Highlights
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The prevalence of antibiotic administration without a prescription was 37.02%.
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The administration of antibiotic without prescription was higher among those who had taken antibiotics within the previous 2 months.
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Attitudes toward antibiotics were associated with administration without prescription.
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Knowledge on antibiotics was associated with administration without prescription.
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Knowledge on antimicrobial specifications was similarly associated.
Keywords: Antibiotic, Antimicrobial, Without presciption, Resistance, Knowledge, Attitude, Bangladesh
Abstract
Background
Antibiotic resistance is a global challenge. Therefore, adhering to proper antibiotic administration protocols is essential to mitigating the problem. This study investigated the prevalence, and factors associated with, antibiotics administration without prescription by registered doctors in Bangladesh.
Method
This cross-sectional survey was carried out among 1102 adults. The outcome variable was antibiotics administration without prescription. The exploratory variables included the those relating to sociodemographics, attitudes, and knowledge (antibiotic-treatable diseases, types of disease specification, and antimicrobial drugs specifications). Descriptive and inferential statistics were performed, with a p-value of 0.05 considered significant with a 95% confidence interval.
Results
The prevalence of antibiotics administration without prescription was found to be 37.02%. Age was significantly associated with the administration of antibiotics without prescription. Those who had taken antibiotics in the previous 2 months reported a significantly higher prevalence of antibiotics administration without prescription. The participants’ attitudes toward antibiotics and knowledge of antibiotic-treatable diseases, types of disease, and antimicrobial drugs were significantly associated with antibiotics administration without prescription.
Conclusion
These findings may assist in facilitating relevant initiatives to improve the magnitude of antibiotics utilization without prescription, and mitigate the emergence of antibiotic resistance in Bangladesh.
Introduction
Antibiotics are commonly administered to treat infections caused by microorganisms, most notably bacteria [1]. Antibiotics have proven to be highly beneficial in preventing infectious diseases and enhancing healthcare outcomes after their inception [2]. However, non-adherence to and misuse of antibiotics have resulted in a rise in antibiotic resistance globally [3]. Moreover, the association between antibiotic administration and the emergence of antimicrobial resistance is well recognized.
Antibiotic resistance is a significant global public health concern [4]. Murray et al. (2022) reported that 4.95 million individuals died due to antibiotic resistance in 2019 [5]. Brauer et al. (2017) warned that improper antibiotic administration could significantly contribute to antibiotic resistance in Southeast Asia [6]. Antibiotic resistance is common, and first-line antibiotics are now often ineffective [7]. Therefore, it is highly recommended that patients follow antibiotic administration protocols prescribed by registered doctors [8]. In Bangladesh, 67% of patients studied were shown by one study to have utilized antibiotics, although at least half of the administration was deemed unnecessary [9].
Antibiotics save lives, but overuse contributes to the development of antibiotic resistance [10]. Studies have suggested that appropriate knowledge, positive attitudes, and awareness could influence the proper administration of antibiotics [11,12]. In many countries, several studies have found that the general population might buy antibiotics without a prescription. For example, You et al. (2008) reported that nearly 9% of Hong Kong respondents had obtained antibiotics without a prescription [13]. Antibiotics are widely available without a prescription in Bangladesh. Biswas et al. (2014) revealed that 26.69% of respondents self-medicated with antibiotics [14]. The authors reported that prior experience, advice from others, and a lack of information encouraged non-adherence to antibiotic protocols [14].
Our study focused on urban residents, since antibiotic administration without prescription was a rapidly growing concern among this population in Bangladesh [15]. A limited number of studies was found in the literature, including one conducted in a rural area to investigate the level of antibiotic use [16], and another carried out in southern Bangladesh to examine the irrational practices of antibiotic administration [8]. Nevertheless, to our best knowledge, no studies were available relating to the urban population in Bangladesh.
To establish prudent antibiotic administration and minimize the emergence of antibiotic resistance, a better understanding of antibiotic administration in different geographical areas has been recommended [17]. Therefore, our study investigated the prevalence and factors associated with antibiotics administration without prescription from registered doctors in the urban Bangladeshi population.
Methods and materials
Study design, population, and setting
This cross-sectional survey was carried out among 1102 Bangladeshi urban adults between May 22 and June 15, 2021, during the COVID-19 pandemic. The eligibility criteria for the participants were: age ≥ 18 years, willingness to participate, and providing online consent to participate.
Questionnaire development and data collection
A structured questionnaire was created, based on a rigorous literature review. The questionnaire is provided in detail in Supplementary material 1. To allow online data collection, the questionnaire was then converted to a ‘Google Form’, and a URL was generated. Data were collected by following convenient and snowball sampling procedures. Research assistants posted the online questionnaire URL on social media platforms such as Facebook, LinkedIn, and WhatsApp. Furthermore, the assistants collected data from their friends, families, and social media followers before determining their eligibility standards. After receiving a total of 1139 responses and removing 37 incomplete ones, 1102 completed responses were included in the final analysis. The investigators trained the assistants for data collection by organizing online training sessions.
Study variables
The outcome variable of the study was antibiotic administration without prescription, which was measured by asking a single item, ‘Do you administer antibiotic without the prescription of a registered doctor?’, with a choice of ‘Yes’ or ‘No’. Jamhour et al. (2017) also assessed antibiotic administration without prescription by applying a single item measurement [18]. The exploratory variables included sociodemographic data (age, sex, marital status, and educational status), attitudes towards antibiotic administration (history of antibiotic taking within previous 2 months, awareness of administration, abuse of antibiotics, antibiotic resistance, and effects of resistance), and knowledge on which diseases are or are not treatable with antibiotics (COVID-19, dengue, diabetes, pneumonia, and tuberculosis), types of disease (bacterial, viral, parasitic, fungal, and helminthic), and antimicrobial specifications (penicillin, amoxicillin, cefixime, azithromycin, remdisivir, and albendazole).
Statistical analysis
Due to the nature of data collection, responses were automatically entered into an online Excel spreadsheet. After cleaning the data in the spreadsheet, only completed responses were included and processed using the statistical tools. The data analysis was performed using STATA version 16, and R version 4.2.2, and all graphics were created using R version 4.2.2.
Both descriptive and inferential statistics were performed for this study. The descriptive statistics included frequency distribution, and the inferential statistics included the Pearson chi-square test to address the association between the outcome and the predictor variables. Fisher's exact test was used instead of the Pearson chi-square test when any cell frequency was less than 5. A p-value of < 0.05 was considered statistically significant with a 95% confidence interval.
Ethical considerations and consents
The study's objectives and aims were explicitly stated on the front page of the online questionnaire. Participants were asked for electronic signatures, before they could submit their responses. The Ethical Review Committee of Tejgoan College in Dhaka, Bangladesh, reviewed and approved the study (reference number: 2021/OR-TGC/0201). The study was conducted following the Helsinki Declaration and its latest revision [19].
Results
Background characteristics of the survey participants
The background characteristics of the survey participants are presented in Table 1. The majority (62.52%) were aged between 20 and 29 years. Around half of these (53.27%) were male, and more than half (60.16%) were unmarried. Those with an educational level of at least higher school secondary pass (i.e. including graduates) accounted for almost 85% of respondents. The prevalence of antibiotic administration without prescriptions was 37.02%.
Table 1.
Background characteristics of the survey participants (n = 1102)
| Variables | n | Percent (95% CI) |
|---|---|---|
| Age | ||
| < 20 years | 77 | 6.99 (5.62–8.65) |
| 20–29 years | 689 | 62.52 (59.62–65.34) |
| 30–39 years | 139 | 12.61 (10.78–14.71) |
| ≥ 40 years | 197 | 17.88 (15.72–20.26) |
| Sex | ||
| Male | 587 | 53.27 (50.31–56.20) |
| Female | 515 | 46.73 (43.80–49.69) |
| Marital status | ||
| Married | 439 | 39.84 (36.98–42.76) |
| Unmarried | 663 | 60.16 (57.24–63.02) |
| Educational status | ||
| Graduated | 474 | 43.01 (40.11–45.96) |
| HSC passed | 460 | 41.74 (38.86–44.68) |
| Up to SSC passed | 168 | 15.25 (13.24–17.49) |
| Division | ||
| Dhaka | 945 | 85.75 (83.56–87.70) |
| Chattogram | 39 | 3.54 (2.60–4.81) |
| Rangpur | 33 | 2.99 (2.14–4.19) |
| Sylhet | 27 | 2.45 (1.69–3.55) |
| Rajshahi | 23 | 2.09 (1.39–3.12) |
| Barishal | 15 | 1.36 (0.82–2.25) |
| Khulna | 10 | 0.91 (0.49–1.68) |
| Mymensingh | 10 | 0.91 (0.49–1.68) |
| Administration of antibiotics without prescription | ||
| Yes | 408 | 37.02 (34.22–39.92) |
| No | 694 | 62.98 (60.08–65.78) |
Association between sociodemographic characteristics and the administration of antibiotics without prescription
Table 2 shows the association between background characteristics and antibiotics administration without the advice of registered doctors. Age was significantly associated with the administration of antibiotics without prescription (p = 0.016), with the prevalence highest (44.16%) among the younger respondents (< 20 years); Figure 1 shows the distribution of antibiotics administration without prescription by age. Administration of antibiotics without prescription was higher among males than females (39.01% vs 34.76%) and unmarried respondents (38.91% vs 34.17%). Figure 2 shows the distribution of administration of antibiotics without prescription by sex. Division (regional location) was associated with the administration of antibiotics without prescription (p = 0.002). The distribution of prevalences of administration of antibiotics without prescription by division is presented in Figure 3.
Table 2.
Association between sociodemographic characteristics and the administration of antibiotics without prescription
| Variables |
Administration of antibiotics without prescription |
χ2 | p-value | |||
|---|---|---|---|---|---|---|
| Yes |
No |
|||||
| n | Percent (95% CI) | n | Percent (95% CI) | |||
| Age | ||||||
| < 20 years | 34 | 44.16 (33.35–55.44) | 43 | 55.84 (44.56–66.55) | 10.28 | 0.016 |
| 20–29 years | 268 | 38.90 (35.32–42.60) | 421 | 61.10 (57.40–64.68) | ||
| 30–39 years | 36 | 25.90 (19.27–33.85) | 103 | 74.10 (66.15–80.73) | ||
| ≥ 40 years | 70 | 35.53 (29.14–42.49) | 127 | 64.47 (57.51–70.86) | ||
| Sex | ||||||
| Male | 229 | 39.01 (35.14–43.03) | 358 | 60.99 (56.97–64.86) | 2.13 | 0.144 |
| Female | 179 | 34.76 (30.76–38.98) | 336 | 65.24 (61.02–69.24) | ||
| Marital status | ||||||
| Married | 150 | 34.17 (29.87–38.74) | 289 | 65.83 (61.26–70.13) | 2.55 | 0.110 |
| Unmarried | 258 | 38.91 (35.27–42.69) | 405 | 61.09 (57.31–64.73) | ||
| Educational status | ||||||
| Graduated | 168 | 35.44 (31.25–39.87) | 306 | 64.56 (60.13–68.75) | 0.893 | 0.640 |
| HSC passed | 176 | 38.10 (33.92–42.80) | 284 | 61.74 (57.20–66.08) | ||
| Up to SSC passed | 64 | 38.10 (31.04–45.69) | 104 | 61.90 (54.31–68.96) | ||
| Division | ||||||
| Dhaka | 334 | 35.34 (32.35–38.45) | 611 | 64.66 (61.55–67.65) | Fisher's exact | 0.002 |
| Chattogram | 15 | 38.46 (24.52–54.59) | 24 | 61.54 (45.41–75.48) | ||
| Rangpur | 13 | 39.39 (24.22–56.93) | 20 | 60.61 (43.07–75.78) | ||
| Sylhet | 13 | 48.15 (30.06–66.73) | 14 | 51.85 (33.27–69.94) | ||
| Rajshahi | 11 | 47.83 (28.41–67.93) | 12 | 52.17 (32.07–71.59) | ||
| Barishal | 13 | 86.67 (58.16–96.82) | 2 | 13.33 (3.18–41.84) | ||
| Khulna | 3 | 30.00 (9.33–64.11) | 7 | 70.00 (35.89–90.67) | ||
| Mymensingh | 6 | 60.00 (28.30–85.08) | 4 | 40.00 (14.92–71.70) | ||
Figure 1.
Distribution of administration of antibiotics without prescription by age (years)
Figure 2.
Distribution of administration of antibiotics without prescription by sex
Figure 3.
Distribution of administration of antibiotics without prescription by division
Association between attitude towards antibiotic administration and the administration of antibiotics without prescription
As shown in Table 3, having a history of taking antibiotics in the previous 2 months was significantly associated with higher prevalence of administration of antibiotics without prescription (44.44%, p = 0.004). The administration of antibiotics without prescription was significantly high (78.26%, p < 0.001) among those who disagreed with the statement ‘it is necessary to be aware of the proper administration of antibiotic’ as well as among those who disagreed that ‘abuse of antibiotic is a reason for adverse health outcome’ (73.17%, p <0.001). The administration of antibiotics without prescription was also significantly high among those who disagreed that ‘antibiotic resistance is a major health concern in Bangladesh’ (51.76%, p <0.001) or that ‘antibiotic resistance may affect the global public health’ (50.00%, p < 0.001).
Table 3.
Association between attitudes towards antibiotics administration and the administration of antibiotics without prescription
| Variables |
Administration of antibiotics without prescription |
χ2 | p-value | |||
|---|---|---|---|---|---|---|
| Yes |
No |
|||||
| n | Percent (95% CI) | n | Percent (95% CI) | |||
| Have you taken antibiotics in the last 2 months? | ||||||
| No | 292 | 34.72 (31.57–38.01) | 549 | 65.28 (61.99–68.43) | 8.08 | 0.004 |
| Yes | 116 | 44.44 (38.51–50.54) | 145 | 55.56 (49.46–61.49) | ||
| It is necessary to be aware of the proper use of antibiotics | ||||||
| Disagree | 18 | 78.26 (56.63–90.85) | 5 | 21.74 (9.15–43.37) | 110.72 | < 0.001 |
| Neutral | 90 | 76.92 (68.39–83.70) | 27 | 23.08 (16.30–31.61) | ||
| Agree | 300 | 31.19 (28.33–34.19) | 662 | 68.81 (65.81–71.67) | ||
| Abuse of antibiotics is a reason for adverse health outcomes | ||||||
| Disagree | 30 | 73.17 (57.52–84.60) | 11 | 26.83 (15.40–42.48) | 99.06 | < 0.001 |
| Neutral | 99 | 67.81 (59.78–74.91) | 47 | 32.19 (25.09–40.22) | ||
| Agree | 279 | 30.49 (27.59–33.56) | 636 | 69.51 (66.44–72.41) | ||
| Antibiotic resistance is a major health concern in Bangladesh | ||||||
| Disagree | 44 | 51.76 (41.15–62.22) | 41 | 48.24 (37.78–58.85) | 44.06 | < 0.001 |
| Neutral | 144 | 50.17 (44.40–55.95) | 143 | 49.83 (44.05–55.60) | ||
| Agree | 220 | 30.14 (26.91–33.57) | 510 | 69.86 (66.43–73.09) | ||
| Antibiotic resistance may affect global public health | ||||||
| Disagree | 20 | 50.00 (34.79–65.21) | 20 | 50.00 (34.79–65.21) | 33.53 | < 0.001 |
| Neutral | 119 | 52.19 (45.69–58.63) | 109 | 47.81 (41.37–54.31) | ||
| Agree | 269 | 32.25 (29.16–35.51) | 565 | 67.75 (64.49–70.84) | ||
Association between knowledge on antibiotic-treatable diseases, types of disease, and antimicrobial specifications and the administration of antibiotics without prescription
As shown in Table 4, those who responded that COVID-19 is an antibiotic-treatable disease had higher prevalence of antibiotics administration without prescription (64.84%). Antibiotics administration without prescription was also significantly higher among those who thought dengue (41.13%, p = 0.005) or diabetes (49.74%, p < 0.001) could be treated with antibiotics. Those who could not identify tuberculosis as an antibiotics-treatable disease reported a significantly higher prevalence of antibiotics administration without prescription (44.39%, p < 0.001). The prevalence of antibiotics administration without prescription was also significantly higher among participants who identified viral or helminthic diseases as antibiotics-treatable (33.95%, p = 0.022 and 47.62%, p < 0.001, respectively).
Table 4.
Association between knowledge on antibiotic-treatable diseases, types of disease, and antimicrobial specifications and the administration of antibiotics without prescription
| Variables |
Administration of antibiotics without prescription |
χ2 | p–value | |||
|---|---|---|---|---|---|---|
| Yes |
No |
|||||
| n | Percent (95% CI) | n | Percent (95% CI) | |||
| Which of the following diseases are treated by antibiotics specifically? | ||||||
| COVID–19 | ||||||
| No* | 224 | 35.16 (31.55–38.96) | 413 | 64.84 (61.04–68.45) | 2.24 | 0.135 |
| Yes | 184 | 39.57 (35.21–44.10) | 281 | 60.43 (55.90–64.79) | ||
| Dengue | ||||||
| No* | 183 | 32.97 (29.18–37.00) | 372 | 67.03 (63.00–70.82) | 7.87 | 0.005 |
| Yes | 225 | 41.13 (37.07–45.32) | 322 | 58.87 (54.68–62.93) | ||
| Diabetes | ||||||
| No* | 314 | 34.39 (31.37–37.54) | 599 | 65.61 (62.46–68.63) | 15.81 | <0.001 |
| Yes | 94 | 49.74 (41.63–56.85) | 95 | 50.26 (43.15–57.37) | ||
| Pneumonia | ||||||
| No | 137 | 39.60 (34.56–44.86) | 209 | 60.40 (55.14–65.44) | 1.43 | 0.232 |
| Yes* | 271 | 35.85 (32.50–39.34) | 485 | 64.15 (60.66–67.50) | ||
| Tuberculosis | ||||||
| No | 170 | 44.39 (39.47–49.41) | 213 | 55.61 (50.59–60.53) | 13.65 | <0.001 |
| Yes* | 238 | 33.10 (29.75–36.63) | 481 | 66.90 (63.37–70.25) | ||
| What of the following disease types can be treated by antibiotics specifically? | ||||||
| Bacterial | ||||||
| No | 84 | 39.44 (33.08–46.18) | 129 | 60.56 (53.82–66.92) | 0.66 | 0.417 |
| Yes* | 324 | 36.45 (33.34–39.67) | 565 | 63.55 (60.33–66.66) | ||
| Viral | ||||||
| No* | 202 | 33.95 (30.25–37.86) | 393 | 66.05 (62.14–69.75) | 5.24 | 0.022 |
| Yes | 206 | 40.63 (36.43–44.98) | 301 | 59.37 (55.02–63.57) | ||
| Parasitic | ||||||
| No* | 206 | 34.92 (31.17–38.86) | 384 | 65.08 (61.14–68.83) | 2.42 | 0.120 |
| Yes | 202 | 39.45 (35.30–43.76) | 310 | 60.55 (56.24–64.70) | ||
| Fungal | ||||||
| No* | 201 | 36.41 (32.49–40.52) | 351 | 63.59 (59.48–67.51) | 0.177 | 0.674 |
| Yes | 207 | 37.64 (33.67–41.77) | 343 | 62.36 (58.23–66.33) | ||
| Helminthic | ||||||
| No* | 278 | 33.53 (30.40–36.83) | 551 | 66.47 (63.17–63.60) | 17.47 | < 0.001 |
| Yes | 130 | 47.62 (41.74–53.57) | 143 | 52.38 (46.43–58.26) | ||
| Which of the following are antibiotics? | ||||||
| Penicillin | ||||||
| No | 124 | 35.94 (31.04–41.16) | 221 | 64.06 (58.84–68.96) | 0.25 | 0.616 |
| Yes* | 284 | 37.52 (34.13–41.03) | 473 | 62.48 (58.97–65.87) | ||
| Amoxicillin | ||||||
| No | 156 | 38.52 (33.89–43.36) | 249 | 61.48 (56.64–66.11) | 0.614 | 0.433 |
| Yes* | 252 | 36.15 (32.66–39.80) | 445 | 63.85 (60.20–67.34) | ||
| Cefixime | ||||||
| No | 153 | 41.35 (36.43–46.45) | 217 | 58.65 (53.55–63.57) | 4.48 | 0.034 |
| Yes* | 255 | 34.84 (31.46–38.37) | 477 | 65.16 (61.63–68.54) | ||
| Azithromycin | ||||||
| No | 136 | 44.01 (38.56–49.61) | 173 | 55.99 (50.39–61.44) | 8.99 | 0.003 |
| Yes* | 272 | 34.30 (31.07–37.68) | 521 | 65.70 (62.32–68.93) | ||
| Remdisivir | ||||||
| No* | 247 | 34.99 (31.55–38.59) | 459 | 65.01 (61.41–68.45) | 3.50 | 0.061 |
| Yes | 161 | 40.66 (35.91–45.58) | 235 | 59.34 (54.42–64.09) | ||
| Albendazole | ||||||
| No* | 223 | 31.77 (28.42–35.31) | 479 | 68.23 (64.69–71.58) | 22.93 | < 0.001 |
| Yes | 185 | 46.25 (41.40–51.17) | 215 | 53.75 (48.83–58.60) | ||
Indicates the correct answer to that item
Those who could not identfy cefixime or azithromycin as antibiotics reported significantly higher prevalence of antibiotics administration without prescription (41.35%, p = 0.034 and 44.01%, p = 0.003, respectively). Finally, antibiotics administration without prescription was also significantly higher (46.25%, p <0.001) among those who identified albendazole as an antibiotic.
Discussion
This study investigated antibiotics administration without prescription and the associated factors among the urban population in Bangladesh. It found that 37.02% of the respondents administered antibiotics without prescription of registered doctors. The respondents’ age, history of antibiotic taking within the last 2 months, and a range of factors related to attitude towards antibiotic administration and knowledge on antimicrobials, specific antibiotic-treatable diseases, and types of disease were significantly associated with the administration of antibiotics without prescription.
The prevalence of antibiotics administration without prescription was very high in our study. This finding might be explained by the fact that our survey was commenced during the second wave of the COVID-19 pandemic, which might have an influence on this prevalence. During the pandemic, antibiotic resistance was found to be at a higher prevalencethan previously reported [20], possibly due to the increased administration of antibiotics without prescription to relieve from COVID-19 symptoms related to illness. Although telehealth services were available nationwide to support the general population in terms of providing symptomatic treatment at that time, a substantial proportion of the population might not have been aware of it [21].
According to protocol, antibiotics administration must comply with registered doctor's prescription [22]. Misuse of antibiotics results in the emergence of antimicrobial resistance, a recently growing concern. Resistance to previously efficient antimicrobial agents has arisen in numerous regions in recent decades, posing a worldwide health-related crisis [23]. Our study showed that the respondents’ age was significantly associated with antibiotics administration without prescription, which was found to be high among relatively younger participants (< 20 years). Numerous studies have supported this finding [24,25].
Those who disagreed that ‘it is necessary to be aware of the proper administration of antibiotics’ showed a high prevalence of antibiotics administration without prescription. Similarly, many researchers found that a lack of knowledge and awareness of antimicrobials affected people's perception of antibiotics administration without prescription [26], [27], [28]. Those who disagreed with concerns such as ‘abuse of antibiotics is a reason for adverse health outcomes’ and ‘antibiotic resistance may affect global public health’ were also significantly associated with a higher frequency of antibiotics administration without prescription. The study findings therefore suggest that people with a negative attitude were more inclined to administer antibiotics without a registered doctor's prescriptions.
Several studies have supported our findings. For example, studies carried out in Palestine and the UK showed that the majority of respondents did not know that antibiotics administration without prescription could lead to antibiotic resistance, and that this could prove fatal [29,30]. Numerous studies also emphasized that negative attitude is an indicator of antibiotics administration without prescription [31,32].
Our study also investigated the association between the respondent's knowledge of which antibiotics could treat specific diseases and tendency to administer without prescription. Antibiotics are ineffective in treating dengue and diabetes, but they can be administered to treat tuberculosis. Our study found that those respondents who thought that dengue and diabetes are antibiotic-treatable diseases, or who failed to report that tuberculosis is treatable with antibiotics, showed a high frequency of antibiotics administration without prescription. Finally, the study findings concluded that those with a high understanding of antibiotic-treatable diseases were likely to administer antibiotics appropriately. Similarly, Horvat et al. (2017) found that respondents in Serbia with more knowledge of antimicrobials were three times more likely to administer antibiotics appropriately [33].
Our results also showed an association between knowledge of disease types and antibiotics administration without prescription. Usually, diseases related to bacterial infections are treatable with antibiotics. However, on investigating the participants’ knowledge on whether antibiotics could treat viral, parasitic, fungal, or helminthic diseases as well, the respondents who reported that antibiotics can treat viral or helminthic diseases were likely to administer antibiotics without prescription. In addition, most of the respondents who utilized antibiotics without prescription reported that antibiotics could treat these other infections too. A study conducted in Romania found that most of the respondents believed that antibiotics could treat bacterial infections; however, 22.89% and 14.46% thought that antibiotics could also treat viral diseases and other pathogenic conditions, respectively [34].
Respondents who failed to recognize commonly administered antimicrobials were more likely to administer antibiotics without prescription. For example, they were unable to identify cefixime and azithromycin as antibiotics. Furthermore, when investigating knowledge of other often-administered antimicrobials such as remdisivir (antiviral) and albendazole (antihelminthic), the respondents who administered antibiotics without prescription identified albendazole as an antibiotic.
Our findings therefore imply a negative association between knowledge of antimicrobial specifications and antibiotics administration without prescription. Similarly, other studies have found that antibiotics administration without prescription is more likely attributable to a poor understanding of antibiotic specifications [26,27,32].
Limitations and strengths
This study had some limitations. First, the data were acquired using a convenient sampling technique, for which selection bias was unavoidable. It was not feasible to capture the same number of samples from all the regions of the country. Second, the questionnaire involved self-reporting, which may also lead to response bias. Moreover, causality could not be established due to the nature of the cross-sectional design. Nevertheless, the study was not explicitly targeted at the professionals specialized in biology, life sciences, clinical epidemiology, medicine, or other clinically related subjects, which might have influenced their responses to specific questionnaire items. Despite these limitations, the large sample size was reasonably high, and there had been no prior studies of antibiotics administration without prescription among urban people in Bangladesh.
Conclusion
In addition to revealing a high prevalence of antibiotics administration without prescription in the sample population, our study revealed significant gaps in the participants’ fundamental knowledge or understanding regarding the administration of antibiotics, including antibiotic identification, disease types, and the ability to differentiate antibiotic-treatable diseases from those that would not respond to antibiotics. Respondents’ perceptions of antibiotic administration may therefore be influenced by the level of relevant knowledge, attitude, and information needed to comply with proper antibiotic administration protocols. This study's findings need to be taken into consideration when establishing relevant initiatives, such as health education programs or campaigns to enhance understanding of antibiotic administration, diseases that respond to antibiotic treatment, and the need to control the surge of antibiotic resistance among the general population in Bangladesh. An appropriate policy initiative would aim to prevent drug sellers from providing convenient access to antibiotics for members of the general public looking to purchase antibiotics without prescription.
Declarations
Ethical approval and consent to participate
The study objectives and aims were stated on the front page of the online questionnaire. Participants could only submit their responses once they had provided an electronic signature. The Ethical Review Committee of Tejgoan College, Dhaka-1215, Bangladesh, reviewed and approved the study (reference number: 2021/OR-TGC/0201).
Consent for publication
Not applicable for this study.
Availability of data and materials
The raw data from questionnaire responses are provided in Supplementary material 2.
Funding
The authors received no funding for this study.
Authors’ contributions
Conceptualization — H. Kabir, M. Hasan, D. Mitra. Methodology — H. Kabir, M. Hasan, D. Mitra. Data collection — M. Hasan, H. Kabir, S. Mahmud, H. Tassdik, F. Islam, H. Jannat, A. Haque, O. Akter, R. Ara, M. Islam, M. Akter. Data analysis — H. Kabir, D. Mitra. Validation and scrutinization — H. Kabir, M. Hasan, H. Tassdik, F. Islam, H. Jannat, M. Islam, N. Akter. Investigation — H. Kabir, M. Hasan, A. Haque, S. Mahmud, H Tassdik, F. Islam, D. Jannat, A. Haque, O. Akter, R. Ara, M. Islam, M. Akter. Writing, original draft preparation — H. Kabir, N. Akter, M. Hasan. Review and editing — H. Kabir, M. Hasan, N. Akter, A. Haque, O. Akter, R. Ara, M. Islam, M. Akter, D. Mitra. Supervision — D. Mitra. All authors have read and agreed to the current version of the manuscript.
Acknowledgements
The authors would like to express their thanks and gratitude to the project's research assistants who contributed to the data collection for the study.
Footnotes
Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.ijregi.2023.02.001.
Contributor Information
Humayun Kabir, Email: humayun.kabir03@northsouth.edu, humayun.kabir.mcmaster@gmail.com.
Md Kamrul Hasan, Email: kamrul.hasan11@northsouth.edu.
Nahida Akter, Email: gccn.nahidaakter@gmail.com.
Dr Hamim Tassdik, Email: htnavo@gmail.com.
Dr Md Fakrul Islam, Email: mdfakrul999@gmail.com.
Dr Hasina Jannat, Email: hasinajannat1993@gmail.com.
Ariful Haque Tutul, Email: arif.tutul88@gmail.com.
Ojifa Akter, Email: tasnova.ojifa000@gmail.com.
Rawshan Ara, Email: rawshanara907@gmail.com.
Muhammad Didarul Islam, Email: kamruldidar007@gmail.com.
Sohel Mahmud, Email: sohelmahmud.bmb@gmail.com.
Masuda Akter, Email: masuda.akter.snc@gmail.com.
Dipak Kumar Mitra, Email: dipak.mitra@northsouth.edu.
Appendix. Supplementary materials
Supplementary material 1: The study questionnaire
Supplementary material 2: The study data set
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplementary material 1: The study questionnaire
Supplementary material 2: The study data set
Data Availability Statement
The raw data from questionnaire responses are provided in Supplementary material 2.