Public knowledge and misconceptions regarding antibiotic use and resistance in Jordan

Abstract

Studying public knowledge regarding antibiotic use and resistance is beneficial in providing effective interventions to encourage responsible use of antibiotics. This study aimed to examine antibiotic misuse among Jordanian citizens and their awareness of the risks that this problem can cause. Between February 14, 2025, and May 13, 2025, an online cross-sectional survey study using Qualtrics software was conducted in Jordan. This study utilized a previously developed questionnaire tool to examine antibiotic and antibiotic resistance knowledge developed by the World Health Organization. A total of 654 participants were included in this research. The most commonly misunderstood conditions were sore throat and cold and flu, with 75.5% and 67.3% incorrectly believing they can be treated by antibiotics. The total mean score of antibiotic knowledge was 5.9 ± 2.2 out of 12 and 4.40 ± 1.3 for antibiotic resistance, indicating a moderate level of knowledge of both antibiotic use and resistance. Participants with a bachelor’s degree had significantly lower odds of antibiotic knowledge (adjusted odds ratio [AOR] = 0.52, 95% confidence interval [CI] = 0.29–0.91, P = .02). Participants who used antibiotics in the last 6 months or last year also demonstrated significantly lower odds of antibiotic knowledge (AOR = 0.49, 95% CI = 0.32–0.74, P = .001) and (AOR = 0.50, 95% CI = 0.28–0.89, P = .02), respectively. Participants with an income between 500 and 1000 had a significantly higher odds of possessing antibiotic resistance knowledge (AOR = 1.59, 95% CI = 1.01–2.51, P = .04). Participants who worked in the medical field and were university students had a significantly higher odd of antibiotic resistance knowledge (AOR = 4.54, 95% CI = 1.74–11.84, P = .002) and (AOR = 2.98, 95% CI = 1.09–8.13, P = .03), respectively. Participants who obtained their antibiotics from a doctor or nurse the last time had a significantly higher odd of possessing antibiotic resistance knowledge (AOR = 2.26, 95% CI = 1.46–3.49, P < .001). This study indicates a moderate level of knowledge of both antibiotic use and resistance among Jordanian citizens. The public has several misconceptions regarding antibiotic use, resistance, obtaining, and prescribing. Comprehensive public education programs that consider these factors and the identified misconceptions are recommended to enhance understanding regarding antibiotic use and resistance among the Jordanian public.

1. Introduction

Antibiotics are a class of antimicrobial medications used to prevent and treat bacterial infections.^[1] Thus, antibiotics are significant for public health,^[2] but they are often misused.^[3] Misuse of antibiotics includes wrong treatment duration or dosage, negligent use, or using them to treat viral infections.^[4-6] Misuse of antibiotics is associated with many negative consequences, such as increased treatment costs, mortality, morbidity, duration of hospital stays, and consumption of antibiotics.^[7,8] Hence, it is a substantial international problem^[9]; and according to the World Health Organization (WHO), it is among the leading 10 global public health problems.^[10]

Factors such as a lack of awareness, misconceptions, and self-medication practices are linked to antibiotics’ misuse.^[11] Besides, self-medication practices are frequently associated with developing medication resistance.^[12,13] The global annual deaths related to antibiotic resistance are estimated to be 5 million, according to the WHO.^[14] The high overuse and misuse of antibiotics in diverse settings are paramount contributors to antibiotic resistance.^[15] Overuse of antibiotics has resulted in the emergence and prevalence of new antibiotic-resistant pathogens,^[16-19] which influence diseases such as tuberculosis, pneumonia, septicemia, and gonorrhea.^[20] In community settings, antibiotics are widely used, dispensed, and prescribed.^[21,22]

Community pharmacists play a crucial role in the transition from physician prescription to patient utilization of medication, supporting antimicrobial stewardship. In addition to dispensing medications, pharmacists’ duties encompass patient counseling regarding dosing and adherence, in addition, they frequently serve as a primary point of contact for minor ailments.^[23]On the other hand, clinical pharmacists play a unique, stewardship-oriented role by providing structured medication counseling on administration and adherence, as well as targeted interventions. Previous literature identified that pharmacist-structured counseling and education at the point of medication dispensing can improve adherence and reduce the misuse of antibiotics.^[24]

A previous study on 4265 pharmacy students in 7 Middle Eastern countries showed a moderate level of knowledge concerning antibiotic resistance.^[25] Besides, 89.2% of the study participants agreed that antibiotic resistance is increasing.^[25] Antibiotics can be prescribed without a medical prescription in both developed and developing countries.^[26,27] In Jordan, prior studies demonstrated a high prevalence of antibiotic misuse^[28] and self-medication^[29] and diverse trends in inappropriate antibiotic dispensing and prescription.^[30-32] Studying public knowledge regarding antibiotic use and resistance is beneficial in providing effective interventions to encourage the responsible use of antibiotics,^[33] consequently decreasing problems related to inappropriate antibiotic use. Previous research in Jordan focused on specific aspects of improper antibiotic utilization, including self-medication or non-prescription antibiotic dispensing.^[28-32] However, there are limited studies that have comprehensively assessed the general public’s awareness concerning antibiotic utilization patterns and perceptions, knowledge about antibiotic resistance, public opinions on antibiotic use, resistance, and prevention measures, and public perceptions and concerns about antibiotic resistance. This research addresses these gaps simultaneously and offers a more comprehensive understanding of the factors that contribute to antibiotic misuse among the Jordanian public. Therefore, this study aimed to examine antibiotic misuse and antibiotic resistance knowledge among Jordanian citizens and their associated predictors.

2. Materials and methods

2.1. Study design and settings

Between February 14, 2025, and May 13, 2025, an online cross-sectional survey study using Qualtrics software was conducted in Jordan.

2.2. Sampling procedure

The study sample was collected using a convenience sampling technique. This study comprised eligible individuals who met the inclusion criteria and were available and willing to participate. On the first page of the questionnaire, a consent form was displayed, and the participants were informed that completing the survey was considered informed consent. Besides, the invitation letter highlighted the inclusion criteria of the study. Multiple responses per IP/device were restricted.

2.3. Study population

We asked adults aged 18 years and above who are currently living in Jordan to participate in this study. No exclusion criteria were applied based on participants’ area of residency, educational level, or other socioeconomic characteristics.

2.4. Study instrument

This study used an Arabic-translated and culturally adapted version of a previously developed WHO questionnaire tool to examine antibiotic misuse and antibiotic resistance knowledge.^[20] The questionnaire tool for this study retained all items that assessed antibiotic use, knowledge, and attitudes toward antibiotic resistance and expanded the demographic characteristics section. The questionnaire tool examined antibiotic utilization and perceptions (utilizing 6 multiple-choice questions and a yes/no format), knowledge of conditions that can be treated with antibiotics (utilizing 1 true/false format question of 12-items), participants’ knowledge about antibiotic resistance (utilizing 8 yes/no format questions), public opinions on antibiotic use, resistance, and prevention measures (utilizing eight 5-point Likert scale questions that ranged between strongly disagree to strongly agree), and public perceptions and concerns about antibiotic resistance (utilizing six 5-point Likert scale questions that ranged between strongly disagree to strongly agree). Besides, the questionnaire tool examined the demographic characteristics of the study participants such as age, gender, marital status, education level, monthly income, occupation, smoking status, comorbidities history, and when was the last time they took antibiotics, utilizing a multiple-choice questions format.

Participants’ knowledge about antibiotic resistance as mentioned above was assessed using eight yes/no format questions. For each correct answer, the participant was given a score of 1; the higher the score, the more knowledgeable the participants were about antibiotic resistance. Knowledge of conditions that can be treated with antibiotics was assessed using 1 true/false format question that asked the participants about 12 conditions. For each correct answer, the participant was given a score of 1; the higher the score, the more knowledgeable the participants were about antibiotics.

2.5. Questionnaire translation

The questionnaire was translated from English to Arabic using the forward-backward translation technique. The Arabic-translated version was then validated by an expert panel who assessed the content validity and instrument clarity and cultural appropriateness. The panel, which comprised clinical pharmacists, validated the questionnaire tool. They confirmed content validity of the tool after reviewing the instrument’s linguistic and cultural appropriateness for the targeted study population. Then, a pilot study was conducted using 40 participants from the targeted study population. Similarly, the study confirmed the clarity of the survey items. The internal consistency of the public opinions on antibiotic use, resistance, and prevention measures scale and public perceptions and concerns about antibiotic resistance was tested using Cronbach Alpha test, which measured 0.929 and 0.894, respectively, reflecting excellent internal consistencies. Furthermore, using Cronbach Alpha test the internal consistency of knowledge of conditions can be treated with antibiotics scale and knowledge about antibiotic resistance scale, measured 0.841 and 0.783, respectively. reflecting good internal consistencies.

2.6. Questionnaire tool piloting

The questionnaire instrument was evaluated and validated by clinical pharmacists at Isra University regarding the clarity and comprehensibility of the questionnaire items, as well as their face validity. The questionnaire was deemed easy to comprehend and complete. In addition, prior to applying the questionnaire on a broader scale, a pilot study was done with a number of individuals to verify its clarity.

2.7. Sample size

To estimate the required sample size for this research, we used the following formula: N = Z2 p (1−p)/d2; where N is the minimum required sample size, Z is the value for the 95% confidence interval, which was equal to 1.96; the expected proportion (which was estimated to be 0.5); and d is the margin of error (which was equal to 0.05). Based on the above, the minimum required sample size was 383 participants. The sample size provided an adequate number of events per variable (EPV) for both multivariable models (EPV ≥ 10).

2.8. Data analysis

Statistical methods were employed to analyze the data. Descriptive statistics, including frequency and percentage, were calculated for categorical variables. Multiple variable logistic regression was performed to identify factors associated with antibiotic knowledge and antibiotic resistance knowledge, treating them as dependent variables and demographic characteristics as independent variables. All demographic characteristics were included as covariates in the regression models based on previous literature that identified them as important factors associated with antibiotic-related knowledge and misuse.^{[20,31,34,35]} The results of the regression analyses are presented as adjusted odds ratios (AOR) with 95% confidence intervals (CI) and corresponding p-values identifying predictors of a higher level of antibiotic and antibiotic resistance knowledge. The total mean score of antibiotic knowledge was 5.9 ± 2.2 out of 12 and 4.40 ± 1.3 out of 8 for antibiotic resistance were utilized to define the cutoff points as the dummy variables used in the regression models. The use of the mean score was adopted as there are no validated external cutoff points to define adequate antibiotic knowledge. Furthermore, using the mean score of the study sample is considered an appropriate approach representing the central tendency of the knowledge score of the study sample itself, enhancing comparability with other studies, which is consistent with the approach adopted in previous literature.^[36,37] The level of significance was defined as α = 0.05. All calculations and analyses were carried out with the Statistical Package of Social Sciences (SPSS), version 31.0.

Multicollinearity was assessed for the 2 knowledge domains being investigated (knowledge about antibiotic resistance and knowledge of conditions that can be treated with antibiotics) using variance inflation factors (VIF) and tolerance statistics, ranging from 1.057 to 1.490 in the antibiotic use knowledge model and 1.070 to 1.480 in the antibiotic resistance knowledge model, indicating no evidence of problematic multicollinearity. No missing data were identified in the study dataset.

3. Results

A total of 654 participants were included in this research. Regarding age distribution, the majority were aged between 24 to 30 years (276; 42.2%). Most participants were female (356; 54.4%). The majority of the sample was single (369; 56.4%). Regarding education level, 463 participants (70.8%) had a bachelor’s degree. A total of 303 participants were active smokers (46.3%), and 190 (29.1%) had comorbidities. Most participants used antibiotics within the last month (272; 41.6%). Additional details about demographic characteristics are provided in Table 1.

Table 1.

Demographic characteristics of the participants.

Demographic characteristics		N	%
Age (yr)	18–23	184	28.1%
	24–30	276	42.2%
	31–40	103	15.7%
	41–50	48	7.3%
	51–60	37	5.7%
	Above 61	6	0.9%
Gender	Female	356	54.4%
	Male	298	45.6%
Marital status	Single	369	56.4%
	Married	253	38.7%
	Divorced	25	3.8%
	Widowed	7	1.1%
Education level	High school or less	109	16.7%
	Bachelor	463	70.8%
	Post graduate	82	12.5%
Monthly income (JOD)	<500	243	37.2%
	500–1000	220	33.6%
	1000–1500	138	21.1%
	Above 1500	53	8.1%
Occupation	Retired	42	6.4%
	Not working	235	35.9%
	Medical fields	110	16.8%
	Student	119	18.2%
	Other fields	148	22.6%
Smoking status	No	351	53.7%
	Yes	303	46.3%
Comorbidities	No	464	70.9%
	Yes	190	29.1%
When was the last time you took antibiotics?	Last month	272	41.6%
	Last 6 months	220	33.6%
	Last year	82	12.5%
	More than year	51	7.8%
	Never	29	4.4%

JOD = Jordanian Dinar.

3.1. Antibiotics utilization and perceptions

When asked where they obtained antibiotics the last time, 415 respondents (69.9%) got them from pharmacy, while 55 (9.3%) acquired them from street vendor, and (46;7.7%) used the internet. Regarding the appropriate time to stop taking antibiotics, 348 individuals (56.0%) believed they should stop after taking all the prescribed antibiotics, while 208 (33.5%) thought they should stop once feeling better. For those who believed it was okay to buy the same antibiotics or request them from a doctor based on prior experience, 220 respondents (35.4%) agreed. Additional details about antibiotic consumption and perceptions are provided in Table 2.

Table 2.

Antibiotics utilization and perceptions.

Antibiotics utilization and perceptions		N	%
“Where did you get the antibiotics the last time you took them”	Pharmacy	415	69.9%
	a street vendor	55	9.3%
	Internet	46	7.7%
	A friend or family member	36	6.1%
	I had stored them from an earlier time	28	4.7%
	Other	14	2.4%
“When do you think, you should stop taking antibiotics once you start treatment?”	When you start feeling better	208	33.5%
	When you have taken all the antibiotics as instructed	348	56.0%
	I don’t know	65	10.5%
“It is okay to use antibiotics that were given to a friend or family member, as long as they were used to treat the same illness”	I don’t know	189	30.4%
	False	315	50.7%
	True	117	18.8%
“It is okay to buy the same antibiotics or request them from a doctor if you are sick and they helped you improve when you had the same symptoms before”	I don’t know	172	27.7%
	False	229	36.9%
	True	220	35.4%
“In the last time you took antibiotics, did you get the antibiotics (or a prescription for them) from a doctor or nurse?”	Yes	358	60.3%
	No	236	39.7%
“In the last time you took antibiotics, did you get advice from a doctor, nurse, or pharmacist on how to take them”	Yes	395	60.4%
	No	199	33.5%

3.2. Knowledge of conditions that can be treated with antibiotics

For HIV/AIDS, 422 respondents (68.0%) believed it cannot be treated with antibiotics, while 199 (32.0%) thought it could. Regarding gonorrhea, 306 respondents (49.3%) thought it cannot be treated with antibiotics, while 315 (50.7%) answered correctly. Similarly, for urinary tract infection (UTI), 396 participants (63.8%) correctly responded it can be treated with antibiotics. The most commonly misunderstood conditions were sore throat and cold and flu, with 469 participants (75.5%) and 418 respondents (67.3%) incorrectly believing they can be treated by antibiotics. Additional details about the knowledge of conditions that can be treated with antibiotics are provided in Table 3.

Table 3.

Knowledge of conditions treatable with antibiotics.

Do you think these conditions can be treated with antibiotics?	False		True
	N	%	N	%
HIV/AIDS*	422	68.0%	199	32.0%
Gonorrhea	306	49.3%	315	50.7%
UTI	225	36.2%	396	63.8%
Diarrhea*	280	45.1%	341	54.9%
Cold and Flu*	203	32.7%	418	67.3%
Fever*	243	39.1%	378	60.9%
Malaria*	320	51.5%	301	48.5%
Measles*	337	54.3%	284	45.7%
Skin infection	244	39.3%	377	60.7%
Sore throat*	152	24.5%	469	75.5%
Body pain*	305	49.1%	316	50.9%
Headache*	357	57.5%	264	42.5%

AIDS = acquired immunodeficiency syndrome, HIV = human immunodeficiency virus, UTI = urinary tract infection.

^*False statements.

3.3. Participants’ knowledge about antibiotic resistance

The table below highlights respondents’ awareness of antibiotic resistance. For the statement “Antibiotic resistance occurs when your body becomes resistant to antibiotics and they no longer work as well,” 198 respondents (34.8%) answered correctly. Regarding the impact of antibiotic resistance on medical treatment, 248 participants (43.6%) wrongly believed it would not be difficult to treat infections caused by resistant bacteria. Additionally, 275 respondents (48.3%) correctly responded to the statement “Antibiotic resistance is only a problem for people who take antibiotics regularly.” Additional details about awareness of antibiotic resistance are provided in Table 4.

Table 4.

Participants’ knowledge about antibiotic resistance.

Participants’ knowledge about antibiotic resistance items	No		Yes
	N	%	N	%
“Antibiotic resistance occurs when your body becomes resistant to antibiotics and they no longer work as well*”	198	34.8%	371	65.2%
“Many infections are becoming increasingly resistant to treatment by antibiotics”	190	33.4%	379	66.6%
“If bacteria are resistant to antibiotics, it can be very difficult or impossible to treat the infections they cause”	248	43.6%	321	56.4%
“Antibiotic resistance is an issue that could affect me or my family”	218	38.3%	351	61.7%
“Antibiotic resistance is an issue in other countries but not here*”	305	53.6%	264	46.4%
“Antibiotic resistance is only a problem for people who take antibiotics regularly*”	275	48.3%	294	51.7%
“Bacteria which are resistant to antibiotics can be spread from person to person”	273	48.0%	296	52.0%
“Antibiotic-resistant infections could make medical procedures like surgery, organ transplants and cancer treatment much more dangerous”	189	33.2%	380	66.8%

^*False statements.

3.4. Public opinions on antibiotic use, resistance, and prevention measures

The majority of the participants (136; 23.9%) strongly agreed that people should only use antibiotics when prescribed by a doctor or nurse, while 166 participants (29.2%) agreed. Regarding the practice of keeping antibiotics and using them later for other illnesses, 169 participants (29.7%) agreed. A total of 185 participants (32.5%) agreed that doctors should prescribe antibiotics only when necessary, and 173 participants (30.4%) strongly agreed. Additional details about opinions on antibiotic use, resistance, and prevention measures are provided in Table 5.

Table 5.

Public opinions on antibiotic use, resistance, and prevention measures.

Public opinions on antibiotic use, resistance, and prevention measures items	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
“People should only use antibiotics when prescribed by a doctor or nurse”	114 (20.0%)	62 (10.9%)	91 (16.0%)	166 (29.2%)	136 (23.9%)
“Farmers should give fewer antibiotics to food-producing animals”	70 (12.3%)	73 (12.8%)	164 (28.8%)	172 (30.2%)	90 (15.8%)
“People should not keep antibiotics and use them later for other illnesses”	82 (14.4%)	80 (14.1%)	136 (23.9%)	169 (29.7%)	102 (17.9%)
“Parents should ensure that all of their children’s vaccinations are up to date”	70 (12.3%)	51 (9.0%)	103 (18.1%)	184 (32.3%)	161 (28.3%)
“People should wash their hands regularly”	54 (9.5%)	42 (7.4%)	105 (18.5%)	165 (29.0%)	203 (35.7%)
“Doctors should prescribe antibiotics only when necessary”	55 (9.7%)	52 (9.1%)	104 (18.3%)	185 (32.5%)	173 (30.4%)
“Governments should reward the development of new antibiotics”	55 (9.7%)	54 (9.5%)	130 (22.8%)	188 (33.0%)	142 (25.0%)
“Pharmaceutical companies should develop new antibiotics”	50 (8.8%)	36 (6.3%)	119 (20.9%)	221 (38.8%)	143 (25.1%)

3.5. Public perceptions and concerns about antibiotic resistance

The majority of the participants (197; 34.6%) agreed that antibiotic resistance is one of the biggest problems facing the world. Most participants (210; 36.9%) agreed that medical experts will work on solving the problem of antibiotic resistance before it becomes too serious. A total of 199 participants (35.0%) agreed that everyone needs to take responsibility for using antibiotics responsibly, and 120 participants (21.1%) also agreed. Additional details about public perceptions and concerns about antibiotic resistance are provided in Table 6.

Table 6.

Public perceptions and concerns about antibiotic resistance.

Public perceptions and concerns about antibiotic resistance	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
“Antibiotic resistance is one of the biggest problems facing the world”	67 (11.8%)	61 (10.7%)	159 (27.9%)	197 (34.6%)	85 (14.9%)
“Medical experts will work on solving the problem of antibiotic resistance before it becomes too serious”	63 (11.1%)	59 (10.4%)	149 (26.2%)	210 (36.9%)	88 (15.5%)
“Everyone needs to take responsibility for using antibiotics responsibly”	63 (11.1%)	59 (10.4%)	128 (22.5%)	199 (35.0%)	120 (21.1%)
“There is not much that people like me can do to stop antibiotic resistance”	58 (10.2%)	78 (13.7%)	176 (30.9%)	176 (30.9%)	81 (14.2%)
“I am concerned about the impact that antibiotic resistance will have on my health and the health of others”	44 (7.7%)	59 (10.4%)	166 (29.2%)	193 (33.9%)	107 (18.8%)
“I am not at risk of contracting an antibiotic-resistant infection as long as I take antibiotics properly”	54 (9.5%)	70 (12.3%)	153 (26.9%)	204 (35.9%)	88 (15.5%)

3.6. Predictors of antibiotic knowledge and resistance knowledge

The total mean score of antibiotic knowledge was 5.9 ± 2.2 out of 12 and 4.40 ± 1.3 out of 8 for antibiotic resistance, indicating a moderate level of knowledge of both antibiotic use and resistance, with 59.1% of participants meeting the adequate-knowledge threshold for antibiotic use and 89.1% for antibiotic resistance.

A multiple variable logistic regression model was developed to assess the factors influencing antibiotic knowledge and antibiotic resistance knowledge. Participants with a bachelor’s degree had significantly lower odds of antibiotic knowledge (AOR = 0.52, 95% CI = 0.29 − 0.91, P = .02). Participants who used antibiotics in the last six months or last year also demonstrated significantly lower odds of antibiotic knowledge (AOR = 0.49, 95% CI = 0.32–0.74, P = .001) and (AOR = 0.50,95% CI = 0.28–0.89, P = .02), respectively. Participants with an income between 500 and 1000 had significantly higher odds of possessing antibiotic resistance knowledge (AOR = 1.59, 95% CI = 1.01–2.51, P = .04). Participants who worked in the medical field and were university students had significantly higher odds of antibiotic resistance knowledge (AOR = 4.54, 95% CI = 1.74–11.84, P = .002) and (AOR = 2.98, 95% CI = 1.09–8.13, P = .03), respectively. Participants who obtained their antibiotics from a doctor or nurse the last time had significantly higher odds of possessing antibiotic resistance knowledge (AOR = 2.26, 95% CI = 1.46–3.49, P < .001). Further details about factors influencing antibiotic knowledge and resistance knowledge are provided in Table 7. On the other hand, participants with comorbidities had significantly lower odds of antibiotic knowledge (AOR = 0.42, 95% CI 0.27–0.64, P < .001), and participants who obtained their antibiotics from a doctor or nurse the last time also had significantly lower odds of antibiotic knowledge (AOR = 0.42, 95% CI = 0.27–0.65, P < .001).

Table 7.

Logistic regression analysis of demographic characteristics and antibiotic knowledge and resistance knowledge.

Variables		Antibiotic knowledge		Antibiotic resistance knowledge
		AOR (95% CI)	P value	AOR (95 % CI)	P value
Age (yr)	18–23	Reference category		Reference category
	24–30	1.30 (0.78–2.18)	.318	1.03 (0.61–1.74)	.917
	31–40	1.11 (0.55–2.23)	.774	1.88 (0.93–3.80)	.079
	41–50	1.92 (0.77–4.78)	.161	1.12 (0.45–2.77)	.804
	51–60	2.52 (0.89–7.09)	.080	1.81 (0.67–4.87)	.243
	Above 61	3.17 (0.35–28.95)	.306	2.46 (0.18–32.79)	.497
Gender	Females	Reference category		Reference category
	Male	0.82 (0.55–1.22)	.320	0.95 (0.64–1.43)	.818
Mrital status	Single	Reference category		Reference category
	Married	0.66 (0.42–1.05)	.077	0.79 (0.50–1.25)	.320
	Divorced	0.43 (0.15–1.25)	.121	0.89 (0.34–2.36)	.820
	Widowed	0.10 (0.01–1.05)	.055	1.04 (0.17–6.53)	.966
Education level	High school or less	Reference category		Reference category
	Bachelor	0.52 (0.29–0.91)	.023*	1.34 (0.76–2.35)	.311
	Post graduate	0.80 (0.37–1.73)	.567	1.00 (0.47–2.12)	.994
Monthly income (JOD)	<500	Reference category		Reference category
	500–1000	1.48 (0.94–2.31)	.089	1.59 (1.01–2.51)	.045*
	1000–1500	0.74 (0.44–1.25)	.256	1.53 (0.90–2.61)	.114
	Above 1500	1.06 (0.50–2.23)	.884	1.45 (0.70–2.98)	.314
Occupation	Retired	Reference category		Reference category
	Not working	0.63 (0.27–1.51)	.304	1.58 (0.65–3.82)	.308
	Medical fields	1.02 (0.40–2.60)	.973	4.54 (1.74–11.84)	.002*
	Student	0.90 (0.33–2.43)	.830	2.98 (1.09–8.13)	.033*
	Other fields	0.58 (0.24–1.41)	.231	1.92 (0.79–4.66)	.151
Smoking status	Yes	0.83 (0.56–1.23)	.354	0.85 (0.56–1.28)	.440
Comorbidities	Yes	0.42 (0.27–0.64)	<.001*	1.05 (0.68–1.62)	.823
When was the last time you took antibiotics?	Last month	Reference category		Reference category
	Last 6 months	0.49 (0.32–0.74)	.001*	1.39 (0.91–2.12)	.124
	Last year	0.50 (0.28–0.89)	.019*	0.88 (0.49–1.59)	.676
	More than year	0.55 (0.27–1.10)	.092	1.54 (0.72–3.31)	.271
In the last time you took antibiotics, did you get the antibiotics (or a prescription for them) from a doctor or nurse?	Yes	0.42 (0.27–0.65)	<.001*	2.26 (1.46–3.49)	<.001*
In the last time you took antibiotics, did you get advice from a doctor, nurse, or pharmacist on how to take them	Yes	1.41 (0.89–2.22)	.140	1.16 (0.75–1.81)	.503

AOR = adjusted odds ratio, CI = confidence interval, JOD = Jordanian Dinar.

^*P < .05.

4. Discussion

Although the antibiotic resistance burden increased in Jordan,^[38] the inappropriate use^[39] and dispensing of antibiotics without medical prescriptions^[40] continue to be high. Therefore, it is imperative to control the use of antibiotics in Jordan.^[41] Assessing public knowledge about antibiotic use and resistance can help identify related misconceptions, thereby enabling the development of targeted interventions to address antibiotic misuse and resistance problems. Consequently, our study aimed to investigate knowledge regarding antibiotic use and resistance among Jordanian citizens.

This study indicates a moderate level of knowledge of both antibiotic use and resistance among Jordanian citizens. Consistent with this, the level of knowledge about antibiotic use and resistance was moderate among the majority of public participants from Saudi Arabia^[42] and Bangladesh.^[43] Likewise, the level of knowledge of antibiotic use was moderate among parents in Jordan^[34] and among most public participants from Malaysia.^[44] On the other hand, previous studies among the public from various regions and countries,^[45-48] including Jordan,^[49,50] have documented that knowledge about antibiotics was insufficient or lacking. Knowledge regarding antibiotic use was also limited among university students in Jordan.^[51] Indeed, limited knowledge and awareness regarding antibiotics are significant contributors to antibiotic misuse.^[52] In line with this, research showed a high burden of antibiotic misuse among the Jordanian community.^[28] Misuse of antibiotics plays a substantial role in increasing global antibiotic resistance^[53]; therefore, interventions are required to improve public knowledge about the consequences of antibiotic misuse. However, such interventions are not enough to address problems because the public in America is aware of the consequences of antibiotic misuse, specifically antibiotic resistance, but they do not consider it a significant issue.^[54] Hence, comprehensive public education programs are recommended to enhance knowledge and understanding regarding antibiotic use, misuse, and resistance.^[42,50,51]

In our study, the most commonly misunderstood conditions were sore throat and cold and flu, with 75.5% and 67.3% incorrectly believing they can be treated with antibiotics. Several prior studies demonstrated similar misunderstandings about antibiotic use among diverse public communities. For instance, 86.2% of the Saudi public believed that antibiotics can treat fever, inflammation, pain, sore throat, flu, and cold^[55]; 80% of the Japanese public thought that they treat flu, cold, and viral infections^[56]; 70% of multinational public believed that they treat sore throat; 74.2% of the Jordanian public thought that they treat sore throats, flu, and cold^[57]; 67.1% of the Jordanian public believed that they treat cough and common cold^[50]; 64% of multinational public thought that they treat colds and flu^[20]; and 61.5% of the Saudi public believed that they treat viral infections (such as influenza and common cold).^[58] However, other studies found that the proportions of the public with such misunderstandings were lower than those documented among participants in our investigation and the studies mentioned above; as such misunderstandings were reported among 3%, 17%, 19%, 27%, and 38% of participants from Australia,^[59] Hong Kong,^[60] Sweden,^[61] America,^[62] and Malaysia,^[44] respectively. These differences in the level of misunderstandings about antibiotics may be attributed to various factors, including culture,^[63,64] age,^[63] level of education,^[63,64] socioeconomic status,^[63] public health campaigns,^[65] and health literacy.^[57,66] Prior studies indicate that low or gaps in antibiotic knowledge among Arab populations principally result from high self-medication with antibiotics for conditions like flu and cold.^[67-69] Thus, low levels or gaps in antibiotic knowledge are alarming because antibiotics are not effective in treating viral conditions.^[14] Consequently, education interventions regarding the use of antibiotics may help mitigate these threatening issues in Arab countries^[67] and other countries with a similar trend in antibiotic knowledge among their communities.^[54] Moreover, focusing on antibiotic indications and the appropriate time to discontinue antibiotics could be beneficial.

The public often has several misconceptions regarding antibiotic resistance.^[70,71] In this investigation, for the statement that antibiotic resistance occurs when your body becomes resistant to antibiotics and they no longer work as well, 65.2% of participants answered incorrectly. Concerning the impact of antibiotic resistance on medical treatment, 43.6% believed it would not be difficult to treat infections caused by antibiotic-resistant bacteria. Besides, 48.3% incorrectly believed that antibiotic resistance is only a problem for people who regularly take antibiotics. Prior studies showed comparable findings. For example, 93% of the Cambodian public,^[72] 81% of the Saudi public,^[73] 71% of the Cypriot public,^[74] and 76% of the multicounty public^[20] answered incorrectly about the statement that antibiotic resistance occurs when your body becomes resistant to antibiotics, and they no longer work as well. Besides, 33% of the Saudi public believed it would not be difficult to treat infections caused by antibiotic-resistant bacteria.^[73] Moreover, 93% of the Cambodian public,^[72] 72% of the Nigerian public, 58% of the Saudi public,^[73] 50% of the Cypriot public,^[74] and 44% of the multicounty public^[20] incorrectly thought that antibiotic resistance is only a problem for people who regularly take antibiotics. These differences in the percentage of the public who hold misconceptions about antibiotic resistance between studies may reflect discrepancies in education level, socioeconomic status, cultural factors, and participant age.^[63] Despite these differences, infections that resist antibiotic treatment occur when bacteria resist the antibiotic, not when the body resists it. Indeed, bacterial resistance infections can influence anyone, not only individuals who regularly take antibiotics.^[20] Also, treating these infections is challenging and linked with high rates of mortality and morbidity.^[20,75] Ultimately, the high prevalence of misconceptions about antibiotic resistance underlines the need for targeted public education initiatives to improve knowledge about antibiotic resistance.^[33] Such initiatives may also decrease the prevalence of antibiotic-resistant bacteria and related mortality and morbidity.

In the current investigation, when the participants were asked where they obtained antibiotics the last time, 69.9% got them from a pharmacy; however, 9.3% acquired them from a street vendor, and 7.7% used the internet. Besides, 60.3% of the participants got their antibiotics (or a prescription for them) from a doctor or nurse the last time. In comparison, earlier investigations have revealed that their public has better knowledge levels regarding obtaining and prescribing antibiotics. In Mexico, 97% of participants received their antibiotics from a medical store or pharmacy, and 92% got antibiotic prescriptions from a doctor or nurse.^[20] Similarly, 98% of participants from Thailand obtained antibiotics from healthcare professionals.^[76] Furthermore, a previous study in Jordan examined medication disposal and medication storage in Jordan and showed that a high proportion of the Jordanian population improperly handles their unused, leftover, or expired medications.^[77] Thus, public health campaigns are required to enhance levels of knowledge regarding obtaining and prescribing antibiotics among the Jordanian public. Also, it is imperative to ensure that healthcare providers are prescribing antibiotics appropriately and that patients do not get antibiotics from pharmacies for self-medication without prescriptions from healthcare providers, as a previous systematic review found that individuals received most self-medication antibiotics from pharmacies.^[35] Further studies are needed to assess the trust between healthcare professionals and the population, as trust between them is associated with a more responsible use of antibiotics.^[78]

The results of this study show that participants with a bachelor’s degree had significantly lower odds of antibiotic knowledge. Participants who used antibiotics in the last year or last 6 months also demonstrated substantially lower odds of possessing knowledge about antibiotics. Participants with an income between 500 and 1000 JD had significantly higher odds of possessing knowledge about antibiotic resistance. Participants who worked in the medical field and were university students had significantly higher odds of knowledge regarding antibiotic resistance. Participants who obtained their antibiotics from a doctor or nurse the last time had substantially higher odds of possessing knowledge about antibiotic resistance. Our findings are consistent with several prior studies. As mentioned before, research found that education level^[2,79,80] and socioeconomic status^[63] influence knowledge about antibiotic use and/or resistance. The literature also reveals that healthcare workers reported higher knowledge regarding antibiotic resistance.^[2,81] The lower odds of possessing knowledge about antibiotics among participants with a bachelor’s degree and those who used antibiotics in the last year or last 6 months, and higher odds of possessing knowledge about antibiotic resistance among participants who obtained their antibiotics from a doctor or nurse, may reflect the sources from which they receive antibiotic knowledge; nonprofessional sources are linked with misconceptions.^[82,83] Hence, any targeted interventions aimed at increasing knowledge about antibiotic use and/or resistance must consider these factors. Furthermore, only 20.1% of participants with a bachelor’s degree in our study sample reported that they work in medical fields, while the remaining were either students (22.9%), not working (32.0%), working in other non-medical fields (19.7%), or retired (5.4%). This highlights that bachelor’s degree holders in our study sample were dominated by participants who were either unemployed/students or working outside medical fields. This could have contributed to the low level of knowledge of antibiotics observed in this study among bachelor’s degree holders.

Participants with comorbidities had significantly lower odds of antibiotic knowledge (AOR = 0.42, 95% CI = 0.27–0.64, P < .001), and those who obtained their antibiotics from a doctor or nurse the last time also had significantly lower odds of antibiotic knowledge (AOR = 0.42, 95% CI = 0.27–0.65, P < .001). At the same time, they showed higher odds of possessing knowledge about antibiotic resistance (AOR = 2.26, 95% CI = 1.46–3.49, P < .001). This could be due to possible confounding by indication, since frequent contact with prescribers may track with chronic conditions/recent antibiotic use, which this study separately shows is associated with lower antibiotic-use knowledge.

Despite the multiple significant associations that were identified in this research, including monthly income and occupation as a student, it’s worth mentioning that they had modest effect sizes. Therefore, these findings should be interpreted carefully as exploratory rather than conclusive, as they may indicate statistical rather than practically meaningful significant associations.

The findings of this research emphasize the important role of community pharmacies as a central point for antibiotic utilization in Jordan, as the vast majority of participants in our study obtained antibiotics from pharmacies (69.9%). Despite national regulations requiring that antibiotics should be dispensed by prescription only, non-prescription dispensing is still frequently reported in Jordanian community pharmacies, often due to patient demand, economic pressures, and inadequate antimicrobial stewardship training among pharmacists. This was confirmed by previous research by Haddadin et al., which reported that one-third of antibiotics are dispensed without a prescription.^[39] There are multiple approaches that could be adopted to decrease the burden of non-prescription antibiotic practices, including incorporating structured antimicrobial stewardship training into pharmacist continuing education, as well as strengthening regulatory enforcement.

This study has limitations. The cross-sectional survey study design has a limited ability to examine causality. The online study design has limited generalizability for the study findings. Furthermore, the use of a convenience sampling technique limits the generalizability of the study findings and may be biased towards a younger population and more educated participants. Adults without reliable internet access were less likely to be represented. Furthermore, the response rate for this study cannot be estimated as the number of individuals who received the survey invitation could not be determined using the convenience sampling recruitment method. A self-administered survey study is prone to reporting bias and recall bias. In addition, social desirability bias is inherent to self-reported surveys. This research lacked behavioral outcome assessment (knowledge vs. actual antibiotic use). Besides, the use of a sample-dependent mean cutoff can reduce comparability with studies using different thresholds. Therefore, the study findings should be interpreted carefully.

5. Conclusion

This study indicates a moderate level of knowledge of both antibiotic use and resistance among Jordanian citizens. Education level, income, use of antibiotics during the last year or last 6 months, sources of antibiotic knowledge, working in the medical field, and studying at university affect the level of knowledge about antibiotic use and/or resistance. Hence, comprehensive public education programs that consider these factors and the identified misconceptions are recommended to enhance understanding regarding antibiotic use and resistance among the Jordanian public. Structured training in antimicrobial stewardship should be provided to community pharmacists, emphasizing patient counseling during medication dispensing and avoiding dispensing non-prescription antibiotics. Prescribers must be supported with continuous education on clinical guideline recommendations concerning rational antibiotic prescribing. Policymakers should reinforce prescription-only antibiotic dispensing.

Author contributions

Conceptualization: Abdallah Y. Naser, Alaa A. Alsharif.

Data curation: Abdallah Y. Naser.

Formal analysis: Abdallah Y. Naser.

Funding Acquisition: Alaa A. Alsharif.

Investigation: Abdallah Y. Naser, Sayer Al-Azzam, Alaa A. Alsharif.

Methodology: Abdallah Y. Naser.

Project administration: Abdallah Y. Naser.

Resources: Abdallah Y. Naser, Sayer Al-Azzam, Alaa A. Alsharif.

Software: Abdallah Y. Naser.

Supervision: Abdallah Y. Naser, Alaa A. Alsharif.

Validation: Abdallah Y. Naser, Alaa A. Alsharif.

Visualization: Abdallah Y. Naser, Alaa A. Alsharif.

Writing – original draft: Abdallah Y. Naser, Alaa A. Alsharif.

Writing – review & editing: Abdallah Y. Naser, Sayer Al-Azzam, Alaa A. Alsharif.