Construction of a Science Popularization Framework for Antimicrobial Use in Children at Hospital Discharge

MA Linling¹, WANG Qiqiong²,³, NI Xiaofeng²,³, SHI Yuqing²,³, WEN Yan²,³, PAN Xiangcheng²,³*

¹West China School of Pharmacy, Sichuan University, Chengdu 610041, China
²Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu 610041, China
³Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu 610041, China

Corresponding author: PAN Xiangcheng, Pharmacist; E-mail: xiangchengp@gmail.com

Abstract

Background The irrational use of antimicrobial agents by parents after their children's hospital discharge represents a significant problem. Providing correct guidance and science education on antimicrobial use to children and their parents constitutes an important measure to improve parental awareness and promote rational use. However, no standardized science popularization framework currently exists to guide the development of educational resources on antimicrobial use in children.

Objective To develop a science popularization framework for antimicrobial use in children at hospital discharge, providing a reference for standardized development of educational resources and guiding parents in rational antimicrobial use post-discharge.

Methods A systematic scoping review of literature on science education regarding pediatric antimicrobial use at discharge was conducted from December 2024 to February 2025, with content integrated using thematic synthesis. Based on these results, a preliminary questionnaire on the science popularization framework was developed. Clinical experts specializing in pediatric infections, pediatric science education, and pediatric medication counseling were selected, and Delphi expert consultation was completed in March 2025 using the "Wenjuanxing" platform for questionnaire distribution and collection. Consensus was determined based on expert importance ratings (mean score ≥4 and coefficient of variation [CV] ≤25%) to finalize framework indicators.

Results The initial search yielded 7,886 articles, with 55 ultimately included after screening. Thematic synthesis identified 19 descriptive themes (secondary indicators) and 4 analytical themes (primary indicators). Of 35 questionnaires distributed, 21 were returned. Expert ratings of the 19 secondary and 4 primary indicators showed importance scores of 4–5 for all items, with CV ≤25% and intraclass correlation coefficient (ICC) = 0.52 (95%CI: 0.18–0.76, P=0.003), indicating good consensus. The final framework comprised 4 primary indicators (basic knowledge, medication methods, adverse reactions, and behavioral habits) and 19 secondary indicators (antibiotic definitions, classification, concept differentiation, disease awareness, etc.).

Conclusion The developed framework demonstrates high scientific validity and reliability, providing an important reference for creating educational resources and guiding parents in rational antimicrobial use for children at hospital discharge.

Keywords Anti-bacterial agents; Child; Patient discharge; Science popularization framework; Thematic synthesis; Delphi technique

Introduction

Children represent a high-risk population for infectious diseases, and antimicrobial agents are among the most commonly used medications in pediatrics. However, the widespread use of antimicrobials in children has led to prominent issues of irrational use. Multiple national surveys conducted in China from 2016–2019 revealed a severe situation of bacterial resistance in children closely related to antimicrobial overuse. Science education campaigns providing correct guidance to children and parents serve as crucial measures to improve awareness and promote rational antimicrobial use. The Chinese government attaches great importance to such education, as emphasized in the 2022 National Action Plan to Contain Antimicrobial Resistance (2022–2025) and the 2023 Notice on Strengthening Clinical Medication Management in Children, both of which highlight the need for science education in primary and secondary schools and enhanced monitoring of pediatric antimicrobial use.

Despite these policy initiatives, studies consistently demonstrate that parents have insufficient knowledge about antimicrobials, engaging in various irrational behaviors including self-medication, non-indicated use, non-adherence to medical advice, and disregard for bacterial resistance. Research investigating parental needs for antimicrobial education has identified nine key areas including basic knowledge, dosage, precautions, and indications. However, no standardized framework currently guides the development of educational resources. This study aims to establish science popularization standards to guide parents in rational antimicrobial use after discharge.

Methods

Literature Search and Screening

Inclusion Criteria Based on the PCC (Population, Concept, Context) principle: (1) Population: children, parents or guardians, and discharged patients; (2) Concept: science popularization standards or materials for pediatric antimicrobials, parental awareness and educational needs, and current status of irrational antimicrobial use after discharge; (3) Context: outpatient/emergency settings, post-discharge, community pharmacies, and home environments.

Exclusion Criteria: (1) Duplicate publications; (2) Studies with incomplete original data or questionnaire structures; (3) Unavailable full texts; (4) Conference papers and dissertations.

Search Strategy: Systematic searches were conducted in CNKI, Wanfang, VIP, SinoMed, PubMed, National Standard Information Public Service Platform, National Standards Library, CNKI Standards Database, International Organization for Standardization, American National Standards Institute, European Standards, and American Society of Health-system Pharmacists, with supplementary searches in Baidu and Bing. The timeframe spanned from database inception to August 2024. Chinese search terms included: antimicrobial agents, antibiotics, rational drug use, usage patterns, discharge, parents, children, science popularization, education, and knowledge-attitude-practice. English terms included: Anti-Bacterial Agents, Patient Discharge, Inappropriate Prescribing, Parents, Child, Health Education, and Popular Science.

Data Extraction and Integration: From December 2024 to February 2025, basic information was extracted from included studies (first author, publication year, country), context, research purpose, population characteristics (type, child age, parent age), survey methods, research content items, and influencing factors. Thematic synthesis using a "three-level interpretation" approach was employed. The DeepSeek web platform (https://chat.deepseek.com) was used to initially categorize extracted content items into themes, which two researchers then independently classified and translated into descriptive themes (secondary indicators). These were further synthesized into analytical themes (primary indicators) through discussion and consensus.

Delphi Expert Consultation

Expert Selection: Experts from pediatric departments in children's hospitals and general hospitals across eastern, central, and western China were selected based on: (1) Clinical work in pediatric infections, pediatric science education, or pediatric medication counseling; (2) Inclusion of physicians, nurses, and pharmacists.

Questionnaire Design: Based on the scoping review, a preliminary questionnaire was developed with three sections: (1) Expert basic information; (2) Expert ratings of primary indicators (4 items) for familiarity, importance, relevance, and judgment basis; (3) Expert ratings of secondary indicators (19 items) for the same dimensions. All ratings used a 5-point Likert scale.

Consultation Process and Consensus Criteria: In March 2025, questionnaires were distributed and collected via "Wenjuanxing." A modified Delphi method was employed. After the first round, items with mean importance scores ≥4 and CV ≤25% were considered to have reached consensus and excluded from further consultation. Items not meeting criteria were revised based on expert feedback and subjected to a second round. Persistent non-consensus items after two rounds were resolved through researcher discussion.

Statistical Analysis

Excel 365 and SPSS 25.0 were used for statistical analysis. Questionnaire response rate (R) indicated expert engagement (R ≥60% considered good). Importance scores were expressed as mean±SD, with scores ≥4 (out of 5) indicating high importance. ICC and CV evaluated consensus (ICC ≥0.60 or CV ≤25% indicating good consistency). Expert authority coefficient (Cr), determined by familiarity (Ca) and judgment basis (Cs), with Cr ≥0.70 indicating high authority. Cronbach's α evaluated reliability (≥0.80 considered good). Item-level content validity index (I-CVI) and scale-level CVI (S-CVI) evaluated validity, with I-CVI ≥0.78 and S-CVI ≥0.90 considered acceptable. Significance level was set at α=0.05.

Results

Literature Search Results

The initial search retrieved 7,886 articles. After removing duplicates (n=1,370), 6,516 remained. Title and abstract screening yielded 85 articles, and full-text review resulted in final inclusion of 55 articles [FIGURE:1]. Basic information on included studies is provided in Appendix Table 1 [TABLE:1].

Framework Development Through Thematic Synthesis

From the 55 included studies, 691 content items were extracted and synthesized into 19 descriptive themes (secondary indicators), which were further integrated into 4 analytical themes (primary indicators), forming the preliminary framework.

Expert Consultation Results

Response Rate: In the first Delphi round, 35 questionnaires were distributed and 21 returned (R=60%).

Expert Characteristics: The 21 responding experts came from children's hospitals and general hospitals across eastern China (Beijing Children's Hospital, Peking University Third Hospital), central China (Hunan Children's Hospital), and western China (West China Second University Hospital, West China Hospital, Kunming Children's Hospital, Qiandongnan Prefecture People's Hospital). Departments included pediatric infectious diseases, respiratory medicine, otolaryngology, neurology, emergency pediatrics, general pediatrics, and pharmacy departments. Detailed expert information is shown in Table 1 [TABLE:1].

Importance Ratings and Consensus: First-round expert ratings of the 19 secondary and 4 primary indicators showed importance scores of 4–5 for all items, with CV ≤25% and ICC=0.52 (95%CI: 0.18–0.76, P=0.003), indicating moderate agreement and consensus. No second round was needed. Detailed ratings and consistency measures are shown in Table 2 [TABLE:2].

Expert Authority: Expert authority coefficients (Cr) ranged from 0.8–1.0 for all indicators, demonstrating high authority. Familiarity (Ca) and judgment basis (Cs) scores are detailed in Table 2.

Questionnaire Reliability and Validity: Cronbach's α was 0.94, indicating excellent reliability. Two indicators (route of administration, medication tendency) had I-CVI <0.78, while all others exceeded 0.78, demonstrating good item-level content validity. S-CVI was 0.87, indicating acceptable overall content validity.

Final Framework: Based on the thematic synthesis and expert consultation, the final science popularization framework for pediatric antimicrobial use at discharge was established [FIGURE:2], comprising 4 primary indicators (basic knowledge, medication methods, adverse reactions, behavioral habits) and 19 secondary indicators (antibiotic definitions, classification, concept differentiation, disease awareness, etc.).

Discussion

Parents exhibit numerous misconceptions and irrational behaviors regarding antimicrobial use in children. Lack of professional knowledge leads to non-indicated use, unauthorized dosage adjustments, self-medication, and confusion about antimicrobial classification, mechanisms, or treatment principles for bacterial versus viral infections. These issues not only affect treatment efficacy but also contribute to adverse drug reactions and resistant strain transmission.

Science education represents a crucial strategy to improve parental antimicrobial use behaviors. The Outline for the Development of Chinese Children (2021–2030) emphasizes strengthening health knowledge dissemination and guiding guardians toward rational medication concepts. Systematic knowledge transmission through science popularization helps correct misconceptions and reduce antimicrobial misuse. Our framework covers four dimensions—basic knowledge, medication methods, adverse reactions, and behavioral habits—systematically addressing parental needs.

The basic knowledge dimension addresses common confusions (e.g., mixing "anti-inflammatory" with "anti-infective" concepts) and covers antibiotic definitions, classification, concept differentiation, and disease awareness to establish scientific understanding. The medication methods and adverse reactions dimensions address parents' primary concerns, detailing indications, dosage, drug interactions, timing of changes/discontinuation, and management of common adverse effects. The behavioral habits dimension targets post-discharge issues such as self-medication, pressuring clinicians for prescriptions, and improper storage, which increase unnecessary antimicrobial exposure and medical risks.

Clinical pharmacists play an irreplaceable role in pediatric antimicrobial education. Their pharmaceutical and medical expertise, disseminated through counseling, materials, and lectures, enhances parental understanding and promotes rational use. This process also advances pharmacists' professional capabilities and public recognition, ultimately optimizing therapeutic outcomes.

Limitations include: (1) Limited expert numbers may restrict comprehensiveness, with potential for "high agreement" bias due to similar professional backgrounds; future expansion of expert sources and parental surveys could enhance diversity. (2) Regional variations in culture, economy, and healthcare resources require further validation of the framework's applicability. (3) The framework lacks empirical effectiveness evaluation, necessitating future outcome studies. (4) Limited included literature and heterogeneity in sample sizes and methodologies prevented weighting of framework themes.

Conclusion

This study constructed a science popularization framework for pediatric antimicrobial use at discharge through literature synthesis and expert consultation. The framework includes 4 primary indicators and 19 secondary indicators, with all indicators receiving importance scores ≥4, CV ≤25%, and Cr >0.8, demonstrating high importance and scientific validity. The questionnaire showed excellent reliability (Cronbach's α=0.94) and acceptable validity (most I-CVI >0.78, S-CVI=0.87). This framework provides clear standards and practical guidance for healthcare institutions conducting science education activities and guiding parents in rational antimicrobial use.

Acknowledgments

We thank all experts who participated in the consultation and provided valuable suggestions for this study.

Author Contributions

MA Linling: study design, literature screening, systematic review, content integration, framework development, manuscript writing. WANG Qiqiong, NI Xiaofeng: protocol design, questionnaire development, expert liaison. SHI Yuqing, WEN Yan: questionnaire development, expert liaison. PAN Xiangcheng: overall planning, data analysis, manuscript writing, review and editing.

Conflict of Interest

The authors declare no conflict of interest.

MA Linling https://orcid.org/0009-0005-0094-2529
PAN Xiangcheng https://orcid.org/0000-0001-8499-6623

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Appendix

Appendix Table 1. Basic Information of Included Studies

Study Country Setting Descriptive Theme Categories* DAI Min [1] China Community A, C, D, E, J, L, M, N, P, Q LI Jing [2] China Community B, C, E, F, J, L, N, O, P, Q, R ZHANG Yunxia [3] China Hospital C, E, F, G, H, I, J, K, L, M, N, O, P, S LIU Cui [4] China Hospital B, C, E, F, G, H, J, K, L, R CHEN Siqi [5] China Community C, E, H, J, L, M, O, P, Q YU Shuo [6] China Community E, F, G, H, J, M, O, P, Q, R HAI Yaping [7] China Community E, C, F, G, H, I, J, K, L, M, N, O, P, Q, R, S LI Xinying [8] China School E, H, I, N, O, P, R CHEN Jijie [9] China Community F, G, J, K, N, Q, R YU Zhuibo [10] China Community B, E, G, H, M, P WANG Dafang [11] China Community C, E, H, J, L, M, O, P, Q PENG Dandan [12] China Community C, E, H, L, R ZHANG Ying [13] China Hospital C, D, E, G, H, I, J, K, M, O, R ZHANG Yufang [14] China Hospital D, E, F, H, J, M, O, P, Q, R GAO Jingrong [15] China Community E, G, H, N, O, P, Q, R WANG Jingxia [16] China Community A, N, Q, R YANG Hongmei [17] China Community C, D, N, P, R ZHANG Yi [18] China Community E, G, L, N TANG Li [19] China School B, E, F, H, I, J, M, N, O, R, S LUO Youhong [20] China Hospital M, P, Q LIU Meiling [21] China Community A, E, F, G, I, J, K, L, L, N, O, Q, R, S DING Lilu [22] China Community E, G, H, I, J, L, M, M, N, O, P LI Yueling [23] China Hospital D, E, F, I, J, L, M, N, O, P, Q, R, S CUI Feifei [24] China Hospital E, F, G, J, K, N, Q, R ALKHALDI [25] Jordan Community E, G, M, N, O, P, Q LECKY [26] UK School E, G, H, M, O, P, Q, R WANG Xiangjun [27] China Community C, E, M, N, O ZHANG Guoqing [28] China Hospital C, E, F, G, H, J, L, M, N, O, P, Q, R YU [29] China Community E, G, H, N, O, P, Q, R FRANCIS [30] UK Hospital C, E, H, J, L, L, O, P WANG Qiuliang [31] China Hospital A, E, G, M, N, O, P, Q ZENG Qiang [32] China Hospital C, E, F, G, H, J, L, L, O, P LIAO Riyan [33] China School A, D, E, N YANG Lin [34] China Community A, E, J, M WUN [35] Hong Kong Community D, E, M, N, O, P, R MAOR [36] Israel Community D, E, M PANAGAKOU [37] Greece Community D, E, M, N FAN Qin [38] China Community A, D, E, J, M, R YANG Rongfeng [39] China Community D, E, M, N SCHNELLINGER [40] USA Hospital D, E, I, M LI Bi'e [41] China Hospital A, D, E, N LIU Meiling [42] China Hospital A, D, E, J, M DONG Ya [43] China Hospital C, E ZONG Qing [44] China Hospital E, F, G, J, L, N HUANG [45] USA Community M, N, O, P CROFT [46] USA Community D, E, F, H, J, M, N, O, R, S CHO [47] Korea Community E, G, H, M, O, P, Q, R PARIMI [48] Trinidad Community E, G, H, N VINKER [49] Israel Community B, E, F, G, H, J, L, L, O BELONGIA [50] USA Community E, Q TREPKA [51] USA Community C, D, O, P, R BAUCHNER [52] USA Community E, G, L, M, N, O, P COLLETT [53] USA Community E, G, L, M, N, O, P, Q, R WANG [54] USA Hospital D, E, M TANG Li [19] China Hospital D, E, M, N LI Yueling [23] China Hospital D, J, M HU [55] Taiwan Hospital B, E, F, G, M

*Descriptive theme categories: A-Antibiotic definition, B-Antibiotic classification, C-Concept differentiation, D-Disease awareness, E-Indication, F-Dosage and frequency, G-Route of administration, H-Combination therapy, I-Timing of change, J-Timing of discontinuation, K-Dietary effects, L-Common adverse reactions and management, M-Other adverse reactions, N-Doctor-patient communication, O-Medication tendency, P-Self-medication, Q-Self-purchase, R-Drug storage, S-Reading drug instructions.