key component of evidence-based practice and quality care (Strauss, Richardson, Glaszious, & Haynes, 2005). When NPs see children for acute respiratory infections (ARIs; i.e., common colds, pharyngitis, acute bronchitis, acute otitis media, acute sinusitis), understanding parental values, beliefs, and expectations is critical, particularly as NPs educate parents regarding effective ARI treatment, including the appropriate use of antibiotics. With a few exceptions, including acute otitis media, Group A Streptococcus pharyngitis, and cough illness stemming from Bordetella pertussis, antibiotics are not recommended as first-line treatment for ARIs experienced in
children (Coker et al., 2010; Dowell, Marcy, Phillips, Gerber, & Schwartz, 1998; O’Brien et al., 1998a, 1998b; Rosenstein et al., 1998; Schwartz, Marcy, Phillips, Gerber, & Dowell, 1998), yet they are frequently prescribed by NPs and other healthcare providers (HCPs; Goolsby, 2007; Ladd, 2005; Roumie et al., 2005). Inappropriate antibiotic use is believed to be a primary contributor to antibiotic resistance, which is one of the most significant public health challenges facing the United States and world today (Centers for Disease Control and Prevention, 2011; Friedman & Whitney, 2008). Thus, it is essential that NPs and other HCPs working with children make judicious antibiotic prescribing decisions based upon current, evidence-based guidelines and information (American Academy of Microbiology, 2009). Current national data indicate that although inappropriate antibiotic prescribing rates for pediatric ARIs are declining, rates are still higher than desired at 23%–48%
C 2012 The Author(s) Journal of the American Association of Nurse Practitioners 25 (2013) 431–439
C 2012 American Association of Nurse Practitioners
431
Rural parent behaviors and expectations
(Grijalva, Nuorti, & Griffin, 2009). Factors that may contribute to inappropriate antibiotic prescribing in pediatric ARIs include perceptions that parents desire antibiotics (Barden, Dowell, Schwartz, & Lackey, 1998; Ciofi degli Atti et al., 2006; Mangione-Smith, McGlynn, Elliott, Krogstad, & Brook, 1999), parental misconceptions regarding appropriate antibiotic use (Belongia, Naimi, Gal, & Besser, 2002; Lee, Friedman, Ross-Degnan, Hibberd, & Goldmann, 2003), and parental pressure for antibiotics (Bauchner, Pelton, & Klein, 1999). Research has also shown that HCPs often misread parental communication regarding visit expectations (Stivers, Mangione-Smith, Elliott, McDonald, & Heritage, 2003), which in turn may lead to inappropriate antibiotic prescribing. Thus a better understanding of parental expectations and behaviors regarding children’s ARI management and ARI-related HCP visits may assist NPs to both better address parental expectations and decrease inappropriate antibiotic use. At present, the research related to behaviors and expectations for pediatric ARI management has been limited to parents residing in urban and suburban communities. No similar research has been conducted with the 21% of the U.S. population who reside in rural communities (United States Census Bureau, 2011). Despite this, the rural health literature indicates that rural inhabitants experience unique health-related challenges, which could impact their behaviors and expectations related to ARI management. Studies indicate that rural inhabitants frequently experience decreased access to a variety of healthcare services, including mental and behavioral illness (Sawyer, Gale, & Lambert, 2006), specialty care (Baldwin et al., 2008; Cook et al., 2007), preventive care (Casey, Call, & Klingner, 2001; Krishna, Gillespie, & McBride, 2010; McCall-Hosenfeld & Weisman, 2011), and oral health care (Ahn, Burdine, Smith, Ory, & Phillips, 2011; Allison & Manski, 2007). Barriers to rural healthcare access are multiple, including but not limited to availability of HCPs, long travel distances, inclement weather and poor road conditions, lack of public transportation, and inadequate or no healthcare coverage (Bushy, 2011). Even if healthcare services are available and accessible to rural communities, there is no guarantee that these services will be accepted or utilized. Healthcare utilization by rural populations is influenced by a number of factors including cultural beliefs and traditions (e.g., health-illness beliefs, self-reliance, illness care practices, etc.), community support, trust in the HCPs, and concerns regarding confidentiality and anonymity (Brems & Johnson, 2007; Bushy, 2011). NPs play a key role in the healthcare network of rural communities (Cipher, Hooker, & Guerra, 2006; Everett, Schumacher, Wright, & Smith 2009). Thus, it is essential that NPs who work with rural families appreciate how 432
A. M. Hart et al.
these families approach ARI management, their beliefs and values regarding ARI management, and their expectations for ARI-related HCP visits, including but not limited to the prescribing of antibiotics. This article reports on findings from a larger study conducted to assess patient values, beliefs, behaviors, and expectations regarding ARI management and care (Hart & Morgan, 2008). Specifically, the purpose of this study was to explore rural parents’ values and beliefs regarding ARI management, as well as their behaviors and expectations for management of their children’s ARIs, including the use of antibiotics.
Methods A random digit dial telephone survey was administered to English-speaking adults (18 years of age or older) in Wyoming. The survey contained 53 items (excluding demographic items), which were developed from previously collected focus group data regarding ARI management (Morgan & Hart, 2009). ARIs were defined as a “cold” or any other illness where nasal congestion, sinus pain, nasal discharge, cough, or sore throat is experienced, and did not include ear pain. Survey items covered the following general topic areas: (a) initial symptom management, (b) when professional care is typically sought for an ARI, (c) why professional care would not be sought for an ARI, (d) expectations for ARI management from HCPs, and (e) informational resources for ARI management. For each general topic, respondents were asked more detailed questions, to which they were able to respond “always,” “sometimes,” “never,” or “don’t know/not sure” or “very important,” “quite important,” “not important,” or “don’t know/not sure.” For example, under the general topic of initial ARI management, participants were asked, “When you begin noticing that you have symptoms of a respiratory infection, do you ——?” (stay at home and rest, increase the intake of fluids, take herbal and natural remedies, etc.). Under the general topic of expectations from an HCP, respondents were asked “How important is it for the HCP to ——?” (e.g., give you advice about managing your symptoms, explain different treatment options, provide you with an antibiotic script, etc.). Data were analyzed by the Wyoming Survey & Analysis Center using version 15 of the Statistical Package for the Social Sciences. The study was approved by the University of Wyoming’s Human Subjects Review Board and was conducted by a University affiliated survey research center. Before beginning the survey, participants were informed of the nature of the study, the associated risks and benefits, and their right to refuse or stop participating.
Rural parent behaviors and expectations
A. M. Hart et al.
Figure 1 Age of respondents.
Figure 2 Educational level of respondents.
Results
Table 1 Age distribution of children
Demographics
Age range
n
All participants resided in Wyoming, which is the least populated state in the United States with a little over 500,000 inhabitants, 70% of whom are classified as rural (United States Department of Agriculture, 2011) and 94% of whom are classified as Caucasian, non-Hispanic (Wyoming Department of Administration and Information, 2010). The survey was administered to 655 Englishspeaking adults (≥18 years), 233 (35%) of whom reported having one or more child (≤18 years) living in their home. Of these, 176 (76%) agreed to answer a series of child-related question. Sixty-six percent (66%) of the respondents were female and most were over the age of 45 years and had completed high school or General
0–2 years 3–6 years 7–10 years 11–14 years 15–18 years
18 37 30 43 48
Education Development (GED) equivalent (see Figures 1 and 2 for breakdown of respondents’ age ranges and educational levels). Respondents with more than one child were asked to answer for their child with the most recent birthday. See Table 1 for the age distribution of the children; 57% of the children were male and 43% were 433
Rural parent behaviors and expectations
A. M. Hart et al.
Table 2 Actions taken when caring for a child with ARI symptoms
Table 3 Rationale for seeing an HCP regarding child’s ARI symptoms
Item
Always, % Sometimes, % Never, %
Item
Always, %
Sometimes, %
Never, %
Increase child’s intake of fluids.
80.3 (n = 139) 65.7 (n = 115) 48.6 (n = 85) 36.0 (n = 63)
14.5 (n = 25) 25.7 (n = 45) 37.7 (n = 66) 53.7 (n = 94)
5.2 (n = 9) 8.6 (n = 15) 13.7 (n = 24) 10.3 (n = 18)
When you “just know” child won’t get better without something from their HCP. When child is coughing up discolored phlegm. When child’s nasal discharge is discolored. When child runs a fever.
74.8 (n = 119)
19.5 (n = 31)
5.7 (n = 9)
33.3 (n = 58) 27.8 (n = 49) 24.9 (n = 42) 22.7 (n = 40) 18.2 (n = 32)
55.7 (n = 97) 62.5 (n = 110) 28.4 (n = 48) 43.8 (n = 77) 27.3 (n = 48)
10.9 (n = 19) 9.7 (n = 17) 46.7 (n = 79) 33.5 (n = 59) 54.5 (n = 96)
When you’ve waited for a week or so and child’s symptoms get worse When you hear that others who have the same symptoms as child have gone to an HCP and received a prescription. Go in at first sign of a respiratory infection. Go in no matter what.
55.9 (n = 85) 43.9 (n = 68) 35.7 (n = 56) 33.8 (n = 53)
36.2 (n = 55) 42.6 (n = 66) 51.6 (n = 81) 36.3 (n = 57)
7.9 (n = 12) 13.5 (n = 21) 12.7 (n = 20) 29.9 (n = 47)
15.1 (n = 24)
41.5 (n = 66)
43.4 (n = 69)
12.5 (n = 20) 6.3 (n = 10) 4.5 (n = 7) 3.1 (n = 5) 1.3 (n = 2)
35.6 (n = 57) 32.5 (n = 52) 58.6 (n = 92) 22.6 (n = 36) 16.9 (n = 27)
51.9 (n = 83) 61.3 (n = 98) 36.9 (n = 58) 74.2 (n = 118) 81.9 (n = 131)
Talk to others in their family about child’s symptoms. Have child stay away from others to keep them from getting sick. Have child take medicines they can buy at the store over the counter. Stay home and rest Have child seen by an HCP. Act the same as when child does not have any symptoms. Talk to others in their community about child’s symptoms. Have child take herbal and natural remedies.
female. Most (88.7%) of respondents reported that their child had healthcare coverage and 95% reported that their child had an HCP. Data were not collected regarding race/ethnicity or primary language of the participants. In addition, data were not collected regarding type of child’s healthcare coverage.
When child is coughing up any phlegm at all. Because someone (else) in their family wants them to. Because someone outside of their family (i.e., a friend or co-worker) wants them to.
Caring for a child with an ARI When caring for a child with an ARI, parents indicated that they “always” or “sometimes” (reported respectively) increased their child’s intake of fluids (80.3%, 14.5%), talked to others in their family about their child’s symptoms (65.7%, 25.7%), and had their child stay away from others to keep them from getting sick (48.6%, 37.7%). They also reported giving their child over the counter medicines (36.0%, 53.7%) and having their child stay home and rest (33.3%, 55.7%). The action they were least likely to take was having their child take herbal or natural remedies (18.2%, 27.3%). See Table 2 for a complete listing of responses.
Rationale for seeing an HCP for a child’s ARI symptoms When asked about their rationale for seeing an HCP when their child is experiencing an ARI, the vast majority of parents reported that “always” or sometimes” (reported respectively) went to see an HCP when they “just knew” that their child would not get better without something from their HCP (74.8%, 19.5%). They 434
also reported that specific symptoms such as discolored phlegm (55.9%, 36.2%), discolored nasal discharge (43.9%, 42.6%), or fever (35.7%, 51.6%) were reasons that they would take their child to see an HCP. Few parents reported that they would see an HCP “no matter what” (6.3%, 32.5%) or at the first sign of an ARI (12.5%, 35.6%). Rather, most parents reported that they would wait a week to see if symptoms worsened prior to seeking help from an HCP (33.8%, 36.3%). See Table 3 for a complete listing of responses.
Rationale for not seeking treatment from an HCP for a child’s ARI Two primary reasons for not seeking treatment for a child’s ARI were: “waited it out and the child got better on their own” (97.1%) and that they “knew how to treat the child without consulting a HCP” (96.2%). Many parents also agreed with the statement that “HCPs can’t do much for a cold” (58.1%). Additionally, a few indicated that HCPs are not much help when dealing with
Rural parent behaviors and expectations
A. M. Hart et al.
Table 4 Reasons for not seeing an HCP regarding child’s ARI symptoms Item Waited it out and child got better on his/her own. Knew how to treat child without consulting an HCP. HCPs can’t do much for a cold. HCPs aren’t much help. Bad weather. Costs too much money. Couldn’t get child in soon enough. HCP doesn’t listen or respect parental knowledge of child. Too hard to get away from family or work commitments. Child’s HCP too far away. Didn’t have time to go in. Child did not have an HCP to see. No transportation. HCP won’t give child an antibiotic. Other.
All respondents, %
n
97.1
102
96.2
101
58.1 16.2 15.2 15.2 14.3 11.4
61 17 16 16 15 12
9.5
10
7.6 7.6 5.7 2.9 2.9 11.4
8 8 6 3 3 12
ARI symptoms (16.2%). See Table 4 for a complete listing of responses.
Desired behaviors when seeking help from an HCP When parents chose to seek help from an HCP for their child’s ARI symptoms, they indicated that it was “very important” or “quite important” (reported respectively) for the HCP to listen to their child’s symptoms (89.3%, 10.2%), examine the child for the cause of the symptoms (83%, 11%), and give advice based on these symptoms (83%, 14%). They also wanted the HCP to talk to them about their worries and concerns (80.2%, 19.8%) and explain the severity the child’s symptoms (80.2%, 17.5%). See Table 5 for a complete listing of responses.
Expectations regarding treatment of a child with an ARI Parents indicated that it was “very” or “quite” important (reported respectively) that their child’s ARI be handled in one visit (51.1%, 44.3%). If parents had additional questions, they wanted to be able to talk with the child’s HCP by phone or e-mail (48%, 40.1%). A small percentage of parents reported that it was “very important” to receive a prescription for symptom management (28.3%) or an antibiotic (21.1%), however, the majority felt it was “quite” important” to receive a prescription for symptom management (65.9%) or an antibiotic (70.2%). Additionally, almost half of the parents indicated that it was important to receive a prescription for other family members who were experiencing the same symptoms as
the sick child (13.6%, 34.5%). See Table 6 for additional details on these responses.
Discussion and implications for practice The purpose of this study was to explore rural parents’ values and beliefs regarding ARI management, as well as their behaviors and expectations for management of their children’s ARIs, including the use of antibiotics. The results of this study have implications for NPs who are attempting to engage in evidence-based antibiotic prescribing for rural children experiencing ARIs. Although the literature indicates that antibiotics are typically ineffective for the treatment of most pediatric ARIs (Coker et al. 2010; Dowell et al., 1998; O’Brien et al., 1998a, 1998b; Rosenstein et al., 1998; Schwartz et al., 1998) and that most parents are satisfied even when antibiotics are not prescribed for their child’s ARIs (Welschen, Kuyvenhoven, Hoes, & Verheij, 2004; White, Moir, Zweifler, & Hughes, 2010), it is often difficult to put this “evidence into practice” when the NP is engaged in a real life encounter with a sick child and a concerned parent. At times, NPs may feel like they are “hitting the wall” in their attempts to work with parents to appropriately prescribe antibiotics for their children. However, it may be that by trying to understand parents’ underlying expectations, NPs may be better equipped to explain why antibiotics are not appropriate and to develop an alternative plan of care. Findings from our study support the notion that rural parents want to be listened to and desire to discuss their child’s symptoms. Although most of the parents in our study expressed interest in and/or indicated an expectation for antibiotics, they primarily reported desiring to discuss their child’s symptoms with an HCP, as well as their own worries and concerns. This finding confirms results from a study in the UK and the Netherlands that found that parents sought medical advice when they were worried about their child and their ability to care for their child (Hugenholtz, Broer, & van Daalen, 2009). NPs may find that parents send mixed messages about their desires for antibiotics. Parental communication patterns may be to blame for this misunderstanding. For example, a study conducted in the United States found that parental use of “candidate diagnoses” (e.g., “I think he has strep”) and parental resistance to viral diagnoses were related to physicians’ beliefs that the parents expected antibiotics (Stivers et al., 2003). However, when parents were probed regarding their expectations for antibiotics, they denied having such expectations. Stivers et al. suggested that parents may be using “candidate diagnoses” and resisting “viral” diagnoses because they are concerned that their child has something more 435
Rural parent behaviors and expectations
A. M. Hart et al.
Table 5 Parental expectations for HCPs’ behaviors when child is being seen for ARI symptoms
Item HCP talks to parents about their worries and concerns HCP listens to child’s symptoms HCP gives advice about managing child’s symptoms HCP examines child for cause of their symptoms HCP explains severity of child’s symptoms HCP is aware of child’s personal health history HCP explains different treatment options HCP provides recommendations based on current scientific knowledge HCP respects that they know child and know what child needs to get better HCP provides information on how child’s illness may affect other members of their family HCP is aware of family’s health history HCP does something so child does not spread the infection to others HCP explains how child’s symptoms may change in the next few days or weeks HCP discusses how soon child will be well HCP provides treatment the parent requests Child receives prescription to manage symptoms HCP provides child with the same treatment as other children parents know who have same symptoms Child receives a note for sick leave from school or work Child is prescribed an antibiotic HCP is aware of their financial circumstances HCP is aware of how difficult it is for parents to get to a store or pharmacy HCP is aware of how far they have traveled for appointment
significant or are simply wanting validation for being seen by an HCP. NPs may find it useful to reflect on the messages that rural parents are sending regarding antibiotic use, and specifically address these messages with parents as a means of opening the door for discussion of antibiotic use and how to best address parents’ actual concerns and worries regarding their child. Parents in our study 436
Very important, %
Quite important, %
Not very important, %
Not important at all, %
80.2 (n = 142) 89.3 (n = 158) 83 (n = 147) 83 (n = 146) 80.2 (n = 142) 79.5 (n = 140) 72.6 (n = 127) 70.3 (n = 123) 65.3 (n = 115) 63.4 (n = 111) 55.7 (n = 97) 54.3 (n = 95) 47% (n = 135) 46.6 (n = 82) 43.9 (n = 75) 40.4 (n = 69) 39.3 (n = 68) 35.7 (n = 61) 25.6 (n = 42) 22.3 (n = 39) 19.4 (n = 34) 17.7 (n = 31)
19.8 (n = 35) 10.2 (n = 18) 14 (n = 25) 11 (n = 20) 17.5 (n = 31) 19.3 (n = 34) 24.6 (n = 43) 26.3 (n = 46) 22.2 (n = 39) 32.6 (n = 57) 35.1 (n = 61) 29.7 (n = 52) 33 (n = 33) 33.0 (n = 58) 24.6 (n = 42) 29.8 (n = 51) 23.1 (n = 40) 27.5 (n = 47) 33.5 (n = 55) 26.3 (n = 46) 17.7 (n = 31) 18.9 (n = 33)
0.0 (n = 0) 0.0% (n = 0) 3 (n = 5) 5 (n = 8) 1.7 (n = 3) 1.1 (n = 2) 2.9 (n = 5) 2.3 (n = 4) 10.2 (n = 18) 3.4 (n = 6) 8.0 (n = 14) 10.3 (n = 18) 18 (n = 6) 17.6 (n = 31) 21.6 (n = 37) 25.1 (n = 43) 23.7 (n = 41) 22.8 (n = 39) 32.9 (n = 54) 30.3 (n = 53) 37.1 (n = 65) 34.9 (n = 61)
0.0 (n = 0) 0.6 (n = 1) 0.0 0.6 (n = 1) 0.6 (n = 1) 0.0 (n = 0) 0.0 (n = 0) 1.1 (n = 2) 2.3 (n = 4) 0.6 (n = 1) 1.1 (n = 2) 5.7 (n = 10) 3 (n = 2) 2.8 (n = 5) 9.9 (n = 17) 4.7 (n = 8) 13.9 (n = 24) 14.0 (n = 24) 7.9 (n = 13) 21.1 (n = 37) 25.7 (n = 45) 28.6 (n = 50)
wanted to talk about their worries and concerns, so perhaps by creating a relaxed environment where parents can truly express their worries and desires, antibiotic use can be minimized. Because parents also reported that they wanted recommendations based on current scientific knowledge (i.e., 70.3% said that this was very important; 26.3% said that this was quite important), there is reason to believe that parents want to know what is
Rural parent behaviors and expectations
A. M. Hart et al.
Table 6 Parental expectations when consulting with HCP regarding child’s ARI symptoms
Item ARI handled in one visit. Able to follow up with HCP regarding child’s ARI by phone or e-mail. Receive a prescription for symptoms of child’s ARI. Receive an antibiotic prescription for child’s ARI. Answer parental questions over the phone without an appointment. Provide advice outside of the office. Provide prescriptions for other members in the family who have the same symptoms without first seeing them.
Very Quite Not very important, % important, % important, % 51.1 (n = 90) 48.0 (n = 85)
44.3 (n = 78) 40.1 (n = 71)
4.5 (n = 8) 11.9 (n = 21)
28.3 (n = 49) 21.1 (n = 36)
65.9 (n = 114) 70.2 (n = 120)
5.8 (n = 10) 8.8 (n = 15)
28.2 (n = 50)
52.5 (n = 93)
19.2 (n = 34)
16.4 (n = 29) 13.6 (n = 24)
40.1 (n = 71) 34.5 (n = 61)
43.5 (n = 77) 52.0 (n = 92)
best for the care of their children and may be receptive to current, research-based information on why or why not to use antibiotics. Our study also support findings from another study that found parents use a variety of criteria to assess their children’s conditions prior to seeking medical advice, although, their understanding of the particular phenomena their child is experiencing may be limited or even faulty (Saunders, Tennis, Jacobson, Gans, & Dick, 2003). Specifically, parents in our study appeared to have misinformation regarding ARI symptoms and how to interpret these symptoms. For example, discolored phlegm, discolored nasal discharge, and fever were cited by a majority of parents as reasons to see an HCP. Current best practice recommendations do not warrant antibiotics for mucopurulent rhinitis until they have been present for 10–14 days (Rosenstein et al., 1998), and fevers are also commonly misunderstood and feared by parents (Saunders et al., 2003). Based on the findings from our study indicating that parents would like to discuss symptoms and have their child examined for the cause of the symptoms more than they would like to receive antibiotics, it may be an opportunity for discussion of symptom management (e.g., saline rinse, fever reduction, etc.), and phone or e-mail follow up if symptoms persist. Others have confirmed the potential value in educating parents regarding the interpretation of symptoms, including fevers (Saunders et al., 2003). Again, our study indicates that parents
are interested in receiving current, research-based information regarding the health of their children, and thus, efforts to educate rural parents on current knowledge of symptoms may be well received. Our finding that 91% of the parents in our study agreed that it was either “very” or “quite” important for an HCP to prescribe an antibiotic for their child’s ARI is not dissimilar from results of studies conducted with parents primarily living in urban and suburban areas (Cho, Hong, & Park, 2004; Lee, Friedman, Ross-Degnan, Hibberd, & Goldmann, 2003). Both of these studies found that although most parents reported knowing that colds were viral in nature, many also believed that antibiotics could either shorten the duration of symptoms or prevent ARI-related complications. Although our study did not inquire about parental beliefs regarding the etiology of ARIs or how antibiotics might help ARIs, it may be that rural parents have similar beliefs regarding ARIs and antibiotics. The aforementioned implications for practice might also apply to NPs working in urban or suburban settings. However, travel distances to an HCP or pharmacy are two items that may be unique to rural settings. For example, 36.6% of the parents in our study reported that they wanted their HCP to be aware of how far they traveled to come to this appointment, and 37.1% indicated that it was “very” or “quite” important for their child’s HCP to be aware of how difficult it is to get to a store or pharmacy. It is tempting to think that these expectations mean that parents will not be satisfied without receiving an antibiotic, or that they may have antibiotics on hand at home that they will use regardless of advice that is provided. However, NPs should resist the temptation to prescribe based on assumptions or perceived parental pressure, rather, it is essential to discuss appropriate antibiotic use with parents and to develop a treatment plan that acknowledges the family’s distance from a pharmacy or HCP. In addition, previous research conducted with rural families did not indicate that families in this state keep antibiotics on hand for “just in case” situations (Morgan & Hart, 2009). Awareness of these and other potentially unique issues will allow NPs to work more efficiently with rural families in their practice and better provide appropriate education and anticipatory guidance for rural patients. In addition to eliciting parents’ specific expectations and concerns, NPs may also be wise to develop different models of care for children experiencing ARIs. Parents in our study indicated they would appreciate being able to consult with HCPs over the phone, and several studies support protocol-based telephone consultations for ARI management (Chaudhry et al., 2006; McConnochie et al., 2006). Thus, NPs who care for children should consider 437
Rural parent behaviors and expectations
developing a protocol or mechanism to accommodate this patient need.
Limitations There were several limitations to this study that should be noted. First, this survey was conducted during the summer, when individuals are least likely to experience ARIs. Because the respondents and their children were most likely not experiencing ARIs during the survey’s administration, they may have had difficulty accurately recalling behaviors that they typically engage in when their children experience ARI symptoms. Second, respondents may have answered survey items in a manner they perceived as socially desirable or politically correct (Macnee & McCabe, 2008). Third, the interviews were conducted in a large, sparsely populated, rural state and results may not be generalizable to nonrural populations or rural populations in more densely populated regions or other regions of the United States. Lastly, because it is likely that the majority of our participants were Caucasian and nonHispanic, our results may not be applicable to other racial or ethnic populations.
Conclusion Our study is one of the first to address rural parents’ behaviors and expectations for managing their children’s ARIs. Although some of our results are similar to those conducted with families residing in urban and suburban communities (i.e., expectations for antibiotics and concerns regarding discolored phlegm and nasal discharge), some were unique, such as expecting that the HCP be aware of distance traveled for the appointment and distance to a pharmacy. In summary, our results suggest that by better understanding expectations and behaviors of rural parents, NPs can develop better strategies for providing evidencebased care for patients (both children and adults) who present with ARIs and other common concerns. NPs play a key role in many rural communities (Cipher, Hooker, & Guerra, 2006; Everett, Schumacher, Wright, & Smith 2009) and are uniquely positioned to educate parents regarding ARI symptom management and appropriate antibiotic use by developing relationships based on knowledge of rural families’ expectations and behaviors.
Acknowledgments This study was funded by an Agricultural Experiment Station grant through the University of Wyoming College of Agriculture and Natural Resources. 438
A. M. Hart et al.
References Ahn, S., Burdine, J. N., Smith, M. L., Ory, M. G., & Phillips, C. D. (2011). Residential rurality and oral health disparities: influences of contextual and individual factors. Journal of Primary Prevention, 32, 29–41. Allison, R. A., & Manski, R. J. (2007). The supply of dentists and access to care in rural Kansas. Journal of Rural Health, 23, 198–206. American Academy of Microbiology (2009). Antibiotic resistance: An ecological perspective on an old problem. Retrieved from http://academy.asm.org/ images/stories/documents/ antibioticresistance.pdf Baldwin, L. M., Hollow, W. B., Casey, S., Hart, L. G., Larson, E. H., Moore, K., . . . Grossman, D. C. (2008). Access to specialty health care for rural American Indians in two states. Journal of Rural Health, 24, 269–278. Barden, L. S., Dowell, S. F., Schwartz, B., & Lackey, C. (1998). Current attitudes regarding use of antimicrobial agents: Results from physicians’ and parents’ focus group discussions. Clinical Pediatrics, 37, 665–671. Bauchner, H., Pelton, S. I., & Klein, J. O. (1999). Parents, physicians, and antibiotic use. Pediatrics, 103, 395–401. Belongia, E. A., Naimi, T. S., Gale, C. M., & Besser, R. E. (2002). Antibiotic use and upper respiratory infections: A survey of knowledge, attitudes, and experience in Wisconsin and Minnesota. Preventive Medicine, 34, 346–352. Brems, C., & Johnson, M. (2007). Challenges and uniqueness of rural and frontier services in the United States. Journal of Psychological Practice, 14, 93–122. Bushy, A. (2011). Rural nursing: Practice and issues. American Nurses Association Continuing Education Program. Washington, DC: American Nurses Association. Casey, M. M., Call, K. T., & Klingner, J. M. (2001). Are rural residents less likely to obtain recommended preventive healthcare services? American Journal of Preventive Medicine, 21, 182–188. Centers for Disease Control (2011). Fast facts about antibiotic resistance. Retrieved from http://www.cdc.gov/getsmart/antibiotic-use/anitbiotic-resistancefaqs.html#d Chaudhry, R., Stroebel, R. J., McLeod, T. G., Van Houten, H. K., Naessens, J. M., Jaeger, T. M., . . .Scheitel, S. M. (2006). Nurse-based telephone protocol versus usual care for management of URI and acute sinusitis: A controlled trial. Managed Care Interface, 19, 26–31. Cho, H., Hong, S., & Park, S. (2004). Knowledge and beliefs of primary care physicians, pharmacists, and parents on antibiotic use for the pediatric common cold. Social Science and Medicine, 58, 623–629. Ciofi detli Atti, M. L., Massari, M., Bella, A., Boccia, D., Filia, A., & Salmaso, S. (2006). Clinical, social, and relational determinants of paediatric ambulatory drug prescriptions due to respiratory tract infections in Italy. European Journal of Clinical Pharmacology, 62, 1055–1064. Cipher, D. J., Hooker, R. S., & Guerra, P. (2006). Prescribing trends by nurse practitioners and physician assistants in the United States. Journal of the American Academy of Nurse Practitioners, 18, 291–296. Coker, T. R., Chan, L. S., Newberry, S. J., Limbos, S. A., Suttorp, M. J., Shekelle, P. G., & Takata, G. S. (2010). Diagnosis, microbial epidemiology, and antibiotic treatment of acute otitis media in children. Journal of the American Medical Association, 304, 2161–2169. Cook, N. L., Hicks, L. S., O’Malley, A. J., Keegan, T., Guadagnoli, E., & Landon, B. E. (2007). Access to specialty care and medical services in community health centers. Health Affairs, 26, 1459–1468. Dowell, S. F., Marcy, S. M., Phillips, W. R., Gerber, M. A., & Schwartz, B. (1998). Principles of judicious use of antimicrobial agents for pediatric upper respiratory tract infections. Pediatrics, 101, 163–165. Dunphy, L. M., & Winland-Brown, J. E. (2007). Advanced practice nursing in the twenty-first century: A circle of caring. In L. M. Dunphy & J. E. Winland-Brown (Eds.), Primary care: The art and science of advanced practice nursing (2nd ed., pp. 3–18). Philadelphia: F.A. Davis. Everett, C. M., Schumacher, J. M., Wright, A., & Smith, M. A. (2009). Physician assistants and nurse practitioners as a usual source of care. Journal of Rural Health, 25, 407–414. Friedman, C. R., & Whitney, G. C. (2008). It’s time for a change in practice: Reducing antibiotic use can alter antibiotic resistance. Journal of Infectious Diseases, 197, 1082–1083.
A. M. Hart et al.
Goolsby, M. J. (2007). Antibiotic prescribing habits of nurse practitioners treating pediatric patients: AntiBUGS pediatrics. Journal of the American Academy of Nurse Practitioners, 19, 332–334. Grijalva, C. G., Nuorti, J. P., & Griffin, M. R. (2009). Antibiotic prescription rates for acute respiratory tract infections in U.S. ambulatory settings. American Medical Association, 302, 758–766. Hart, A. M., & Morgan, K. (2008). Integrating patient values into evidencebased practice (EBP): How individuals and families manage acute respiratory infections (ARIs). Poster presented at the 34th Annual Meeting of the National Organization for Nurse Practitioner Faculties (NONPF), Louisville, KY. Hugenholtz, M., Broer, C., & van Daalen, R. (2009). Apprehensive parents: A qualitative study of parents seeking immediate primary care for their children. British Journal of General Practice, 59, 173–179. Krishna, S., Gillespie, K. N., & McBride, T. M. (2010). Diabetes burden and access to preventive care in the rural United States. Journal of Rural Health Care, 26, 3–11. Ladd, E. (2005). The use of antibiotics for viral upper respiratory tract infections: An analysis of nurse practitioner and physician prescribing practices in ambulatory care, 1997–2001. Journal of the American Academy of Nurse Practitioners, 17, 416–424. Lee, G. M., Friedman, J. F., Ross-Degnan, D., Hibberd, P. L., & Goldmann, D. A. (2003). Misconceptions about colds and predictors of health service utilization. Pediatrics, 111, 231–237. Macnee, C. L., & McCabe, S. (2008). Understanding nursing research: Reading and using research in evidence-based practice (2nd ed.). Philadelphia: Lippincott, Williams, & Wilkins. Mangione-Smith, R., McGlynn, E. A., Elliott, M. N., Krogstad, P., & Brook, R. H. (1999). The relationship between perceived parental expectations and pediatrician antimicrobial prescribing behavior. Pediatrics, 103, 711–718. McCall-Hosenfeld, J. S., & Weisman, C. S. (2011). Receipt of preventive counseling among reproductive-aged women in rural and urban communities. Rural and Remote Health, 11, Article No. 1617. McConnochie, K. M., Conners, G. P., Brayer, A. F., Goepp, J., Herendeen, N. E., Wood, N. E., et al. (2006). Differences in diagnosis and treatment using telemedicine versus in-person evaluation of acute illness. Ambulatory Pediatrics, 6, 187–195. Morgan, K., & Hart, A. M. (2009). Families in rural settings: Values regarding acute respiratory infections. Families, Systems, and Health, 27, 85–97.
Rural parent behaviors and expectations
O’Brien, K. L., Dowell, S. F., Schwartz, B., Marcy, S. M., Phillips, W. R., & Gerber, M. A. (1998a). Acute sinusitis—Principles of judicious use of antimicrobial agents. Pediatrics, 101, 174–177. O’Brien, K. L., Dowell, S. F., Schwartz, B., Marcy, S. M., Phillips, W. R., & Gerber, M. A. (1998b). Cough illness/bronchitis—Principles of judicious use of antimicrobial agents. Pediatrics, 101, 178–181. Rosenstein, N. Phillips, W. R., Gerber, M. A., Marcy, S. M., Schwartz, B., & Dowell, S. F. (1998). The common cold—Principles of judicious use of antimicrobial agents. Pediatrics, 101, 181–184. Roumie, C. L., Halasa, N. B., Grijalva, C. G., Edwards, K. M., Zhu, Y., Dittus, R. S. et al. (2005). Trends in antibiotic prescribing for adults in the United States—1995 to 2002. Journal of General Internal Medicine, 20, 697–702. Saunders, N. R., Tennis, O., Jacobson, S., Gans, M., & Dick, P. T. (2003). Parents’ responses to symptoms or respiratory tract infections in their children. Canadian Medical Association Journal, 168, 26–31. Sawyer, D., Gale, J., & Lambert, D. (2006). Rural and frontier mental and behavioral health care: Barriers, effective policy strategies, best practices. National Association for Rural Mental Health (NARMH). Retrieved from http://www.narmh.org/publications/archives/ rural˙frontier.pdf Schwartz, B., Marcy, S. M., Phillips, W. R., Gerber, M. A., & Dowell, S. F. (1998). Pharyngitis—Principles of judicious use of antimicrobial agents. Pediatrics, 101, 171–174. Stivers, T., Mangione-Smith, R., Elliott, M. N., McDonald, L., & Heritage, J. (2003). Why do physicians think parents expect antibiotics? What parents report vs what physicians believe. Journal of Family Practice, 52, 140–148. Strauss, S. E., Richardson, W. S., Glaszious, P., & Haynes, R. B. (2005). Evidence-based medicine: How to practice and teach evidence-based medicine (3rd ed.). Edinburgh: Elsevier. United States Census Bureau (2011). The 2011 statistical abstract: The national databook. Retrieved from http://www.census.gov/compendia/statab/ cats/population.html United States Department of Agriculture (2011). State Fact Sheet: Wyoming. Retrieved from http://www.ers.usda.gov/statefacts/WY.htm Welschen, I., Kuyvenhoven, M., Hoes, A., & Verheij, T. (2004). Antibiotics for acute respiratory tract symptoms: patients’ expectations, GPs’ management and patient satisfaction. Family Practice, 21, 234–237. White, D., Moir, A., Zweifler, J., & Hughes, S. (2010). Parental satisfaction without antibiotics. Nurse Practitioner, 35, 40–42. Wyoming Department of Administration and Information (2010). Wyoming population estimates and forecasts. Retrieved from http://eadiv.state.wy.us/pop/CO Minority09.htm
439
![[Children with respiratory infections - How and when to perform anesthesia].](/assets/img/hold.png)
