Let's Talk About Antibiotics: a randomised trial of two interventions to reduce antibiotic misuse.

BACKGROUND: Children with acute respiratory tract infections (ARTIs) receive ≈11.4 million unnecessary antibiotic prescriptions annually. A noted contributor is inadequate parent-clinician communication, however, efforts to reduce overprescribing have only indirectly targeted communication or been impractical. OBJECTIVES: Compare two feasible (higher vs lower intensity) interventions for enhancing parent-clinician communication on the rate of inappropriate antibiotic prescribing. DESIGN: Multisite, parallel group, cluster randomised comparative effectiveness trial. Data collected between March 2017 and March 2019. SETTING: Academic and private practice outpatient clinics. PARTICIPANTS: Clinicians (n=41, 85% of eligible approached) and 1599 parent-child dyads (ages 1-5 years with ARTI symptoms, 71% of eligible approached). INTERVENTIONS: All clinicians received 20 min ARTI diagnosis and treatment education. Higher intensity clinicians received an additional 50 min communication skills training. All parents viewed a 90 second antibiotic education video. MAIN OUTCOMES AND MEASURES: Inappropriate antibiotic treatment was assessed via blinded medical record review by study clinicians and a priori defined as prescriptions for the wrong diagnosis or use of the wrong agent. Secondary outcomes were revisits, adverse drug reactions (both assessed 2 weeks after the visit) and parent ratings of provider communication, shared decision-making and visit satisfaction (assessed at end of the visit on Likert-type scales). RESULTS: Most clinicians completed the study (n=38, 93%), were doctors (n=25, 66%), female (n=30, 78%) and averaged 8 years in practice. All parent-child dyad provided data for the main outcome (n=855 (54%) male, n=1043 (53%) <2 years). Inappropriate antibiotic prescribing was similar among patients who consulted with a higher intensity (54/696, 7.8%) versus a lower intensity (85/904, 9.4%) clinician. A generalised linear mixed effect regression model (adjusted for the two-stage nested design, clinician type, clinic setting and clinician experience) revealed that the odds of receiving inappropriate antibiotic treatment did not significantly vary by group (AOR 0.99, 95% CI: 0.52 to 1.89, p=0.98). Secondary outcomes of revisits and adverse reactions did not vary between arms, and parent ratings of satisfaction with quality of parent-provider communication (5/5), shared decision making (9/10) and visit satisfaction (5/5) were similarly high in both arms. CONCLUSIONS AND RELEVANCE: Rate of inappropriate prescribing was low in both arms. Clinician education coupled with parent education may be sufficient to yield low inappropriate antibiotic prescribing rates. The absence of a significant difference between groups indicates that communication principles previously thought to drive inappropriate prescribing may need to be re-examined or may not have as much of an impact in practices where prescribing has improved in recent years. TRIAL REGISTRATION NUMBER: NCT03037112.

Designing an Adaptive Adolescent Physical Activity and Nutrition Intervention for COVID-19-Related Health Challenges: Formative Research Study.

BACKGROUND: With rates of childhood obesity continually increasing, effective physical activity and nutrition interventions are needed. Formative research is used to tailor interventions to different cultural and geographic contexts and can be vital in adapting intervention strategies in the face of significant disruptive circumstances (like COVID-19). OBJECTIVE: We conducted formative research via in-person and web-based focus groups among middle schoolers and parents to better understand the facilitators and barriers to physical activity and fruit and vegetable consumption and to inform the design of a large intervention for a low-income, urban setting in the US Midwest. METHODS: We conducted 2 phases of qualitative focus groups with parents (n=20) and 6th-9th grade middle schoolers (n=23). Phase 1 was conducted prior to the COVID-19 pandemic in late 2019, and phase 2 was conducted during the COVID-19 pandemic in the summer of 2020. Focus groups were transcribed and thematically coded using the Dedoose software. RESULTS: The main facilitators of physical activity prior to the pandemic included the opportunity to have fun, peer influence, competition (for some), and incentives, while the main barriers to physical activity were time constraints and social discomfort. The main facilitators of eating fruits and vegetables included parental influence, preparation technique, and convenience, while barriers included dislike of vegetables, time constraints, and preparation or freshness. During the pandemic, facilitators of physical activity remained the same, while additional barriers to physical activity such as lack of motivation and limited time spent outside of the home were reported. For fruit and vegetable consumption, both facilitators and barriers remained the same for both time periods. Additionally, for some participants, the pandemic offered an opportunity to offer more fruits and vegetables to middle schoolers throughout the day. CONCLUSIONS: Some themes identified were common to those reported in previous studies, such as peer influence on physical activity and parental influence on fruit and vegetable consumption. Novel themes such as lack of motivation to be active and limited time outside the home helped improve intervention adaptation, specifically during the COVID-19 pandemic. The continuity of formative research after a major unexpected change in the intervention context can be essential in targeting areas of an intervention that can be retained and those that need to be adjusted.