Parents’ beliefs and knowledge about the management of acute otitis media: a qualitative study
Hansen et al. BMC Family Practice
Parents' beliefs and knowledge about the management of acute otitis media: a qualitative study
Malene Plejdrup Hansen 0
Janine Howlett 0
Chris Del Mar 0
Tammy C. Hoffmann 0
0 Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University , Gold Coast, Queensland 4229 , Australia
Background: Acute otitis media is a common reason for antibiotic prescribing, despite strong evidence that antibiotics provide minimal benefit. Studies have demonstrated that patients' (or parents') expectations of antibiotics often influence general practitioners' (GPs) decision to prescribe antibiotics, but few have explored parents' expectations of the management of infections in children, or which factors influence the development of these expectations. This study aimed to explore parents' knowledge and beliefs about the management of acute otitis media in children. Methods: Individual semi-structured interviews were conducted with 15 parents of children who had recently presented to their GP with acute otitis media. Parents were recruited at childcare centres or playgroups in Brisbane, Australia. Results: Many parents did not have an accurate understanding of what causes acute otitis media. GPs were primarily consulted for the management of symptoms such as pain and fever. Others specifically wanted reassurance or were concerned about hearing loss. Most parents assumed that antibiotics were the best treatment option. Parents' perceptions about the best treatment were mainly based on their previous experience and the advice of the GP. Pain relief medications, such as paracetamol and non-steroidal anti-inflammatory drugs, were not considered by parents to be sufficient treatment on their own. Conclusion: There is discrepancy between parents' beliefs and expectations of management of acute otitis media and the evidence-based recommendations. This study provides insights into parents' expectations of management of acute otitis media, which may help inform clinicians about perceptions and misperceptions that may be valuable to elicit and discuss.
Otitis media; Knowledge; Family practice; Primary health care; Qualitative research; Antibiotics
Acute otitis media is a common community-acquired
infection and the majority of children will experience at
least one episode of it during childhood. Children
recover spontaneously without treatment, and antibiotics
only have a modest overall benefit on the clinical course
of acute otitis media. Twenty children have to be treated
with antibiotics to prevent one child suffering ear pain
after 2–7 days – that is, a number needed to treat to
benefit of 20 . The benefits of antibiotics are in the
same order as the mild adverse effects, such as diarrhoea
and candidiasis , which have numbers needed to harm
of 14 . Antibiotics seem to be most beneficial in
children younger than 2 years of age with bilateral acute
otitis media, and in children with both acute otitis media
and otorrhoea .
Decisions about whether to use antibiotics need to
weigh up their benefits with their harms, as prescribing
leads to antibiotic resistance . Antibiotic resistance is
an increasing public health concern, not only at a
population level, but also for individual patients, for whom
use of antibiotics can result in bacterial resistance to that
antibiotic for up to 12 months . Although, current
guidelines recommend withholding antibiotics in most
cases of children with acute otitis media, many are still
treated with antibiotics . Antibiotic prescribing rates
vary considerably between countries from less than 50 %
in Dutch primary care  to more than 80 % in primary
care in the UK . One of the likely drivers of antibiotic
overuse is demand, perceived or real, from parents. It is
well-known that patients (or parents’) expectations of
antibiotics influence general practitioners’ (GPs) decision
to prescribe them . Patients who are perceived by
clinicians as expecting an antibiotic are 10 times more
likely to be prescribed one . However, there has been
little exploration into parents’ expectations of the
management of acute otitis media in children and what influences
the development of these expectations. GPs need to be
aware of parents’ knowledge and expectations to facilitate
optimal communication during the consultation. The aim
of this study was to explore parents’ knowledge and beliefs
about the management of acute otitis media in children.
In this qualitative study, a convenience sample of
parents was recruited from 3 childcare centres and 2
playgroups in Brisbane, Australia. Parents of children
younger than 5 years, who had presented to a GP with
acute otitis media in the last 6 months, were invited to
participate. We gathered socio-demographic information
(age, gender, education level and occupation), as well as
a measure of their health literacy (the Rapid Estimate of
Adult Literacy in Medicine (REALM)) . All parents
gave written informed consent and ethical approval was
granted by Bond University Human Research Ethics
Data collection and analysis
One of the researchers (JH) completed face-to-face
semistructured interviews with each parent. The interview
guide was based on clinical experience, expert knowledge
and relevant literature on patient expectations (Table 1).
Table 1 Topics in the interview guide
Topics in the interview guide
What do you think causes the illness?
What treatments are available?
Which treatment do you think is best?
How do you know this?
How does your GP know?
Do you think ‘no antibiotic treatment’ is an option?
In what ways can you decide which treatment is the best?
The interviews were audio-recorded and transcribed
The 5-stage framework approach  was used to
analyse the textual data; a) reading and re-reading
transcripts until familiar with the experiences, perspectives
and language of each participant; b) creating a thematic
framework which reflected the data and the interview
questions; c) coding the data line-by-line against the
themes and emerging sub-themes of the framework; d)
summarising data into the framework, and; e) refining,
comparing and interpreting themes. Two researchers
(MPH, TH) independently identified the themes and in a
face-to-face meeting, themes were discussed until
consensus was reached. Recruitment of participants
continued until data saturation, i.e. no new themes emerged
from the analysis. All analysis were performed manually
without any software tools.
We interviewed 15 mothers with a mean age of 37 years
(SD = 5, range 29 to 49). They had an average of two
children; most (n = 12) had tertiary education and 4 had
a health professional qualification (nursing or allied
health). Participants had a mean REALM score of 65.53
(SD = .83, range 63 to 66), which indicates that all
parents had a reading level above Grade 9. Table 2 shows
characteristics of parents. Thirteen out of the 15
children were treated with per oral antibiotics for the most
recent episode of acute otitis media (Table 3). A
delayed prescription was offered to one family however
antibiotics were initiated at the same day. The mean
duration of interviews was 21 min (range 15 to 31 min).
The results which emerged could be framed around 4
themes: causes of acute otitis media, reasons for
consulting a GP, beliefs about treatments, and sources of
Causes of acute otitis media
Various causes of acute otitis media were suggested by
parents, with many not having an accurate understanding.
“Absolutely no idea, I don’t even know what an ear
infection is really, it’s just something that I’m told that
my children have” (Participant 1)
Some parents related the cause of acute otitis media to
having a cold that develops into an ear infection.
“I thought it was like an extended version of a cold. A
cold gone wrong basically, or gone worse” (Participant 6)
“I’d say he probably had a cold beforehand which then
turned into something more than that” (Participant 9)
Table 2 Characteristics of parents
REALM = the Rapid Estimate of Adult Literacy in Medicine
Acute otitis media was also associated with teething,
ear wax congestion, swimming, dirty bathing water and
the size or shape of the Eustachian tubes in children.
“Teething maybe, build up of ear wax I think” (Participant 1)
“I think in our children they have been water related.
They’ve been swimming, something hasn’t drained, a
little germ has festered in the ear and it’s got out of all
control” (Participant 4)
Table 3 Antibiotic treatment of children
aPer oral antibiotic treatment for the most recent episode of AOM
bAntibiotics were initiated at the same day
“I think it’s because the Eustachian tubes are straight
at that age, so anything like mucus and saliva and
things that they have a cold can quite easily make
their way to their ears” (Participant 12)
Reasons for consulting a GP
Pulling at the ear, pain, fever, no appetite and sleep
disturbance were the signs and symptoms most
parents reported when they suspected acute otitis media.
Parents predominantly attended the GP because they
did not want their child to be in any pain or because
they wanted reassurance. The concerns that parents
desired reassurance for were related to the possibility
of a serious infection (e.g. septicaemia) or that their
child would require hospitalisation.
“…you don’t like little ones to be in pain, so it is quite
traumatising when they carry on. You know when
you’re not really treating anything and just letting go.
So it is quite emotional as well. I want it to be fixed
right then and there” (Participant 11)
“Well it could go further down and they could get like a…
I have heard of people getting, well even septicaemia from
going into the blood systems” (Participant 15)
“Possibly end up in hospital on a rehydration drip,
which she has done previously, when she was very
little” (Participant 4)
Some parents were also concerned that their child’s
eardrum would perforate and many worried about
longterm damage, especially hearing loss.
“I would try it [no antibiotic treatment], as long as my
option would be then to go back in a few days to make
sure that it hasn’t got worse…” (Participant 3)
“I don’t really want his eardrum to burst” (Participant 5)
“I think most mothers worry about their child’s
hearing…” (Participant 14)
“I would probably say that it might have a long-term
impact on hearing. Irreversible” (Participant 13)
Beliefs about treatments
Most parents believed that antibiotics were the best and
only treatment for their child’s acute otitis media. Others
thought that the treatment strategy should depend on
the type of infection (that is, viral or bacterial origin)
and a few parents were unsure about the treatment.
“…each time the antibiotics have worked like
magic.” (Participant 4)
“I kind of thought it was quite simple really, just had an
ear infection and that I needed antibiotics” (Participant 15)
“I think first of all you need to find out whether it’s
viral or bacterial and then follow the according
treatment” (Participant 11)
Parents’ perceptions about the best treatment were
mainly based on their previous experience and the
advice of the GP. However, responses from parents
suggested that they were not fully informed and had not
previously considered the options.
“The only option we were given was antibiotics.
Apart from that, I wouldn’t imagine that there’s
much else” (Participant 7)
“Well the only thing I’ve ever been offered is antibiotics,
so I don’t know of anything else” (Participant 1)
“No, it was just, ‘Here’s the antibiotics and off
you go’” (Participant 14)
A few parents would accept ‘no antibiotic treatment’
as an option, if their child’s infection was monitored
and they had the back-up of being able to re-consult if
“Yes, I think in certain circumstances, but it would
have to be monitored, so… that the infection is
resolving and that they’re not going to have any
hearing issues as a result” (Participant 10)
Other parents were more cautious about this option
and feared long-term damage such as hearing loss if
antibiotics were not used or wanted a fast recovery
(believing antibiotics would provide this). The time
pressure of recovery was related to the importance of
getting back to work or being on holiday for some
“… I am thinking well if they don’t treat him, what if
he goes deaf?” (Participant 1)
“Preferably not, not when it comes to ears.
I don’t want to take that chance with my child’s
hearing” (Participant 2)
“…he was in full-time day care and from my point of
view I had to get it fixed. So we went and got it filled
that morning” (Participant 9)
“We are on holidays, we are in a different
environment, if antibiotic is a suggested option, I will
certainly go down that track…” (Participant 5)
Pain relief medication, such as paracetamol
(acetaminophen) or non-steroidal anti-inflammatory drug
(NSAID), were used by all parents, mainly for temperature
reduction and pain relief. However, most parents did not
think of symptomatic relief of paracetamol or NSAIDs as
a sufficient treatment on their own and they believed that
treatment (such as antibiotics) to cure the infection was
“But if I knew straight away that it was an ear infection,
then I wouldn’t bother with just Panadol or something
like that, I would go straight to the antibiotics to help
their body knock it” (Participant 4)
Sources of knowledge
All parents relied on and trusted the GPs’ knowledge
and assumed it was based on recent research and
continuing medical education such as reading medical
journals or attending conferences. A few parents mentioned
that they preferred GPs who had children themselves
because they felt that they had a better understanding of
managing sick children.
“Well I actually hope he knows what’s best, because
he’s done more studies that what I’ve done… yeah, I
mean we put a lot of faith in our GP’s” (Participant 3)
“Well, one hopes that they’re [GP’s] trained better than
us to have a lot more information than we do, and I
suppose we have to trust that they have done the
research and that they do know” (Participant 13)
…some GPs have children themselves and understand that
children need to be seen straight away… (Participant 6)
Most parents preferred to receive information from
the GP when they had a sick child. However, three other
major sources of information for this situation were
identified; (a) the internet; (b) close family and social
contacts, particularly participants’ mothers and (c) other
health professionals such as ear, nose and throat
specialists and pharmacists.
“I probably get the most information from the GP and
trust that that source of information is relevant to my child,
because I think every child is different” (Participant 5)
“I probably go to ‘Google’ or ‘Doctor Google’, one of
those” (Participant 14)
“…mum usually diagnoses anything for everyone
before they even suspect there’s something wrong
themselves” (Participant 4)
“…if I couldn’t get into a doctor or something, which
happens quite regularly, I would maybe go to the
pharmacist…” (Participant 1)
While it was expected that GPs knew about the best
treatment for acute otitis media, only four parents
recalled receiving an adequate explanation about the
evidence of the management options for acute otitis
“…there [are] options presented as hypotheticals, but
they [GP’s] will always come to a decision and say, look I
think we need to do the medication”… (Participant 5)
“Well I know they [GPs] used to give antibiotics,
but I’ve been explained by the GP that that’s not
what they do anymore. That they [antibiotics] don’t
seem to alter the course of the illness, they tend to
just give them pain relief and wait and see what
happens…” (Participant 12)
Although most parents thought they could ask their
usual GP for a thorough explanation, some stated that if
they saw another GP or an after hours doctor they often
felt as if the consultation was rushed and there was no
time for explanations.
“…because it is an emergency appointment it feels
quite rushed, it’s in and out the door…” (Participant 2)
Many parents did not have an accurate understanding of
what causes acute otitis media. Parents primarily
consulted the GP for the management of symptoms such as
pain and fever or reassurance about possible
complications, with many believing that antibiotics were
necessary to prevent complications and hasten recovery. Most
parents preferred to receive information from the GP
when they had a sick child, but also the internet, close
social contacts and other health professionals were used
as a source of knowledge. Few parents recalled receiving
an adequate explanation about the options for
management of acute otitis media or their benefits and harms.
Most parents assumed that antibiotics were the best and
only treatment option for acute otitis media. Parents’
perceptions about the best treatment were mainly based
on their previous experience and the advice of the GP.
Pain relief medications (e.g. paracetamol or NSAIDs)
were not considered by parents to be sufficient
treatment on their own.
All interviews were completed by one author, who was
not a GP, to ensure both consistency and bracketing of
bias. However, our sample was a convenience sample,
relatively small, exclusively female, and all had a high
reading ability and most had a tertiary education. This
limits the transferability of these results. Expectations
for antibiotics may have been even higher in a sample
that included male parents and parents with lower
reading ability, as accurate knowledge of antibiotic
effectiveness is associated with female sex and higher education
level . As most participants in the study received
antibiotics, exploration of these issues in parents who
have managed acute otitis media in their children
without antibiotics would be worthwhile.
Comparison with existing literature
We found, that the GP was primarily consulted for the
management of symptoms such as pain and fever or for
reassurance. Other studies have also shown, that patients
with upper respiratory tract infections seek symptom
relief  and that patient satisfaction is associated with
reassurance and gaining information about the course of
the disease . A recent systematic review by Lucas et
al. identified that parents would accept clinicians’
decisions if they felt they had received a good evaluation,
even where this differed from their expectations .
A Dutch study of an internet-based survey of parents, found that almost 90 % of parents knew that not every
child with a fever needs antibiotic treatment . In
contrast, we found that most parents believed that
antibiotics were the optimal treatment. However, our study
specifically focused on children with acute otitis media,
and not childhood fever in general. We found that
parents’ concern about hearing loss was prominent and it is
possible that this concern may heighten perceptions of
the need for and hence expectations of antibiotics. This
finding emphasises the importance of exploring parents’
beliefs and expectations when consulting with a child
with symptoms of acute otitis media and managing the
expectations and reassuring where appropriate. Parents’
perceived vulnerability of children to health threats,
increase their desire to remove the risk of such threats, and
seeking consultations for reassurance were also identified
in the systematic review by Lucas and colleagues  – all
of which influence clinician antibiotic prescribing.
In a recent randomised double-blind placebo-controlled
trial, the duration of middle ear effusion was reduced in
children with acute otitis media who received antibiotics
, although concerns about the lack of patient-centred
outcomes in this trial have been raised [19, 20]. More
information is needed, both of the possible long-term
benefits and harms of antibiotic treatment of children
with acute otitis media, e.g. risk of hearing impairment
and recurrence rates .
Expectations of antibiotics were quite high among the
group of parents, and this was attributed by parents as a
consequence of the past experience of GP advice and
treatment. In general, a positive feedback loop seems to
have been established as patients’ expectations of
antibiotics are associated with receiving an antibiotic [9, 10]
and this perpetuates expectations of them in subsequent
illness episodes . Breaking this feedback loop is
important and the use of antibiotics reserved for those who
will benefit the most . The tendency of people to
overestimate the benefit of medical interventions, which
subsequently drives their expectations for them, has
been shown across various treatments and tests .
The role of use of pain relief medication should be
explained to parents. We found that many parents
confused the use of antibiotics with the use of medicine to
manage symptoms. This finding is in line with a study in
Greece where almost 70 % of parents confused antibiotics
with other medicines used for symptomatic therapy for
children with upper respiratory infections .
This study provides insights into parents’ knowledge and
expectations of management of acute otitis media, which
may help inform clinicians about perceptions and
misperceptions that may be valuable to elicit and discuss. It
is very important that GPs are aware of parents’
knowledge and expectations to ensure optimal communication
during the consultation . GPs often elicit expectations
for antibiotics in an indirect manner , hence
expectations are not clearly addressed and managed. Shared
decision making has an important role to play here. As
part of the shared decision making process, evidence is
brought into the discussion and patients’ concerns and
expectations are explicitly sought and discussed .
Since the benefits of antibiotics for acute otitis media may
only marginally, if at all, outweigh the harms,
communicating this to patients/parents has been shown to reduce
their desire for antibiotics . Future efforts should
focus on optimising the GPs’ awareness of the need to
elicit and manage expectations and develop skills in
integrating shared decision making into the consultation.
There is a discrepancy between parents’ beliefs and
expectations of management of acute otitis media and the
evidence-based recommendations. Most parents
primarily consulted the GP for the management of symptoms
such as pain and fever. Others specifically wanted
reassurance or were concerned about hearing loss. Most
parents assumed that antibiotics were the best treatment
option and pain relief medications were not considered
by parents to be sufficient treatment on their own.
Parents need more information about acute otitis
media, particularly the management options, including
the option of ‘no antibiotics’, and the empirical benefits
and harms of each option.
GP: General practitioner; AOM: Acute otitis media; REALM: The Rapid Estimate
of Adult Literacy in Medicine; NSAID: Non-steroidal anti-inflammatory drugs.
The authors declare that they have no competing interests.
MPH: Contributed to the interpretation of data and did the drafting and
revising of the manuscript. JH: Involved in the conception and design of the
study and revised the manuscript. CDM: Involved in the conception and
design of the study and revised the manuscript. TH: Involved in the conception
and design of the study, the interpretation of data and revised the manuscript.
All authors have agreed on this manuscript and given final approval of the
version to be published.
We would like to thank the 15 parents from childcare centres and
playgroups in Brisbane, Australia for their participation in this study.
Funding was provided by the Australian Government Department of Health
and Ageing through the Primary Health Care Research, Evaluation and
Tammy C Hoffmann is supported by a National Health and Medical Research
Council of Australia (NHMRC)/Primary Health Care Research, Evaluation and
Development Career Development Fellowship (1033038), with funding
provided by the Australian Government Department of Health.
Tammy C Hoffmann and Chris Del Mar are chief investigators at the Centre
for Research Excellence in Minimising Antibiotic Resistance from Acute
Respiratory Infections (NHMRC grant 1044904).
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