KNOWLEDGE, ATTITUDES AND PRACTICES ABOUT ANTIBIOTIC USE AMONG THE GENERAL PUBLIC IN MALAYSIA

KNOWLEDGE, ATTITUDES AND PRACTICES ABOUT ANTIBIOTIC USE AMONG THE GENERAL PUBLIC IN MALAYSIA Frid Islhudin, Aly Mdihh Ahmd Tmezi nd Norid Mohmed Shh Fculty of Phrmcy, Universiti Kebngsn Mlysi, Kul Lumpur, Mlysi Abstrct. Antibiotic resistnce is mjor problem globlly. Awreness of the impct nd significnce of ntibiotic resistnce is first step in hindering its progression. We conducted this survey to evlute knowledge, ttitudes nd prctices regrding ntibiotic use in Mlysi. A totl of 373 respondents were surveyed, 219 (58.1%) were femle nd 312 (83%) were Mly ethnicity. Eighty-four point two percent (314) hd used ntibiotics more thn once (>1) during the previous yer. We found respondents who were less likely to tke ntibiotics ( 1) during the previous yer were more likely to gree tht ntibiotic resistnce ws serious public helth issue compred to those tht took ntibiotic more thn once during the previous yer (p<0.0001). A significntly greter number of ptients (67.2%) who took ntibiotics more thn once during the previous yer did not complete the full course thn those who took ntibiotics no more thn once (55.9%) during the previous yer (p<0.01). We found the frequency of ntibiotic use ws relted to knowledge bout ntibiotics mong the study popultion. It is essentil to develop eductionl interventions to correct the misuse nd misunderstnding of ntibiotics. Keywords: ntibiotics, knowledge, ttitude, prctices, generl public, Mlysi INTRODUCTION Antibiotic resistnce is globl issue (Morgn et l, 2011). Infectious diseses cused by resistnt bcteri re often difficult to tret nd my led to greter morbidity nd mortlity mong ptients (Ntgiopoulos et l, 2007). A mjor cuse of ntibiotic resistnce is inpproprite use of ntibiotics, which commonly occurs due to lck of prudent ntibiotic use nd the ese t which medicine cn be Correspondence: Frid Islhudin, Fculty of Phrmcy, Universiti Kebngsn Mlysi, Jln Rj Mud Abdul Aziz, 50300 Kul Lumpur, Mlysi. Tel: 603-92897328 E-mil: fridislhudin@yhoo.com obtined by ptients without prescription (McNulty et l, 2007). There is lso n incresing trend in tking ntibiotics for virl indictions, such s the common cold (Srdmm et l, 2000). This inpproprite behvior hd consequences, one is using n ntimicrobil without perceived benefit (Morgn et l, 2011). The lck of new clss of ntibiotics within the pst decde hs lso contributed to the high risk for resistnt strins (Chn et l, 2012). The lck of knowledge regrding ntibiotic use mong the public could led to inpproprite ntibiotic use nd ultimtely ntibiotic resistnce (Chn et l, 2012). One study found the public took ntibiotics without knowing the exct indiction for tretment (Chn et l, 2012). 1474 Vol 45 No. 6 November 2014

Antibiotic Knowledge, Attitudes nd Prctices in Mlysi The public tend not to finish course of ntibiotics becuse they were unwre of the importnce of finishing course of ntibiotics (Duong et l, 1997). The impct of the knowledge, ttitudes nd prctices of the generl public on ntibiotic use is importnt to prevent misuse of ntibiotics nd ntibiotic resistnce (Chn et l, 2012). Eduction cn improve understnding of ntibiotic use mong the public to potentilly reduce resistnce (Morgn et l, 2011). An understnding of the current knowledge, ttitudes nd prctices of the public in regrd to ntibiotic use is importnt to inform intervention development plns. MATERIALS AND METHODS Study design This study ws performed s cross sectionl, prospective study. Respondents were recruited conveniently mong the generl public in Kuntn nd Kul Lumpur, Mlysi. Volunteers from shopping mlls round the Kuntn nd Kul Lumpur re were recruited with informed consent. Inclusion criteri for the study were: 18 yers, bility to red nd understnd both English nd Mly, nd understnding the term ntibiotic. Respondents unble to complete the questionnire were excluded. The dt were collected from August 2013 to November 2013. Ethicl pprovl ws obtined from the Ntionl University Hospitl Ethics Committee (UKM 1.5.3.5/244/NF-050-2013). Demogrphic dt Gender, rce, dte of birth, ge nd level of eduction were collected for ech ptient using stndrdized form. Ech respondent ws sked to nswer questions regrding frequency of ntibiotic use. The frequency of ntibiotic use ws ctegorized into two groups: those hving used ntibiotics no more thn once during the previous yer ( 1), nd those who used ntibiotics more thn once (>1) during the previous yer. Knowledge, ttitudes nd prctices questionnire The knowledge, ttitudes nd prctices regrding ntibiotic use were collected using questionnire (Khn et l, 2013). The knowledge, ttitudes nd prctices questions re found in Tbles 1-6. Dt nlyses All nlysis ws performed using the sttisticl pckge SPSS version 17.0 (IBM; Armonk, NY). Descriptive sttistics, such s mens, stndrd devitions nd frequencies were used to nlyze continuous nd ctegoricl dt, such s respondent demogrphic fctors nd their knowledge level. A chi-squre test ws used to mke comprisons nd evlute possible ssocitions regrding their knowledge, ttitudes nd prctices. RESULTS Demogrphics A totl of 373 subjects were included in the study. The mjority of the respondents were femle (n=219, 58.1%), ged 21 to 60 yers old. Most of the subjects were Mly (n=224, 78.9 %), followed by Indins (n=30, 7.9%), Chinese (n=25, 6.7%) nd other rces (n=9, 2.4%). A mjority of subjects were non-professionls (n=167, 44.8%) or unemployed (n=156, 41.8%). A totl of 299 subjects (79.3%) hd tertiry eduction. Most of the subjects (n=314, 84.2%) hd tken ntibiotics more thn once during the previous yer. Knowledge bout ntibiotics The knowledge section evluted two key res: ntibiotic use nd ntibiotic resistnce (Tble 1). Most subjects Vol 45 No. 6 November 2014 1475

Tble 1 Knowledge bout ntibiotics (N=373). Knowledge sttements True (n) Flse (n) p-vlue Indiscriminte use of ntibiotics cn led to: Ineffective tretment 313 60 0.0001 Incresed dverse effects 311 62 0.0001 Excerbtion or prolongtion of illness 276 94 0.0001 Emergence of bcteril resistnce 292 81 0.0001 Additionl cost to the ptient 286 87 0.0001 If tken too often, ntibiotics re less likely to work in the future 296 77 0.0001 Bcteri re germs tht cuse the common cold nd flu 314 59 0.0001 Agree Uncertin Disgree p-vlue (n) (n) (n) Antibiotic resistnce is n importnt public helth issue: Fcing the world 220 144 9 0.0001 In our country 180 176 17 0.0001 In our hospitl 181 178 14 0.0001 were wre tht inpproprite ntibiotic use hd hrmful effects (Tble 1). Most subjects found ntibiotic resistnce ws problem (Tble 1). No significnt ssocition ws seen between the frequency of ntibiotic use nd knowledge bout ntibiotics nd between the frequency of ntibiotic use during the previous yer nd knowledge bout ntibiotic resistnce (Tble 2). Subjects who took ntibiotics 1 time during the previous yer were more likely to gree tht ntibiotic resistnce ws serious public helth problem (Tble 2). Attitudes bout ntibiotic use Attitudes bout ntibiotic use vried mong subjects (Tble 3). In the ttitudes section, subjects were sked bout ntibiotic use, resistnce nd sfety. The mjority of subjects believed fever nd colds should be treted with ntibiotics (Tble 3). The mjority of subjects were uncertin if tking n ntibiotic could contribute to ntibiotic resistnce. A significntly lrge number of subjects were uncertin if ntibiotics were sfe or not. No ssocition ws seen between ttitudes bout ntibiotic use nd the frequency of ntibiotic use (Tble 4). Prctices regrding ntibiotic use Prctices regrding ntibiotic use vried (Tble 5). Mny subjects stted tht they stopped tking ntibiotics once they felt better, prior to finishing the course. Mny subjects seldom finished the complete ntibiotic course. Most subjects did not give their remining unused ntibiotics to others or sved their ntibiotics for future use once they felt better. Most subjects consulted doctor before strting ntibiotics nd checked expiry dtes prior to using ntibiotics (Tble 5). Subjects who took 1 courses of ntibiotics during the previous yer were significntly more likely to finish the course of ntibiotics (Tble 6). 1476 Vol 45 No. 6 November 2014

Antibiotic Knowledge, Attitudes nd Prctices in Mlysi Tble 2 Antibiotic knowledge nd frequency of ntibiotic use (N=373). Knowledge sttements True (n) Flse (n) p-vlue Indiscriminte use of ntibiotics cn led to : Ineffective tretment 1 46 13 0.18 >1 267 47 Incresed dverse effects 1 45 14 0.11 >1 266 48 Excerbtion or prolongtion of illness 1 49 10 0.10 >1 227 87 Emergence of bcteril resistnce 1 47 12 0.78 >1 245 69 Additionl cost to the ptient 1 44 15 0.68 >1 242 72 If tken too often, ntibiotics re less likely to work in the future 1 43 16 0.18 >1 253 61 Bcteri re germs tht cuse the common cold nd flu 1 49 10 0.79 >1 265 49 Agree Uncertin Disgree p-vlue (n) (n) (n) Antibiotic resistnce is n importnt nd serious public helth issue: Fcing the world 1 57 1 1 0.0001 >1 163 143 8 In our country 1 56 2 1 0.0001 >1 124 174 16 In our hospitl 1 57 1 1 0.0001 >1 124 177 13 1 = took ntibiotics no more thn once during the previous yer. >1 = took ntibiotics more thn once during the previous yer. DISCUSSION Antibiotic use by the generl public is common prctice worldwide (Krds et l, 2005). Antibiotics esily vilble to the generl public cn contribute to ntibiotic resistnce (Pomoni, 2010). With the rise in ntibiotic resistnce over the pst decde (Ntgiopoulos et l, 2007), methods to curb inpproprite ntibiotic use need to Vol 45 No. 6 November 2014 1477

Tble 3 Attitude bout ntibiotic use. Attitude sttements Agree Uncertin Disgree p-vlue When I hve cold, I should tke ntibiotics 199 70 104 0.0001 to prevent getting more serious illness. When I get fever, ntibiotics help me to 214 87 72 0.0001 get better more quickly. When I tke ntibiotics, I contribute to 118 210 45 0.0001 the development of ntibiotic resistnce. Skipping one or two doses of ntibiotics does 97 210 66 0.0001 not contribute to the development of resistnce. Antibiotics re sfe nd cn be used commonly. 74 144 155 0.0001 be improved. In our study lrge number of subjects stted they took ntibiotics more thn once during the previous yer. This finding is similr to nother study (Krds et l, 2005), nd demonstrtes the need to better understnd the resons for injudicious use of ntibiotics mong the generl public. Interestingly, knowledge bout ntibiotic use mong the subjects in our study ws good, with pproximtely 80% of respondents stting indiscriminte use of ntibiotics could led to poor outcomes. Our results re similr to previous study from Mlysi who found 76% of respondents t n outptient phrmcy were ble to correctly identify the proper use of ntibiotics (Oh et l, 2011). In study from Jordn the respondents were lso wre of the problems cused by misusing ntibiotics (Shehdeh et l, 2012). Despite understnding tht misuse of ntibiotics could led to ntibiotic resistnce, dverse rections nd increse the economic burden on the ntionl helth system (Gyssen 2001), mny respondents in our study took ntibiotics more thn once during the previous yer. In our study, n ssocition ws observed between the frequency of ntibiotic use nd knowledge bout ntibiotic resistnce. Respondents were less likely to hve tken ntibiotics during the previous yer if they were wre of the problem of resistnce, similr to other studies (Eng et l, 2003; Shehdeh et l, 2012). This demonstrtes the impct of knowledge bout ntibiotic resistnce on preventing injudicious use of ntibiotics. Further studies of the effect of ptient eduction bout correct ntibiotic use on ntibiotic resistnce need to be conducted. Approximtely hlf of our study subjects greed tht ntibiotics my be used to tret common cold nd fever. Public ttitudes bout ntibiotic use ply n importnt role in tretment outcomes (Oh et l, 2011). A csul ttitude bout ntibiotic use cn led to incresed risk of ntibiotic resistnce (Chn et l, 2012). In our study, firly lrge number of subjects were uncertin bout wht ttitudes were ssocited with ntibiotic resistnce. This finding ws lso reported by previous study (Oh et l, 2011). The poor understnding of the importnce of completing the full course of ntibiotics seen in our study ws seen in 1478 Vol 45 No. 6 November 2014

Antibiotic Knowledge, Attitudes nd Prctices in Mlysi Tble 4 Assocition between ttitudes bout ntibiotic use nd frequency of ntibiotic use. Attitude sttements Agree Uncertin Disgree p-vlue When I hve cold, I should tke ntibiotics to prevent getting more serious illness. 1 28 12 19 0.60 >1 171 58 85 When I get fever, ntibiotics help me to get better more quickly. 1 34 13 12 0.96 >1 180 74 60 When I tke ntibiotics, I contribute to the development of ntibiotic resistnce. 1 25 30 4 0.10 >1 93 180 41 Skipping one or two doses of ntibiotics does not contribute to the development of resistnce. 1 19 30 10 0.49 >1 78 180 56 Antibiotics re sfe nd cn be used commonly. 1 10 30 19 0.11 >1 64 114 136 1 = took ntibiotics no more thn once the previous yer. >1 = took ntibiotics more thn once the previous yer. Tble 5 Prctices regrding ntibiotic use. Prctice sttements Alwys Sometimes Seldom p-vlue /never The doctor prescribes course of ntibiotic for you. After tking 2-3 doses you strt feeling better. Do you stop tking the ntibiotics? 119 153 101 0.0036 Do you sve the remining ntibiotics for the next 88 106 179 0.0001 time you get sick? Do you discrd the remining ntibiotics? 115 124 134 0.48 Do you give the leftover ntibiotics to someone else 44 107 222 0.0001 who is sick? Do you complete the full course of ntibiotics? 115 164 94 <0.0001 Do you consult doctor before strting ntibiotics? 205 120 48 0.0001 Do you check the expiry dte of the ntibiotic 246 90 37 0.0001 before using it? Do you prefer to tke ntibiotics when you hve 95 165 113 <0.0001 cough or sore throt? Vol 45 No. 6 November 2014 1479

Tble 6 Prctices regrding ntibiotic use by frequency of ntibiotic use. Prctice sttements Alwys Sometimes Seldom p-vlue /never The doctor prescribes course of ntibiotic for you. After tking 2-3 doses you strt feeling better. Do you stop tking the ntibiotics? 1 17 21 21 0.28 >1 102 132 80 Do you sve the remining ntibiotics for the next time you get sick? 1 16 18 25 0.63 >1 72 88 154 Do you discrd the remining ntibiotics? 1 15 20 24 0.57 >1 100 104 110 Do you give the leftover ntibiotics to someone else who is sick? 1 8 16 35 0.76 >1 36 101 187 Do you complete the full course of ntibiotics? 1 26 10 23 <0.01 >1 103 140 71 Do you consult doctor before strting ntibiotics? 1 35 16 8 0.66 >1 170 104 40 Do you check the expiry dte of the ntibiotic before using it? 1 42 11 6 0.56 >1 204 79 31 Do you prefer to tke ntibiotics when you hve cough or sore throt? 1 19 24 16 0.43 >1 76 141 97 1 = took ntibiotics no more thn once the previous yer. >1 = took ntibiotics more thn once the previous yer. similr study (Shehdeh et l, 2012). Only 55% of the subjects in our study consulted doctor prior to tking ntibiotics. This demonstrtes the ese which ntibiotics cn be obtined by the generl public in Mlysi. Other studies hve lso found purchsing ntibiotics without prescription is common prctice (Llor et l, 2009). Directly purchsing ntibiotics my hve been done to void the cost of consulting doctor (Dmeh et l, 2012). Seventy percent of those who used ntibiotics more thn once during the previous yer in our study filed to complete the course of ntibiotics; this cn led to insufficient erdiction of the infection (McNulty et l, 2007). Fctors such s feeling better fter few dys of tretment or believing the ntibiotics were not working re common resons for not completing 1480 Vol 45 No. 6 November 2014

Antibiotic Knowledge, Attitudes nd Prctices in Mlysi tretment (McNulty et l, 2007). Filing to complete the course of tretment could be reson why ntibiotics were used more thn once during the previous yer in our study. The lck of knowledge bout correct ntibiotic use in our studied popultion poses problem. The ssocition between frequent use of ntibiotics nd lck of knowledge nd poor prctices demonstrtes lck of knowledge bout correct use of ntibiotics in the study popultion. There were some limittions with our study. The ccurcy of the survey depends on the honesty of the subjects. The subjects were chosen by convenience smpling, thus the results re subject to bis nd cnnot be pplied to other popultions. Our results suggest eduction progrms for the public regrding correct ntibiotic use need to be developed to reduce the risk of ntibiotic resistnce. Eductionl interventions for prctitioners nd the generl public cn significntly improve knowledge regrding ntibiotic indictions nd resistnce (Trepk et l, 2001). This study provides vluble informtion bout the knowledge regrding correct ntibiotic use in the studied popultion. REFERENCES Chn YH, Mndy M, Fok CM, et l. Antibiotic nondherence nd knowledge in community with the world s leding prevlence of ntibiotics resistnce: Implictions for public helth intervention. Am J Infect Control 2012; 40: 113-7. Dmeh M, Norris P, Green J. New Zelnd phrmcists experiences, prctices nd views regrding ntibiotic use without prescription. J Prim Helth Cre 2012; 4: 131-40. Duong DV, Binns CW, Le TV. Avilbility of ntibiotics s over-the counter drugs in phrmcies: thret to public helth in Vietnm. Trop Med Int Helth 1997; 2: 1133-9. Eng JV, Mrcus R, Hdler JL, et l. Consumer ttitudes nd use of ntibiotics. Emerg Infect Dis 2003; 9: 1128-35. Gyssens IC. Qulity mesures of ntimicrobil drug use. Int J Antimicrobil Agents 2001; 17: 9-19. Krds P, Devine S, Golembesky A, Roberts C. A systemic review nd met nlysis of misuse of ntibiotic therpies in the community. Int J Antimicrobil Agents 2005; 106-13. Khn A, Bnu G, Reshm K. Antibiotic resistnce nd usge: A survey on the knowledge, ttitude, perceptions nd prctices mong the medicl students of southern Indin teching hospitl. J Clin Dign Res 2013; 7: 1613-6. Llor C, Sierr N, Hernndez S, et l. The higher the number of dily doses of ntibiotic tretment in lower respirtory trct infection the worse the complince. J Antimicrobil Chemother 2009; 63: 396-9. McNulty CA, Boyle P, Nichols T, Clppison P, Dvey P. Don t wer me out: The public s knowledge of nd ttitudes to ntibiotics use. J Antimicrob Chemother 2007; 59: 727-38. Morgn DJ, Okeke IN, Lxminryn R, Perencevich EN, Weisenberg S. Nonprescription ntimicrobil use worldwide: systemtic review. Lncet Infect Dis 2011; 11: 692-701. Ntgiopoulos PG, Prmythiotou E, Antonidou A, Gimrellou H, Krbinis A. Impct of n ntibiotic restriction policy on the ntibiotic resistnce ptterns of Grmnegtive microorgnisms in n intensive cre unit in Greece. Int J Antimicrobil Agents 2007; 30: 360-65. Oh AL, Hssli MA, Al-Hddd MS, Syed Sulimin SA, Shfie AS, Awisu A. Public knowledge nd ttitudes towrds ntibiotic usge: cross-sectionl study mong the generl public in the stte of Penng, Vol 45 No. 6 November 2014 1481

Mlysi. J Infect Dev Ctries 2011; 5: 338-47. Pomoni C. Differences in urbn nd suburbn schools. (2010, Jul 11), Andover: Helium, 2010. [Cited 2014 Jun 15]. Avilble from URL: http://www.helium.com/ items/1888099-differences-in-urbn-ndsuburbn-schools 2010 April 11 Srdmm RD, Higginbothm N, Nichter M. Socil fctors influencing the cquisition of ntibiotics without prescription in Kerl Stte, South Indi. Soc Sci Med 2000; 50: 891-903. Shehdeh M, Suifn G, Drwish RM, Wzify M, Zru L, Alj fri S. Knowledge, ttitudes nd behvior regrding ntibiotics use nd misuse mong dults in the community of Jordn. A pilot study. Sudi Phrm J 2012; 20: 125-33. Trepk MJ, Belongi EA, Chyou PH, Dvis JP, Schwrtz B. The effect of the community intervention tril on prentl knowledge nd wreness of ntibiotic resistnce nd pproprite ntibiotic use in children. Peditr 2001; 107: E6. 1482 Vol 45 No. 6 November 2014