Dear Label_Name,

Greetings! I hope you are well.

I am writing on behalf of an international publishing house, Science and Education Publishing, USA (http://www.sciepub.com).

Science and Education Publishing (SciEP) is a multidisciplinary open access publisher of Journals covering the fields of Science, Technology and Medicine. All SciEP publications are subject to high-quality peer review, editorial and production processes and are freely available online.

Welcome to the April, 2013 edition of SciEP newsletter, providing monthly summaries of articles on science & education related topics of interest to scientist and professionals. The mission of our journals is to provide an open access forum for publishing new findings on issues pertinent to scientific and academic field. We also invite you to submit original research papers, review articles, short reports, or case studies are considered for publication in our Multidisciplinary Journals.

American Journal of Public Health Research
DOI: 10.12691/ajphr-1-1-3

The Implementation of a Tele-Homecare System with Service Oriented Architecture and HL7 Message Transmission Standard
Ching-Sung Wang

American Journal of Medical and Biological Research
DOI: 10.12691/ajmbr-1-1-2

The Influence of Ethanol on Pyruvate Kinases Activity in Vivo, in Vitro, in Silico
Lelevich Sergey Vladimirovich, Khrustalev Vladislav Victorovich, Barkovsky Eugene Victorovich, Shedogubova Tatyana Aleksandrovna

American Journal of Medical Sciences and Medicine
DOI: 10.12691/ajmsm-1-1-1

Clinical and Histological Features in Wegener Granulomatosis
Li Cavoli Gioacchino, Passantino Rita, Bono Luisa, Tortorici Calogera, Ferrantelli Angelo, Giammarresi Carlo, Rotolo Ugo

American Journal of Infectious Diseases and Microbiology
DOI: 10.12691/ajidm-1-1-2

The Curse of Lymphatic Filariasis: Would the Continual Use of Diethylcarbamazine Eliminate this Scourge in Papua New Guinea?
Anne Lanham, Lillian Mwanri

We have released issues of some journals on February 2013.
American Journal of Public Health Research
American Journal of Medical Sciences and Medicine
American Journal of Medical and Biological Research
American Journal of Pharmacological Sciences
American Journal of Clinical Medicine Research
American Journal of Nursing Research
American Journal of Cancer Prevention
American Journal of Medicine Studies
American Journal of Infectious Diseases and Microbiology
American Journal of Cardiovascular Disease Research
American Journal of Biomedical Research
American Journal of Mechanical Engineering
American Journal of Microbiological Research
Journal of Preventive Medicine
American Journal of Food and Nutrition
American Journal of Hypertension Research
American Journal of Sports Science and Medicine
Journal of Cancer Research and Treatment
American Journal of Zoological Research
Journal of Biomedical Engineering and Technology
American Journal of Microbiological Research
Biomedical Science and Engineering

We are pleased to announce that submissions are now being accepted for peer review for all the journals across all our subject areas in SciEP.

Please submit your manuscript via our online submission system:
http://www.sciepub.com/author/signin

To unsubscribe from our mailing list, please click on the following link: unsubscribe

I am looking forward to hearing from you.

Kind regards,

David Rain
Email:join@sciepub.com
Science and Education Publishing (http://www.sciepub.com)

Public Knowledge and Attitude towards Antibiotic Use in Lebanon

Malak Khalifeh*, Nicholas Moore, Pascale Salameh

INSERM U 1219 - Pharmaco-épidémiologie et évaluation de l'impact des produits de santé sur les populations, University de Bordeaux, Bordeaux, France

Abstract: Introduction: Antibiotic resistance is a major threat in global public health. This study aims to assess the public knowledge, attitude and practice towards antibiotic use among general public in Lebanon. Method: It was a cross sectional study in a community-based pharmacy setting in Lebanon. It used a structured random interview to patients visiting community pharmacy seeking for antibiotics. Descriptive statistics were presented and multivariate logistic regressions were performed in data analysis. Results: A total of 495 participated in the study. The study sample had in general low knowledge (average = 6) and attitude score (average=3.16). High proportion of Lebanese participants believed that antibiotics were used for treatment of common cough cold and sore throat symptoms (59%) or viral infections (53%). 42% preferred to take antibiotics from the pharmacy without physician prescription. In the multivariable logistic regression analysis, females showed better knowledge toward antibiotic use compared to males (ORa=1.59, 95%CI=1.01-2.53). Compared to participants aged >50 years old, the level of adequate knowledge was higher in those aged 25-50 years old (ORa=3.66, 95%CI=1.79-7.49). Conclusion: This study identified important knowledge and attitude gaps among general public in Lebanon. Future antibiotic awareness campaigns and patient counselling should be implemented to reduce the risk of antibiotic resistance.

Keywords: antibiotic, knowledge, attitude, Lebanon

Citation: Malak Khalifeh, Nicholas Moore, Pascale Salameh, Public Knowledge and Attitude towards Antibiotic Use in Lebanon. American Journal of Epidemiology and Infectious Disease, 5 (2). 35-41. January 2017. doi:10.12691/ajeid-5-2-3

1. Introduction

Antibiotic resistance is a major threat in global public health. The overuse and misuse of antibiotics may generate several problems, including the development of bacterial resistance, [1] adverse reactions, treatment failure and waste of resources. [1]

The World Health Organization (WHO) identified three key issues for public involvement: improving access to medical facilities, decreasing unnecessary use of antimicrobials, taking a full course of treatment, and not giving out medication to other people or keeping left-over medication for future needs. The WHO also urged member countries to initiate educational interventions for patients and the general population aimed at rationalizing the use of antibiotics to combat resistance. [2]

The lack of knowledge of medication such as antibiotics may greatly influence the probability of misuse or compliance. [3] Studies conducted elsewhere have demonstrated inappropriate practices such as sharing of antibiotics, [3] and the use of left over antibiotics. [4,5] There have been reports of a general lack of knowledge of correct antibiotic use and a lack of public awareness on the basic principles of antibiotic use, as well as indication for therapy. [4,5]

The World Health Organization (WHO) have also issued a Global Strategy for Containment of Antimicrobial Resistance in 2001 which urged member countries to initiate awareness and educational campaigns for patients and general community on appropriate use of antibiotics to combat antibiotic resistance. [2] This was echoed by International Pharmaceutical Federation (FIP) in 2008 in its Statement of Policy on Control of Antimicrobial Drug Resistance [6] and WHO Regional Office for South-East Asia [7] in 2010.

In Lebanon, antibiotics are mostly accessed without prescription despite the presence of a law that bans such practices. Therefore, it is important to assess the public knowledge, attitude and practice of antibiotic use among Lebanese population. The findings from this study would provide useful data which could form the basis for educational campaigns on appropriate use of antibiotics, thus addressing any misconceptions among the public.

2. Method

2.1. Design and Study Population

A cross sectional prospective study was conducted in a community-based pharmacy setting in Lebanon. Data was collected over a 1-year period (September 2015 to September 2016) from 50 community pharmacies CPs distributed in six different districts in Lebanon: Beirut, South Lebanon, Nabatiyeh, Mount Lebanon, Bekaa, and North. Data on antibiotic use was collected using a structured random interview conducted by study researchers who had been briefed about the study’s aims and methods. Consecutive customers aged 16 years and older arriving at community pharmacies seeking antibiotics were interviewed. The interview was based on a well-structured questionnaire, which had been pre-tested on a small pilot scale and subsequently modified to ensure that the data would provide reliable information.

The Lebanese University, Faculty of Pharmacy Internal Review Board waived the need for written informed consent. The patients were informed about the objective of the study and were asked to give an oral consent. Only those who were interested and who give their voluntary informed oral consent to participate in the study were enrolled.

2.2. Sample Size Calculation

A sample size was calculated assuming a type I error of 5% and a study power of 80% and 95%CI. Based on a previous study, 40% of patients were expected to self-medicate with antibiotics. [8] The minimal sample size necessary to show a twofold increase in the risk of exposure to non-prescribed antibiotics consists of 442 subjects.

2.3. Data Collection

Data was acquired through a structured questionnaire filled by an interviewer. If a customer had more than one request, CPs filled out one documentation form per request. The questionnaire was obtained after wide review of literature. (Lim & Teh, 2012; Kim et al., 2011; Alzoubi et al., 2013; Awad & Aboud, 2015; Napolitano, Izzo, Di Giuseppe, & Angelillo, 2013) The questionnaire included many sections that were chosen following an extensive review of literature. The questionnaire was translated into Arabic and subjected to a process of forward and backward translation into English. It was pretested and validated first on 20 patients visiting 4 different pharmacies before starting the survey.

The questionnaire consisted of dichotomous, and close-ended questions. It consisted of 5 sections. The first section was related to sociodemographic characteristics including age, sex, occupation, educational and marital status, monthly income, medical insurance, and the presence of a care provider at home. Education was divided into five classes of illiterate, primary, complementary, secondary, and academic education levels. Work status was categorized into currently working, retired and never working, while marital status was categorized into married, single, and widow/divorced.

The second section consisted of 13 questions to evaluate respondent’s knowledge bout antibiotics in four aspects: action and use (5 statements), side effects (4 sentences) and resistance (4 questions). A three-likert scale (1=agree, 2=uncertain, 3=disagree) was used to evaluate the participants’ response. Nine attitude statements were included in section three, and the participants were required to answer in three likert scale also. Finally, the fifth section included 6 statements to explore the patient and doctor relationship regarding prescribed antibiotic and the responses were measured using three-likert scale also.

2.4. Statistical Analysis

Statistical analysis was done using SPSS version 19. Descriptive statistics of the respondents’ knowledge and attitudes regarding antibiotic use and bacterial resistance were reported. After data cleaning, data was assessed. Percentages was used for multinomial variables, means and standard deviations for continuous variables. The internal consistency for the sections to determine knowledge of and attitude towards use of antibiotics was assessed using Cronbach’s α test. The Cronbach’s alpha for the knowledge score was 0.795 and 0.651 for the attitude score. To describe the knowledge and attitudes of the participants, a score was calculated according to the number of correctly answered questions targeting the knowledge and attitudes regarding antibiotic usage. The knowledge score was categorized as inadequate or adequate. The attitude score was categorized as poor and good. Each correct answer was assigned 1 point while wrong or uncertain responses were assigned 0 points. Then, the sum of the responses for each patient was calculated. The maximum knowledge score was 13 points and 9 points for the attitude score. Thus, the knowledge scores were categorized into inadequate (0-6/13) or adequate (7-13/13) while the attitude score was divided into poor (0-4/9) or good (5-9/9) as dichotomous variables. [9,10]

Associations of demographic variables (gender, age, family income level, education level, employment and marital status) with knowledge and attitudes were first evaluated using a bivariate analysis by chi-squared test. The correlation test was used to examine the association between knowledge and attitude score. Multivariate analysis using Logistic regressions was used to assess the correlation between the Knowledge and attitude dichotomous score as dependent variables and sociodemographic characteristics as independent variables taking into account potential confounding variables that had a p <0.2 in bivariate analysis. A p-value <0.05 was considered significant.

3. Results

3.1. Baseline Characteristics

A total of 495 patients were recorded in the study. Table 1 shows the demographic characteristics of the participants. In this sample, females were more than males (69.9% vs 30.1%). The majority being between 16 and 50 years of age (88.3%), while 11.7% were >51 years of age. About half of patients had a university degree (56.2%), while 13.8% had secondary education, 30.3% had intermediate and elementary education. 34.3% were currently working. The monthly income with greatest prevalence among the respondents was 2000000 LL (62.2%). Almost 21.8% had concomitant comorbidities.

Table 1. Characteristics of the study population

3.2. Knowledge Description

The study sample had in general low knowledge score (average = 6 points). Only 13.1% believed that antibiotics can kill bacteria. 54% and 59% responded that antibiotics can kill viruses and are effective against cough and cold. 54.3% of participants believed that antibiotics are effective in reducing fever and pain and can kill normal flora that live in the skin and gut. Almost 53% of participants realized that bacteria are becoming resistant to antibiotics and that the unnecessarily use of antibiotics has increased the risk of bacterial resistance. 25% believed that if antibiotics are taken for long period of time, the bacteria become more resistant to antibiotics and 36% believed that taken less doses do not decrease the bacterial resistance. Approximately, 45% of participants believed that antibiotics can cause side effects including hepatic and renal problems. Almost 65% stopped taking antibiotic if they get side effects including skin allergic reaction. (Table 2)

Table 2. Knowledge Attitude and Patient Physician Relationship among participants

Five variables (age, education, employment and family income level and presence of insurance) showed a significant association (p-value<.005) with the respondents’ knowledge regarding antibiotic use, according to the chi-squared test. Young age participants and those with higher educational level showed more adequate knowledge. Employed participants with higher income and with medical insurance showed better knowledge. Gender was not significantly associated with better knowledge of antibiotic use. (Table 3).

Table 3. Factors significantly associated with Public Knowledge toward antibiotic use:

3.3. Attitude and Patient Physician Relationship

The study sample had in general poor attitude score (mean= 4.19). Almost 57.4% stopped taking the medication if the symptoms disappear. 42% preferred to take antibiotic from the pharmacy without physician prescription. About 33% preferred to take antibiotic in cases of cough, flu and sore throat. 26% preferred keeping antibiotic at home in case of emergency and 31% shared the antibiotics with someone else if he had similar signs and symptoms. Approximately 73% checked the expiry date of medication before taking it and that there was need for patient education about the appropriate use of antibiotics. (Table 2)

According to the chi-squared test, females showed better attitude compared to males toward the appropriate use of antibiotic (p=.052). Age and education were not significantly associated with better attitude of appropriate antibiotic use. (Table 3)

Approximately 76% of participants responded that pharmacists tell them how to administer antibiotic. 51% expected that physicians routinely prescribe antibiotics in case of cold symptoms and that 37% of physicians spent time to inform patient about the usage of antibiotics. 66% trusted physicians if they decided not to prescribe antibiotic and 34% consulted another physician if the first physician disagreed to prescribe antibiotic. (Table 2)

3.4. Practice

Almost half read the instructions on the label to see the correct usage and safe of medication. 26.4% told the pharmacist about the concurrent medication at the time of OTC. Greater than half of participants reported requesting antibiotic more than once per year. Almost 65% of participants reported returning to pharmacy if the symptoms do not improve and returning to physician.

3.5. Multivariable Analysis

In the multivariable logistic regression analysis (Table 4), females showed better knowledge score compared to males (ORa=1.59, 95%CI=1.01-2.53). Compared to participants aged >50 years old, the level of adequate knowledge of antibiotic was higher in those aged 25-50 years old (ORa=3.66, 95%CI=1.79-7.49). Compared to unemployed participants, those with higher income had better knowledge score (ORa=3.17, 95%CI=1.78-6.79). Participants with insurance on medication coverage had also better knowledge score (ORa=2.06, 95%CI = 1.38-3.07).

Moreover, a step-wise multiple logistic regression was conducted on attitude of antibiotic usage (Table 4); three were shown to be significant predictors. Patients with comorbidities showed lower attitude score (ORa=.62, 95%CI= .38-1). Compared to unemployed participants with income <2000000 showed lower attitudes (ORa=.41, 95%CI=.26-.66) but those with income >2000000 didn’t show significant difference in attitude toward appropriate antibiotic usage. Presence of medical insurance showed better attitude score (ORa=1.62, 95%CI=1.08-2.42).

Table 4. Multivariable logistic regression of Knowledge and Attitude score:

4. Discussion

The results of this study demonstrated the knowledge, attitudes and practice toward antibiotic use among general public in Lebanon. This will help in testing the adequacy of knowledge and provide further insight in designing future educational campaigns targeting general public to promote appropriate antibiotic use and help in reducing antibiotic resistance. The average knowledge and attitude score was low. This finding is similar to that of neighboring countries in Jordan. [11] These results were supported by high proportion of Lebanese participants using antibiotic for common cough cold and sore throat symptoms. This means that that they are using antibiotic for diseases that do not require them. Other studies conducted in United Kingdom, [12] Sweden, [13] Korea, [14] Italy [15] and United State [16] showed that many people thought that antibiotics are effective for common cold and cough symptoms and may be used for viral infections.

Participants were not well informed to the meaning of antibiotic resistance and were unaware of the spread of bacterial resistance. They didn’t know that stopping the antibiotic early or as the symptoms disappear without completing the full course of antibiotic can increase the risk of antibiotic resistance. In our study, almost half of participants knew that antibiotics can kill normal flora that lives normally in the skin and gut which is similar percentage to that reported in Korea (57%) [14] but higher than that in UK (43%). [12] Many participants were aware of antibiotic side effects where approximately 60% stopped taking antibiotic as soon as side effects occur and stopped taking it again later. But only 40% knew that antibiotic can cause hepatic or renal problems.

In term of attitudes our study showed that 42% preferred to take antibiotic from the pharmacy without physician prescription. Recent studies from Lebanon reported similar self-medication rate (40%). [8] It is similar to that reported in Mediterranean countries which ranged from 40.7% to 78% namely Jordan, [17] United Arab Emirates, [18] Iraq [19] and Kuwait. [20] In contrast it is higher than that reported in Hong Kong, Malaysia, UK and European countries which ranged between 4.8 to 9%. [12,21,22,23,24] This is due to unregulated rules in Lebanon to restrict the self-medication use of prescribed antibiotic in community pharmacies. Hence, the current study highlights the need for further enforcement of regulations. Moreover, almost 48% stopped taking the medication if the symptoms disappear. This explains the rapid increase in bacterial resistance in Lebanon due to use of antibiotic beyond the scope.

About 33% preferred to take antibiotic in cases of cough, flu and sore throat. This explains the misconception present among the study participants regarding the role of antibiotic. A possible reason for inadequacy of knowledge in this area is the use of term “germ” rather than “bacteria” or “viruses” by the physicians during medical counseling. [13] Moreover, 26% preferred keeping antibiotic at home in case of emergency and 31% shared the antibiotics with someone else if he has similar signs and symptoms. This suggests that many Lebanese individuals share antibiotics with others and use them as necessary thus subjecting the Lebanese population to the problem of antibiotic misuse.

Approximately 76% of participants responded that pharmacists tell them how to administer antibiotic. This showed that many individuals obtained information about antibiotic use from pharmacists which highlight that pharmacists can have a vital role to play in public education about the prudent use of antibiotics. Therefore, implementation of pharmaceutical care in community pharmacies can help to improve public knowledge and attitude towards antibiotics in Lebanon. Community pharmacists are the most accessible health care providers to the public, and can contribute to public knowledge about appropriate antibiotic use.

51% expected that physicians routinely prescribe antibiotics in case of cold symptoms It is well documented that overprescribing by physicians even in the absence of appropriate indications due to diagnostic doubt and patient demand are factors contributing to antibiotic resistance. [2,25] Numerous reports show that patient’s expectation is an important factor for antibiotic prescribing and that antibiotics are more likely to be prescribed under patient pressure. [26,27]

Our results identified demographic groups with poor knowledge toward antibiotic use, including persons with low educational status and those aged >50 years old. As we found, a higher educational level was associated with better knowledge and attitude [23,28], and the elderly are less knowledgeable about antibiotics in general. [12] Moreover, females and those with higher income or medical insurance show better knowledge and attitude score compared to males. Previous studies reported significant association between self-medication and age, male gender, education level and lower socioeconomic status. [29,30]

Participants’ knowledge found to correlate positive attitude. Appropriate knowledge of antibiotics was identified to be a predictor for positive attitude towards antibiotic use. [14] These findings support the idea that the better knowledge on antibiotics usage and the potential for antibiotic resistance can change attitudes and behaviors regarding the appropriate use of antibiotic. An understanding of antibiotic use is important because personal decisions are based on these understandings. [22] They can impact physicians’ prescription behavior, [31] as well as lead to decreasing suboptimal use of antibiotics, such as using short courses and sub-therapeutic doses. [22]

This study has several limitations. While efforts were done to obtain representative samples, the over presentation of female gender and higher educational level indicate selection bias. This surveys were also filled using face to face questionnaire, therefore, there is a possibility of information and recall bias. Moreover, it is a cross sectional study, therefore, it does not allow causality to be attributed to the observed associations. Despite these limitations, this study provides important information for evaluating and improving knowledge, attitude and practice towards antibiotics use among general public in Lebanon.

5. Conclusion

This study identified important knowledge and attitude gaps among general public in Lebanon. Future antibiotic awareness campaigns and patient counselling should be implemented to fill up the knowledge and attitude gaps as an effort against antibiotic resistance. This aim to reduce the risk of antibiotic resistance.

Conflicts of Interest

The authors declare no conflicts of interest.

Funding

Malak Khalifeh received a grant from Lebanese University for her PhD research.

Acknowledgements

The authors thank the Lebanese University for funding this project.

Contribution of Authors

Malak Khalifeh shared the original idea, did the study, and wrote the original manuscript.

Nicholas Moore shared the original idea, and edited/amended the manuscript.

Pascale Salameh shared the original idea, and edited/amended the manuscript.

All authors read and approved the final manuscript as submitted.

References

[1]   | Va¨a¨na¨nen, M.H., K. Pietila, and M. Airaksinen, Self-medication with antibiotics– does it really happen in Europe? . Health Policy 2006. 77: p. 166-171.
[2]   | World Health Organization. WHO Global Strategy for Containment of Antimicrobial Resistance. 2001 [cited 2014 11 July]; Available from: http://www.who.int/csr/resources/publications/drugresist/en/EGlobal_Strat.pdf.
[3]   | Kandakai, T.L., et al., Knowledge, beliefs, and use of prescribed antibiotic medications among low-socioeconomic African Americans. J Natl Med Assoc, 1996. 88(5): p. 289-94.
[4]   | Curry, M., et al., Public views and use of antibiotics for the common cold before and after an education campaign in New Zealand. N Z Med J, 2006. 119(1233): p. U1957.
[5]   | Prakasam, K.C., N. Kumar, and J. Ramesh, Student's knowledge of antibiotics: A cross- sectional study of students in Tamil Nadu. International Journal of Pharmacy and Pharmaceutical Science 2011. 3(1): p. 232-233.
[6]   | International Pharmaceutical Federation. FIP. Statement of Policy Control of Antimicrobial Medicines Resistance (AMR). The Hague: International Pharmaceutical Federation; 2008. 2008 [cited 2012 15 Jan]; Available from: http://www.fip.org/www/uploads/database_file.php?id=289&table_id=.
[7]   | World Health Organization. Regional Strategy on Prevention and Containment of Antimicrobial Resistance 2010 – 2015. 2010 [cited 2012 15 Jan]; Available from: http://www.searo.who.int/LinkFiles/BCT_hlm-407.pdf.
[8]   | Cheaito, L., et al., Assessment of self-medication in population buying antibiotics in pharmacies: a pilot study from Beirut and its suburbs. Int J Public Health, 2014. 59(2): p. 319-27.
[9]   | Suaifan, G., et al., A cross sectional study on knowledge, attitude, and Behaviour related to antibiotic use and resistanc among medical and non-medical university students in Jordan. Afr. J. Pharm. Pharmacol., 2012. 10(6): p. 763-770.
[10]   | Awad, A., et al., Self-medication with antibiotics and antimalarials in the community of Khartoum State, Sudan. J Pharm Pharm Sci, 2005. 8(2): p. 326-31.
[11]   | Alzoubi, K., et al., An audit on the knowledge, beliefs and attitudes about the uses and side-effects of antibiotics among outpatients attending 2 teaching hospitals in Jordan. East Mediterr Health J, 2013. 19(5): p. 478-84.
[12]   | McNulty, C.A., et al., Don't wear me out--the public's knowledge of and attitudes to antibiotic use. J Antimicrob Chemother, 2007. 59(4): p. 727-38.
[13]   | Andre, M., et al., A survey of public knowledge and awareness related to antibiotic use and resistance in Sweden. J Antimicrob Chemother, 2010. 65(6): p. 1292-6.
[14]   | Kim, S.S., S. Moon, and E.J. Kim, Public knowledge and attitudes regarding antibiotic use in South Korea. J Korean Acad Nurs, 2011. 41(6): p. 742-9.
[15]   | Napolitano, F., et al., Public knowledge, attitudes, and experience regarding the use of antibiotics in Italy. PLoS One, 2013. 8(12): p. e84177.
[16]   | Filipetto, F.A., et al., Patient knowledge and perception of upper respiratory infections, antibiotic indications and resistance. Patient Prefer Adherence, 2008. 2: p. 35-9.
[17]   | Shehadeh, M., et al., Knowledge, attitudes and behavior regarding antibiotics use and misuse among adults in the community of Jordan. A pilot study. Saudi Pharm J, 2012. 20(2): p. 125-33.
[18]   | Abasaeed, A., et al., Self-medication with antibiotics by the community of Abu Dhabi Emirate, United Arab Emirates. J Infect Dev Ctries, 2009. 3(7): p. 491-7.
[19]   | Jassim, A.M., In-home Drug Storage and Self-medication with Antimicrobial Drugs in Basrah, Iraq. Oman Med J, 2010. 25(2): p. 79-87.
[20]   | Awad, A.I. and E.A. Aboud, Knowledge, attitude and practice towards antibiotic use among the public in Kuwait. PLoS One, 2015. 10(2): p. e0117910.
[21]   | Lim, K.K. and C.C. Teh, A Cross Sectional Study of Public Knowledge and Attitude towards Antibiotics in Putrajaya, Malaysia. South Med Rev, 2012. 5(2): p. 26-33.
[22]   | Norris, P., et al., Knowledge and reported use of antibiotics amongst immigrant ethnic groups in New Zealand. J Immigr Minor Health, 2010. 12(1): p. 107-12.
[23]   | You, J.H., et al., Public knowledge, attitudes and behavior on antibiotic use: a telephone survey in Hong Kong. Infection, 2008. 36(2): p. 153-7.
[24]   | European Commission. Antimicrobial Resistance. Brussels, Belgium: European Commission. 2013 [cited 2014 12 December]; Available from: http://www.who.int/csr/resources/publications/drugresist/en/ebs_407_en.pdf.
[25]   | Franco, B.E., et al., The determinants of the antibiotic resistance process. Infect Drug Resist, 2009. 2: p. 1-11.
[26]   | Kumar, S., P. Little, and N. Britten, Why do general practitioners prescribe antibiotics for sore throat? Grounded theory interview study. BMJ, 2003. 326(7381): p. 138.
[27]   | Butler, C.C., et al., Understanding the culture of prescribing: qualitative study of general practitioners' and patients' perceptions of antibiotics for sore throats. BMJ, 1998. 317(7159): p. 637-42.
[28]   | Van den Eng, J., et al., Consumer attitudes and use of antibiotics. Emerging Infectious Diseases, 2003. 9(1128-1135).
[29]   | Belkina, T., et al., Antibiotic use and knowledge in the community of Yemen, Saudi Arabia, and Uzbekistan. J Infect Dev Ctries, 2014. 8(4): p. 424-9.
[30]   | Jafari, F., A. Khatony, and E. Rahmani, Prevalence of self-medication among the elderly in Kermanshah-Iran. Glob J Health Sci, 2015. 7(2): p. 360-5.
[31]   | Belongia, E.A., et al., Antibiotic use and upper respiratory infections: a survey of knowledge, attitudes, and experience in Wisconsin and Minnesota. Prev Med, 2002. 34(3): p. 346-52.