Public knowledge and attitude toward antibiotic use and antimicrobial resistance in Riyadh region

ABSTRACT

Background:

One of the world’s most significant challenges is antimicrobial resistance. The WHO agreed to tackle the threat of antibiotic resistance globally. The CDC announced in 2013 that the human race is now in the “post-antibiotic period.” In 2014, the WHO warned that the problem of antibiotic resistance is becoming more and more severe.

Objective:

To assess the population’s knowledge and attitudes toward antibiotic use and antimicrobial resistance in Riyadh region.

Methods:

A cross-sectional study was conducted in the Primary health care centers (PHC) in four regions of Riyadh (North, East, South, and West). A random sample of 639 patients/visitors was selected in each region by stratified random sampling. Data were collected through Self-administered, closed-type questionnaires, which were analyzed by Chi-square and relative risk calculation. Results: Sixty-five percent of participants had insufficient knowledge about antibiotic use and antimicrobial resistance. Twenty-four percent of participants had negative attitudes toward antibiotic use and antimicrobial resistance.

Conclusion:

The research results conclude that the Riyadh Community possibly has a high percentage of insufficient antibiotic awareness. The results may benefit the Health Education Specialists in preparing a suitable intervention to enhance the use of antibiotics in the future among patients or help Specialists in Health Promotion to establish educational programs aimed at HCWs to help them prompt their method of delivering information to the public, as they are the source of information for the community.

Introduction

Antimicrobial resistance is one of the world’s challenges, which is defined as the development of a new antibiotic resistance mechanism or the ability of a specific type of bacteria to survive when using an antibiotic that has been effective in treating bacterial diseases.[1,2]

Several public health organizations have identified the rapid emergence of resistant bacteria as a “crisis.”[3,4] The CDC announced in 2013 that the human race is now in the “postantibiotic period.” In 2014, the WHO warned that antibiotic resistance is getting increasingly serious.[4] The World Antibiotic Resistance Global Health Assembly established an agreement in May 2015 to address the danger, with the primary goal being to raise antibiotic resistance knowledge and understanding.[5]

The World Health Organization estimates that 10 million deaths will be due to AMR alone by 2050, which is greater than the number of deaths caused by cancer.[5] Around two million people across the United States are hospitalized due to antibiotic resistance, and about 23,000 people die each year of the main cause of these infections, as reported by the CDC.[6,7] Antibiotic resistance can appear worldwide and affect countries and people of all age groups.[8,9] Every country, including the Kingdom of Saudi Arabia, is in danger due to antimicrobial abuse and overuse in human treatment and food production.[9] 58% of Asia’s, 47% of Southern Europe’s, 30% of Eastern Europe’s, 25% of South America’s, and 39% of the Middle East’s antimicrobial drugs are acquired without a prescription.[10] KSA has the greatest incidence of resistant pathogens in clinical isolates in comparison to the other Gulf Corporation Council (GCC) countries.[11,12] Approximately 78% of participants in a recently conducted hospital-based cross-sectional study in Riyadh have obtained one nonprescribed antibiotic medication, at the least, which is considered as misuse.[13] Antibiotic misuse is described as a failure to complete the prescribed doses or to miss doses, reuse of the leftover, or antibiotic self-medication. Interaction between various factors, such as physician practices, patient attitudes, beliefs, knowledge of antibiotic use, self-medication, patient-physician interaction perceptions, patient expectations, and antibiotic experience.[14,15]

However, there is a strong correlation between a lack of knowledge of antibiotic use and resistance to increased use of this medication in communities. So, antibiotic use is closely linked to people’s attitudes and behaviors.[16]

To find out what education the public might need, it is important to determine the level of knowledge and attitude of the public toward the use of antibiotics. Therefore, in reducing the misuse of antibiotics and their excessive use, the public plays a significant role in either worsening or improving the condition.[17] Many studies have shown that excessive use of antibiotics is decreased and counted as effective when interventions concentrate on many levels, focused on the level of patients/guardians and physicians, including health care providers, patients, and public education, after overcoming local barriers to change.[18]

Subsequently, this research will provide insights into contributing factors such as the impact of interventions designed recently to change antimicrobial use on the patient outcome and what patient educational materials and other supportive tools impact patient behavior toward antibiotic use. The current research aimed to assess the populations’ knowledge and attitudes toward antibiotic use and antimicrobial resistance among the population of Riyadh, and to measure knowledge and attitude on antibiotic use, knowledge and attitude on antimicrobial resistance and the association between the demographic variables and knowledge level and test for significance.

Methods

A cross-sectional study was conducted among Saudi citizens and non-Saudi residents between the ages of 18 and 60 years visiting the PHC. With a 50% anticipated response rate, a 5% margin of error, and a 95% confidence level, the minimum needed sample size was determined to be 639.

Stratified random sampling was adopted to select the PHC from the four regions of Riyadh (North, East, South, and West). The participants (patients/visitors) were selected from the PHC under Health Clusters 1 and 2 in the central province of Riyadh region. The selected PHCs were North Riyadh: Prince Sultan bin Abdulaziz Primary Health Care Center—Primary Health Care Center in Al-Raed. East Riyadh: Primary Health Care Center Alhamra—Primary Health Care Center Alsalam. South Riyadh: Primary Health Care Center in Alshafa—Primary Health Care Center in Aldar Albida. West Riyadh: Primary Health Care Center in Swuaidi—Primary Health Care Center in Alzahra.

With an assumption of 80 from each PHC, participants were selected randomly. A structured Self-administered, closed-type questionnaire was distributed to the participants after they gave verbal informed consent. An experienced Physician and a Health Educator with an alpha of 0.92 standardized the standardized questionnaire [Supplement data]. It was later translated into Arabic, checked for consistency, and conducted a pilot study in a tertiary care center. The tool with 44 questions has four sections: Sociodemographic details (name, age, gender, nationality, level of education, occupation, marital status, family type, role in the family, and total number of family members), Section 2 with knowledge and attitude about antibiotic use, Section 3 on knowledge about antibiotic resistance and Section 4 about source of information and preferred method of health education. [Appendix].

Statistical analysis

SPSS 25.0 (IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp.) was used to analyze the data. The findings of variables on demographic and knowledge about antibiotics and antimicrobial resistance were presented in Descriptive Statistics—frequency, percentage, and 95% confidence interval. Pearson’s Chi-square test for categorical data and risk assessed with a 95% confidence interval are the inferential statistics. The correct response by the participant for each question was scored as “1,” and their total score and percentage were calculated. They were further classified into two groups with a knowledge level ≤50% as with “inadequate knowledge” and a knowledge level >50% as with “adequate knowledge.” Considering this binary outcome variable (knowledge level) as the response variable, we performed logistic regression analysis at level 1. The univariate Binary LR was tested on these demographic variables and in level 2 with Multivariate Binary LR for the statistically significant predictor variables at a 5% significance level. The β-value (regression coefficient) with the odds ratio and 95% confidence level were also presented.

Ethical consideration

This study was approved by the Institutional Review Board [IRB: H1R1-21-Jul19-01], adhering to the National Bioethics Committee and maintaining the confidentiality of the participants.

Results

Figure 1 shows that 65% of participants had insufficient knowledge about antibiotic use and antimicrobial resistance.

Figure 1.

Knowledge Level of Participants

Figure 2 shows that 23.5% of participants had negative attitudes toward antibiotic use and antimicrobial resistance.

Figure 2.

Attitude toward Antibiotic Use and Antimicrobial Resistance

Figure 3 shows that the most common sources of health information about antibiotic use and antimicrobial resistance were healthcare providers and community health campaigns, followed by relatives, friends, and colleagues, then newspapers, magazines, or books.

Figure 3.

Number of Participants with Their Source of Health Information

Table 1 shows the demographic characteristics of the study participants. 52.7% of participants were females, while 47.3% were males. Age was categorized into groups. 37.1% were in the age group (18-28), while 34.0% were between 29 and 39. 21.0% were between the ages of 40 and 50, while only 8.0% were between 51 and 61. The majority of them were Saudis (81.4%). More than half of the participants (59%) had a postgraduate degree. 64.2% were married, and 61.7% played the role of a parent in the family. Less than half of the participants (47.6%) were either students or unemployed, while only 5.9% worked in the healthcare sector.

Table 1.

Demographic Characteristics in Riyadh regions (n=639)

Characteristics	No. (%)	Characteristics	No. (%)
Gender		Type of Family
Female	337 (52.7%)	Nuclear	455 (71.2)
Male	302 (47.3%)	Extended	184 (28.8%)
Age Group		Role in the family
18-28	237 (37.1%)	Grandparent	19 (3.0%)
29-39	217 (34.0%)	Parent	394 (61.7%)
40-50	134 (21.0%)	Son and Daughter	226 (35.4%)
51-61	51 (8.0%)
Nationality		Educational level
Saudi	520 (81.4%)	Illiterate	9 (1.4%)
Non-Saudi	119 (18.6%)	Elementary/secondary/high school	249 (39.0%)
		Postgraduate	377 (59.0%)
Marital Status		Occupation
Single	201 (31.5%)	Unemployed and Student	304 (47.6%)
Married	410 (64.2%)	Health Care Sector	38 (5.9%)
Widowed	10 (1.6%)	Non-Health Care Sector	272 (42.6%)
Divorced	18 (2.8%)

Table 2 represents the impact of the level of education in the knowledge of antibiotics. 43% of the elementary, secondary, and high school certificate holders showed inadequate knowledge, while 0.7% were illiterate. There were three participants: illiterate, who were found to have 0.7% inadequate knowledge of antimicrobial resistance (elementary, secondary, and high). Schools have 1.2 times more inadequate knowledge than others. The type of family in Table 2 was another significant factor, and it shows a significant relationship with knowledge; therefore, the extended family was 1.4 times the risk of inadequate knowledge compared to the nuclear family. In this study (28.8%) of participants were from extended families, and the majority of them were from a nuclear family (71.2%).

Table 2.

Determinants associated with Knowledge

	Determinants (Demographics)	Knowledge
		Inadequate	Adequate	P
Gender	Female	207	130	0.020*
	Male	212	90
	Non-Saudi	86	33
	Married	265	145
	Widowed	9	1
	Divorced	12	6
Type of family	Nuclear	285	170	0.014*
	Extended	134	50
	Parent	253	141
	Son or Daughter	154	72
Educational Level	Illiterate	3	6	0.005*
	(Elementary, Secondary, High) School	179	70
	Postgraduate	234	143
Occupation	Unemployed, Student	204	100	0.044*
	HCW (Private, Governmental)	18	20
	Non-HCW (Private, Governmental)	183	89

*Statically Significant at 5% level

Table 2: Determinants associated with Knowledge

Table 3 shows the determinants associated with attitude of participants toward antibiotic use. The results show that all demographic characteristics such as gender, age, marital status, role in the family, and educational level were significant factors (P < 0.05) affecting the attitude of participants toward antibiotic use and antibiotic resistance. In addition, the younger adults showed a 5.8 higher risk of negative attitude than people above 40 years old.

Table 3.

Determinants associated with attitude

	Determinants (Demographics)	Attitude
		Negative	Positive	P
Gender	Female	63	274	0.003*
	Male	87	215
Age	18-28	81	156	0.000*
	29-39	42	175
	40-50	21	113
	51-60	6	45
	Non-Saudi	32	87
Marital Status	Single	69	132	0.000*
	Married	73	337
	Widowed	3	7
	Divorced	5	13
	Extended	44	140
Role in the Family	Grandparent	2	17	0.000*
	Parent	75	319
	Son or Daughter	73	153
	6-10	52	213
	≥11	11	22
Educational Level Occupation	Illiterate	1	8	0.000*
	(Elementary, Secondary, High) School	79	170
	Postgraduate	69	308
	HCW (Private, Governmental)	8	30
	Non-HCW (Private, Governmental)	57	215

*Statically Significant at 5% level

Table 3: Determinants associated with attitude

Table 4 shows the above-mentioned significant factors contributed to the adequate knowledge level using multivariate binary logistic regression model; that is, males had 1.5 times less adequate knowledge about antibiotics and antimicrobial resistance compared to females. Participants from the nuclear family had 1.5 times less adequate knowledge compared to those from the extended family. Those who had an educational level of elementary/secondary/high had a 1.5 times risk of inadequate knowledge compared to the postgraduates, and the unemployed were 2.2 times risk of inadequate knowledge compared to those employed in healthcare or non-health care sectors was also statistically significant.

Table 4.

Multivariate Logistic Regression Model

Variable	Inadequate Knowledge	Adequate Knowledge	β-value	Odds Ratio	95% CI
*Gender - Male	212	90	0.424	1.528*	1.07 to 2.17
-Female	207	130	-	-
*Family Type -Nuclear	285	170	0.433	1.542*
-Extended	134	50	-	-	1.04 to 2.27
*Education Level
-Elementary/Secondary/High	182	76	0.463	1.589*
- Postgraduate	234	143	-	-
*Occupation - Unemployed	204	100	0.795	2.214	1.17 to 2.28
Employed in Healthcare & Non-Healthcare Sector	201	109	-	-
*Constant	-	-	1.359	0.014*	1.11 to 4.41 -

*Statistically significant at 5% level

Discussion

The type of family was a significant factor, showing a significant relationship with knowledge; therefore, the extended family was 1.4 times the risk of inadequate knowledge compared to the nuclear family. In this study (28.8%) of participants were from extended families, and the majority of them were from a nuclear family (71.2%). Compared to another study, children living in extended families are less likely to bear immune E. coli isolates. In contrast to nuclear families, this may be attributed to the availability of appropriate medical advice on antibiotic consumption for older adults in households, which is not available in nuclear families where parents are more occupied with their responsibilities and duties.[19]

Our results showed the impact of the level of education in the knowledge of antibiotics. 43% of the elementary, secondary, and high school certificate holders showed inadequate knowledge, while 0.7% were illiterate. Three participants were illiterate and found to have 0.7% inadequate knowledge of antimicrobial resistance (elementary, secondary, and high). Schools have 1.2 times inadequate knowledge compared to others. However, GCC countries’ studies have conflicting results regarding education level impact on knowledge and attitude toward antibiotics and antibiotic resistance. The same result was found in a study conducted in Oman, where the level of education was significantly associated with the knowledge of antibiotic use.[20]

Most studies in GCC countries showed dominance in female participants compared to males in terms of population.[21] Gender was one of the factors that showed significant differences in knowledge and attitude in our study; males were 1.2 times higher than females in both inadequate knowledge and negative attitude toward antibiotic use and antimicrobial resistance. Females show better knowledge regarding antimicrobial resistance and the correct use of antibiotics than males. A similar correlation was discovered in a 2017 research on antibiotic knowledge, attitude, and practice in Riyadh. One of the main results was that females had adequate knowledge of antibiotics during pregnancy and breastfeeding.[22] Most participants chose healthcare providers as the first source of health information, as shown in Figure 3. Therefore, it could be related to the Continuous communication of females with health care providers and asking for consultations regarding antibiotics medicines during pregnancy and for children caring when infected. What reinforces this result is the answer to one of the attitude questions in our study.

Regarding whether participants are willing to visit the hospital if they have a sore throat or URTI, 396 (61.9%) of the participants answered they would head to the nearest PHC or hospital; only 163 (41.2%) were males, and 233 (58.8%) were females. So, with this willingness from females to go to hospitals once there are any symptoms of infection, a Possible explanation of the significant difference between males and females in knowledge and attitude is the frequent contact of females with healthcare providers, which might enhance their knowledge toward antibiotics.

In terms of attitude, nearly half of the studies in the Gulf Cooperation Council region found a lack of knowledge about antibiotic use and showed negative attitudes toward antibiotic utilization.[23] However, the attitude results in this study were satisfactory. (24%) of all participants had a negative attitude toward antibiotic use and antimicrobial resistance, and (76%) had a positive attitude.

The present results illustrated that younger adults showed 5.8 higher risks of negative attitudes than people above 40 years old. That might be justified by the accumulation of life experiences and a better understanding of the consequences of misuse; looking at the marital status, single/widowed/divorced have 1.8 times the risk of negative attitude compared to married. However, further studies might be needed to understand better why married couples showed a lower risk toward negative attitudes than other marital statuses. On the other hand, sons or daughters/grandparents have a 1.6 higher risk of negative attitude than parents. Our result supports this conclusion that a son or daughter/grandparents have 1.6 times the risk of a negative attitude than parents. Similarly, a study conducted in Qatar emphasized that participants who had children were more knowledgeable regarding antibiotic use than those who did not. Therefore, it was observed that parents had a greater understanding of knowledge about antibiotics.[24]

Furthermore, educational levels have a significant relationship with attitude, according to these study findings in Table 3. For example, elementary/secondary/high schools have a 1.7 times risk of negative attitude compared to illiterate and postgraduate combined. Similarly, in three studies conducted in Yemen, Saudi Arabia, and Uzbekistan, where irrational use of antibiotics was compared to the level of education, they found a direct link with the lower level of education.[25]

Limitations

The closure of this research might be affected by its limitations. There is an overrepresentation in many categories in the research. This demonstrated and affected the external validity of generalizing the result to a broader population. In this type of research, we used a self-administrated questionnaire depending on the information provided by the participants. Therefore, there is a possibility that they can over-report or under-report the desirable or maybe undesirable social behaviors.

Conclusion

The research results conclude that the Riyadh Community possibly has a high percentage of insufficient antibiotic awareness. The results may benefit the Health Education Specialists in preparing a suitable intervention to enhance the use of antibiotics in the future among patients or help Specialists in Health Promotion to establish educational programs aimed at HCWs to help them prompt their method of delivering information to the public, as they are the source of information for the community.

Conflicts of interest

There are no conflicts of interest.

Supplement data

Questionnaire

1. Social/General Information
1	Participant Name (Optional):
2	Gender:	• Female				• Male
3	Age:	• 18 - 28	• 29 - 39			• 40 - 50	• 51 - 60
4	Nationality:	• Saudi			• Non-Saudi
5	Marital State:	• Single		• Married		• Widowed	• Divorced
6	Type of family:	• Nuclear family			• Extended family
7	What are you in your family:	• Grandparent		• Parent		• Son or Daughter
8	The number of family members:
9	Educational level	• Illiterate	• (Elementary, Secondary, High) school			• Postgraduate
10	Occupation	• (1) Unemployed	• (2) Student, Specify: ………………….	Employed:
				(3) Health Care Sector: • (3.1) Private Sector, Specify:…. • (3.2) Governmental, specify:……	(4) Non-Health Care Sector: • (4.1) Private Sector, Specify:……. • (4.2) Governmental, specify:……….

2. Knowledge & Attitude: Please answer the following items:
A. Antibiotic
11	Have you ever used antibiotics?	• Yes			• No
12	When did you last use antibiotics?	• Within the last 12 months		• More than 12 months ago	• More than 10 years ago
13	Left-over antibiotics are good to keep at home in case they might be needed later on.	• Yes		• No	• Don’t know
14	It’s good to be able to get antibiotics from relatives or friends without having to see a doctor.	• Yes		• No	• Don’t know
15	Antibiotics are effective against bacteria.	• Yes		• No	• Don’t know
16	Antibiotics are effective against viruses.	• Yes		• No	• Don’t know
17	Can influenza be caused by Bacteria?	• Yes		• No	• Don’t know
18	Can influenza be caused by Viruses?	• Yes		• No	• Don’t know
19	Antibiotics speed up recovery from an Influenza.	• Yes		• No	• Don’t know
20	If you have a cough for more than a week, you often need antibiotics to treat it.	• Yes		• No	• Don’t know
21	It’s appropriate to use antibiotics when you have a sore throat because otherwise, you might catch something more serious.	• Yes		• No	• Don’t know
22	Different antibiotics are needed to cure different diseases.	• Yes		• No	• Don’t know
23	Antibiotics kill all the bacteria in the body.	• Yes		• No	• Don’t know
24	What do you do if you have sore throat or URTI?	• Nothing	• Head to the nearest PHC or hospital	• Head to pharmacy to get medication	• Head to Apothecary for herbs
25	If you have cold symptoms with fever you need Antibiotics	• Yes		• No	• Don’t know
26	In your opinion, The Doctor who always prescribe antibiotic for his patient considered as a good doctor.	• Yes		• No	• Don’t know
27	Do you need labs before starting antibiotic?	• Yes		• No	• Don’t know
B. Antimicrobial Resistance
28	Have you heard about of any of these terms? Antibiotic Resistance, Drug Resistance, Antibiotic-resistant bacteria, Superbugs and Antimicrobial	• Yes		• No	• Don’t know
29	If my symptoms not improve, I must start antibiotic	• Yes		• No	• Don’t know
30	If you get some kind of skin reaction when using an antibiotic, you should not use the same antibiotic again.	• Yes		• No	• Don’t know
31	If you feel better after half the treatment with antibiotics, you can stop taking them.	• Yes		• No	• Don’t know
32	The use of antibiotics can reduce your own capacity to fight off infections in the future.	• Yes		• No	• Don’t know
33	Humans can be resistant to antibiotics.	• Yes		• No	• Don’t know
34	Bacteria can be resistant to antibiotics.	• Yes		• No	• Don’t know
35	Viruses can be resistant to antibiotics	• Yes		• No	• Don’t know
36	If my symptoms not improve, I should seek medical advice for further assessment.	• Yes		• No	• Don’t know
37	If you get side-effects during a course of antibiotics treatment you should stop taking them as soon as possible.	• Yes		• No	• Don’t know
38	IV Antibiotic is better than oral Antibiotic.	• Yes		• No	• Don’t know
39	I agree to take IV dose of Antibiotic in the hospital. Then change it to oral Antibiotic, after being discharged.	• Yes		• No	• Don’t know
40	Resistance is a problem in Saudi Arabia today.	• Yes		• No	• Don’t know
41	Resistance is a problem in the rest of the world today.	• Yes		• No	• Don’t know

3. Community Health
Health Education “You can pick more than an answer”
42	What are your health information sources?	• (1) Health Care Providers
		• (2) Relatives/Friends/Colleagues
		• (3) Community Health Campaigns
		(4) Internet
		• (4.1) WhatsApp
		• (4.2) Twitter
		• (4.3) Snapchat
		• (4.4) Instagram
		• (4.5) Telegram
		• (5) Newspapers/Magazines/Books
		• (6) TV/Radio
		• (7) Others:
43	The preferable method to deliver information?	• (1) Visual (e.g.: Infographic, demonstrations etc.)
		• (2) Audio (Podcast, etc.)
		• (3) Written (Pamphlet, Burcher, Instruction, etc.)
		• (4) Oral (Health Care Providers, etc.)
		• (5) Audiovisual (Videos, etc.)
44	Do you think that our community needs more awareness regarding antibiotics and antimicrobial reactance?	• Yes	• No	• I don’t know

Funding Statement

Nil.