Public understanding and misuse of antibiotics in China: insights from a comprehensive national survey

Summary

Background

Antimicrobial resistance (AMR) is a major global health threat, with antibiotic misuse as a key driver. This study assessed public understanding and misuse of antibiotics in China to inform targeted interventions.

Methods

Data were extracted from the Psychology and Behaviour Investigation of Chinese Residents (2024), including 25,047 respondents over the age of 18 years. The study evaluated antibiotic knowledge, use practices, and associated factors using validated electronic health literacy scales.

Findings

Of the 25,047 respondents, 59.1% (14,806/25,047) reported having heard about antibiotics, with 34.8% (5154/14,806) correctly identifying their function. Regarding antibiotic use, 49.3% (7292/14,806) reported purchasing antibiotics without prescription at least once; 36.8% (5454/14,806) did not follow physicians’ instructions specifically, 15.1% (2235/14,806) discontinued their medication independently, 9.4% (1391/14,806) adjusted their doses, and 16.6% (2457/14,806) stopped taking the antibiotic immediately after their symptoms disappeared during the treatment. Female (OR = 0.843, 95% CI: 0.790–0.900), minority (OR = 0.786, 95% CI: 0.674–0.917) and rural respondents (OR = 0.812, 95% CI: 0.743–0.887) were less likely to have a correct knowledge of antibiotics. Minority respondents and those with children were likelier to purchase antibiotics without prescription, whereas those without companion animals (OR = 0.680, 95% CI: 0.631–0.733) were less so. Higher educated respondents were less likely to follow medication instructions (OR = 0.848, 95% CI: 0.765–0.941), so were those with children or companion animals.

Interpretation

Public understanding and use of antibiotics in China fall short of national targets. The study reveals complex relationships between demographic factors and antibiotic practices, suggesting the need for targeted interventions to address AMR effectively.

Funding

This work was supported by the National Natural Science Foundation of China (NO. 72474119) and National Health Commission Key Lab of Health Economics and Policy Research (NO. NHC-HEPR202401).

Research in context.

Evidence before this study

We searched PubMed and CNKI for articles published in English or Chinese between Jan 1, 2017, and Oct 31, 2024, using the terms “antibiotic”, “antimicrobials”, “antibiotic use”, “antimicrobial resistance”, “AMR”, “knowledge”, “practice”, “KAP” (Knowledge, Attitude, and Practice), and “China”. The terms ‘antibiotics’ (to mean antimicrobials with an antibacterial effects) and ‘antimicrobials’ (with a broader ranger of target pathogens) are different words in the Chinese language. Most existing studies focused on specific populations such as clinicians, pharmacists, parents, or rural residents, and were limited to particular geographical areas. A comprehensive assessment of public understanding and misuse of antibiotics at the national level in China was lacking.

Added value of this study

This study provides the first large-scale, nationwide assessment of public understanding and misuse of antibiotics in China, surveying 25,047 respondents across all provinces, autonomous regions, municipalities, and special administrative regions. Key findings include: 59.1% of respondents had heard of antibiotics, with only 34.8% correctly identifying their function; 49.3% reported purchasing antibiotics without prescription; and 36.8% did not follow physicians’ instructions for antibiotic use. The study revealed unexpected patterns, such as higher education being associated with increased likelihood of antibiotic misuse, and respondents with children or companion animals may drive antibiotic misuse.

Implications of all the available evidence

The findings indicate that public understanding and use of antibiotics in China fall short of national targets. The complex relationships between demographic factors and antibiotic practices suggest the need for more nuanced, targeted interventions. Future public health strategies should integrate cross-sector education campaigns throughout the whole-lifecycle and focusing on key groups such as young people, parents, and companion animal owners. The study provides crucial insights for optimizing AMR containment strategies in China and countries facing similar challenges.

Introduction

Antimicrobial resistance (AMR) represents one of the most pressing global health threats of the 21st century, with antibiotic misuse serving as a primary driver. Misuse is highly prevalent in low- and middle-income countries (LMICs).1, 2, 3 For the public, this is particularly evident in their self-medication with antibiotics, which includes widespread practices such as use them without prescription, incomplete or short-term medication courses, and inappropriate dose selections in many countries.⁴ Public understanding and awareness of antibiotics remain crucial factors that influence appropriate use of antibiotic.⁵ The widespread misconceptions and inconsistent practices among the public regarding antibiotic use further exacerbate the misuse of antibiotics in society, which may accelerate the emergence and spread of AMR.⁶ This is why countries worldwide have always attached great importance to public health education campaigns and listed them as a key goal in Global Action Plan on AMR.⁷ Regular comprehensive assessments of public understanding and misuse of antibiotics help to grasp the characteristics of antibiotic misuse among the population, enabling timely adjustments to public health education strategies and targeted interventions for those who misuse them.

China is a major producer and consumer of antibiotics, where antibiotic misuse and AMR are particularly severe.⁸ The public mainly obtains antibiotics through medical institutions and community pharmacies. Despite the prescription-only regulation for antibiotic sales, performance is good in medical institutions but concerning in community pharmacies. Previous observational studies indicate that in Chinese cities, over half of community pharmacies dispense antibiotics without a prescription when common illnesses are simulated with no signs of bacterial infection.⁹ In the 2022 National Action Plans (NAPs) on AMR, the Chinese government also included public education as a main goal, specifically stating the goal of achieving an 80% awareness rate regarding AMR issues among urban and rural residents and correct knowledge of infection prevention and rational antibiotic use, as well as a 60% correct use rate of antibiotic by 2025.¹⁰ A series of activities, such as health education campaigns and annual antimicrobial awareness weeks, have been vigorously carried out. However, it remains unclear how the public understanding and misuse of antibiotics actually are. Previous studies have mainly focused on surveys of antibiotic use knowledge and practices among specific populations, such as physicians, pharmacists, and rural parents, conducted in localized areas.11, 12, 13 What is lacking is a nationwide survey targeting the whole population.

To address this gap, we examine the understanding and misuse of antibiotics among the Chinese public and the factors associated with these behaviors through a large-sample, multi-center, nationwide cross-sectional study in China. The comprehensive survey, covering 150 cities and 800 communities or villages across all of China’s provinces, autonomous regions, municipalities, and special administrative regions, represents the first nationwide assessment of its kind. The results will not only shed light on the current state of public understanding and misuse of antibiotics in China, but also contribute to the broader field of AMR research and public health policy globally.

Methods

Data collection

Data were extracted from the Psychology and Behaviour Investigation of Chinese Residents (PBICR), which is a population-based cross-sectional study conducted in China. It was also registered in the China Clinical Trial Registry (No. ChiCTR2400085016). The survey was conducted between June 20th, 2024, and September 15th, 2024. It included 150 cities and 800 communities or villages across 22 provinces, 5 autonomous regions, 4 municipalities directly under the central government, the Hong Kong and the Macao Special Administrative Region (SAR). A multi-stage stratified random sampling method was used. In the first stage, the number of cities to be selected was determined based on the population size of each province or autonomous region, with 2–12 cities randomly drawn from each using a random number table, totaling 150 cities. In the second stage, the number of communities to be sampled was determined based on the population of the administrative region where each selected city was located. Within the cities selected from each province, 10 to 60 communities were sampled in a ratio of 3 urban communities to 2 villages, totaling 800 communities. In the third stage, quota sampling was conducted within each selected community to ensure that the demographic characteristics of the sampled population across these regions aligned with those from China’s Seventh National Population Census. The quotas were based on gender (with a 1:1 ratio) and age (distributed approximately in line with China’s population pyramid) (see Appendix). Each community survey involved approximately 40 respondents. Equal-probability sampling was used in the first and second stage, while unequal-probability sampling (quota sampling) was used in the third stage.

In each province, investigators contacted primary healthcare centers or neighborhood committees that were willing to participate and then worked with them to establish local survey sites. During the survey, investigators posted posters and distributed recruitment notices (either in paper or electronic form) to potential participants with the help of staff from these centers or committees. They verified participants’ identities and ensured that participants met the inclusion criteria and did not meet the exclusion criteria. Investigators distributed electronic questionnaires, accessible by scanning a QR code, to participants in-person. Completed questionnaire data were automatically collected on a backend server. The electronic questionnaire was created at https://www.wjx.cn/. The survey started only with the respondents’ informed consent. If participants had cognitive ability but lacked sufficient motor ability to respond, investigators conducted one-on-one interviews. All investigators underwent a uniform training prior to formal investigations. For more detailed information, see the preprinted study protocol (https://www.medrxiv.org/content/10.1101/2025.01.14.25320520v1).

Participants

The inclusion criteria of participants are: a) aged 18 years or older; b) Chinese nationality and permanent resident of China (with annual time away from home ≤1 month); c) able to complete the online questionnaire independently or with the assistance of an investigator; d) able to understand the meaning of each item in the questionnaire. We excluded participants who: a) had unconsciousness or mental abnormalities; b) had cognitive impairments (Information on whether the respondent has cognitive impairments or other mental illnesses was obtained through records in the community health service center system and self-reports from the respondent); and c) were participating in other similar research projects. The survey questionnaires were developed through expert consultation and discussion among 48 experts, and three pre-surveys were conducted to guarantee the validity of the results. In total, 38,793 questionnaires were distributed, with 38,424 returned, achieving a 99.0% (38,424/38,793) response rate. Among the 36,240 valid surveys, 35,861 met the eligibility criteria after logical checks. After quota sampling adjustments based on Chinese demographic characteristics, 25,047 respondents were included.

Measures

Misunderstandings about the function of antibiotics are common among the public, which is a major cause of antibiotic misuse. Purchases without prescription and non-following physicians’ instructions during antibiotics medication are weak points in regulation and main forms of misuse. To address this, we have focused on the following questions to assess the public basic understanding and misuse of antibiotics, providing insights for refining public health education strategies and targeted interventions.

• (1)Have you heard about antibiotics? (Yes or No)
• (2)What is the function of antibiotics? (Anti-bacteria; Anti-virus; Both; Neither; I don’t know)
• (3)In daily life, I purchase antibiotics without a prescription (Never, Occasionally, Sometimes, Frequently, Always)
• (4)During antibiotic use, have you engaged in any of the following practices? (Self-discontinuation of medication; Self-adjustment of doses; Immediate cessation of medication upon symptom disappearance; Cessation of medication 1–2 days after symptom disappearance; Other self-medication practices; Following physician’s instructions for medication.) Multiple answers were allowed for this question.

The factors related to public understanding and misuse of antibiotics are complex and multifaceted. Possible related factors include sex, age, education level (junior high or below, senior high, undergraduate or above), ethnicity (Han, minority), residence (urban, rural), average monthly household income (≤3,000yuan, 3001–6,000yuan, ≥6,001yuan), living region (east, central, west, northeast, Hong Kong and Macao SAR), number of children (0, 1, 2, ≥3), companion animal ownership (yes, no), and e-health literacy. Living regions were categorized based on standards provided by the National Bureau of Statistics of China.¹⁴

Electronic health literacy was assessed by the eHealth Literacy (eHEALS) Scale, which measured individuals’ knowledge level regarding electronic health information.15, 16, 17 In this study, the original scale was streamlined to five items, using a Likert five-point rating scale with a maximum total score of 25. Higher scores indicated a higher level of individual electronic health knowledge. In this study, the Cronbach’s α coefficient for the eHEALS scale was 0.956.

Statistical analysis

The collected data were analyzed by Stata (version 14.0). Count data were summarized using frequencies and percentages. Considering data clustering, we used a generalized linear mixed model (GLMM) for analysis, incorporating provinces and cities (including intercepts) as random effects. We included in the GLMM analysis factors that were significantly different and theoretically relevant. A collinearity test was conducted prior to conducting GLMM analysis. A P value from 2-sided tests was considered statistically significant if it was <0.05. Data analysis and reporting followed the strengthening the reporting of observational studies in epidemiology (STROBE) Statement checklist (see Appendix).

Ethics approval

This survey was approved by the Ethics Committee for Scientific and Technological Research Involving Human Beings at Shanghai Jiao Tong University (No. H20240237I) and complied with the Declaration of Helsinki. All participants voluntarily participated and provided informed consent.

Role of the funding source

The funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report.

Results

Sociological characteristics of the respondents

25,047 respondents were included in the final analysis (50.5% female, 92.2% Han). The average age of respondents was 40.7 ± 16.3 years, with 51.6% aged ≤40 and 8.9% aged >65. In terms of education level, junior high or below, senior high, and undergraduate or above accounted for 34.0%, 28.4%, and 37.6%, respectively. Of all respondents, 75.1% lived in urban areas, while 24.9% resided in rural areas. They were distributed across eastern, central, western, and northeastern China, as well as the Hong Kong and Macao SAR, accounting for 36.9%, 35.8%, 22.1%, 4.1%, and 1.1%, respectively. Average monthly household income was ≤3000 yuan for 24.7%, 3001–6000 yuan for 42.2%, and ≥6001 yuan for 33.1% (1 USD equals 7.12 CNY based on average exchange rate in 2024). Additionally, 36.7% had no children, and 32.6% had at least three children. A total of 7586 respondents (30.3%) owned companion animals (Table 1).

Table 1.

Sociodemographic characteristics of respondents.

Characteristic	Number (n)	Percentage (%)
Sex
Male	12,401	49.5
Female	12,646	50.5
Age (in years)
18–40	12,909	51.6
41–65	9900	39.5
>65	2238	8.9
Ethnicity
Han	23,095	92.2
Minority	1952	7.8
Education
Junior high or below	8516	34.0
Senior high	7115	28.4
Undergraduate or above	9416	37.6
Residence
Urban	18,815	75.1
Rural	6232	24.9
Household income (per capita monthly, yuan)
≤3000	6199	24.7
3001–6000	10,582	42.2
≥6001	8266	33.1
Living region
East	9244	36.9
Central	8976	35.8
West	5545	22.1
Northeast	1025	4.1
Hong Kong and Macao SAR	257	1.1
Number of children
0	9195	36.7
1	1265	5.1
2	6407	25.6
≥3	8180	32.6
Companion animal ownership
Yes	7586	30.3
No	17,461	69.7

Understanding of antibiotics

Of the 25,047 respondents, 59.1% (14,806/25,047) heard about antibiotics. When further asked about the function of antibiotics, 34.8% (5154/14,806) of these respondents answered anti-bacteria, 19.2% (2850/14,806) answered anti-virus, and 38.0% (5624/14,806) answered they did both. Among respondents aged 18–40 who heard about antibiotics, only 34.7% (2932/8457) could correctly answer their function. This proportion was 34.0% (1874/5504) and 41.2% (348/845) for the 41–65 and > 65 age groups, respectively. In the eastern region, 64.9% (5995/9244) heard about antibiotics, with 40.0% (2394/5995) correctly answering their function. This proportion was 33.9% (1645/4853) and 26.8% (826/3087) for the groups in the central and western region, respectively. The eHEALS scores were higher in the group with correct knowledge of antibiotics than in the group without (19.0 ± 4.6 vs. 17.6 ± 5.0).

Our study found that female (OR = 0.843, 95% CI: 0.790–0.900), minority (OR = 0.786, 95% CI: 0.674–0.917) and rural respondents (OR = 0.812, 95% CI: 0.743–0.887) were less likely to have a correct knowledge of antibiotics. Those with higher education, and higher eHEALS scores were more likely to have correct understanding of antibiotics. As for living region, respondents in central (OR = 0.778, 95% CI: 0.612–0.990), west (OR = 0.636, 95% CI: 0.502–0.807) had less understanding of antibiotics than respondents in the east (Table 2).

Table 2.

GLMM analysis concerning a correct understanding of antibiotics.

Factor	With correct knowledge of antibiotics n (%)	OR (95%CI)	P value
Ethnicity
Han	4856 (35.4)	1 (–)
Minority	298 (27.2)	0.786 (0.674–0.917)	0.002
Sex
Male	2752 (22.1)	1 (–)
Female	2402 (18.9)	0.843 (0.790–0.900)	<0.001
Age (in years)
18–40	2932 (34.7)	1 (–)
41–65	1874 (34.0)	1.073 (0.982–1.171)	0.119
>65	348 (41.2)	1.170 (1.008–1.355)	0.038
Education
Junior high or below	1118 (31.5)	1 (–)
Senior high	1511 (33.7)	1.502 (1.364–1.654)	<0.001
Undergraduate or above	2525 (37.2)	1.910 (1.729–2.110)	<0.001
Residence
Urban	4207 (35.3)	1 (–)
Rural	947 (32.7)	0.812 (0.743–0.887)	<0.001
Living region
East	2394 (40.0)	1 (–)
Central	1645 (33.9)	0.778 (0.612–0.990)	0.041
West	826 (26.8)	0.636 (0.502–0.807)	<0.001
Northeast	217 (31.5)	0.921 (0.607–1.397)	0.699
Hong Kong and Macao SAR	72 (39.1)	1.457 (0.627–3.385)	0.381
eHEALS	19.0 ± 4.6∗	1.036 (1.028–1.044)	<0.001

Notes: In this study, respondents with correct understanding of antibiotics meant they heard about antibiotics and correctly answered about their function. For binary analyses, respondents who had a correct understanding of antibiotics (answered “anti-bacteria”) were coded with 1 and others were coded with 0. n (%): “n” denotes the number of respondents with correct antibiotic knowledge in each category, and “%” represents the percentage of those respondents relative to the total number who have heard about antibiotics within the same category. “∗” indicates the mean ± standard deviation of eHEALS scores for individuals with correct knowledge of antibiotics.

Self-reported antibiotic misuse practices

Among the 14,806 respondents heard about antibiotics, their self-reported antibiotic use practices in daily life showed that 50.7% (7514/14,806) have never purchased antibiotics without a prescription, while 49.3% (7292/14,806) have done so at least once. Among those with children or companion animals, the proportion purchasing antibiotics without a prescription was higher than the average. Respondents from the western region (54.2%, 1673/3087) had the highest proportion of purchasing antibiotics without a prescription, while those from Hong Kong and Macao SAR (26.1%, 48/184) had the lowest. Participants purchasing antibiotics without a prescription scored lower on eHEALS than those purchasing with a prescription (18.9 ± 4.4 vs. 19.4 ± 4.4).

GLMM results showed that minority respondents (OR = 1.252, 95% CI: 1.073–1.461) were more likely to purchase antibiotics without prescription, while respondents without companion animals (OR = 0.680, 95% CI: 0.631–0.733) were less likely. Compared to those aged 18–40, those aged 41–65 were more likely to purchase antibiotics without prescription (OR = 1.260, 95% CI: 1.151–1.379). Respondents with children were more prone to purchase antibiotics without prescription (P < 0.001). Higher eHEALS scores (OR = 0.963, 95% CI: 0.955–0.971) were negatively correlated with purchasing antibiotics without prescription (Table 3).

Table 3.

GLMM analysis concerning antibiotic purchase without prescription.

Characteristic	Antibiotic purchase without prescription n (%)	OR (95%CI)	P value
Age (in years)
18–40	3766 (44.5)	1 (–)
41–65	3072 (55.7)	1.260 (1.151–1.379)	<0.001
>65	454 (53.7)	1.032 (0.877–1.217)	0.700
Ethnicity
Han	6658 (48.6)	1 (–)
Minority	634 (57.8)	1.252 (1.073–1.461)	0.004
Living region
East	2979 (49.7)	1 (–)
Central	2243 (46.2)	0.954 (0.708–1.286)	0.757
West	1673 (54.2)	1.158 (0.879–1.526)	0.297
Northeast	349 (50.7)	1.111 (0.672–1.772)	0.656
Hong Kong and Macao SAR	48 (26.1)	0.373 (0.167–0.833)	0.016
Number of children
0	2626 (43.2)	1 (–)
1	421 (53.3)	1.465 (1.252–1.714)	<0.001
2	2181 (53.8)	1.454 (1.314–1.609)	<0.001
≥3	2064 (53.1)	1.439 (1.292–1.603)	<0.001
Companion animal ownership
Yes	2724 (56.5)	1 (–)
No	4568 (45.8)	0.680 (0.631–0.733)	<0.001
eHEALS	18.9 ± 4.4∗	0.963 (0.955–0.971)	<0.001

Notes: n (%): “n” denotes the number of respondents who have purchased antibiotics without a prescription in each category, and “%” represents the percentage of those respondents relative to the total number who have heard about antibiotics within the same category. “∗” indicates the mean ± standard deviation of eHEALS scores for individuals who have purchased antibiotics without a prescription.

Of the respondents who heard about antibiotics, 63.2% (9352/14,806) self-reported following physicians’ instructions when using antibiotics in daily life, while 15.1% (2235/14,806) discontinued their medication on their own, 9.4% (1391/14,806) adjusted their doses, and 16.6% (2457/14,806) stopped taking the antibiotic immediately after symptoms disappeared. Among those with children or companion animals, the proportion following physicians’ instructions were lower than the average. Respondents from Hong Kong and Macao SAR (79.9%, 147/184) had the highest proportion of following physicians’ instructions, while those from the northeast region (60.4%, 416/689) had the lowest. Participants following physicians’ instructions scored higher on eHEALS than those who did not (19.3 ± 4.3 vs. 18.3 ± 4.6).

Based on the self-reported antibiotic use practices of respondents, they were divided into two groups: the “Following physicians’ instructions group” that fully followed physicians’ instructions and the “Non-following physicians’ instructions group” that exhibited self-medication practices, including self-discontinuation of medication, self-adjustment of doses, immediate cessation upon symptom disappearance, cessation 1–2 days after symptom disappearance, or other forms of self-medication.

Compared to those in the eastern region, respondents from Hong Kong and Macao SAR were more likely to follow (OR = 2.190, 95% CI: 1.062–4.515). Respondents with children were less likely to follow medication (P < 0.001). While those without companion animals were more likely to follow medication instructions (OR = 1.331, 95% CI: 1.234–1.436). Higher educated respondents (undergraduate or above) were less likely to follow compared to those with junior high or below (OR = 0.848, 95% CI: 0.765–0.941). Those with higher eHEALS scores were more likely to follow medication instructions (0R = 1.051, 95%CI:1.043–1.060), see Table 4.

Table 4.

GLMM analysis concerning following physicians’ instructions.

Characteristic	Following physicians’ instructions n (%)	OR (95%CI)	P value
Education
Junior high or below	2209 (62.3)	1 (–)
Senior high	2902 (64.8)	0.981 (0.886–1.086)	0.709
Undergraduate or above	4241 (62.5)	0.848 (0.765–0.941)	0.002
Living region
East	3754 (62.6)	1 (–)
Central	3157 (65.1)	0.963 (0.746–1.243)	0.771
West	1878 (60.8)	0.927 (0.729–1.180)	0.539
Northeast	416 (60.4)	0.711 (0.474–1.066)	0.099
Hong Kong and Macao SAR	147 (79.9)	2.190 (1.062–4.515)	0.034
Number of children
0	4074 (67.1)	1 (–)
1	477 (60.4)	0.758 (0.646–0.888)	<0.001
2	2416 (59.6)	0.708 (0.638–0.785)	<0.001
≥3	2385 (61.3)	0.732 (0.656–0.818)	<0.001
Companion animal ownership
Yes	2850 (59.1)	1 (–)
No	6502 (65.1)	1.331 (1.234–1.436)	<0.001
eHEALS	19.3 ± 4.3∗	1.051 (1.043–1.060)	<0.001

Notes: n (%): “n” denotes the number of respondents who self-reported following physicians’ instructions when using antibiotics in daily life in each category, and “%” represents the percentage of those respondents relative to the total number who have heard about antibiotics within the same category. “∗” indicates the mean ± standard deviation of eHEALS scores for individuals who self-reported following physicians’ instructions when using antibiotics.

Discussion

To our knowledge, this is the first nationwide cross-sectional survey in China to investigate public understanding and misuse of antibiotics. Our findings reveal a concerning gap between the current state of public knowledge and the targets set in China’s 2022 National Action Plans on AMR. Only 59.1% of respondents had heard of antibiotics, with a mere 34.8% correctly identifying their function. It still falls significantly short of the 80% awareness target for 2025 outlined in the NAPs,¹⁰ and is also lower than the 70% global public awareness of AMR/antibiotic reported in a systematic review.¹⁸ Additionally, 49.3% of the public have once purchased antibiotics without a prescription; 36.8% did not follow physicians’ instructions. A survey of 428 patients from five primary care clinics in Catalonia reported much higher rates of non-adherence to dosing schedules (25.2%) and non-adherence to treatment durations (28.7%).¹⁹

Our research findings reveal that the public understanding about antibiotics does not fully align with their misuse practices. Despite most highly educated individuals have heard about antibiotics, only about one-third have a correct understanding of them, and the proportion of proper antibiotic use is even below average. Health literacy does not seem to fully coincide with higher education levels²⁰; individuals with high levels of education tend to have stronger self-confidence in sticking to their own opinions, which, without professional health knowledge, may hinder their rational use of antibiotics.²¹ An online survey found that college-educated Saudis had better antibiotic knowledge than those with middle school education or below, but scored lower on antibiotic practice.²² This counterintuitive finding suggests that education alone may not be sufficient to promote proper antibiotic use. It highlights the need for targeted interventions that address not only knowledge gaps but also attitudes and behaviors across all educational levels.

An unexpected outcome is that while younger people are more likely to hear about antibiotics, older adults have a more correct understanding of them. The survey conducted among the general population in northeast France suggested that inappropriate behaviors concerning antibiotics were less frequent among older age groups (P = 0.01).²³ One plausible reason is that older adults, who visit healthcare providers more frequently, have more opportunities to receive health education from physicians. Physicians’ health education during treatment plays a crucial role, leading to better antibiotic understanding and use among older adults. In contrast, although younger people have various ways to hear about antibiotics, their understanding and use are unsatisfactory due to a lack of professional education. A study assessing antibiotic use patterns in an urban community setting in Italy found that respondents aged 25–44 years had a significantly higher risk of self-prescribing antibiotics compared to those aged >45 years (HR = 5.01; 95% CI: 3.06–8.19; P < 0.001).²⁴ Younger people tend to be more inclined to question their doctor’s advice and, consequently, may engage in behaviors that are not deemed appropriate. This further emphasizes the need for professional health knowledge in education campaigns. Meanwhile, it also highlights the necessity of integrating health education into daily university curriculum through diverse activity formats.

Another notable point is that respondents with more children tend to hear about antibiotics but have incorrect understanding of antibiotics and exhibit more evident irrational use. Those with 1, 2, or ≥3 children used antibiotics correctly at rates of 60.4%, 59.6%, and 61.3% respectively, which are lower than the overall average of 63.2%. Although the focus of our study is on respondents’ own medication use, parents, as primary caregivers, influence not only their own health management but also childhood illness management. Parents’ own understanding and practices regarding antibiotic use are highly likely to influence the antibiotics use for their children. In China, children are one of the primary sources of antibiotic prescriptions.^25,26 A prior study in 10 rural western China provinces’ primary health facilities found that nearly 25% of antibiotic-treated patients were under 10 years old.²⁷ Additionally, AMR were also frequently found in children, especially infants.^25,28 Another study from Shandong province in China found that 62% of rural parents gave their children antibiotics without a prescription.¹² Parents, especially who have incorrect understanding about the function of antibiotics, often use antibiotics without a prescription to alleviate symptoms like fever, cough, runny nose, and sore throat, or to prevent colds, and they tend to discontinue treatment or adjust doses even when prescribed. All of this misuse can potentially lead to AMR occurring. Promoting health education for parents, particularly new parents, is crucial, not only for their own well-being but also for the health of the next generation.

An intriguing finding highlights companion animal ownership as a key factor influencing public rational use of antibiotics. Smith pointed out that companion animal owners’ low awareness of AMR could jeopardize antimicrobial stewardship policies.²⁹ Most bacteria and resistance genes can move within and between humans, animals, and the environment. It demonstrates that the governance of AMR need to extend beyond human health to encompass “human-animal-environment” interactions.30, 31, 32 Although our study didn’t delve into the use of antibiotics in animals, the impact of companion animal owners’ practices regarding the use of antibiotics for both humans and animals needs to be further explored in the future. It’s noteworthy that companion animal owners’ inadequate understanding affects antibiotic use in both humans and companion animals, often leading to the oversight of potential interspecies transmission of resistant bacteria.^33,34 A study from Portugal showed that 53.4% of respondents agree to use human antibiotics for companion animals to ensure treatment,³⁵ necessitating government attention, as this often falls into regulatory gaps.

Our results indicate significant differences in the understanding and misuse of antibiotics among different living regions in China. This disparity may reflect variations in economic development, healthcare access, and the effectiveness of local health promotion strategies. Future interventions should be tailored to address these regional disparities.

Public understanding and rational use of antibiotics primarily still stem from medical consultations and health education campaigns. At present, public health education levels alone appear insufficient; professional health knowledge is also indispensable. Besides, human-animal interaction is inevitable. Young people, parents (especially new parents), and companion animal owners are key target groups for future health education interventions. We advocate for cross-sectoral health education throughout the whole-lifecycle. Government should integrate antibiotic knowledge and rational use education into university curricula, newborn health education, community activities, and routine medical consultations. Our results also indicate that higher e-Health literacy is associated with greater knowledge and rational use of antibiotics. Previous studies also show that research populations who are more connected to media, the internet, and other social communication systems have a better understanding of antibiotic use.³⁶ Nowadays, the rapid dissemination of multimedia and internet information has become a primary channel for health knowledge popularization. Government departments should leverage this advantage to enhance the effectiveness of health education.

This study has several limitations that warrant attention. First, the survey data in this study originate from a cross-sectional design, which can only describe correlations but cannot establish causal relationships between factors. Future research needs to focus on longitudinal studies to explore the causal relationships among factors. Second, this study only surveyed the public at the community level and did not include data analysis of hospitalized patients, which may limit the generality of the research findings. Third, due to the unavailability of community-level data, random effects at the community level were not taken into account, which may affect the research results. Fourth, excluding respondents who never heard of antibiotics may underestimate the true prevalence of antibiotic misuse in China. Fifth, the questionnaire used in this study includes self-report and self-assessment sections, which may introduce bias to the results. Sixth, the questions designed in this study mainly revolve around understanding and practices related to human antibiotic use, with insufficient attention paid to the use of animal antibiotics. In the future, further in-depth investigation and analysis should be conducted, combining the knowledge, attitudes, and practices of key populations towards both human and animal antibiotic use, to propose optimization suggestions more comprehensively and accurately.

In conclusion, our findings underscore the urgent need for more nuanced, targeted approaches to antibiotic education and AMR containment in China. By addressing the specific needs of different demographic groups and regions, public health strategies can be optimized to more effectively combat the growing threat of AMR. These insights may also prove valuable for other countries facing similar challenges in their efforts to promote responsible antibiotic use and contain AMR.

Contributors

ZF, YZ, YW, JY, QS conceived and designed the work. ZF and YW collected and analyzed the data. ZF drafted the manuscript. QS, JY, YZ critically revised the manuscript for important intellectual content. ZF, YW, JY and QS accessed and verified the data. QS and JY supervised the study. All authors were responsible for the interpretation of the data, and revised, and gave final approval of the manuscript.

Data sharing statement

The data are not publicly available but may be requested from the authors on reasonable request. Data used in this study were extracted from the Psychology and Behaviour Investigation of Chinese Residents (PBICR) conducted by the author YW.

Declaration of interests

The authors declare that there are no conflicts of interest.