Parental perceptions and understanding of information provision, management options and factors influencing the decision-making process in the treatment of children with glue ear

Objectives Otitis media with effusion (OME) is a common cause of hearing loss and possible developmental delay in children, and there are a range of ‘preference sensitive’ treatment options. We aimed to evaluate the attitudes and beliefs of parents of affected children to treatment options including watchful-waiting, hearing aids, grommets, and, oral steroids with the intention of developing our understanding of decision-making and the factors influencing it, sources of parental information, and satisfaction with information provision. Design We recruited a convenience sample of twelve parents of eleven children with OME at a single ENT department of a teaching hospital into a qualitative research study. The children of the parents interviewed had already been recruited into the Oral Steroids for the Resolution of Otitis Media with effusion In Children (OSTRICH) study. Semi structured interviews were audio recorded, transcribed and then coded using an inductive, thematic approach. Results Parents were satisfied with the verbal provision of information during the treatment consultation, although many were keen to receive supplementary printed information. Discussion with family and friends helped the decision-making process, whereas insufficient information and a paternalistic approach were viewed as obstacles. Parents were particularly influenced by the following: the immediacy of the treatment option effect, perceived efficacy, perceived risks and adverse effects, social implications (especially with hearing aids) and past personal and informant experience. Conclusions Parents appreciate clinicians tailoring information provision to parents' information needs and preferred format. Clinicians should also elicit parental attitudes towards the different management options for OME and the factors influencing their decisions, in order to optimise shared-decision making and ultimately provide a better standard of clinical care

Trust, openness and continuity of care influence acceptance of antibiotics for children with respiratory tract infections: a four country qualitative study

Background. Clinician–parent interaction and health system influences on parental acceptance of prescribing decisions for children with respiratory tract infections (RTIs) may be important determinants of antibiotic use. Objective. To achieve a deeper understanding of parents’ acceptance, or otherwise, of clinicians’ antibiotic prescribing decisions for children with RTIs. Methods. Qualitative interviews with parents of child patients who had recently consulted in primary care with a RTI in four European countries, with a five-stage analytic framework approach (familiarization, developing a thematic framework from interview questions and emerging themes, indexing, charting and interpretation). Results. Fifty of 63 parents accepted clinicians’ management decisions, irrespective of antibiotic prescription. There were no notable differences between networks. Parents ascribed their acceptance to a trusting and open clinician–patient relationship, enhanced through continuity of care, in which parents felt able to express their views. There was a lack of congruence about antibiotics between parents and clinicians in 13 instances, mostly when parents disagreed about clinicians’ decision to prescribe (10 accounts) rather than objecting to withholding antibiotics (three accounts). All but one parent adhered to the prescribing decision, although some modified how the antibiotic was administered. Conclusions. Parents from contrasting countries indicated that continuity of care, open communication in consultations and clinician–patient trust was important in acceptance of management of RTI in their children and in motivating adherence. Interventions to promote appropriate antibiotic use in children should consider a focus on eliciting parents’ perspectives and promoting and building on continuity of care within a trusting clinician–patient relationship

Comparison of microbiological diagnosis of urinary tract infection in young children by routine health service laboratories and a research laboratory: Diagnostic cohort study

OBJECTIVES: To compare the validity of diagnosis of urinary tract infection (UTI) through urine culture between samples processed in routine health service laboratories and those processed in a research laboratory. POPULATION AND METHODS: We conducted a prospective diagnostic cohort study in 4808 acutely ill children aged <5 years attending UK primary health care. UTI, defined as pure/predominant growth ≥105 CFU/mL of a uropathogen (the reference standard), was diagnosed at routine health service laboratories and a central research laboratory by culture of urine samples. We calculated areas under the receiver-operator curve (AUC) for UTI predicted by pre-specified symptoms, signs and dipstick test results (the "index test"), separately according to whether samples were obtained by clean catch or nappy (diaper) pads. RESULTS: 251 (5.2%) and 88 (1.8%) children were classified as UTI positive by health service and research laboratories respectively. Agreement between laboratories was moderate (kappa = 0.36; 95% confidence interval [CI] 0.29, 0.43), and better for clean catch (0.54; 0.45, 0.63) than nappy pad samples (0.20; 0.12, 0.28). In clean catch samples, the AUC was lower for health service laboratories (AUC = 0.75; 95% CI 0.69, 0.80) than the research laboratory (0.86; 0.79, 0.92). Values of AUC were lower in nappy pad samples (0.65 [0.61, 0.70] and 0.79 [0.70, 0.88] for health service and research laboratory positivity, respectively) than clean catch samples. CONCLUSIONS: The agreement of microbiological diagnosis of UTI comparing routine health service laboratories with a research laboratory was moderate for clean catch samples and poor for nappy pad samples and reliability is lower for nappy pad than for clean catch samples. Positive results from the research laboratory appear more likely to reflect real UTIs than those from routine health service laboratories, many of which (particularly from nappy pad samples) could be due to contamination. Health service laboratories should consider adopting procedures used in the research laboratory for paediatric urine samples. Primary care clinicians should try to obtain clean catch samples, even in very young children

The 'maternal grimace' sign. A clue to the importance of the contextual diagnosis

Parents sometimes present illness in a child as an expression of their own distress, and patient-centered medicine attempts to address the underlying causes of problems by incorporating psychosocial factors in the diagnosis. However, in the real world of busy primary care, it is not always possible or appropriate to broaden every consultation, and the clinician may have to rely on certain clues that suggest the importance of exploring hidden reasons for consulting. Two cases are presented in which a mother's dramatic grimace during the gentle examination of a comfortable child alerted the clinician to parental anxiety disproportionate to the child's illness. Addressing parental anxiety proved fruitful. This "maternal grimace sign," pointing to the importance of the contextual diagnosis, underlines the usefulness of careful observation of all those involved in the consultation and may have implications for the way clinicians choose to position children and parents during physical examination

Late psychological sequelae of abortion: questions from a primary care perspective

Research strongly supports the view that pregnancy termination is seldom associated with adverse psychological sequelae in the short to medium term, but experience shows that there is a small group of women who experience long and intense suffering. This is a report of the cases of two women who presented with psychological problems associated with a termination 19 and 5 years earlie