The knowledge gap and common injudicious attitude towards antibiotic among the population.
The most common incorrect knowledge item among this population is regarding the role of antibiotics whereby more than 80% believe that antibiotics is used to treat viral infection and can work for cough and colds. This is consistent across two other local studies whereby 83% and 86.6% of the population in Putrajaya and Penang respectively thought that antibiotics can work for viral infection.(15, 19) 82% of the population of Putrajaya thought that antibiotics could work to cure cough and colds.(19) Therefore, the misconception about the role of antibiotics is a nationwide issue. In develop countries such as the Great Britain, it was found that percentage is lower whereby only 53% of their population believe that antibiotics is the medicine of choice for viral infections.(20)
The highest inappropriate attitude response was expecting antibiotic from the doctor for symptoms of common colds (76%). This is followed by taking antibiotic to recover faster from their illness (55%) and stopping antibiotics once they start feeling better (48%). This finding is comparable to a study done within Putrajaya population whereby they had found 73.8 % of their respondents were also expecting antibiotics from their doctors when they experienced common cold. However, several other studies found lower percentage for this attitude item. In a study done in Penang, the percentage is lower at 57.8%, which is comparable to the study done in United States at 53.6%. The lowest percentage of inappropriate attitude in relation to this attitude item is a study in Taiwan with only 25 % of the population would expect antibiotics from their doctor for common colds.(21)
The relationship between antibiotic knowledge and attitude towards antibiotic.
A positive correlation was demonstrated between the respondent’s antibiotic knowledge and their attitude towards antibiotic usage. This indicates that the higher the respondent’s antibiotic knowledge the more appropriate their attitude towards antibiotic. However, the relationship is found to be a weak correlation but highly significant. This finding is supported by another local study conducted in Putrajaya whereby they have also found a similar positive but weak correlation (r = 0.462, p<0.001).(12) In Ethiopia, there was also a positive correlation between health care professionals antibiotic knowledge and their attitude towards antibiotic but with an even weaker correlation (r = 0.117, p=0.229).(22)
Common sense would suggest that good antibiotic knowledge would lead to appropriate attitude when handling antibiotics as reflected in this study. It does so to a certain extent until the situation becomes challenging or unfavourable.(23) For an example, studies have shown that clinicians are prone to self-medicate with antibiotics when they are unwell.(24) This is because their clinical background made them to believe that they could self-diagnose. Self-medication may save time and they can avoid sick leaves in order to maintain their work performance in their busy schedule.(25) Previous study has demonstrated that the link between antibiotic knowledge and attitude towards antibiotic is weak in the context of LMIC.(26) As people from rural areas become more financially secure, they also become more empowered and assertive towards their health. In other words, their attitude towards handling antibiotic is inappropriate not because of ignorance but because they are now able to exercise this assertiveness.(26)
Factors associated with inappropriate attitude towards antibiotic usage
(i) Poor antibiotic knowledge
This study shows that respondents with poor antibiotic knowledge are 2.5 times more likely to have inappropriate attitude towards antibiotic.(27) In South Korea, respondents with good antibiotic knowledge were 1.52 times more likely to demonstrate appropriate attitude when using antibiotic.(28) In Northern Tanzania, respondents with good antibiotic knowledge were three times more likely to have appropriate attitude towards antibiotic. (29) Previous studies have also demonstrated that good antibiotic knowledge does not always translate to appropriate attitude. Another study in Korea demonstrated that good antibiotic knowledge is associated with antibiotic self-medication.(28) Furthermore, the Korean elderly population with the lowest overall knowledge score on antibiotics has a more appropriate attitude towards antibiotics usage. (28) In Trinidad and Tobago, it was found that even though their respondents’ antibiotic knowledge were outstanding, it was not associated with appropriate attitude towards their antibiotics. Some of their respondents believed that skipping antibiotic doses would not contribute to ABR. They are also incline to self-medicate with antibiotics especially for common colds.(30) In Sweden, male respondents were found to be more knowledgeable on antibiotics compared to females however they were also found to have unsatisfactory attitude towards antibiotics. (31) In the UK, a survey conducted by the Department of Health Standing Medical Advisory Committee on Antimicrobial Resistance (SMAC) found that individuals with good antibiotics knowledge were more likely to be prescribed antibiotics during consultations as they are more inclined to request for antibiotics. Furthermore, the respondents with goods knowledge on antibiotics were more likely to self-medicate themselves with antibiotic and to keep left-over antibiotics from previous prescriptions.(32)
(ii) Low education level
This study has also demonstrated that respondents with low education level are 2.6 times more likely to have inappropriate attitude towards antibiotic.(27) This is similar to a study done Penang whereby respondents with low education level were significantly associated with inappropriate attitudes towards antibiotic.(15) In another local study conducted in Putrajaya, education level is significantly associated with their mean attitude score.(19) It was also found that respondent with lower education level is significantly associated with using leftover antibiotics to self- treat themselves and not using antibiotics according to instructions.(19) In a cross-sectional study done in Nigeria, similar finding was found whereby their respondents with low education level were less likely to behave appropriately when handling antibiotic. However, low education level in their population was defined as no formal education at all.(33) In addition, a study done in Kuwait found that respondents with higher level education level were two times likely to a positive attitude towards antibiotic usage.(34) In contrary, among the Lebanese, education level is not an associated with attitude towards antibiotic.(35)
The non-probability sampling method applied in this study is vulnerable to selection bias. However, great effort was put into covering all patients who attended the centre during the study period. The self-administered questionnaire allows for recall bias and it depends heavily on the honesty and understanding of the respondents. Therefore, the findings of this study should be interpreted with caution. The findings of this study may not be generalizable to this country. However, it is the first of its kind around this district and among patients attending a primary care setting. It also compliments other findings around the country for the nation to further consolidate our effort to combat antibiotic resistance.
(i) Targeted counselling for busy clinics and patient education as part of non-pharmacological management in viral illness
Patient education should be routinely incorporated in the management of patients with viral illness as part of the non-pharmacological management of viral infections. For clinics with high patient load whereby time is a barrier to effective patient education, perhaps a targeted approach should be administered. This may involve focusing on “high risk” individuals identified in this study such as patients with poor antibiotic knowledge and lower education background. This requires clinicians to improve on their communication skills especially when handling patients who expects antibiotics during consultation.(36) Previous study have shown that improved communication skills in primary care setting can bridge the gap between clinicians and patients expectation. In a study conducted in Netherlands, primary care doctors who were given training in communication skills prescribe less antibiotics for patients who came in with respiratory symptoms. (36)
(ii) Design an awareness campaign focusing on behavioural change.
This study has demonstrated that the relationship between antibiotic knowledge and attitude appropriateness is weak. Recent studies on behavioural science delineates that a person’s attitude is more important than intelligence when it comes to having a successful life. Attitudes are often the result of experience and have a very powerful influence over a patient’s behaviour. Therefore, it is crucial for educational intervention to adopt a different approach by screening the population for inappropriate attitude when handling antibiotics and rectifying their misconceptions. Health campaign should also shift their approach to instilling appropriate behaviour rather than focusing on theoretical aspects. In fact, previous study have demonstrated that campaigns focusing on antibiotic knowledge among the public increases the incidence of self-medication.(12)