Background
Over the last 5 decades, antibiotics have proven to be an effective and decisive weapon against several diseases. Today, the emergence of pathogenic bacteria that have become resistant to antibiotics, and their spread in the human population, is a growing problem worldwide presenting a significant threat to public health in the twenty-first century, particularly in the developing countries [
1,
2]. Self-medication, incorrect prescription, inappropriate consumption and excessive use of these antimicrobial drugs could be the key factors for the increase and spread of antimicrobial resistance (AMR) in addition to other equally important social and cultural factors [
2‐
5]. This increase in antibiotic resistance will eventually diminish their therapeutic effectiveness and increase treatment failures leading to more severe illnesses with higher mortality rates [
6]. Not to mention the heavy burden this will have on the global economies as well as the different healthcare management systems [
7].
Antibiotic self-medication has become a serious concern and a leading cause of antibiotic resistance. Antibiotic self-medication can result from many factors, such as poor public knowledge and attitude towards antibiotics, easy access to antibiotics in many places and lack of awareness policies on appropriate antibiotic usage [
8]. Numerous studies have reported improper antibiotic use among university students due to self-medication and lack of adequate knowledge of antibacterial agents. Specifically, their indications, their specificity to pathogens and the compliance to dosage regiments [
9].
The assessment of knowledge, attitude and practices (KAP) on a representative sample of university students could be an efficient tool to help improve the use of antibiotics [
10]. Jairoun and colleagues (2019), after conducting a KAP study related to the use of antibiotics among university students in the United Arab Emirates, recommended in their conclusions the development of comprehensive programs and effective educational interventions to remediate the gap in the medical curriculum leading to self-medication practice [
8]. In the same year, Al-Salih and colleagues, after conducting a study about knowledge and attitude regarding antibiotic use among nursing and dentistry students in Babylon University (Iraq), have concluded that despite their knowledge about the appropriate antibiotic use, students lacked in the appropriate attitude [
11]. The same conclusion has been reached regarding professional Indian medical students by Khajuria and colleagues in 2018 [
12]. A cross-sectional questionnaire based study conducted among 2500 Chinese students regarding their KAP of antibiotics concluded that the medical curriculum improves the students’ knowledge on antibiotics. However, since senior medical students showed excessive use of antibiotics, this indicated a lack of appropriate instructions on antibiotic use in their curriculum [
13]. The attitude toward antibiotic use and resistance was average among students of International university of Africa (Sudan) despite having good knowledge as reported by Sunusi and colleagues in 2019 [
9].
Chamoun et al. have reported in 2016, based on a study about the prevalence of antibiotic resistance in 76,278 isolated bacterial strains obtained from 16 Lebanese hospitals (between the years 2013 and 2016), that antimicrobial resistance is becoming a major problem in Lebanon [
14]. In 2017, a study conducted by El Khoury and collaborators, concluded that the low educational and socioeconomic levels of parents as factors significantly associated with poor knowledge and misuse regarding antibiotics [
15]. Cheaito and colleagues, in 2014, conducted a survey among buyers of antibiotics in pharmacies. Their results show that 42% of the participants reported purchasing antibiotics without a prescription. Whereas, almost 19% of the respondents, declared referring to the advice of the pharmacist. Almost 40% justified these practices as a way to save money [
16].
To our knowledge, the evaluation of KAP about rational use of antibiotics among university students, enrolled into health related majors and non-health related majors, in Lebanon has not been assessed yet. Accordingly, the current study aims to evaluate the knowledge, attitude and practices (KAP) towards the antibiotic use and resistance among the university students with health and non-health related majors.
Discussion
Antibiotic resistance is a serious public health problem. Assessment of knowledge, attitude and practices of antibiotic use in university students can greatly impact how best to tackle the growing threat of the antibiotic resistance and its related issues [
18,
20]. In the present study, students in health related majors had better knowledge (higher percentages of correct answers) in almost all the questions related to knowledge; and, had more informed attitude towards dealing with the problem of antibiotic resistance (had higher percentages of correct answers in all questions related to attitude). Thus exhibiting a good knowledge, and satisfactory behavioural attitude towards a rational use of antibiotics. The knowledge and attitude of students in non-health majors were, as expected, less satisfactory. Strikingly, both groups of students have shown exemplary attitude when it comes to antibiotic resistance. As for practices, most of the students regardless of their majors were well aware of good practices. Our findings showed that 80.2% (
n = 381) of students in health related majors were aware that antibiotics are used to treat bacterial infections. Whereas 36.9% (
n = 101) of the students in non-health related majors were knowledgeable about the effectiveness of antibiotic against bacterial or viral infection. Moreover, the current study revealed that the large majority of students in health related majors compared to non-health majors (95.2% vs. 80.7, respectively), were knowledgeable about the timing of when to stop the antibiotics use.
In an article published in 2017 by Jamhour et al. including 400 adults’ respondents from two cities in Lebanon, they found that 61% thought that antibiotics should be taken as a common cold treatment. They also showed a significant correlation between self-medication and lower educational level. In addition, the respondents in that study who had lower knowledge about antibiotics, usually stopped antibiotics at the inappropriate time [
21]. Mouhieddine and colleagues have reported in 2015, based on a random convenience sample of 500 people in Lebanon, that 46.1% of them expressed moderate knowledge levels, where 3.5% did not know that antibiotics are not anti-viral. In this study, 56.0% of the respondents also expect the doctor to prescribe an antibiotic for the common cold [
22]. Similarly, Jifar and Ayele in 2018, reported that 83% of respondents in Harar city, Eastern of Ethiopia, replied that antibiotics speed up the recovery colds [
17]. On the other hand, Jairoun and his colleagues have reported in 2019 that the large majority of university students were aware that antibiotics can kill bacteria and can be used to cure bacterial infections [
8]. Moreover, Khajuria et al. 2019 showed that 90% of medical students agreed that antibiotics are useful for bacterial infections [
12]. Gary and colleagues, have reported in 2012, while comparing the KAP related to antibiotic use and resistance among medical and non-medical university students in Jordan, that 44% percent of non-medical students and 28.1% of medical students agreed that antibiotics could cure cold and viral infections [
23]. In Britain, 38% of respondents ignored that antibiotics cannot resolve colds [
24]. Several studies have revealed that antibiotics are more likely to be prescribed under patients’ pressure [
25]. Another study revealed widespread misconceptions about the utility of antibiotics for viral infections [
26]. This is consistent with the findings of a global survey conducted by the world health organization (WHO) in 2015 [
27]. WHO established a key strategy by engaging the prescribers and educating the public to reduce misuse of antibiotic use [
28,
29].
In our study, the majority of the students enrolled in health related majors (93.3%), were familiar with terms related to antibiotic resistance, whereas around half of non-health related major students (56.6%) were aware of such terms. Jamhour and colleagues published in 2017 that 83% of the 500 respondents in Lebanon knew that the misuse of antibiotics could result in microbial resistance [
21]. In a report published in 2015, it showed that 48.5% of respondents from Lebanon, declared continuing to take their full course of antibiotics even if their symptoms improved, underlying an alarmingly 51.5% who could stop their treatment after symptoms improvement [
22]; similar to what was found by a number of previous studies [
22,
30,
31].
In the current study, about half of the university students reported the use of antibiotics at least once in the year prior to study. A study done in Lebanon (2015) showed that 68.3% of the considered sample consumed antibiotics 1–3 times per year [
22]. Our data is more consistent with a study (53.5%) conducted in Harar city, Eastern Ethiopia [
17]. At the same time, our scores were higher than what was reported by Tesfaye (2017) who reported that 35.9% of participants consume antibiotics once during the year preceding the study [
32]. On the other hand, our finding was considerably lower than what was found in Namibia, which was 80% [
33].
The average knowledge score was significantly higher in the health major group compared to the non-health major students (
p-value≤0.001). The average attitudes score was higher in the health major group of students compared to the non-health group. When comparing our data with other studies conducted among university students, our results agree with the survey conducted among medical and non-medical Chinese university students as reported by Huang et al. 2013 where they reported that Medical students were better than non-medical students in terms of attitude, knowledge and perception on the level of public education on antibiotic use, but worse on behavior. However, they found that but senior medical students have more positive behavior on the usage of antibiotics compared with low grade medical students and non-medical students in general [
13]. Same pattern was observed by another study of medical school students scoring remarkably better than those the non-medical school in KAP towards antibiotic use and resistance [
8]. In another study, it was found that 80% of nursing and dentistry students in Babylon University, Iraq have high knowledge but inappropriate attitude [
11], results which were similarly found among Indian and Sudanese medical university students [
9,
14]. Higuita-Gutiérrez and colleagues, reported in 2020 that medical students from three medical schools in Medellin, Colombia exhibit poor knowledge regarding antibiotic use due to insufficient training with regard to antibiotic use and bacterial resistance [
34]. Whereas, Veses and colleagues in the same year, after surveying undergraduate dental students at Universidad Cardenal Herrera, concluded that awareness campaigns are needed to promote student’s use of antibiotics in young generations particularly among the pre-professional health sciences students [
35]. Interestingly, as a result of the lack of training they discovered, Tsopra et al. 2020 used a game called ‘AntibioGame’ through which students play the role of a doctor meeting patients in consultation as a promising tool for improving knowledge in antibiotic prescription [
36].
Taking all of the above into consideration, as well as our findings about the lack of appropriate knowledge among university students, irrespective of their major, when questioned about the effectiveness of antibiotics to treat urinary tract infection, malaria, and headache or fever (where the correct answers varied between 17.7 and 53.3%), we recommend that awareness programs and educative measures must be better incorporated in students’ curricula to remediate the gaps related to their knowledge about antibiotic use.
As for the attitude assessment, all students, whether they were enrolled in health or non-health related majors, agreed that AMR is a serious public health issue and that repeated use of antibiotics and insufficient knowledge could lead to antibiotic resistance. These findings were similar, though in better numbers, to the previous studies [
20,
31]. Jifar and Ayele in 2018, published in their study that 78.4% of subjects in Harar city agreed that the unnecessarily use of antibiotics can increase the antibiotic resistance [
17], 69.7% in Ethiopia [
32], 50% in Jordan [
37], and 72% in Namibia [
33]. Our presented results revealed that students with health related major had a favorable and better attitude about rational use of antibiotics compared to the group of students with non-health major. Only 68.6% (
n = 120) of the students with non-health major agreed that “a doctor is a good one even if he does not prescribe antibiotics when the patient thinks that it is needed” whereas, 83.1% (
n = 305) of the opposite group of students share the same opinion. It has been published by Mouhieddine and his colleagues that 65.1% of the 500 respondents questioned in Lebanon in 2015, referred to doctors’ prescriptions regarding antibiotics, and 22.4% declared, alarmingly, that they self-medicate [
22]. In the study of Jifar and Ayele in 2018, most respondent (90%) agreed on the need for physician consultation before purchasing antibiotics and 73.1% declared getting prescription to purchase antibiotics. This finding is just higher than study done in Saudi Arabia in which they reported, 76.6 and 66.6%, respectively for the same questions [
17]. According to Jamhour and colleagues in 2017, it is common that Lebanese get access to antibiotics without a prescription despite the high ratio of physicians to patients in Lebanon [
38]. The same pattern was observed in our study when students of different majors where questioned about the efficiency of using same antibiotics to treat same symptoms faced in a previous disease. Almost 70% of non-health related major compared to 84% of students of the second group answered this question correctly. Surprisingly, significant number of both group of students, 85.2% (
n = 202) and 94% (
n = 435) from non-health and health majoring students respectively, found it unacceptable to use antibiotics from a friend or family member to treat an infection. On the same topic, it has been reported by Jifar and Ayele in 2018 that 87.2% of respondents in Harar city in Ethiopia were aware not to keep antibiotics for future use; 90% also thought that antibiotics should not be shared among friends and family members without prior physician consultation; and 65.3% self-prescribed antibiotics translating poor knowledge and attitude toward antibiotics use [
17]. Another study reported that only 17% of participants kept antibiotics in their home for future use [
39]. A Namibian study reported that 28.5% of users kept antibiotics for future use [
40]. In India, 76% used antibiotics without prescription [
41], 32.7% in Italy [
42], 28.8% in Saudi Arabia [
43], and 9% in Hong Kong [
44]. This difference might be due to variation of regulations and their application from one country to another in addition to differences in the socio-demographical conditions. The findings presented in the current study indicate that students were not well aware of the irrational use of antibiotics, though students in health majors showed a better attitude, this is different from findings published previously [
45,
46]. Based on our sample, university students were well aware of the development of antibiotic resistance. However, the responses of the students in the present study cannot be generalized to other universities, since students could have different educational programs, skills and experiences [
47,
48]. It is indeed a striking findings of this study having such a disparity in the attitude towards antibiotic use where 100% of students, regardless their respective majors, are aware of the issue of antibiotic resistance but up to 32%, in some cases, lack the appropriate attitude, particularly among the group of students in non-health related major. In this regards, our findings are similar to those reported by Mouhieddine et al., in 2015 that 40.6% of the 500 respondents demonstrated only moderate attitudes [
22].
Our findings clearly indicate that it is urgent to limit the granted access for antibiotics in Lebanon and other developed countries. Indeed, the WHO is voicing alarms about the increasing levels of the development, worldwide, of antibiotic resistant pathogenic bacteria. In order to remediate to this major issue, the WHO issued a “Global Strategy for Containment of Antimicrobial Resistance” pressing governments and decision makers to apply and take actions as has happened in South Korea where a number of national educational campaigns on the appropriate use of antibiotics in various ways targeting the general public have been implemented [
49]. Our report shows that knowledge and attitude, of university students, towards antibiotic use and antibiotic resistance could be positively impacted, though not always sufficiently, by more specialized course material related to health. This strengthens the need of the inclusion in the curriculum of students in non-health majors of strategies allowing to get familiarized with public health issues.
Our study highlighted the possible need for knowledge-based education programs for students, especially in the non-medical or non-health related fields. Specifically, our suggestions include seminars, workshops and courses in students’ curricula the extent and effectiveness of which can be the aim of future studies. The quick implementation of awareness campaigns about knowledge and appropriate use of antibiotics seems to be a priority based on ours and others findings. In addition, health authorities should expand their investments in policy making and in a more rigorous surveillance system regarding the access to antibiotics. Awareness campaigns could be done in a number of different routes: i) through national strategies promoting vaccination and hygiene; ii) by updating curricula in universities including public health courses/ workshops in all majors; ii) through media campaigns and intervention; and, iv) through a greater proactive role for pharmacists. The absence of such strategies could result in a continuous degradation of the KAP towards antibiotic use and resistance, leading to more serious consequences on the development of AR.
Limitations of the study
The present study has a few limitations. To start with, results should be treated with caution before their generalization to the population of university students in Lebanon or the region since they are based on a cross-sectional design among a random sample of one university in Lebanon. Although the response rate was acceptable (60%), further studies with larger sample sizes and including more university and non-university students are needed to understand better the level of awareness of young adults and adolescents about the issue of antimicrobial resistance in Lebanon and the region.