Parental Knowledge, Attitudes and Practices on Antibiotics Use for Childhood Upper Respiratory Tract Infections in Kicukiro District, Rwanda

Nshimiyimana M; Habtu FM; Manishimwe F; Ndayisenga J; Murekatete A

Research Article

Austin Public Health. 2022; 6(1): 1018.

Parental Knowledge, Attitudes and Practices on Antibiotics Use for Childhood Upper Respiratory Tract Infections in Kicukiro District, Rwanda

Nshimiyimana M¹*, Habtu FM², Manishimwe F², Ndayisenga J² and Murekatete A²

¹Postgraduate Student, Department of Public Health, Mount Kenya University, Rwanda

²Mount Kenya University, Kigali, Rwanda

*Corresponding author: Nshimiyimana M, Postgraduate Student, Department of Public Health, Mount Kenya University, Rwanda

Received: May 11, 2022; Accepted: June 10, 2022; Published: June 17, 2022

Abstract

Parents’ attitudes and expectations towards antibiotics use for children’s Upper Respiratory Tract Infections are among major causes of antibiotics misuse and the latter leads to the antimicrobial resistance. Thus, this study aimed at assessing parents’ knowledge, attitude and practices on antibiotics use for childhood URTIs in Kicukiro District. A cross-sectional study was conducted and a questionnaire was used to collect data from a sample size of 384 parents with under 12 years of age attending selected Health Centers in Kicukiro District. (SPPS) version 21 was used for data analysis; Chi-square test and regression analysis were used to examine the association between variables. The study findings indicated that 88.5% of parents were female, 39.6% aged from 25 to 34 years, 81.8% were married, 42.2% completed secondary education, 50% had 2 to 4 children and 57% of them were in economic class 2. The study revealed that 40.4% of parents had low level of knowledge of antibiotics use towards antibiotics use and 62% of them had poor practices regarding antibiotics use for childhood URTIs. Parents with increased level of education, higher economic position, with high knowledge and positive attitude use were more likely to have good practices towards antibiotics use than their corresponding counterparts. In conclusion, parents from Kicukiro District had poor knowledge and poor practices regarding antibiotics use for children’s URTIs. Hence, the study recommended that educational interventions for parents are needed to reduce antibiotics misuse by raising awareness on indications of antibiotics, their side effects and the emergence of antimicrobial resistance.

Keywords: Antibiotics Use; Attitudes and Knowledge; Children, Parents

Abbreviations

AB: Antibiotic; AMR: Antimicrobial Resistance; AOR: Adjusted Odds Ratio; CI: Confidence Interval; SPSS: Statistical Package for Social Sciences; StD: Standard Deviation; URTIs: Upper Respiratory Tract Infections.

Introduction

Childhood Upper Respiratory Tract Infections (URTIs) are prevalent occurrence in primary health care settings [1]. These illnesses are taught to be the leading cause of children’s or parents’ absenteeism from school or from work, consequently posing a financial burden on parents and the health systems [2]. Children become infected as a result of their exposure to a range of ailments and, in general, acquire 6 to 8 URTIs episodes yearly [3]. Evidence from literature showed that bacteria are responsible for less than 10% of URTI cases, yet antibiotics are frequently used to treat them and children get more antibiotics than any other age group, respiratory tract infections accounting for over 20% of pediatric antibiotic prescriptions [4]. It is believed that ten million needless antibiotics are provided each year, with broad-spectrum antibiotics being utilized in the majority of situations; this translates to over forty million US$ for antibiotic expenditures for treating the URTIs [5].

Excessive usage or misuse of antibacterial has resulted in higher health-care costs, greater adverse reactions such as diarrhea, and emergence of Antibacterial Resistance (AMR) [6]. According to the World Health Organization (WHO), 20-50% of antibiotic prescriptions are erroneous, which is a substantial contributor to the imminence of AMR universally [7].

Prescription of antibiotics too frequently, for too long or at too low a dose, stopping medication before it is completed are among human factors that have contributed to the development of AMR in bacteria [8]. Resistance to antibiotics is a severe and an increasing public health concern worldwide [9], severely in countries with increased rate of antibiotic consumption [10]. Literature estimates that ten million deaths will occur each year as a result of AMR [11] and 40% of these deaths will happen in Africa [12]. As a result, the WHO has classified drug resistance as being one of the world’s top ten public health threats that human society has been facing over the last decade [13].

A study that aimed at assessing the prevalence of AMR among common bacterial isolates in a tertiary healthcare facilities in Rwanda, revealed that AMR rates were high, posing a great therapeutic challenge in managing common infectious diseases [14]. According to a recent analysis, 1 out of 3 people in Low Middle Income Countries (LMICs) has serious gaps in knowledge of antibiotics utilization [18]. Physicians’ doubt about diagnosis, parental preferences, misperceptions, unrestricted access to antibiotics, knowledge deficit regarding antibiotic indications, and an unawareness of AMR were all linked to greater rates of antibiotic prescriptions [16,17]. The views and expectations of parents play a big role in whether or not an antibiotic is prescribed. Fear of acute illnesses among parents results in many pediatrician visits for URTIs and, as a result, inappropriate antimicrobial utilization [15]. According to numerous studies conducted in African and beyond, factors that influence antibacterial use include parental educational level, age, economic position, number of children, gender, residence location among others [19,20]. Literature also revealed a correlation between parental knowledge, attitudes and practices regarding antibiotics use [21].

Studies conducted in Rwanda were mainly focused on AMR and the suitability of antibiotic prescription. A study conducted in 3 Health Centers in Gisagara District that was assessing found that 54.2% of medication prescription was antibiotics, main indication was URTIs at 40.6% and only 38.6% of these antibiotics were rational. This study indicated that children took numerous antibiotics for URTIs at 21.4% compared to others [22]. A very little is known about parents’ awareness, attitudes and practices towards antibiotics use for Rwandan children’s URTIs, specifically in Kicukiro District. Therefore, this study looked at the relationships among socioeconomic characteristics and parents’ knowledge, attitudes, and practices on antibiotic usage and childhood URTIs. The findings of this study will be beneficial for decision makers to design strategies for health education especially for susceptible parents for antimicrobial abuse. It will also be used to improve parents’ understanding on URTIs and antibiotic use, thus, elements that influence long-term behavior changes regarding antibiotic usage.

Materials and Methods

The study was based on cross-sectional research design and quantitative data were obtained from parents with under 12 years old children attending who attended selected Health Centers, namely Masaka and Kabuga Kicukiro and Gikondo in Kicukiro District, Rwanda. A sample size of 384 respondents was obtained using Fisher formula and convenience sampling technique was used. A structured questionnaire was used for data collection; It was initially written in English and then translated into Kinyarwanda in order to facilitate better understanding and easy use by respondents.

Data Analysis was performed using SPSS software version 21, using descriptive statistics and presented as associated frequencies, mean and standard deviation. Chi-square test was used to test for association between variables and regression analysis was used to test the strengths of association between dependent and independent variables which were previously identified by Chi-square test. The level of significance (α) was set at 0.05 for all statistical tests and data were presented using tables and figures. For ethical aspects, researchers obtained approval letters from Mount Kenya University and from each of selected Health Centers as a permission for data collection and researchers received signed consent from each participant before participating in the study.

Results

Socio-demographic data presented in the (Table 1) were obtained from 384 respondents who were reached and completed research questionnaires.

Table 1: Socio-Demographic Characteristics of Respondents.




  
    Variables
        
    Frequency (n=384)
    Percent (%)
  
  
    Gender of respondents
    Male 
    44 
    11.5 
  
  
    Female
    340
    88.5
  
  
    Age group of respondents in years
    <25 
    83
    21.6
  
  
    25-34 
    152 
    39.6 
  
  
    35-44
    132
    34.4
  
  
    45    and above
    17
    4.4
  
  
    Marital Status of Respondents
    Single 
    15 
    3.9 
  
  
    Married    or cohabiting
    313 
    81.5 
  
  
    Divorced    or Separated or Widow (er) 
    56 
    14.6 
  
  
    Educational attainment
    No    formal education 
    9 
    2.3 
  
  
    Primary 
    166 
    43.0 
  
  
    Secondary 
    163 
    42.7 
  
  
    Higher education
    47 
    12.0 
  
  
    Employment status of respondents 
    Employed
    124
    32.3
  
  
    Not    employed 
    260
    67.7
  
  
    Economic    status (Ubudehe categories)
    Ubudehe    Category 1 
    53
    13.8
  
  
    Ubudehe    Category 2 
    219
    57.0
  
  
    Ubudehe    category 3 or 4 
    112
    29.2
  
  
    Health    Insurance of respondents
    None
    10
    2.6
  
  
    Mutuelle    de Santé 
    301
    78.4
  
  
    Rwanda    Social Security Board (RSSB) 
    50 
    13.0 
  
  
    Other    HI
    23
    6.0
  
  
    Number    of children 
    1    child
    159
    41.4 
  
  
    2    to 4 children
    192
    50.0
  
  
    5    or more children 
    33
    8.6 
  
  
    1    child
    159
    41.4 
  
  
    Source: Primary data (2022). Ubudehe Category 1: Very poor and    vulnerable citizens; Category 2: Citizens who were able to afford some form of rented or low-class owned    accommodation etc.; Category 3: Citizens who were gainfully employed or were even employers of labour; Category 4: for the richest people.    Source [23].



Table 1: Socio-Demographic Characteristics of Respondents.

Findings in (Table 1) indicated that majority of respondents were female (88.5%), 39.6% aged from 25 to 34 years old, 81.8% were married, 42.2% completed secondary education while only 12.2% of them completed university education. The majority, (67.7%) of respondents was not employed, more than half of them were in Rwandan economic category 2 (ubudehe category two). More than a three-quarter (78.4%) of respondents had Mutuelle de Santé (Community-Based Health Insurance) as Health Insurance and 50% of respondents had 2 to 4 children while minority (8.6%) had 5 or more children.

Parents’ Knowledge of Antibiotic use for Childhood URTIs

The first objective of the current study was to determine parents’ knowledge regarding antibiotics use for childhood URTIs and the researcher explored this by asking 8 knowledge-related questions as demonstrated in the (Table 2).

Table 2: Parents’ knowledge of antibiotic use for childhood URTIs.




  
    Variables 
    Yes 
    No 
    Don’t Know 
  
  
    Freq 
    % 
    Freq 
    % 
    Freq 
    % 
  
  
    Use of antibiotic for every feverish child
    220
    57.3
    98
    25.5
    66
    17.2
  
  
    Quick recovery when antibiotic is given for flu-like    symptoms
    262
    68.2
    80
    20.8
    42
    11
  
  
    Antibiotics should not be given for URTIs since most of    them are of viral origin and self-limited
    80
    20.8
    149
    38.8
    155
    40.4
  
  
    Antibiotic do not have any side effects
    109
    28.4
    120
    31.3
    155
    40.3
  
  
    Inappropriate use of antibiotic reduces their efficacy and    leads to AMR
    159
    41.4
    79
    20.6
    146
    38.0
  
  
    Scientists can produce new antibiotics for resistant    bacteria
    195
    50.8
    50
    13.0
    139
    36.2
  
  
    Antibiotics can cause secondary infection after killing    normal flora
    98
    25.5
    87
    22.7
    199
    51.8
  
  
    Many infections are becoming resistant to anti-biotherapy
    118
    30.7
    54
    14.1
    212
    55.2
  
  
    Source: primary data (2022)



Table 2: Parents’ knowledge of antibiotic use for childhood URTIs.

In the Table 2, findings demonstrated that 57.3% of parents incorrectly confirmed that every feverish child should be treated by antibiotics, 68.2% falsely confirmed that there is a quick recovery when antibiotic is give for URTIs with flu-like symptoms. Only 80 (20.8%) of parents correctly confirmed that antibiotics should not be given for URTIs since most of them are of viral origin and selflimited, 31.3% of them were aware of side effects that can be caused by antibiotics while 40.4% of them do not know whether or not side effects can occur during antibiotic therapy, and 74.5% of them don’t know that antibiotic can cause secondary infection after killing normal flora.

Parental Level Knowledge of Antibiotic Use

Total questions for knowledge evaluation were 8 and parents who correctly answered to 6 or more questions out of 8 scored at ≥70% and were qualified as having ‘high level of knowledge of antibiotics. Parents who correctly answered to 4-5 questions out of 8 scored at 50- 69% and were qualified as having with ‘moderate level of knowledge of antibiotics while those who correctly answered to less than 4 questions out of 8 got <50% scores and were qualified as having ‘low level of knowledge of antibiotics.

The (Figure 1) indicates that 40.4% of parents have low level of knowledge of antibiotic use, 36.5% of them have moderate and only 23.2% of them have high level of knowledge of AB use.

Figure 1: Parental level of knowledge antibiotics use.

    
    
    Figure 1: Parental level of knowledge antibiotics use.

Parents’ Attitudes Towards Antibiotic Use for Childhood URTIs

The second objective was to determine parents’ attitudes towards antibiotics use for childhood URTIs and the researcher explored this by asking 8 attitude-related questions as demonstrated in the (Table 3).

Table 3: Parents’ attitudes towards antibiotic use for childhood URTIs.




  
    Statements 
    SA

      N (%) 
    A

      N (%) 
    U

      N (%) 
    D

      N (%) 
    SD

      N (%) 
    Mean 
    StD 
  
  
    Request antibiotics if    suffers from frequent URTIs like flu or cold 
    37(9.6) 
    178(46.4) 
    70(18.2) 
    59(15.4) 
    40(10.4) 
    2.29 
    1.15 
  
  
    Preferring expensive    antibiotics to accelerate the recovery from URTIs like flu or cold 
    45(11.7) 
    172(44.8) 
    80(20.8) 
    56(14.6) 
    31(8.1) 
    2.38 
    1.12 
  
  
    Buying antibiotics in    private pharmacy when the physician refuses to prescribe them 
    47(12.2) 
    160(41.7) 
    31(8.1) 
    67(17.4) 
    79(20.6) 
    2.08 
    1.38 
  
  
    Change pediatrician and    look for another one who can prescribe antibiotics for URTIs like flu or cold 
    65(16.9) 
    117(30.5) 
    41(10.7) 
    105(27.3) 
    56(14.6) 
    2.08 
    1.36 
  
  
    I feel unsatisfied with a    Doctor’s visit if no antibiotics prescribed for my child’s URTIs 
    86(22.4) 
    118(30.7) 
    53(13.8) 
    80(20.8) 
    47(12.3) 
    2.30 
    1.34 
  
  
    Prefer giving antibiotics    for child's flu or cold to prevent getting more serious illness 
    89(23.2)
    189(49.2) 
    39(10.2) 
    33(8.6) 
    34(8.8) 
    2.69 
    1.18 
  
  
    Prefer giving antibiotics    that may not be needed than waiting for recovery without them 
    69(18.0) 
    117(30.5) 
    61(15.9) 
    96(25.0) 
    41(10.6) 
    2.20 
    1.29 
  
  
    Antibiotics are safe,    hence they can be commonly used for childhood URTIs 
    106(27.6) 
    97(25.3) 
    66(17.2) 
    65(16.9) 
    50(13.0) 
    2.38 
    1.38 
  
  
    Source:    Primary data (2022), SD: Strongly Disagree, D: Disagree, U: Undecided, A: Agree, SA: Strongly    Agree, StD: Standard Deviation



Table 3: Parents’ attitudes towards antibiotic use for childhood URTIs.

From the Table 3, it was revealed that 56% of respondents would like to request antibiotics if their child suffers from frequent URTIs, the same number (56.6%) agreed that they prefer expensive antibiotics to accelerate the recovery while 53.9% confirmed that they prefer buying antibiotics in private pharmacy when the physician refuses to prescribe them. On the other hand, 56.2% confirmed that they would feel unsatisfied with doctors’ visits if no antibiotics prescribed for their children’s URTIs while they were expecting to receive them. A big number (73.4%) of respondents expressed that they prefer giving antibiotics for child’s flu or cold to prevent getting more serious illness.

Parental Level of Attitude towards Antibiotic Use

The maximum total score was 40 (100%), and minimum total score was 8 (20%). Parents with positive attitude were those who responded to all questions and scored at least at 28 (≥70%) and above; while those with negative attitude got 27 score or below (<70%).

The (Figure 2) demonstrates that more than half, (59.9%) of parents have negative attitudes towards antibiotic use while 40.1% of them have positive attitude.

Figure 2: Level of parental attitude towards antibiotics use.

    
    
    Figure 2: Level of parental attitude towards antibiotics use.

Parental Practices regarding Antibiotic Utilization for Childhood URTIs

The third objective was to determine parents’ practices towards antibiotics use for childhood URTIs and the researcher explored this by asking 7 practice-related questions as demonstrated in the (Table 4).

Table 4: Parental practices regarding antibiotic utilization for childhood URTIs.




  
    Statements
    Yes
    No
  
  
    N (%)
    N (%)
  
  
    To get a quick recovery of my child, I always give more    antibiotics than the clinicians recommended.
    173(45.1)
    211(54.9)
  
  
    I usually do not check expiry date of antibiotic before    giving it to my child
    233(39.3)
    151(60.7)
  
  
    I will stop giving antibiotics if I think my child is    starting to recover
    199(51.8)
    185(48.2)
  
  
    I reuse the remaining antibiotics when similar symptoms    of  URTIs are present (like Sneezing,    runny nose, cough, sore throat)
    173(45.1)
    211(54.9)
  
  
    I gave antibiotics without a prescription to my child who    had a high fever a few days in the past
    168(43.8)
    216(56.2)
  
  
    I usually store leftover antibiotics at home for a long    period in case they may be needed in the future.
    172(44.8)
    212(55.2)
  
  
    I use antibiotics more frequently if they are more widely    available and less expensive
    220(57.3)
    164(42.7)
  
  
    Source: primary data (2022)



Table 4: Parental practices regarding antibiotic utilization for childhood URTIs.

Based on the Table 4, 60.7% of respondents confirmed that they do not usually check expiry date of antibiotic before giving it to their children, 51.8% would stop giving antibiotics if they think their children start recovering from disease while 45.1% of them confirmed the reuse of remaining antibiotics when similar flu-like symptoms of URTIs are present among family members. Almost a half (44.8%) confirmed that they usually store leftover antibiotics at home for a long period in case they may be needed in the future while 57.3% confirmed that they antibiotics more frequently if they are more widely available and less expensive.

Parental Level of Practice regarding Antibiotic Use

Parents with good practice were those who responded to all questions and scored at least at 5 (≥70%), corresponding to at least 5 out 7 possible appropriate responses; while those with poor practice got less than 5 score (<70%), corresponding to less than 5 out 7 possible appropriate responses.

The (Figure 3) demonstrates that a majority (62%) of respondents scored less than 70% of desired responses on practice towards AB use and was classified as demonstrating poor practice. On the other hand, 38% of respondents scored from 70% and above of desired responses and were classified as demonstrating good practice.

Figure 3: Level of parental practices towards antibiotics use.

    
    
    Figure 3: Level of parental practices towards antibiotics use.

From the table 4.8, it was revealed that married or cohabiting parents with more than one child (p<0.026) parents belonging to ubudehe category 2 and above (p<0.001), employed parents (p<0.001) with secondary and university educational (p<0.001),parents with RSSB (RAMA) as HI (p<0.001),and parents with moderate and high level of knowledge of antibiotics (p<0.001), parents with positive attitude (p<0.0001) had significantly good practice towards antibiotics than their corresponding counterparts. However, the gender of the parents, age of parents did not have an effect on the level of parental practice or use of antibiotics.

Multivariate Analysis for Factors Aassociated with Aantibiotic Use for Childhood URTIs

Researchers also wanted to analyse the identified association between variables using logistic regression with (AOR, 95% CI and p-value) as showed in (Table 5).

Table 5: Factors associated with practice of antibiotic use for childhood URTIs.




  
    Variables
    Level of parental    practices
    p-value
  
  
    Good, N (%)
    Poor, N (%)
  
  
    Gender
    Male
    19(4.9)
    25(6.5)
     
  
  
    Female
    127(33.1)
    213(55.5)
    0.455
  
  
    Marital status
    Single
    4(1.0)
    11(2.9)
     
  
  
    Married or    cohabiting
    114(29.7)
    199(51.8)
     
  
  
    Divorced or    Separated or Widow (er)
    28(7.3)
    28(7.3)
    0.026
  
  
    Number of children 
    1    child
    77(20.1)
    82(21.4)
     
  
  
    2-4    children
    61(15.9)
    131(34.1)
     
  
  
    5    or more children
    25(6.5)
    8(2.1)
    <0.001
  
  
    Ubudehe categories
    Categories    1
    13(3.4)
    40(10.4)
     
  
  
    Categories 2
    95(24.7)
    168(43.8)
     
  
  
    Categories 3 &4
    38(9.9)
    30(7.8)
     
  
  
    Employment status 
    Employed
    87(22.7)
    37(9.6)
     
  
  
    Not    employed
    72(18.8)
    188(49.0)
    <0.001
  
  
    Educational level
    Primary    level
    17(4.4)
    157(40.8)
     
  
  
    Secondary    level
    103(26.8)
    59(15.4)
     
  
  
    Higher    education
    26(6.8)
    22(5.7)
     
  
  
    Health Insurance 
    None 
    2(0.5)
    7(1.8)
    <0.001
  
  
    Mutuelle    de santé
    69(18)
    181(47.1)
     
  
  
    RSSB    (RAMA)
    47(12.2)
    38(9.9)
     
  
  
    Other
    28(7.3)
    12(3.1)
    <0.001
  
  
    Level of Knowledge
    Low    level
    32(8.3)
    143(37.2)
     
  
  
    Moderate    level
    73(19.0)
    54(14.1)
     
  
  
    High    level
    77(20.1)
    5(1.3)
     
  
  
    Attitude 
    Negative 
    2 (0.5) 
    228 (59.4) 
    <0.001
  
  
    Positive 
    144 (37.5) 
    10 (2.6) 
     
  
  
    p<0.05 is statistically significant



Table 5: Factors associated with practice of antibiotic use for childhood URTIs.

Table 6: Multivariate analysis for factors associated with antibiotic use for childhood URTIs.




  
    Variables
     
    AOR
    95% CI
    p-value
  
  
    Marital status
    Married    or Cohabiting
    Reference
     
     
  
  
    Divorced    or separated
    1.2
    0.642-1.745
    0.125
  
  
    Number of children
    Widow    (er)
    0.82
    0.245-1.445
    0.253
  
  
    1    child
    Reference
     
     
  
  
    2-4    children
    0.285
    0.090-0.906
    0.083
  
  
    5 or    more children
    3.683
    1.062-12.771
    0.046
  
  
    Employment status
    Employed
    5.464
    1.870-15.969
    0.002
  
  
    Not    employed
    0.271
    0.060-1.212 
    0.088
  
  
    Ubudehe category
    Ubudehe    category 1
    Reference
     
     
  
  
    Ubudehe    category 2
    0.44
    0.11-1.66
    0.082
  
  
    Ubudehe    category 3 or 4
    2.840 
    1.237-6.523
    0.039
  
  
    Educational level
    No formal    education
    Reference
     
     
  
  
    Primary    level
    0.521
    0.36-0.87
    0.999
  
  
    Secondary    level
    0.855
    0.65-1.25
    0.030
  
  
    Higher    education
    4.371
    1.725-11.077
    0.002
  
  
    Health insurance
    None
    Reference
     
     
  
  
    Mutuelle    de Santé
    0.610
    0.08-1.84
    0.965
  
  
    RSSB(RAMA)
    0.669
    0.278-1.611
    0.370
  
  
    Other    private HI
    0.553
    0.281-1.085
    0.085
  
  
    Level of knowledge
    Low    knowledge
    Reference
     
     
  
  
    Moderate    knowledge
    1.272 
    0.313-5.163 
    0.736 
  
  
    High    knowledge
    13.371
    3.604-49.617
    <0.001
  
  
    Level of attitude
    Negative
    Reference
     
     
  
  
    Positive
    0.309
    0.96-0.489
    <0.001
  
  
    Field    data. AOR:Adjusted Old Ratio;  CI: Confidence Interval; p-value:    probability value; p=<0.05 is statistically    significant.



Table 6: Multivariate analysis for factors associated with antibiotic use for childhood URTIs.

Findings in the Table 5 indicate that there is a strong association between the fact of having 5 and more children where AOR=3.683, 95% CI=[1.062-12.771], p<0.046; being employed, where AOR=5.464, 95% CI=[1.870-15.969], p<0.002; being in ubudehe category 3 and 4 where AOR=2.840, 95% CI=[1.237-6.523], p<0.039, increased educational level (secondary and university) where AOR=0.855, 95% CI=[0.65-1.25], p<0.030 and AOR=4.371, 95% CI=[1.725- 11.077], p<0.002 respectively with good parental practices regarding antibiotics utilization. Parents’ high level of knowledge of antibiotics and positive attitude towards antibiotics had also statistically significant association with good practices on antibiotics where AOR=13.371, 95% CI=[3.604-49.617], p<0.001, and ARO=0.309, 95% CI=[0.96-0.489], p<0.001 respectively.

Discussions

The aim of the study was to assess parental knowledge, attitudes, and practices on antibiotic use for children’ Upper Respiratory Tract Infections URTIs) in Kicukiro District in Rwanda. Regarding knowledge of antibiotics, our study revealed that majority (40.4%) of parents had low level of knowledge of antibiotics use for childhood URTIs. Highlights on low levels were observed on not knowing indications of antibiotics, awareness of potential side effects and AMR concern. Many similar studies discovered the same concern especially in LMICs. For instance, our study revealed that more than three-quarter of parents don’t know that antibiotics should not be given for all URTIs since most of them are of viral origin and selflimited. Similarly, a study conducted Nigeria revealed the same poor knowledge where only about 1 out 3 parents knew that antibiotics could not cure diseases caused by viruses [24]. Our findings are slightly less than what was found in Ethiopian (83%) [25], however, it was higher than findings from Peru (50.2%) and of Namibian (64%) [26,27].

In the current study, almost a three-quarter of parents were not aware of side effects that can be caused by antibiotic therapy. Not knowing potential side effects and other consequences of inappropriate use of antibiotics implies that parents can abuse antibiotics believing that there will be the replacement of ineffective antibiotics resulting from AMR. This also implies the need of health education on the usage of antibiotics among children and parental awareness on negative impact of their irrational use. Evidence from literature showed that antibiotics can produce side effects like gastrointestinal symptoms linked to gut flora disruption [28].

Regarding parental attitudes, our study indicated that slightly a half (59.9%) of parents had negative attitude towards antibiotics use among children suffering URTIs. The misconception were linked to poor knowledge of antibiotics where more than half would request antibiotics for their children’s frequent URTIs with flu-like symptoms, (56.2%) would feel unsatisfied with doctors’ visits if no antibiotics prescribed while 73.4% would prefer giving antibiotics for child’s flu or cold to prevent getting more serious illness. Likewise, the study conducted in Nepal indicated that 88.2% of parents would change a physician if they were not prescribed an antibiotic whenever they were expecting to receive them from their physicians [29]. Similarly, according to [24], 92.9% of Nigerian parents had directly requested ABs and 84.3% of them agreed to have obtained them from physicians. Parent’ attitudes and expectations can result in pressure on clinicians pushing them to prescribe unnecessary antimicrobial or leading cause of self-medication hence one of leading causes of antibiotic overuse worldwide [30]. Experts have proposed for simple education on antibiotic stewardship practices especially in resourcelimited settings where misuse and overuse of antibiotics need to be reduced [24].

Regarding parental practices, our study revealed that the majority (62%) of parents have poor level practices regarding antibiotic use for childhood URTIs. Stopping antibiotics, using leftover and keeping antibiotics for long time for the future use were highlighted as indicators of parental poor practices. More than half of parents claimed that they would stop giving antibiotics if they think that their children start recovering from diseases, almost a half of them confirmed that they reuse the remaining antibiotics when similar flu-like symptoms of URTIs are present while 43.8% have given antibiotics to their children without medical prescription in the past few days prior to our study. Likewise, in the same vein, only 66.4% Ethiopian parents claimed to have completed the regimen of antibiotics and those parents claimed that they would give the leftover antibacterial, sharing them with others, and only bring their children to clinicians if there was no improvement [25]. On the other hand, 27.6% of Palestinian parents reused the leftover and shared antibiotics between their children, while 15% of Malaysian parents reused leftovers and 24% shared antibiotics [31]. According to the World Health Organization, the prevalence of self-medication varies between 2 and 20 per 100 respondents across nations in the European Union [9].

For factors associated with parental practices on antibiotic use, the current study discovered that having 5 and more children with AOR=3.683, 95% CI=[1.062-12.771], p<0.046; being employed with AOR=5.464, 95% CI=[1.870-15.969], p<0.002; advanced economic position (ubudehe category 3 and 4) with AOR=2.840, 95% CI=[1.237-6.523], p<0.039, increased educational level (secondary and university) where AOR=0.855, 95% CI=[0.65-1.25], p<0.030 and AOR=4.371, 95% CI=[1.725-11.077], p<0.002 respectively were strongly associated with good practices regarding antibiotics utilization. In addition, parents’ high level of knowledge of antibiotics and positive attitude had also statistically significant association with good practices on antibiotics with AOR=13.371, 95% CI=[3.604- 49.617], p<0.001, and ARO=0.309, 95% CI=[0.96-0.489], p<0.001 respectively. Similarly, evidence from literature, age, educational status, and socio-economic positions, have been hypothesized to determine the type of antibacterial awareness and usage [20]. Furthermore, it was discovered that there is a correlation between knowledge and attitudes and practices regarding antibiotics use [20,21], therefore, parental education should be a basic step towards better attitudes and practices [32].

Conclusion

Based on the study findings, it can be concluded that majority of parents have low level of knowledge of antibiotics, negative attitudes and poor practices on antibiotics use for childhood URTIs in Kicukiro District, Rwanda. Factors affecting parental practices regarding antibiotics use include number of children, education level, employment status, employment status and economic status. The lack of knowledge and negative attitudes are leading causes of unjustified request of antibiotics, use of leftover ABs, self-medication and interrupting the course of antibiotics among children suffering from URTIs which reflect the connection between knowledge, attitude and practices. Educational interventions for parents would reduce unnecessary antibiotic use and resistance by raising awareness on indications of antibiotics, their side effects and consequences of their inappropriate utilization which include AMR.

Recommendations

The study recommended that educational interventions for parents are needed to reduce antibiotics misuse by raising awareness on indications of antibiotics, their side effects and consequences of their inappropriate use including antimicrobial resistance. Findings of this study are important to guide policy formulation, that can limit the acquisition of antibiotics without prescription in our setting, planning and implementation of antibiotic use and AMR related programs, especially those targeting community-based awareness, education and sensitization. Clinicians should encourage parents to not use antibiotics without prescription in their children and warn them about potential side-effects and the emergence of antibiotic resistance. The priority target for health education should be young parents, parents with low level of education and parents in lower economic class among others.

Acknowledgment

The authors highly appreciated parents who participated in this study and heads of selected HCs for authorizing and facilitating a smooth data collection.

Limitations of the Study

This study can be generalized, as it was a cross-sectional study conducted only in Kicukiro District, one of 30 Rwandan Districts.

Authors Contributions

NM conceptualized the study, HM supervised the study. NM performed data collection, data entry, and analysis. All authors contributed to the development, proofreading and approval of the final version of the manuscript.

References

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Citation: Nshimiyimana M, Habtu FM, Manishimwe F, Ndayisenga J and Murekatete A. Parental Knowledge, Attitudes and Practices on Antibiotics Use for Childhood Upper Respiratory Tract Infections in Kicukiro District, Rwanda. Austin Public Health. 2022; 6(1): 1018.

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