International Journal of Pediatric Otorhinolaryngology (2005) 69, 49—56

www.elsevier.com/locate/ijporl

Comparison of caregiver otitis media risk factor

knowledge in suburban and urban primary
care environments$
Joseph E. Kerschnera,b,*, D. Richard Lindstroma,
Albert Pomeranzc, Robert Rohloffc

a
Children’s Hospital of Wisconsin, Department of Otolaryngology and Communication Sciences,
Medical College of Wisconsin, 9000 W. Wisconsin Avenue, Milwaukee, WI 53226, USA
b
Division of Pediatric Otolaryngology, Medical College of Wisconsin, Milwaukee, WI, USA
c
Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA

Received 28 April 2004; received in revised form 4 August 2004; accepted 6 August 2004

KEYWORDS Summary
Otitis media;
Risk factors; Objective: There are many risk factors for otitis media. Some of these, such as
Caregiver knowledge passive tobacco smoke exposure and childcare arrangements; have the potential to be
modified. The purpose of this study is to assess caregiver knowledge deficits about risk
factors associated with otitis media and their willingness to modify behaviors
associated with those risks.
Research design and methods: This study is a prospective survey study investigating
knowledge deficits of parents or guardians of children ages 6—36 months about the risk
factors of otitis media. The patients were consecutively drawn from a suburban and an
urban pediatric practice. Any difference in survey results between these two groups
was also assessed. Participants completed a survey of 21 questions with content
including demographic and OM risk factor data.
Results: A total of 401 caregivers completed surveys, with 213 from an urban
pediatric practice and 188 from a suburban practice. There was a significant differ-
ence in the ethnic distributions of the two populations. The suburban population had a
significantly greater family history of ear infections, number of ear infections in the
past 12 months, and number of previous ventilation tubes placed. The urban popula-
tion had a significantly greater number of smokers in the household and decreased
knowledge about day care as a risk for OM. The urban population’s question responses

$
Portions of this manuscript were presented at the Society for Ear, Nose and Throat Advances in Children (SENTAC) Annual Meeting,
New Orleans, LA, 31 October 2003.
* Corresponding author. Tel.: +1 414 266 6476; fax: +1 414 266 6989.
E-mail address: kersch@mcw.edu (J.E. Kerschner).

0165-5876/$ — see front matter # 2004 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijporl.2004.08.004
50 J.E. Kerschner et al.

suggested a greater willingness to change day care arrangements to reduce the risk of
otitis media.
Conclusions: Both populations demonstrated knowledge deficits regarding risk fac-
tors associated with OM and both populations exhibited willingness to modify beha-
viors to reduce risk. These findings demonstrate that there are opportunities for
improving education regarding OM risk factors and that this education could poten-
tially reduce risk for OM and in turn reduce the incidence of OM in children.
# 2004 Elsevier Ireland Ltd. All rights reserved.

1. Introduction Hospital of Wisconsin National Outcomes Research

Otitis media (OM) is the most common reason for a
child to see a physician for illness in the United
States and has an estimated annual cost of greater
than US$ 5 billion [1]. Many risk factors (RF) for OM
have been documented. Some are unalterable such
as family history, craniofacial abnormalities and
male gender. Others are potentially modifiable
including breast-feeding, tobacco exposure, child-
care arrangements, and immunizations. While these
RF have been well documented through numerous
studies [2—4], there has been limited study of how
well information regarding RF is communicated to
caregivers and what knowledge of these RF care-
givers retain. One strategy for reducing OM inci-
dence is to reduce RF associated with the disease
[5]. In order to accomplish this, there must first be a
good understanding of what the modifiable RF are by
caregivers, and also a willingness to modify behavior
to reduce those RF.
The purpose of this study was to assess caregiver
knowledge of OM RF and to assess our hypothesis
that there is a general knowledge deficit regarding
RF of OM by caregivers. We also assessed our hypoth-
esis that caregivers would also express some will-
ingness to change behavior if these changes resulted
in less risk for OM. We assessed caregiver knowledge
regarding RF and attitudes regarding behavior mod-
ification from two different practice settings to
determine if there was a difference between these
two settings. To answer these questions, a ques-
tionnaire was administered to caregivers at an urban
and a suburban pediatric practice.
Center and was reviewed and approved by the
Children’s Hospital of Wisconsin Institutional Review
Board. The survey items were chosen to assess
caregiver knowledge of known risk factors for OM.
Due to space and time limitations, an attempt was
not made to questions caregivers about every risk
factor previously described in association with otitis
media. The questionnaire assessed caregiver knowl-
edge of modifiable and non-modifiable RF for OM.
The questionnaire also included items assessing the
willingness of caregivers to modify their behavior in
order to reduce the risk of OM for their child.
Further assessment of willingness to modify beha-
vior was measured by including questions pertaining
to avoidance of surgical intervention through beha-
vior modification. In addition, questions concerning
antibiotic efficacy and vaccines were included to
assess overall knowledge about otitis media.
Results were compared for the urban population
and the suburban population. The urban practice
consists of general pediatricians with an academic
appointment to the Medical College of Wisconsin
and is a setting for medical student and pediatric
resident training. Patients seen in this setting are
generally cared for by a team of general pediatri-
cians, residents and medical students. The suburban
practice consists of a four person general pediatric
practice. These pediatricians have a clinical
appointment to the Medical College of Wisconsin
and outpatients seen in this setting are generally
cared for by the attending physician without resi-
dent or medical student involvement.

2.2. Patient recruitment and questionnaire

2. Methods
2.1. Study design
This study is a prospective, comparative survey
study investigating knowledge deficits of parents
or guardians of children ages 6—36 months about
risk factors for OM. The survey (Appendix A) was
designed with the assistance of the Children’s
development
The patients were consecutively drawn from a sub-
urban and an urban pediatric practice from April
2002 to September 2002. Caregivers were asked to
participate in the survey at the time of registering
for their child’s appointment. Caregivers (parents or
legal guardians) of children 6—36 months were eli-
gible to enroll in the study. The caregivers were not
required to have a child being seen for a problem
Caregiver otitis media risk factor knowledge 51

related to OM or a history of OM to enroll. Any
difference in survey results between these two
groups was also assessed. Participants completed
a survey of 21 questions with content including
demographic data of the caregiver’s child and OM
RF questions. Demographic data corresponding to
the caregivers completing the survey was not col-
lected.
2.3. Data analysis
Statistical analysis of survey results included
descriptive statistics, Levene’s test for equality of
variances, t-test for equality of means and Mann—
Whitney testing. Survey design and statistical ana-
lysis was done in consultation with the National
Outcomes Research Center at Children’s Hospital
of Wisconsin.
3. Results
3.1. Demographics
A total of 401 caregivers completed surveys with 213
from an urban pediatric practice and 188 from a
suburban practice. There was a significant differ-
ence in the ethnic distributions of the two patient
populations (Table 1). The suburban population was
overwhelmingly Caucasian, whereas the urban prac-
tice was primarily African American. The gender
distribution was similar for each location.
3.2. Risk factor exposure
cian’s office. There were no significant differences
between the suburban and urban groups regarding
day care use and previous discussion of RF at their
pediatrician’s office.
In comparing the two cohorts in regard to the RF,
the urban population had a significantly greater
number of smokers in the household (p < 0.0001).
The suburban population had a significantly greater
family history of ear infections (p < 0.0001), number
of ear infections in the past 12 months (p = 0.004),
and number of previous tympanostomy tubes placed
(p = 0.0003) (Table 2).
3.3. Knowledge of risk factors
There was no significant difference between cohorts
for knowledge about tobacco exposure, breast-
feeding or family history of OM as OM RF.
However, the urban population responses sug-
gested less knowledge about day care as a risk factor
for OM (p < 0.004), but greater knowledge about the
possibility of a vaccine to limit OM risk (p = 0.05).
The urban population responses to the question
regarding antibiotic efficacy also suggested less
knowledge regarding antibiotic resistance (p <
0.0001) (Table 3).
An overall assessment of caregiver knowledge of
risk factors suggested that the urban cohort had
significantly less knowledge of OM risk factors com-
pared with the suburban cohort (p = 0.0003).
The overall knowledge about OM RF were also
assessed within each cohort separately. Knowledge
about individual, modifiable risk factors was great-

The overall data for RF exposure revealed that Table 2 Risk factors
28.6% of caregivers noted smokers in the household. Urban Suburban
Caregivers (38.7%) utilize day care for their chil- (%) (%)
dren. Patients (56.1%) indicated that they had been Siblings with OM 18.5a 47.6a
educated regarding the RF for OM at their pediatri- Parent with OM history 7.2a 37.8a
Patient with history of 4.7a 15.5a
ventilation tubes
Table 1 Demographics Siblings with history of 14.1 10.2
ventilation tubes
Urban (%) Suburban (%) Smokers in household 43.4a 11.8a
Gender Patient in daycare 41.8 35.1
Female patients 52.7 45.7 Discussion of OM risk factors 53.4 59.0
Male patients 47.3 54.3 with doctor
Ethnicity/race OM episodes in past 12 months
African American 79.5a 0.0a 0 45.6 32.4
Caucasian 6.9a 95.9a 1—2 35.0 40.1
Hispanic 9.6 2.5 3—4 15.5 18.1
Native American 2.7 0.8 5—6 1.5 5.0
Asian 1.4 0.8 7 or more 2.4 4.4
a a
Indicates statistically significant difference between Indicates statistically significant difference between
populations. populations.
52 J.E. Kerschner et al.

Table 3 Knowledge of risk factors

Survey question Mean scoresa (five-point scale)
Urban Suburban
Contact with cigarette smoke increases OM risk 1.98 1.94
Breast-feeding decreases OM risk 2.17 2.08
Day care attendance increases OM risk 2.27b 1.91b
Family history of OM increases OM risk 2.43 2.58
There is a vaccine which decreases OM risk 2.76b 3.04b
Antibiotics are more effective than ever against OMc 4.00b 3.06b
a
Scale from 1 to 5 with 1 indicating strong agreement and 5 indicating strong disagreement.
b
Indicates statistically significant difference between populations.
c
Note: Analysis of scale was reversed for this question so that, similar to all other questions, a higher score correlated with a
greater knowledge deficit concerning risk factor association with otitis media.

est concerning the risk of tobacco exposure in 4. Discussion

the urban population. Compared to this understand-
ing of tobacco as a RF, there was a significantly
lower understanding of the risks associated with
daycare attendance (p = 0.001) and that there
was the potential for a vaccine to limit OM (p <
0.001). In the suburban population there was
equivalent understanding concerning the risk of
tobacco and daycare attendance but a significantly
lower understanding among suburban respondents
about the potential for a vaccine to limit OM
(p < 0.001).
3.4. Risk factor modification
The mean for all responses to the scaled questions
regarding behavior modification are listed in Table 4.
There was a significant difference between the
urban and suburban populations in their willingness
to change daycare arrangements to reduce OM risk or
the need for ventilation tubes (p = 0.012 and 0.024,
respectively), with the urban population more will-
ing to change. There were trends suggesting that the
suburban population would be more willing to quit
smoking to reduce OM risk or the need for ventilation
tubes.
Studies examining risk factors associated with OM
have demonstrated characteristics that are amen-
able to risk factor modification and those that are
intrinsic and cannot be modified [2—4]. Unalterable
RF include family history, gender, race and anatomic
characteristics [2—4]. Potentially modifiable RF
include tobacco exposure, childcare arrangements,
and breast-feeding [2—4]. Knowledge of these RF
among healthcare providers is well accepted, how-
ever, little has been done to study how well this
knowledge is passed on to caregivers of young chil-
dren. Even less has been written about the will-
ingness of caregivers to modify their behavior to
lessen their child’s risk of OM or sequelae associated
with OM.
There is only one previous large survey analysis in
the literature dealing with caregiver knowledge of
OM RF that was identifiable using a Medline search of
the English literature [6]. This study examined
maternal knowledge of OM RF in mothers of infants
9—15 months of age using a large cross-sectional
design. Results indicated that only 25% of caregivers
in a population-based sample had been educated as
to the RF of OM. Logistic regression revealed that an
infant’s OM history and Caucasian ethnicity were

Table 4 Behavior modification

Survey question Mean scoresa (five-point scale)
Urban Suburban
Willing to change smoking habits to reduce OM risk 1.62 1.35
Willing to change smoking habits to reduce need for ear tubes 1.53 1.19
Willing to change day care arrangements to reduce OM riskb 2.20b 2.62b
Willing to change day care arrangements to reduce need for ear tubesb 2.10b 2.42b
a
Scale from 1 to 5 with 1 indicating strong agreement and 5 indicating strong disagreement.
b
Indicates statistically significant difference between populations.
Caregiver otitis media risk factor knowledge
significantly associated with increased caregiver
knowledge regarding RF for OM.
In this current survey, caregivers reported more
widespread education about OM RF than the pre-
vious report. However, approximately 44% of care-
givers reported that they had not been educated
about OM RF by their primary care physician. This
represents an important segment of the population
with the potential for knowledge deficits. The
increased percentage of caregivers whom reported
receiving education regarding OM RF in this survey,
compared with the previous study, might represent
of number of factors. These include that older
children were included in this survey giving more
opportunity for education, or that more emphasis
has been placed on OM and OM education in the
survey sites assessed. This study did not find a
difference between the suburban or urban practices
regarding caregiver’s perceptions of OM risk factor
education being done by the primary care physician.
4.1. Demographics
Gender distribution of patients of caregivers was
similar for both cohorts in this study. The ethnic
background in the different cohorts revealed a sig-
nificant difference with more African American
patients in the urban practice and more Caucasian
patients in the suburban practice. Previous reports
have documented a difference in rates of OM based
on race and socioeconomic situation [3]. This survey
supports previous studies with a reported increased
incidence of OM and previous ear tube placement in
our suburban, primarily Caucasian, population.
Despite these differences in race and OM incidence
there was not a reported difference in education
regarding OM RF at these two sites.
4.2. Risk factor incidence and knowledge
Exposure to modifiable RF differed between urban
and suburban caregivers. Patients from an urban
population were more likely to be exposed to
tobacco smoke despite the fact that there was no
difference in the knowledge of tobacco as a risk
factor for OM. Day care usage was no different for
the two cohorts, but knowledge of day care usage as
a risk factor for OM was significantly greater in the
suburban cohort. Awareness of antibiotic resistance
as a potential contributing factor in OM was also
greater in the suburban cohort. The urban popula-
tion demonstrated increased knowledge about a
vaccine to potentially protect against OM.
For each separate, modifiable RF, in both popula-
tions there was a greater knowledge about the
association of tobacco exposure as a RF for OM than
53
there was about the potential to decrease OM with a
vaccine. In addition, the urban population had a
better understanding of the association of tobacco
and OM than daycare and OM. These findings would
suggest that educational materials and strategies
focused on these less well understood RF might
provide greater impact in RF modification.
The differences in understanding regarding the
RF associated with OM between the two sites existed
despite caregivers reporting similar levels of educa-
tion provided by healthcare professionals regarding
RF on their survey questions. There are several
possible explanations for the different level of
understanding regarding RF despite apparent equal
attempts at education. These include that neither
participating site employs standardized materials
for education regarding OM RF and that the quality
and scope of education might therefore vary
between patients. The increased incidence of OM
in the suburban cohort might also suggest that more
frequent or more in-depth discussions regarding OM
might have taken place with this group of patients.
Additional factors that could be important in leading
to these differences are the potential impact of
educational background, access to healthcare and
continuity of care provided to patients. These areas
of interest deserve further study.
4.3. Behavior modification
Perhaps the most salient finding in this study is that
as a raw score on a five-point scale, the willingness
to change behaviors regarding tobacco exposure and
childcare arrangements was very affirmative in both
the suburban and urban populations (Table 4). In all
cases, the willingness to modify behavior was even
more affirmative if this modification could be linked
to avoidance of surgery with placement of ventila-
tion tubes to treat the OM. This indicates a signifi-
cant willingness on the part of caregivers to modify
behaviors to lessen the risk of OM for their children.
These findings are important in that they suggest
that programs targeted at OM risk factor education
and linked with risk factor modification strategies
such as smoking cessation programs will find willing
participants and could have the potential to posi-
tively affect risk factor exposure of young children
and reduce OM incidence. The questions regarding
risk factor modification were only directed towards
caregivers whose children were exposed to the risk
in question, smokers and users of daycare, and
therefore this willingness to change behavior exists
in the populations at risk. It was beyond the scope of
this project to examine which type of educational
efforts might have the most impact on changing
behavior, but multiple avenues should be explored
54
in addition to education by physicians including
media campaigns and community efforts.
Caregivers from the urban cohort were signifi-
cantly more willing to consider changing childcare
arrangements to reduce OM risk for their children.
This difference from the suburban cohort existed
despite a greater understanding of the suburban
population regarding the association of daycare
and OM. As daycare is often considered the most
important risk factor associated with OM these find-
ings warrant further investigation.
4.4. Potential study weaknesses
This study also did not attempt to standardize
patient populations in terms of OM incidence,
patient age or other medical conditions. As with
all survey instruments this study relied on caregiver
perceptions rather than more objective measure-
ments. This survey also had a focus on past events
rather than prospective measurements which per-
mits recall bias. The survey used for this study did
not undergo validation in other settings, did not
assess a broad cross-section of the population and
was not assessed for possible cultural and educa-
tional biases. In addition, this survey did not
attempt to correlate caregiver knowledge about
OM RF, or willingness to change behaviors, to their
own child’s particular incidence of OM and these
would be areas of interest in future investigations.
5. Conclusions
There is a knowledge deficit regarding the RF for OM
by caregivers in both urban and suburban pediatric
practices. However, the caregivers of these children
do exhibit a significant willingness to modify beha-
J.E. Kerschner et al.
viors that might reduce the risk of OM to their child.
Standardized teaching materials could be made
available to assist with education of caregivers
and could be a first step in behavior modification
in an attempt to reduce the incidence of OM. This
survey study certainly has some limitations, how-
ever, the data obtained from this investigation
demonstrates a number of important points and
suggests some clear avenues of future investigation
in an area that has been scientifically neglected.
Further study is needed to assess if education alone
can be effective in risk factor modification or if more
intensive programs are needed to assist with risk
reduction. Further study is also needed to assess if
different strategies are required to erase knowledge
deficits in different types of practice locations.
Some of this work has already been initiated. Given
the high prevalence of OM and its potential for
morbidity, the significant health care expenditures
involved in treating this disease and the more recent
declining efficacy of antimicrobial therapy due to
antibiotic resistance, increased study of risk reduc-
tion with implementation of strategies to reduce
this risk should be pursued.
Acknowledgements
Special thanks to all of the physicians, residents,
medical students and staff at the Downtown Health
Clinic, Milwaukee, WI, who assisted in collecting
data for this project and to Dr. Rohloff’s colleagues
(Drs. Gutzeit, Jeruc, Richter and Young) as well as
their staff at Southwest Pediatrics, New Berlin, WI.
Also, special thanks to Stephanie Frisbee and Evelyn
Kuhn from the National Outcomes Research Center
at Children’s Hospital of Wisconsin for their assis-
tance with survey design and data analysis.
Caregiver otitis media risk factor knowledge 55

Appendix A. Ear infection survey

56
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