Attitudes, beliefs and knowledge concerning antibiotic use and self-medication: a comparative European study y

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1 pharmacoepidemiology and drug safety 2007; 16: Publishedonline19September2007inWileyInterScience ( ORIGINAL REPORT Attitudes, beliefs and knowledge concerning antibiotic use and self-medication: a comparative European study y Larissa Grigoryan 1 *, Johannes G. M. Burgerhof 2, John E. Degener 3, Reginald Deschepper 4, Cecilia Stålsby Lundborg 5, Dominique L. Monnet 6, Elizabeth A. Scicluna 7, Joan Birkin 8 and Flora M. Haaijer-Ruskamp 1 on behalf of the SAR consortium z 1 Department of Clinical Pharmacology, University Medical Center Groningen, University of Groningen, Antonius Deusinglaan 1, AV Groningen, The Netherlands 2 Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands 3 Department of Medical Microbiology, University Medical Center Groningen, Groningen, The Netherlands 4 Department of Medical Sociology and Health Sciences, Vrije Universiteit Brussel, Brussels, Belgium 5 Division of International Health (IHCAR), Department of Public Health Sciences, Karolinska Institutet, Stockholm and Nordic School of Public Health and Apoteket AB, Göteborg, Sweden 6 National Center for Antimicrobials and Infection Control, Statens Serum Institut, Copenhagen, Denmark 7 Infection Control Unit, St Luke s Hospital, G Mangia, Malta 8 Health Protection Agency East Midlands, Nottingham City Hospital, Nottingham, UK SUMMARY Purpose Although the relevance of cultural factors for antibiotic use has been recognized, few studies exist in Europe. We compared public attitudes, beliefs and knowledge concerning antibiotic use and self-medication between 11 European countries. Methods In total, 1101 respondents were interviewed on their attitudes towards appropriateness of self-medication with antibiotics and situational use of antibiotics, beliefs about antibiotics for minor ailments, knowledge about the effectiveness of antibiotics on viruses and bacteria and awareness about antibiotic resistance. To deal with the possible confounding effect of both use of self-medication and education we performed stratified analyses, i.e. separate analyses for users and non-users of self-medication, and for respondents with high and low education. The differences between countries were considered relevant when regression coefficients were significant in all stratum-specific analyses. Results Respondents from the UK, Malta, Italy, Czech Republic, Croatia, Israel and Lithuania had significantly less appropriate attitudes, beliefs or knowledge for at least one of the dimensions compared with Swedish respondents. The Dutch, Austrian and Belgian respondents did not differ from Swedish for any dimension. Conclusions The most pronounced differences were for awareness about resistance, followed by attitudes towards situational use of antibiotics. Awareness about antibiotic resistance was the lowest in countries with higher prevalence of resistance. Copyright # 2007 John Wiley & Sons, Ltd. * Correspondence to: L. Grigoryan, Department of Clinical Pharmacology, University Medical Center Groningen, University of Groningen, A. Deusinglaan 1, 9713 AV Groningen, The Netherlands. l.grigoryan@umcutrecht.nl y No conflict of interest was declared. z The SAR-consortium: Antonella Di Matteo (Consorzio Mario Negri Sud, Santa Maria Imbaro, Chieti, Italy); Arjana Tambic-Andrasevic (University Hospital for Infectious Diseases, Zagreb, Croatia); Retnosari Andrajati (Faculty of Pharmacy, Charles University, Prague, Czech Republic); Hana Edelstein (Ha Emek Medical Center, Afula, Israel); Rolanda Valinteliene (Institute of Hygiene, Vilnius, Lithuania); Reli Mechtler (University of Linz, Linz, Austria); Luc Deliens (Vrije Universiteit Brussel, Brussels, Belgium); and Greta Van der Kelen (Vrije Universiteit Brussel, Brussels, Belgium). Copyright # 2007 John Wiley & Sons, Ltd.

2 DIFFERENCES IN ATTITUDES TOWARDS ANTIBIOTIC USE IN EUROPE 1235 key words attitude; knowledge; antibiotic use; Europe; antibiotic resistance Received 5 February 2007; Accepted 11 August 2007 INTRODUCTION Large variations in outpatient antibiotic use between countries have been reported. 1,2 It has been suggested that cultural determinants may have an impact on differences in outpatient antibiotic use in the United States (US) and Germany 3,4 resulting in different resistance prevalences in respiratory pathogens on a national level. Different opinions and traditions regarding how to treat infectious conditions in different countries have been described. 5 Studies in the US reported ethnic and cultural differences in levels of public knowledge and attitudes concerning antibiotic use and awareness of antibiotic resistance. 6 8 A first Pan-European study in five EC countries and Turkey conducted in 1993, 9 and extended to other continents, 10 suggested that patients attitudes towards antibiotic use varied according to their country of residence. In particular, the proportion of patients definitely expecting to receive antibiotics for respiratory tract infections was highest in Turkey, France and Spain among European countries. However, this survey did not test if differences were statistically significant between countries. Moreover, no attention was given to attitudes towards self-medication with antibiotics, which varies widely between countries, 11 awareness about antibiotic resistance and knowledge about effectiveness of antibiotics on bacteria and viruses. Understanding cultural differences in the public s attitudes, beliefs and knowledge is a pre-requisite to develop effective educational interventions. The aim of this study was to explore attitudes, beliefs and knowledge concerning antibiotic use and selfmedication and compare them between countries. SUBJECTS AND METHODS Subjects Face to face structured interviews were conducted in 12 countries. Countries were selected to represent Northern/Western (Austria, The Netherlands, Sweden, United Kingdom and Belgium), Southern (Italy, Malta, Israel and Spain) and Eastern (Czech Republic, Lithuania and Croatia) European regions. Because of data collection problems, Spain was excluded from the analyses. Data were collected between October 2003 and May 2004, after approval of the appropriate institutional review boards. This study is a follow-up from a European survey estimating prevalence of both self-medication and prescribed use of antibiotics. In this previous survey we used a multi-stage sampling design. Within each country, a region with average prescribed antibiotic consumption was chosen and in each chosen region a middle-sized city and rural area were selected. Questionnaires were mailed to randomly selected adults in each country, who were equally distributed in urban and rural areas. The characteristics of the respondents in each country and the prevalence rates of self-medication and prescribed use in each country are described elsewhere. 11 This follow-up study was limited to respondents in 12 countries willing to be interviewed. We aimed to recruit at least 100 respondents in each country, 50 users of self-medication and 50 non-users, both equally distributed in urban and rural areas. If the number of self-medication users willing to be interviewed was less than 50 in a country, non-users of self-medication were added to achieve 100 respondents. In Lithuania, the number of non-users willing to be interviewed did not reach 50, therefore, self-medication users were added. Respondents who failed to identify antibiotics correctly (for example confusing antibiotics with painkillers) were excluded from the study. Survey instrument We developed an English structured interview, translated it into national languages, and back translated it into English to ensure consistency. Pretesting of the questions took place in each country. Interviewers from all countries were trained in a collaborative workshop. The first two interviews with respondents were training interviews and were immediately followed by an in depth discussion between the trainer and the interviewer. These first two interviews were excluded from the analysis. The questions included attitudes towards antibiotic use and self-medication with antibiotics, beliefs about antibiotics for minor ailments, knowledge about the

3 1236 l. grigoryan ET AL. Table 1. Item y Exploratory factor analysis Factor loading Just imagine you have bronchitis. How appropriate is it in your view to get antibiotics without a prescription?...over the weekend in a normal situation Over the weekend with an important event coming up On holiday abroad You have no time to go to the doctor When it is difficult to contact the doctor When the doctor has no time to see you immediately When a consultation with a doctor is too expensive When you have a good experience with taking this 0.4 antibiotic...when your doctor always prescribes you this antibiotic 0.4 When the pharmacist advises you which antibiotic to take 0.5 When one has a sore throat, one should take antibiotics to 0.6 prevent getting a more serious illness When one gets a cold, antibiotics help to get better more quickly 0.7 By the time you yourself are sick enough to visit a doctor with a 0.5 bad cold, you usually expect a prescription for antibiotics You usually know if you yourself need an antibiotic for a sore 0.4 throat before seeing a doctor Most of your friends/relatives think people should take an 0.5 antibiotic for a cold The use of antibiotics when you are sick in order to remain active 0.7 (work, family or study) is appropriate The use of antibiotics when you are sick for helping to get through 0.7 an important event (exam, funeral or wedding) is appropriate Antibiotics can kill bacteria 0.5 Antibiotics can kill viruses 0.6 Cronbach alpha a ¼ 0.9 a ¼ 0.7 a ¼ 0.8 a ¼ 0.4 Mean inter-item correlation Note: Only loadings with an absolute value >0.40 are shown in the table. Factor 1, attitudes towards appropriateness of self-medication with antibiotics for bronchitis (1¼ completely inappropriate and 5 ¼ completely appropriate ); factor 2, beliefs about antibiotics for minor ailments (1 ¼ strongly disagree and 5 ¼ strongly agree ); factor 3, attitudes towards situational use of antibiotics(1 ¼ strongly disagree and 5 ¼ strongly agree ); factor 4, knowledge about the effectiveness of antibiotics on bacteria and viruses (1 ¼ strongly disagree and 4 ¼ strongly agree ). For this item coding was reversed (1 ¼ strongly agree and 4 ¼ strongly disagree ). y Three statements were not included because of low loadings on all factors. effectiveness of antibiotics on bacteria and viruses and awareness of any health dangers associated with taking antibiotics. Each of these domains was assessed with a series of items, partly derived from other studies. 8,12,13 The instrument contained 5-point Likert scale statements (Table 1) and one open ended question. Respondents knowledge about health dangers associated with taking antibiotics was assessed with an open-ended question, Are you aware of any health dangers to your health or the health of other people associated with taking antibiotics? derived from another study. 12 We classified the answers into two categories: knowledge of antibiotic resistance and knowledge of adverse effects of antibiotics (including allergies/reactions, antibiotics may kill friendly / good flora, diarrhoea, vomiting etc.). Sociodemographic information included age, sex, educational level, presence of a chronic disease and place of residence (rural or urban). Education was categorised as low (incomplete primary education, completed primary education and lower vocational or general education) or high (intermediate or higher vocational or general education, college or university). Respondents were asked whether they had ever taken an antibiotic without a prescription. They were classified as users of self-medication if they reported that they had ever taken any antibiotic without a prescription from a physician, dentist or a nurse.

4 DIFFERENCES IN ATTITUDES TOWARDS ANTIBIOTIC USE IN EUROPE 1237 Construction of scales measuring attitudes and beliefs An exploratory factor analysis was performed to demonstrate the dimensionality of the data. The selection of the number of components to be rotated was based on the eigenvalue greater than 1 criterion. We set a cut-off value of 0.40 for factor loadings as inclusion criterion in a factor. After Varimax rotation factor analyses revealed four underlying constructs, which were consistent with the conceptual basis for the scales (Table 1). Reliability of each subset of items was computed using Cronbach s alpha and mean inter-item correlation. As described in Table 1, all four scales showed satisfactory reliability. The first scale was attitudes towards appropriateness of selfmedication with antibiotics for bronchitis (Table 1). Bronchitis was chosen because antibiotics might be indicated for treatment 14 and it is considered as a serious illness by lay people. 15 The other scales were: beliefs about antibiotics for minor ailments (Table 1), attitudes towards situational use of antibiotics and knowledge about the effectiveness of antibiotics on bacteria and viruses. The mean scores were computed for each scale, after reversing those items that were worded in opposite direction (i.e. antibiotics can kill bacteria ). Higher scores for each scale represented less appropriate attitudes, beliefs or knowledge. Ethics approval Ethics or data committee approval for the survey was required in six countries (Belgium, United Kingdom, Malta, Czech Republic, Croatia and Lithuania) and was obtained from the local ethics or data committees of these countries. DATA ANALYSES To analyse the differences between countries, regression analyses were used with the outcome variable being each of the dimensions of attitudes, beliefs and knowledge. Multiple linear regression analysis was used for continuous variables (attitudes towards appropriateness of self-medication with antibiotics for bronchitis, beliefs about minor ailments, attitudes towards situational use of antibiotics and knowledge about the effectiveness of antibiotics on bacteria and viruses) and logistic regression for binary variables (knowledge of antibiotic resistance and adverse effects of antibiotics). The number of users and non-users of selfmedication as well as those with low and high education willing to be interviewed differed between countries. To deal with the possible confounding effect of both use of self-medication and education, we performed stratified analyses, i.e. studying the differences between the countries separately for users and non-users of self-medication, and for participants with high and low education. The differences between countries were considered relevant when regression coefficients were significant in all stratum-specific analyses. The effects of other possible confounding variables (presence of a chronic disease, gender, age and place of residence) were considered in all analyses. Sweden was used as a reference country in all analyses as it has the lowest prevalence of total antibiotic use (prescribed use and self-medication). 11 Data were analysed using SPSS (version 12) for Windows (SPSS, Inc, Chicago, IL). RESULTS In total 1101 respondents were interviewed. The mean-response rate of the countries was 89%. General characteristics of the respondents in each country are shown in Table 2. The number of users of selfmedication differed between the countries because of the variation in both prevalence of self-medication and willingness to be interviewed between the countries (Table 2). In comparison to the respondents in the previous survey, 11 interviewees in the follow-up study more often had a high education, but were similar with regard to age, sex, presence of a chronic disease and place of residence (urban/rural). Eleven respondents who failed to identify what was an antibiotic were excluded from the analyses. There was a wide variation in the percentage of respondents who answered incorrectly to at least 75% of the items for each dimension between the countries (Table 3). In most of the countries this percentage was low. High percentages were obtained in Lithuania and Malta for three dimensions. In the UK high percentage was found regarding the attitudes towards appropriateness of self-medication with antibiotics for bronchitis. More inadequate knowledge was reported about the effectiveness of antibiotics on viruses (on average, 54% of the respondents answered incorrectly) than on bacteria (22% answered incorrectly, data not shown). Overall, non-awareness of antibiotic resistance was high (approximately half of the respondents) with a wide variation between countries, from 87% in Malta to 29% in Belgium. Non-awareness of adverse effects

5 1238 l. grigoryan ET AL. Table 2. General characteristics of interviewees in each participating European country Low education Presence of Urban level (%) a chronic diseases (%) y location (%) Female (%) Mean age (years SD) No. users of self-medication No. respondents interviewed Country Response rate (%) Northern and Western The Netherlands Sweden Austria Belgium United Kingdom Southern Malta Israel Italy Eastern Czech Republic Croatia Lithuania Low education was defined as incomplete primary education, completed primary education and lower vocational or general education. y Including any of the following diseases: asthma, chronic bronchitis, emphysema, HIV, cystic fibrosis, diabetes, endocarditis, tuberculosis, prostatitis, chronic urinary tract infection, chronic osteomyeltis, peptic ulcer disease, chronic pyelonephritis or cancer. of antibiotics was also high (48%) with less variation between countries (Table 3). Country of residence was associated with each dimension of attitudes, beliefs and knowledge when adjusting for use of self-medication, education, presence of a chronic disease, sex, age and place of residence (Tables 4 and 5). Differences significant in all stratum-specific analysis were found for the UK, Malta, Italy, Czech Republic, Croatia, Israel and Lithuania. Respondents from these countries were consistently significantly different compared with respondents from Sweden for at least one of the dimensions (Tables 4 and 5). The Dutch, Austrian and Belgian respondents were not significantly different from Swedish for any of the dimensions. Lithuanian interviewees responded differently on the most dimensions from Swedish, with more positive attitudes towards both self-medication and situational use of antibiotics, stronger beliefs in antibiotics for minor ailments and less knowledge about both antibiotics and antibiotic resistance. Similar significant differences were noted in Malta with the exception of attitudes towards appropriateness of self-medication for bronchitis. In particular, beliefs in antibiotics for minor ailments were very strong in Malta (Table 4). Italian interviewees had more positive attitudes towards situational use of antibiotics and less knowledge of both antibiotics and antibiotic resistance. More positive attitudes towards self-medication and situational use of antibiotics and lower knowledge of antibiotic resistance were noted in Croatia. Interviewees in the UK, Czech Republic and Israel differed only in one dimension from Sweden, indicating more positive attitudes towards selfmedication in the UK and Czech Republic and lower knowledge of antibiotic resistance in Israel. No country was significantly different from Sweden concerning awareness about adverse effects of antibiotics (data not shown). DISCUSSION Our survey results showed significant differences in levels of public attitudes, beliefs and knowledge concerning antibiotic use, self-medication and antibiotic resistance in Europe. Respondents from all participating Southern and Eastern countries had less appropriate attitudes, beliefs or knowledge compared with Swedish respondents at least for one of the dimensions. With the exception of the UK, respondents from Northern and Western countries did not differ from respondents in Sweden for any of the

6 DIFFERENCES IN ATTITUDES TOWARDS ANTIBIOTIC USE IN EUROPE 1239 Table 3. Percentage of interviewees who had inappropriate attitudes, beliefs and knowledge concerning antibiotic use, self-medication and antibiotic resistance by country Country Percentage of interviewees who answered to at least 75% of the items in the dimension incorrectly Percentage of interviewees who answered incorrectly Attitudes towards appropriateness of self-medication with antibiotics for bronchitis Beliefs about antibiotics for minor ailments Attitudes towards situational use of antibiotics Knowledge about the effectiveness of antibiotics on bacteria and viruses Awareness about antibiotic resistance Awareness about adverse effects Sweden The Netherlands Austria Belgium United Kingdom Malta Israel Italy Czech Republic Croatia Lithuania Overall Percentage of respondents who answered completely appropriate or appropriate to at least 75% of the items for attitudes towards appropriateness of self-medication with antibiotics for bronchitis; strongly agree or agree to at least 75% of the items for beliefs about antibiotics for minor ailments, attitudes towards situational use of antibiotics; and strongly disagree or disagree to antibiotics can kill bacteria and strongly agree or agree for antibiotics can kill viruses.

7 1240 l. grigoryan ET AL. Table 4. Results of multiple regression analyses relating respondent characteristic to attitudes, beliefs and knowledge Predictors Attitudes towards appropriateness of self-medication with antibiotics for bronchitis Beliefs about antibiotics for minor ailments Attitudes towards situational use of antibiotics Knowledge about the effectiveness of antibiotics on bacteria and viruses b CI b CI b CI b y CI Country Sweden Referent Referent Referent Referent United Kingdom 1.04 (0.80; 1.28) Malta 1.25 (1.06; 1.44) 1.00 (0.73; 1.27) 1.04 (0.84; 1.23) Italy 0.54 (0.25; 0.82) 0.57 (0.37; 0.77) Israel Czech Republic 0.41 (0.17; 0.65) Croatia (0.02; 0.41) 0.85 (0.57; 1.13) Lithuania 1.04 (0.79; 1.28) 0.62 (0.43; 0.82) 0.84 (0.56; 1.12) 0.69 (0.50; 0.89) The Netherlands Austria Belgium No use of self-medication Referent Referent Referent Referent Use of self-medication with antibiotics 0.64 (0.51; 0.77) 0.39 (0.29; 0.49) 0.31 (0.16; 0.46) 0.11 ( 0.22; 0.01) Low education Referent Referent Referent Referent High education 0.20 ( 0.30; 0.10) 0.24 ( 0.38; 0.10) 0.25 ( 0.35; 0.15) Note: b ¼ regression coefficient; CI ¼ 95% confidence interval; Higher coefficients indicate more positive attitudes towards self-medication and situational use of antibiotics; stronger beliefs in antibiotics for minor ailments; and less knowledge about the effectiveness of antibiotics on bacteria and viruses. Not significant. Not significant in all stratum-specific analyses (by education and by self-medication). Adjusted for place of residence (rural/urban). y Adjusted for sex. Presence of a chronic disease and age were not significant in any of the analyses.

8 DIFFERENCES IN ATTITUDES TOWARDS ANTIBIOTIC USE IN EUROPE 1241 Table 5. Logistic regression analysis of awareness about antibiotic resistance Predictors OR 95% Confidence intervals Country Sweden Reference Israel 0.40 (0.21; 0.75) Italy 0.21 (0.11; 0.43) Malta 0.10 (0.05; 0.22) Croatia 0.32 (0.17; 0.60) Lithuania 0.09 (0.04; 0.18) Education Low education Referent High education 2.44 (1.71; 3.46) Note: lower OR indicates poor awareness about antibiotic resistance. The Netherlands, Austria, UK, Belgium and Czech Republic were not significantly different from Sweden in the stratified analyses. Use of self-medication, sex and age were not significant. Adjusted for presence of a chronic disease and place of residence (rural/urban). dimensions. British respondents had more positive attitudes towards self-medication with antibiotics for bronchitis. This finding is in line with the results of a survey conducted in the UK showing that respondents had great expectations for antibiotics for the symptoms of acute lower respiratory tract illness. In particular, 72% of previously well adults consulting with these symptoms wanted a prescription for antibiotics from their general practitioner. 16 Other countries demonstrating more positive attitudes towards self-medication for bronchitis were Lithuania and Czech Republic. Evidence indicates that patients may influence antibiotic prescribing through overt requests for antibiotics or non-overt pressure We found that respondents in Southern and Eastern countries had stronger beliefs about the need for antibiotics for minor ailments, more positive attitudes towards use of antibiotics in different situations and less accurate knowledge about the effectiveness of antibiotics in killing bacteria and viruses. Higher levels of misconceptions in Southern and Eastern countries may in some part explain the high levels of antibiotic use seen in these countries. 11 The most pronounced differences between countries were for awareness about antibiotic resistance, followed by attitudes towards situational use of antibiotics. In general, there was no consistency between all dimensions, i.e. higher score on one dimension did not lead to higher scores for the other dimensions. The respondents from Northern and Western countries were similar in their beliefs about antibiotics for minor ailments. A study comparing patients views on respiratory tract symptoms and antibiotics in The Netherlands, UK and Belgium also found that the respondents in these three countries were similar in their perception of effectiveness of antibiotics to prevent these symptoms from deteriorating and to speed recovery. 21 Overall, only half of the respondents in our survey were aware about antibiotic resistance. This awareness was the lowest in countries with higher prevalence of resistance. Our average results for Europe are comparable to the US data from , reporting that 48% of the respondents being aware of health dangers associated with taking antibiotics of whom 58% were aware of antibiotic resistance. 12 Other US data have shown much higher levels of such awareness (73% in Colorado), but this could be due to a difference in methodology in the latter study that used a closed-response statement instead of an open question. 6 Differences in implementing drug regulations that affect the availability of antibiotics in different countries can play an important role in misconceptions about antibiotics. 7 In the US, recent immigrants from Mexico, where antibiotics are available over the counter, had the greatest expectations for antibiotics for upper respiratory infections and the least understanding of the problem of inappropriate use and antibiotic resistance. 6 Our study indicates high levels of misconceptions concerning antibiotic use and resistance in Southern and Eastern European countries where acquisition of antibiotics from pharmacies without prescription occurs frequently, 11 despite the fact that this is against the law. In addition to these regulatory aspects, other differences in health care systems such as drug prices and reimbursement policies may also influence the attitudes of the public towards antibiotic use and self-medication. The results of our study are limited by small sample size in each country. The selection of the samples was non-random and the samples of the countries differed in the proportion of both users of self-medication and respondents with high education. To deal with possible confounding effects of both self-medication use and education, we used a conservative approach considering as relevant only those differences which were significant in all stratum-specific analyses. As a consequence, we might have underestimated differences between countries. Our results indicate that, while the inappropriate attitudes and knowledge in the other domains are clustered in a few countries, lack of awareness of antibiotic resistance and adverse effects is a problem in all the participating European countries. This is an

9 1242 l. grigoryan ET AL. indication that most people in these countries still do not realize enough that excessive use of antibiotics is associated with serious risks affecting individuals as well as the ecosystem as a whole. 22 Continuous efforts are needed to reduce these misconceptions. Strategies to improve the situation, however, will have to be country-specific in view of the different problems identified in this study. Such attitude shifts have occurred before for example in public s beliefs about tobacco use and saturated fat consumption. 22 Public-education campaigns have been shown to be effective in changing attitudes and knowledge about antibiotic use and resistance as well. 18,23 This will require concerted action of the medical world in collaboration with patient organisations and policy makers with a long-term view. Our study indicates that the need for public-education campaigns is strong in countries reporting high resistance levels, i.e. Southern and Eastern European countries. One single campaign, however, may not be enough for changing the attitudes of the general public. A national campaign targeting both the general public and health professionals was undertaken in Malta in However, despite the efforts of this campaign, we found high levels of misconceptions concerning antibiotic use in Malta in our study. This campaign was done only once using posters, brochures and sporadic media slots to inform the public. More intensive (such as involving the mass media or other multi-faceted approaches) and focused strategies should be used, which have been found to be effective. 18 In contrast to Malta, a national Swedish project named STRAMA 25 has been continuously implementing activities in multi-disciplinary groups including prescribers, pharmacists and general public since Although not proved, it is believed that STRAMA through its activities has had a positive effect on increasing the knowledge in Sweden regarding antibiotic use and resistance. Repeated national campaigns were also conducted in Belgium. 26 In our study awareness about antibiotic resistance was the highest in Belgium, which might be related to these campaigns. In conclusion, our study showed clear cultural differences in levels of public attitudes, beliefs and knowledge concerning antibiotic use, self-medication and antibiotic resistance in 11 European countries. The levels of misconceptions contributing to inappropriate use were the highest in Southern and Eastern countries, indicating a strong need for public education campaigns in these countries. Awareness about antibiotic resistance was the lowest in countries reporting high prevalence of resistance. KEY POINTS We found cultural differences in public attitudes, beliefs and knowledge concerning antibiotic use, self-medication and antibiotic resistance in 11 European countries. The levels of misconceptions contributing to inappropriate use were the highest in Southern and Eastern countries, indicating a strong need for public education campaigns in these countries. Awareness about antibiotic resistance was the lowest in countries reporting high prevalence of antibiotic resistance. ACKNOWLEDGEMENTS This study was funded by a grant from DG/Sanco of the European Commission (SPC ), the European Commission Public Health Directorate DG SANCO and the participating institutions. REFERENCES 1. Goossens H, Ferech M, Vander Stichele R, Elseviers M. Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. Lancet 2005; 365(9459): Albrich WC, Monnet DL, Harbarth S. Antibiotic selection pressure and resistance in Streptococcus pneumoniae and Streptococcus pyogenes. Emerg Infect Dis 2004; 10(3): Harbarth S, Albrich W, Goldmann DA, Huebner J. Control of multiply resistant cocci: do international comparisons help? Lancet Infect Dis 2001; 1(4): Harbarth S, Albrich W, Brun-Buisson C. Outpatient antibiotic use and prevalence of antibiotic-resistant pneumococci in France and Germany: a sociocultural perspective. Emerg Infect Dis 2002; 8(12): Llor C, Bjerrum L. Background for different use of antibiotics in different countries. Clin Infect Dis 2005; 40(2): Corbett KK, Gonzales R, Leeman-Castillo BA, Flores E, Maselli J, Kafadar K. Appropriate antibiotic use: variation in knowledge and awareness by Hispanic ethnicity and language. Prev Med 2005; 40(2): Cummings KC, Rosenberg J, Vugia DJ. Beliefs about appropriate antibacterial therapy, California. Emerg Infect Dis 2005; 11(7): Belongia EA, Naimi TS, Gale CM, Besser RE. Antibiotic use upper respiratory infections: a survey of knowledge, attitudes, and experience in Wisconsin and Minnesota. Prev Med 2002; 34(3): Branthwaite A. Pan-European survey of patients attitudes to antibiotics and antibiotic. J Int Med Res 1996; 24(3): Pechere JC. Patients interviews and misuse of antibiotics. Clin Infect Dis 2001; 33(Suppl 3): S170 S173.

10 DIFFERENCES IN ATTITUDES TOWARDS ANTIBIOTIC USE IN EUROPE Grigoryan L, Haaijer-Ruskamp FM, Burgerhof JGM, et al. Self-medication with antimicrobial drugs in Europe. Emerg Infect Dis 2006; 12(3): Vanden Eng J, Marcus R, Hadler JL, et al. Consumer attitudes and use of antibiotics. Emerg Infect Dis 2003; 9(9): Collett CA, Pappas DE, Evans BA, Hayden GF. Parental knowledge about common respiratory infections and antibiotic therapy in children. Southern Med J 1999; 92(10): Wong DM, Blumberg DA, Lowe LG. Guidelines for the use of antibiotics in acute upper respiratory tract infections. Am Fam Physician 2006; 74(6): Deschepper R, Vander Stichele RH, Haaijer-Ruskamp FM. Cross-cultural differences in lay attitudes and utilisation of antibiotics in a Belgian and a Dutch city. Patient Educ Couns 2002; 48(2): Macfarlane J, Holmes W, Macfarlane R, Britten N. Influence of patients expectations on antibiotic management of acute lower respiratory tract illness in general practice: questionnaire study. BMJ 1997; 315(7117): Scott JG, Cohen D, DiCicco-Bloom B, Orzano AJ, Jaen CR, Crabtree BF. Antibiotic use in acute respiratory infections and the ways patients pressure physicians for a prescription. JFam Pract 2001; 50(10): Finch RG, Metlay JP, Davey PG, Baker LJ. Educational interventions to improve antibiotic use in the community: report from the International Forum on Antibiotic Resistance (IFAR) colloquium, Lancet Infect Dis 2004; 4(1): Davey P, Pagliari C, Hayes A. The patient s role in the spread and control of bacterial resistance to antibiotics. Clin Microbiol Infect 2002; 8(Suppl 2): Borg MA, Scicluna EA. Over-the-counter acquisition of antibiotics in the Maltese general population. Int J Antimicrob Agents 2002; 20(4): van Duijn H, Kuyvenhoven M, Jones RT, Butler C, Coenen S, Van Royen P. Patients views on respiratory tract symptoms and antibiotics. Br J Gen Pract 2003; 53(491): Avorn J, Solomon DH. Cultural and economic factors that (mis)shape antibiotic use: the nonpharmacologic basis of therapeutics. Ann Intern Med 2000; 133(2): Madle G, Kostkova P, Mani-Saada J, Weinberg J, Williams P. Changing public attitudes to antibiotic prescribing: can the internet help? Inform Prim Care 2004; 12(1): National antibiotic campaign in Malta icunit/icuantibiotic.asp (20 December 2006, date last accessed). 25. The Swedish Strategic Programme for the Rational Use of Antimicrobial Agents (STRAMA) (20 December 2006, date last accessed). 26. Bauraind I, Goossens H, Hendrickx E, et al. Two years of national public campaigns to promote apporpiate use of antibiotics in the community in Belgium [Abstract A-1362]. In Abstracts of the 43rd Annual Interscience Conference on Antimicrobial Agents and Chemotherapy; Chicago, IL; September American Society for Microbiology: Washington, DC, 2003: