Public Knowledge and Attitudes Regarding Antibiotic Use in South Korea

The era of antibiotics transformed the treatment and outcome of infectious diseases, but the overuse and misuse of antibiotics has generated unimaginable problems, primarily antibiotic resistance (Dancer, 2004; WHO, 2001; You et al., 2008). People infected with an antibiotic-resistant organism are more likely to have longer hospital stays and require treatment with second- or third-line drugs that may be less effective, more toxic and more expensive (Farrell et al., 2005; Levy, 2005).

Efforts to reduce antibiotic resistance must include educating the public on the appropriate use of antibiotics. It would be a campaign addressing the fact that antibiotics do not cure common coughs or colds. Several countries have undertaken national campaigns to modify the public's misconceptions regarding the effectiveness of antibiotics, to promote appropriate antibiotic use and prevent the development of antibiotic resistance (Andre, Vernby, Berg, & Lundborg, 2010; Curry et al., 2006; McNulty, Boyle, Nichols, Clappison, & Davey, 2007a; Woodhead & Finch, 2007; Wutzke et al., 2006).

Korea had the sixth highest antibiotic usage in OECD countries according to 2003 health insurance claim data in Korea (Kim et al., 2006). A Korean national study in 2004 (Kim et al., 2004) found that 66% of hospital doctors and 53% of primary doctors prescribed antibiotics for upper respiratory infections (URIs) and two-thirds of the general public believed that antibiotics were helpful in treating the common cold. It is necessary to encourage the general public not to ask for antibiotics without sake and advise the public that antibiotics do not work on common colds and coughs (McNulty et al., 2007a).

To fight against improper use of antibiotics and the associated resistance problems, the Korea Food & Drug Administration (KFDA) organized a National Antimicrobial Resistance Experts Committee (NAREC) in 2003. Since then, the NAREC has implemented a number of national educational campaigns on the appropriate use of antibiotics in various ways targeting the general public. These educational campaigns included the distribution of leaflets and CD-ROMs on appropriate antibiotic use and television addresses on antibiotic resistant bacteria (Kwon et al., 2006), but the general public's knowledge of and attitudes toward antibiotics including effectiveness of the campaigns conducted by KFDA have never been investigated since its launching in 2004.

Therefore, we conducted this study to assess the general public' knowledge of and attitudes toward antibiotic use.

The results of this study demonstrate that the general public has misunderstandings and a lack of knowledge about antibiotics despite national educational campaigns addressing the appropriate use of antibiotics, in comparison to previous studies (Andre et al., 2010; McNulty et al., 2007a; McNulty, Boyle, Nichols, Clappison, & Davey, 2007b; You et al., 2008). The majority of respondents in our study had correct knowledge as to the cause of common colds and coughs. However, the general public is not well informed as to the appropriate use of antibiotics, the meaning of antibiotic resistance and the spread of antibiotic resistant bacteria. In particular, 70% of respondents did not know that antibiotics do not work on most coughs and colds in comparison to a United Kingdom (UK) study (McNulty et al., 2007a) that found this proportion to be 38%. In the same UK survey, 43% of respondents, compared to 57% in our study, understood that antibiotics can kill bacteria that normally live on the skin and in the gut (McNulty et al., 2007a). Similarly, approximately two-thirds of respondents in our survey were unaware of the spread of antibiotic resistant bacteria or that not finishing a course of antibiotics could lead to antibiotic resistance.

In terms of attitude toward antibiotic use, our findings showed that 30% of respondents took antibiotics when they had a cold, which is similar to the findings (27%) reported by Van den Eng and colleagues (2003). However, most respondents in our study had misunderstandings with respect to the effects of not completing an antibiotic treatment course when compared with similar surveys. In our study, 77% of respondents reported that they would stop taking a course of antibiotics when they felt better, compared to 58% (You et al., 2008) and 13% (McNulty et al., 2007b) in other surveys. Similarly, 48% of respondents believed that taking antibiotics would lead to a quicker recovery, as compared to 32% in the UK study (McNulty et al., 2007a) and 19% in a Swedish study (Andre et al., 2010).

The inadequate level of knowledge and poor attitude of respondents in our study seems to be related to the prevalent and inappropriate use of antibiotics in Korea (Kim & Park, 1998). The majority of respondents reported that they did not know whether or not the prescribed drugs included an antibiotic. This may be due in part to the nonchalant attitude toward Korean physicians with regard to prescribing antibiotics for URIs in addition to a lack of explanation provided to patients for the antibiotics they are prescribed (Kim et al., 2004). To reduce unnecessary or improper antibiotic use, a change in beliefs held by physicians as well as the general public is critical. Current public misconceptions could put people at unnecessary risk for infection with antibiotic-resistant bacterial pathogens.

Our results identified demographic groups with poor attitudes toward antibiotic use, including persons with low educational status and those aged 40-59. Groups with inadequate knowledge regarding antibiotic use included the elderly (aged ≥60), and those of lower socioeconomic or educational status. As we found, a higher educational level has been associated with better knowledge and attitude (Parimi, Pereira, & Prabhakar, 2004; Van den Eng et al., 2003; You et al., 2008), and the elderly are less knowledgeable about antibiotics in general (McNulty et al., 2007a). A unique finding in our study was that respondents aged ≥60 had better attitudes than those aged 40-59, even though their knowledge of antibiotics was the lowest overall.

On the whole, respondents who had inadequate knowledge scores were more likely to have a poor attitude toward antibiotic use. More respondents with inadequate antibiotic knowledge than those with adequate knowledge demanded antibiotic prescriptions and were unable to identify the antibiotics among their prescribed drugs. Also, they more frequently believed that antibiotics would cure colds quickly. Multivariate analysis also showed adequate knowledge of appropriate antibiotic use was a predictor for a good attitude. Parimi et al. (2004) found that the antibiotic knowledge score did influence attitude and behavior. In that study, demanding antibiotic prescriptions and keeping these drugs at home to treat illness was higher in respondents with inadequate knowledge than in those with adequate knowledge. These findings support the idea that the provision of accurate and concrete information on antibiotics and the potential for antibiotic resistance can change attitudes and behaviors with regards to antibiotic use. An understanding of antibiotic use is important because personal decisions are based on these understandings (Norris et al., 2010). They can impact physicians' prescription behavior (Belongia, Naimi, Gale, & Besser, 2002), as well as lead to decreasing suboptimal use of antibiotics, such as using short courses and sub-therapeutic doses (Norris et al.).

Educational campaigns by the KFDA are currently being undertaken with the goal of promoting a more judicious use of antibiotics and to prevent antibiotic resistance. Results of the present study revealed that only 12% of respondents had contact with a campaign. This result showed that the national educational campaign might not be considered successful as it was intended in terms of dissemination of education. The campaign needs to be restructured by user characteristics. However, the respondents exposed to the educational campaign had a good attitude toward antibiotic use. The multivariate analysis carried out in the present study showed exposure to the national educational campaign significantly affected attitude, while it did not affect knowledge level. This finding is similar to results reported by Curry et al. (2006) in which the percentage of the general public who understood that antibiotics are ineffective in the treatment of viral infections did not change, even though there was a reduction in those wanting antibiotics for specific symptoms. They suggested that people are aware that they should not be using antibiotics to treat colds, even if they do not know the reason.

Consistent and multifaceted intervention strategies concerning appropriate antibiotic use and the problems of antibiotic resistance are needed in order to correct widespread misconceptions on antibiotic use. The benefits of public campaigns present slowly over time, suggesting the need for continual reinforcement and repetition (Wutzke et al., 2006). Strategies including use of television, newspapers, and the internet are effective modalities for public education, considering transferring time zone (Finch, Metlay, Davey, & Baker, 2004; Madle, Kostkova, Mani-Saada, Weinberg, & Williams, 2004). The focus of interventions designed to change attitudes should be placed primarily on the adults aged 40-59 and those with lower education levels. Repeated information using short, tailored slogans and cues to action would improve general knowledge on antibiotics, especially in groups with lower educational levels (Marx, Nedelmann, Haertle, Dieterich, & Eicke, 2008). Furthermore, if the aim is to reduce antibiotic use for URIs, then public education would work best when aligned with interventions aimed at physicians (Kiang et al., 2005; Wutzke et al., 2006). Educational campaigns including physicians have had a positive effect on knowledge and a reduction in the prescription of antibiotics (Kiang et al.; Wutzke et al.). Our study has several limitations. With respect to the impact of the national educational campaign, we examined knowledge and attitudes only after the national educational campaign, not before, making it difficult to detect any change over time. Additionally, it is difficult to pinpoint the direct effects of the national educational campaign as respondents may have been exposed to other information related to antibiotic use. Another limitation is that our results rely on reported rather than measured behavior. This is, however, the largest face-to-face survey of public knowledge and attitudes on antibiotic use after the national educational campaign in Korea. Reliability of attitudes in the present study was undesirable, used as tools to construct one would need to be carefully. But according to Nunnally (1978), if an instrument is in the early stages of development, particularly when dealing with measurement of a new construct, internal consistency reliabilities of .5 to .6 are sufficient. In terms of representativeness, we were able to minimize sampling error by collecting data from 1,177 respondents residing in seven major metropolitan cities in Korea using a stratified convenient sampling method. However, we did not weigh the data for the age- and sex-specific population, thus the data were unequal probability of selection. The approval of Institutional Review Board (IRB) was not obtained for this study. Since there is no anticipated risk associated with participation in this survey, the study may possibly be deemed an exemption from IRB review.

Our results show that the majority of the general public has misconceptions that include thinking of antibiotics as useful in the treatment of the common cold, and being ignorant of antibiotic effectiveness and resistance despite a national educational campaign. Many also have poor attitudes toward antibiotic use. However, the respondents exposed to the educational campaign have a good attitude toward antibiotic use.