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INTRODUCTION
Antimicrobial Resistance (AMR) is a critical global health issue, with the World Health Organization (WHO) estimating that bacterial AMR directly caused 1.27 million deaths worldwide in 2019 (Tang et al., 2023). Antibiotic resistance is an escalating concern in the global health arena. The issue mostly arises from the improper use of antibiotics, resulting in the resistance of pathogens, including bacteria and fungi, to the medications intended to eliminate them (Salam et al., 2023). The mechanism of antibiotic action necessitates meticulous administration and supervision of drug intake to guarantee alignment with the condition being treated (Alara and Alara, 2024). This would guarantee that the antimicrobial user recovers effectively from the illness and does not acquire resistance to the medication, so preserving its efficacy for future treatment (Shibabaw). Antibiotic resistance is lethal since infections become refractory to the medications intended to eradicate them, necessitating other treatment options that are often inaccessible. Consequently, patients who acquire antibiotic resistance jeopardize their chances of obtaining appropriate treatment in the future, as the developed resistance undermines the efficacy of the medications.
Antibiotic resistance represents a significant threat to human health in contemporary society (Bakri et al., 2024). According to the most recent Saudi census, Saudi nationals represented approximately 68.9% of the total population, which is 27.1 million, while the expatriate (non-Saudi) population constituted 31.1% of the total population of Saudi Arabia (Khraif et al., 2016). The non-Saudi population exhibits unique racial, socioeconomic, and demographic traits; consequently, the healthcare received, therapeutic responses, and clinical outcomes may vary when compared to Saudi nationals (AlFaleh et al., 2015).
The non-prescription dispensing of antibiotics constitutes a significant public health issue in Saudi Arabia, raising concerns regarding its role in the proliferation of antimicrobial-resistant pathogens and the emergence of antimicrobial resistance (Al-Jedai et al., 2022; Kanan et al., 2023).
In Saudi Arabia, the prevalence of antibiotic-resistant bacteria is notably high, with resistance rates ranging from 7.6% to 92.3% among various bacterial strains (Thabit et al., 2023). This situation is exacerbated by factors such as the overuse and misuse of antibiotics, including nonprescription use, which has been reported at rates of 23.6% to 28.8% in different regions of the country (Bhat et al., 2023).
Addressing these challenges in Saudi Arabia's Eastern Province requires comprehensive public education and stringent policy interventions to mitigate the escalating threat of AMR. The availability of antibiotics among the Saudi population is unregulated and not subject to prescription requirements (Al-Mehmadi et al., 2023). Antibiotic agents are readily available to the public and purchased without a prescription. The availability of free access to antibiotics alters the framework for antibiotic-related interventions in Saudi Arabia. Research indicates that awareness of antibiotic resistance among patients and the public is limited (Alajel et al., 2023), highlighting antimicrobial resistance as a growing and significant issue.
There is a limited number of published studies in Saudi Arabia that assess medication compliance among patients, as well as the public's knowledge and attitude regarding drug use, including the use of antibiotics and resistance. The public significantly contributes to mitigating the misuse and overuse of antibiotics. It is essential to evaluate the public's knowledge and attitudes regarding antibiotic use to determine the educational needs of the population. The objective of this study was to assess the knowledge and attitude of individuals in the Eastern Province of Saudi Arabia regarding antibiotic resistance, as well as to evaluate their attitudes and behaviors related to antibiotic use and antibacterial resistance.
METHODOLOGY
Study Design
This observational cross-sectional study was conducted during a period of six months from May 2024 to October 2024 in the eastern province of Saudi Arabia using a validated questionnaire. The inclusion criteria for this study were Saudi males and females of the age of 18 years and above.
Study instrument and translation
The survey instrument was developed based on previous literature about antibiotic and antibiotic resistance (Al-Mehmadi et al., 2024; Alnasser et al., 2021).
Three researchers reviewed the questionnaire tool to evaluate the questions’ appropriateness, relevancy, clarity, and adequacy. The survey instrument consisted of 25 questions, including socio-demographic characteristics, knowledge about antibiotics, antibiotic resistance (three items), and awareness regarding the use of antibiotics. The original form of the survey was written in the English language. After that, a certified translator translated it into Arabic and put it through a backwards-to-forward translation process. Translators who had sector-specific knowledge and experience in translating surveys where their mother tongues were Arabic, performed the forward translation. A second translator whose native language is English was brought in to translate the questionnaire back into the original language after the authors had received the first translation.
The questionnaire was distributed online to a random sample of people living in different regions of the eastern province of Saudi Arabia. All participants were asked to answer all questions and incomplete questionnaires were omitted from the study.
Data Analysis
All data were analyzed by using SPSS version 28 (IBM, Chicago, IL). The suggestive analysis was used to pick the demographic information in rates and percentages. The association was analyzed by logistic regression. A p-value of <0.05 was considered statistically significant (Sharma, 2021).
RESULTS
Socio-demographic characteristics
The study's sample comprised 421 participants, with a higher representation of females (65.1%) compared to males (34.9%). Age distribution indicated that nearly half of the respondents (47.0%) were over 40 years old, while 27.1% were between 31 and 40, and 25.9% were aged 18 to 30. In terms of marital status, a majority were married (59.1%), followed by single (24.9%), widowed (8.3%), and divorced individuals (7.6%). Educational attainment varied, with 36.8% having higher education, 33.0% holding a diploma, 22.3% possessing a bachelor's degree, and 7.8% completing high school. Employment status revealed that a significant majority were employed (92.9%), leaving a small proportion unemployed (7.1%). The results are explained in Table 1.
| Variables | Frequency (n) | Percentage (%) |
|---|---|---|
| Gender | ||
| Male | 147 | 34.9 |
| Female | 274 | 65.1 |
| Age | ||
| 18-30 | 109 | 25.9 |
| 31-40 | 114 | 27.1 |
| >40 | 198 | 47 |
| Marital status | ||
| Single | 105 | 24.9 |
| Married | 249 | 59.1 |
| Divorced | 32 | 7.6 |
| Widowed | 35 | 8.3 |
| Education | ||
| High Education | 155 | 36.8 |
| Bachelors | 94 | 22.3 |
| Diploma | 139 | 33 |
| High School | 33 | 7.8 |
| Occupation | ||
| Employed | 391 | 92.9 |
| Unemployed | 30 | 7.1 |
Source of Information regarding the use of antibiotics
In Figure 1, respondents showed that around 32% of patients were aware of the use of antibiotics through doctors, 31% through pharmacists, 16% through nurses, 20% through the Internet, and 4% through media.
Knowledge of the participants about antibiotics and antibiotic resistance
The findings highlight substantial knowledge gaps regarding antibiotics and antimicrobial resistance among respondents. While 55.4% correctly identified antibiotics as effective against bacterial infections, 29.9% were uncertain, and 12.8% believed they worked for both bacterial and viral infections. Over half (51.3%) thought antibiotics should be used whenever feeling sick, while only 36.1% recognized the importance of a prescription. A significant 81.2% mistakenly believed it was safe to stop antibiotics upon feeling better. Most respondents (79.1%) understood that taking antibiotics without a prescription is risky, and 74.8% recognized misuse could cause resistance or side effects. However, confusion about antimicrobial resistance persisted, with 29.0% attributing it to bodily resistance and only 27.1% identifying bacterial resistance as the correct cause. While 66.3% understood antimicrobial resistance complicates treatment, 34.2% were unaware that misuse contributes to resistance. Additionally, 50.1% acknowledged resistance as a global issue affecting Saudi Arabia, yet only 15.7% felt knowledgeable about Antibiotic Stewardship Programs, though 51.5% believed these programs improve antibiotic use. The results are explained in Table 2.
| Characteristics | Response |
|---|---|
| Antibiotics can treat: | |
| Bacterial infections Viral infections Both bacterial and viral infections I don’t know | 233 (55.4) 8 (1.9) 54 (12.8) 126 (29.9) |
| When should antibiotics be used? | |
| Only when prescribed by a healthcare provider Whenever I feel sick To prevent sickness I don’t know | 152 (36.1) 216 (51.3) 43 (10.2) 10 (2.4) |
| Is it safe to stop taking antibiotics once you feel better? | |
| Yes No I don’t know | 342 (81.2) 63 (15.0) 16 (3.8) |
| Taking antibiotics without a prescription is: | |
| Safe and effective Risky and can cause harm I don’t know | 63 (15.0) 333 (79.1) 25 (5.9) |
| Misuse of antibiotics can lead to side effects such as: | |
| Stomach upset or allergies Development of resistance to antibiotics Both of the above I don’t know | 315 (74.8) 10 (2.4) 80 (19.0) 16 (3.8) |
| Antimicrobial resistance happens when: | |
| The body becomes resistant to antibiotics Bacteria become resistant to antibiotics Antibiotics lose their strength over time I don’t know | 122 (29.0) 114 (27.1) 118 (28.0) 67 (15.9) |
| Misuse of antibiotics (e.g., not completing the course or taking without a prescription) contributes to antimicrobial resistance: | |
| Yes No I don’t know | 136 (32.3) 141 (33.5) 144 (34.2) |
| Antimicrobial resistance makes infections: | |
| Easier to treat Harder to treat I don’t know | 84 (20.0) 279 (66.3) 58 (13.8) |
| Antimicrobial resistance is a global health issue that affects Saudi Arabia: | |
| Yes No I don’t know | 211 (50.1) 133 (31.6) 77 (18.3) |
| I have sufficient knowledge about the Antibiotic Stewardship Program | |
| Yes No I don’t know | 66 (15.7) 174 (41.3) 181 (43.0) |
| I believe the Antibiotic Stewardship Program improves the optimal use of antibiotics. | |
| Yes No I don’t know | 217 (51.5) 68 (16.2) 136 (32.3) |
The attitude of respondents towards antibiotics and antibiotic resistance
The results reveal diverse practices and attitudes toward antibiotic use and antimicrobial resistance. Pharmacies with prescriptions were the most common source of antibiotics (49.7%), while 25.4% obtained them without prescriptions, and 21.1% relied on family or friends. A strong majority (82.7%) disagreed with acquiring antibiotics without prescriptions, and 73.9% reported strict adherence to prescribed durations. Antimicrobial resistance was acknowledged as a serious global issue by 78.9%, with 68.2% agreeing that overuse reduces future effectiveness. Personal susceptibility to resistance was recognized by 49.6%, while 77.9% agreed that healthcare workers play a crucial role in combating bacterial resistance. However, misconceptions remain, with 35.9% agreeing that resistance primarily affects frequent antibiotic users. The results are explained in Table 3.
| Characteristics | Responses |
|---|---|
| Where do you usually get antibiotics? | |
| Pharmacy (with prescription) Pharmacy (without prescription) Leftover from previous illness Shared by family/friends | 209 (49.7) 107 (25.4) 16 (3.8) 89 (21.1) |
| I usually get antibiotics without a prescription. | |
| Strongly agree Agree Neutral Disagree Strongly disagree | 11 (2.6) 15 (3.6) 11 (2.6) 348 (82.7) 36 (8.6) |
| I usually adhere to the duration of antibiotics prescribed by the doctor or pharmacist. | |
| Strongly agree Agree Neutral Disagree Strongly disagree | 311 (73.9) 28 (6.7) 48 (11.4) 30 (7.1) 4 (1.0) |
| The development of antimicrobial resistance is a serious global health issue: | |
| Strongly agree Agree Neutral Disagree Strongly disagree | 332 (78.9) 69 (16.4) 4 (1.0) 13 (3.1) 3 (0.7) |
| Overuse of antibiotics can lead to reduced effectiveness in the future | |
| Strongly agree Agree Neutral Disagree Strongly disagree | 53 (12.6) 287 (68.2) 13 (3.1) 60 (14.3) 8 (1.9) |
| Antibiotic resistance is a problem that can affect me or my family | |
| Strongly agree Agree Neutral Disagree Strongly disagree | 209 (49.6) 184 (43.7) 9 (2.1) 10 (2.4) 9 (2.1) |
| Antibacterial resistance is the only problem for people who regularly take antibiotics | |
| Strongly agree Agree Neutral Disagree Strongly disagree | 151 (35.9) 111 (26.4) 61 (14.5) 90 (21.4) 8 (1.9) |
| Healthcare workers can help in limiting bacterial resistance | |
| Strongly agree Agree Neutral Disagree Strongly disagree | 328 (77.9) 31 (7.4) 32 (7.6) 24 (5.7) 6 (1.4) |
Association between socio-demographic characteristics knowledge and the attitude of respondents towards antibiotics and antibiotic resistance
The analysis reveals significant associations between demographic factors and both knowledge and attitudes toward antibiotic use and antimicrobial resistance. Males exhibited higher odds of possessing knowledge (OR: 1.6; 95% CI: 1.2-1.9; p=0.001) compared to females. Age group 18-30 showed significantly lower odds of a positive attitude (OR: 0.6; 95% CI: 0.4-0.8; p=0.001) relative to those over 40. Married individuals had significantly lower odds of knowledge (OR: 0.1; 95% CI: 0.1-0.2; p=0.01) but higher odds of a positive attitude (OR: 1.2; 95% CI: 1.1-1.6; p=0.01) compared to widowed participants. Regarding education, those with higher education (OR: 0.1; 95% CI: 0.1-0.2; p=0.01) and bachelor's degrees (OR: 0.7; 95% CI: 0.5-0.9; p=0.01) had significantly lower odds of knowledge compared to high school graduates. Employment status also influenced outcomes, with employed individuals showing significantly lower odds of both knowledge (OR: 0.1; 95% CI: 0.1-0.9; p=0.01) and a positive attitude (OR: 0.1; 95% CI: 0.1-0.8; p=0.001) compared to unemployed counterparts. These findings suggest that targeted educational interventions may be necessary to address specific demographic disparities in knowledge and attitudes toward antibiotic use and resistance. These results are explained in Table 4.
| Variables | Knowledge | Attitude | ||
|---|---|---|---|---|
| Odds ratio (95% CI) | p-value | Odds ratio (95% CI) | p-value | |
| Gender | ||||
| Male | 1.6 (1.2- 1.9) | 0.001 | 0.2 (0.1- 1.01) | 0.7 |
| Female | 1 | 1 | ||
| Age | ||||
| 18-30 | 1.0 (0.7- 1.3) | 0.9 | 0.6 (0.4-0.8) | 0.001 |
| 31-40 | 1.1 (0.7- 1.6) | 0.5 | 0.1 (1.2-2.3) | 0.2 |
| >40 | 1 | 1 | ||
| Marital status | ||||
| Single | 0.8 (0.6-1.2) | 0.4 | 0.1 (0.2-1.7) | 0.8 |
| Married | 0.1 (0.1- 0.2) | 0.01 | 1.2 (1.1-1.6) | 0.01 |
| Divorced | 0.8 (0.3-1.7) | 0.2 | 0.2 (0.1-1.9) | 0.1 |
| Widowed | 1 | 1 | ||
| Education | ||||
| High Education | 0.1 (0.1- 0.2) | 0.01 | 1.9 (0.4- 1.9) | 0.7 |
| Bachelors | 0.7 (0.5- 0.9) | 0.01 | 0.2 (0.1-0.5) | 0.01 |
| Diploma | 0.8 (0.6- 1.5) | 0.2 | 0.1 (0.1-2.1) | 0.8 |
| High School | 1 | 1 | ||
| Occupation | ||||
| Employed | 0.1 (0.1- 0.9) | 0.01 | 0.1 (0.1-0.8) | 0.001 |
| Unemployed | 1 | 1 |
Association between knowledge, attitude, and demographic characteristics using Multivariate logistic regression
In Table 5, Married individuals have higher odds of possessing knowledge compared to their unmarried counterparts (Adjusted OR: 1.1; 95% CI: 1.0-1.3; p=0.01). Similarly, those with higher education levels exhibit increased odds of knowledge (Adjusted OR: 1.1; 95% CI: 1.1-1.92; p=0.01). Conversely, individuals holding a bachelor's degree show lower odds of knowledge relative to those with only a high school education (Adjusted OR: 0.1; 95% CI: 0.1-0.9; p=0.01). No significant associations are observed between the examined variables and attitudes toward antibiotic use and resistance, as indicated by p-values greater than 0.05.
| Variables | Knowledge | Attitude | ||
|---|---|---|---|---|
| Adjusted Odds ratio (95% CI) | p-value | Adjusted Odds ratio (95% CI) | p-value | |
| Age | ||||
| 18-30 | ------ | ------ | 1.2 (0.4-1.2) | 0.1 |
| Marital status | ||||
| Married | 1.1 (1.0- 1.3) | 0.01 | 0.2 (0.1-1.2) | 0.1 |
| Education | ||||
| High Education | 1.1 (1.1- 192) | 0.01 | 0.9 (0.4- 0.9) | 0.02 |
| Bachelors | 0.1 (0.1- 0.9) | 0.01 | 0.2 (0.2-1.5) | 0.1 |
| Occupation | ||||
| Employed | 1.1 (0.1- 2.9) | 0.9 | 0.9 (0.1-1.3) | 0.8 |
DISCUSSION
This study highlights critical insights into knowledge and attitudes toward antibiotic use and AMR among the population in the Eastern Province of Saudi Arabia, revealing both significant gaps and positive trends. A notable proportion of participants (25.4%) reported obtaining antibiotics without a prescription, reflecting the persistence of self-medication practices, which are comparable to findings from studies in the western region of Saudi Arabia and other Middle Eastern countries where non-prescription antibiotic use is common (Almaghrabi, 2024; Muflih et al., 2023). Misconceptions were evident, with 51.3% believing antibiotics should be taken whenever sick, a behavior that aligns with reports from similar regions and underscores the need for public education (Gautham et al., 2024).
A majority of respondents (55.4%) correctly identified that antibiotics treat bacterial infections, while a significant portion (12.8%) mistakenly believed antibiotics could treat both bacterial and viral infections, highlighting the need for better education on this critical distinction. Similar findings have been reported in previous studies, where confusion between bacterial and viral infections was prevalent among the general population (Liu et al., 2021; Claassen-Weitz et al., 2021). Furthermore, 81.2% of participants acknowledged the importance of completing an antibiotic course, which is consistent with global guidelines that emphasize the risks of premature cessation of antibiotic therapy (WHO, 2022; Grant et al., 2022). However, the study also revealed concerning gaps, such as the fact that only 32.3% of participants understood the role of antibiotic misuse in contributing to AMR, a major global health challenge. This is in line with research by Tang et al., (2023), which suggests that awareness of AMR and its consequences remains limited among the public (Tang et al., 2023). Notably, while a majority (79.1%) of respondents recognized the risks of taking antibiotics without a prescription, there was a significant portion (33.5%) who were unsure about the impact of misuse on AMR, indicating the need for more targeted educational campaigns. Regarding the Antibiotic Stewardship Program, although over half (51.5%) of participants believed it enhances the optimal use of antibiotics, 43% lacked sufficient knowledge about the program, suggesting a gap in awareness that needs to be addressed through healthcare outreach initiatives (Akkawi et al., 2022).
A significant portion of participants (49.7%) reported obtaining antibiotics from pharmacies with prescriptions, while a concerning 25.4% accessed antibiotics without prescriptions, and 21.1% relied on leftover antibiotics from previous illnesses or shared them with family and friends. This aligns with studies from other countries where unregulated access to antibiotics was found to be a contributing factor to the rise of AMR (Endale et al., 2023; Sulis et al., 2022). Interestingly, 82.7% of respondents stated they disagreed with obtaining antibiotics without a prescription, suggesting that while there is some awareness of the risks, access to antibiotics outside of formal healthcare channels remains prevalent. Participants widely recognized the serious global health threat posed by AMR, with 95.3% either strongly agreeing or agreeing, which is consistent with previous studies that emphasize public awareness of AMR (Bertagnolio et al., 2024). However, while 80.8% of participants agreed that overuse of antibiotics can reduce their effectiveness, the perception that antibiotic resistance is a problem that only affects regular antibiotic users was held by 62.3% of participants, reflecting a common misconception that AMR is not an immediate concern for infrequent users. This highlights a need for more widespread public health education regarding the universal threat of AMR (Al-Haboubi et al., 2021). In multi-logistic regression analysis, age did not show a significant association with either knowledge or attitude, suggesting that age may not play a major role in influencing these aspects within the studied population. However, marital status and education level were found to be significant factors influencing knowledge and attitudes. Specifically, married individuals had better knowledge about antibiotic use (adjusted odds ratio [OR]: 1.1, 95% CI: 1.0-1.3, p-value: 0.01), aligning with prior research that indicates marital status as a potential determinant of health-related knowledge due to increased household responsibilities (Zanobini et al., 2021; Jilani et al., 2021). Education level also emerged as a key factor, with those having higher education levels demonstrating significantly better knowledge (adjusted OR: 1.1, 95% CI: 1.1-1.92, p-value: 0.01), while those with a bachelor's degree showed lower knowledge levels (adjusted OR: 0.1, 95% CI: 0.1-0.9, p-value: 0.01). This finding contrasts with previous studies that suggest bachelor’s degree holders tend to have higher health knowledge (Ashiru-Oredope et al., 2021), indicating that in this specific context, the effect of education on antibiotic knowledge might vary based on other factors such as health literacy or the quality of education received.
The study's strength lies in its large sample size and comprehensive analysis, offering valuable insights into demographic and socioeconomic determinants of antibiotic knowledge and attitudes. However, the cross-sectional design limits causal inferences, and self-reported data may be prone to recall or social desirability bias. Additionally, the study did not explore healthcare provider influences or the role of policy enforcement in curbing non-prescription antibiotic sales, which could have provided a more holistic understanding. Despite these limitations, the findings emphasize the urgent need for targeted interventions, such as public health campaigns and stricter enforcement of prescription-only antibiotic sales, to enhance knowledge, reshape attitudes, and address the growing threat of AMR in the region.
CONCLUSION
Participants reported having moderate knowledge and a negative attitude toward antibiotic use and resistance. Thus, healthcare personnel should provide patients with comprehensive information on the proper administration and intake of antibiotics. Paired with these efforts to educate patients on proper antibiotic usage, there should also be tighter controls regarding the administration of antibiotics, including extensive evaluation of whether a case can be treated only with antibiotics or not; and reducing the cases of using antibiotics unnecessarily. Additionally, local governments are required to spread awareness about AMR by setting up educational campaigns and following WHO recommendations by ensuring a robust national action plan to tackle antibiotic resistance is in place and regulate and promote the appropriate use and disposal of quality medicines.