1. KNOWLEDGE AND ATTITUDE TOWARDS ANTIBIOTICS AMONG PATIENTS IN A TERTIARY HOSPITAL IN KELANTAN
Ahmad Syafiq Zaim, Nurul Syamimi Hamat, Annuysia Mageswaran, Hasniza Mohamed, Nazmi Liana Azmi Department of Pharmacy, Hospital Raja Perempuan Zainab II, Kota Bharu, Kelantan

2. Introduction
Antibiotic consumption is a significant predictor in the emergence of resistance. Excessive use of antibiotics is associated with increase rate of resistant bacteria (Cars & Nordberg, 2004).
Among the key factors leading to uncontrolled use of antibiotics are problems in knowledge, attitude, beliefs and behaviours among public.
Several studies conducted worldwide reported inappropriate knowledge and attitude towards antibiotics among consumers (Gonzales, Steiner & Sande, 1997; Oh et al., 2010; Lim & Teh, 2012; Pereko, Lubbe & Essack, 2015; Awad & Aboud, 2015).

3. Rationale of Study
There were only two studies reported in Malaysia which assess public knowledge and attitude towards antibiotic use (Oh et al., & Lim & Teh, 2012). In view of the different geographic locations, this study was conducted to gather local data among patients attending outpatient pharmacy in Hospital Raja Perempuan Zainab II (HRPZ II), Kelantan.

4. Objectives General Objective:
To investigate the level of knowledge and attitude towards antibiotic use among patients attending outpatient pharmacy in HRPZ II, Kelantan.
Specific Objectives:
To determine the relationship between demographic characteristics and knowledge as well as attitude.
To identify the areas of inappropriate responses for knowledge and attitude statements.

5. Methodology Study Design Cross-sectional study Study Duration
October January 2016
Sampling Method
Convenience sampling
Study Population
Patients attending outpatient pharmacy in HRPZ II, Kelantan

6. Methodology Inclusion Criteria Patients aged 18 years old and above
Able to speak and write in Bahasa Malaysia
Exclusion Criteria
Patients who had never been prescribed with antibiotics
Psychiatric patients

7. Methodology Sample Size
Sample size was calculated based on formula for a classical cross-sectional study (Naing, 2009). Utilizing the values below, minimum sample size was 155 (Actual sample achieved = 158)
n = p1(1 – p1) + p2(1 – p2) x (zα + zβ)2
(p1 – p2)2
Level of significance, α = 0.05
Power, (1 – β) = 0.80
p1 = 0.61 (expected proportion of patients with appropriate attitude based on expert opinion)
p2 = 0.7 (proportion of patients with appropriate attitude in the population given by Lim and Teh, 2012)
Appropriate knowledge: p1 = 0.41, p2 = 0.51; minimum sample size

8. Methodology Instrument
Validated, self-administered questionnaire (Lim & Teh, 2012)
Comprised of 4 parts:
Part I - demographic characteristics
Part II - recent use of antibiotics
Part III - 12 knowledge statements ; “Yes”, “No” or “Not Sure”
Part IV - 8 attitude statements; 5-point Likert scale (1=strongly disagree; 2=disagree; 3=not sure; 4=agree; 5=strongly agree).

9. Methodology Statistical Analysis
Data were analyzed using SPSS version 22.0.
ANALYSIS
VARIABLES
OUTCOME
Descriptive statistics
Demographic characteristics, recent antibiotics consumption, knowledge and attitude scores, inappropriate responses for knowledge and attitude statements
Frequencies
Percentages
Mean(SD)
Independent t-test or one-way ANOVA
The influence of demographic characteristics on knowledge and attitude scores
(categorical vs numerical)
p-value of < 0.05 was considered as statistically significant

10. Results 200 questionnaires were distributed
164 questionnaires were returned (82.0% response rate)
6 questionnaires were incomplete
Total final sample: 158 questionnaires

11. Results PART I - Demographic characteristics (Table I)
Most respondents were Malay (n=137, 86.7%), female (n=102, 64.6%), of years old (n=132, 83.5%) with tertiary education (n=88, 55.7%).
42.4% (n=67) were employed with 27.8% (n=44) worked in healthcare-related occupation.
Mean knowledge score and mean attitude score were significantly influenced by:
education level (p<0.001 and p<0.001, respectively)
employment status (p=0.017 and p=0.022, respectively)
healthcare-related occupation (p=0.003 and p=0.001, respectively)

12. Mean(SD) knowledge score Mean(SD) attitude score
Table I: Characteristics of the respondents
Characteristics
Mean(SD) knowledge score
p-value
Mean(SD) attitude score
Gender
Male (n=56)
5.27(3.24)
0.973
3.96 (2.27)
0.975
Female(n=102)
6.86(3.23)
4.63(2.13)
Age
18-45 (n=132)
6.51(3.28)
0.931
4.58(2.13)
0.464
45-60 (n=26)
5.23(3.35)
3.46(2.35)
Race
Malay (n=137)
6.21(3.39)
0.179
4.33(2.15)
0.489
Others (n=21)
6.86(2.74)
4.81(2.50)
Education level
Tertiary (n= 88)
8.01(2.84)
<0.001
5.38(1.97)
Others (n= 70)
4.14(2.53)
3.16(1.83)
Employment status
Employed (n= 67)
8.13(3.27)
0.017
5.67(1.67)
0.022
Others (n= 91)
4.65(2.64)
3.45(2.07)
Occupations related to healthcare
Yes (n=44)
9.82(1.78)
0.003
6.34(1.29)
0.001
No (n=114)
4.94(2.72)
3.64(2.01)
Family member’s occupation related to healthcare?
Yes (n=77)
7.74(3.16)
0.194
4.92(2.01)
0.054
No (n=81)
4.93(2.85)
3.89(2.26)
Have any chronic disease?
Yes (n=28)
5.86(3.28)
0.683
3.79( 2.18)
0.813
No (n=130)
6.39(3.33)
4.52(2.19)
Most common location seeking healthcare
Government Hospital (n=95)
6.29(3.18)
0.207
4.54(2.28)
0.221
Others (n=63)
6.30(3.54)
4.17(2.08)

13. Results PART II - Recent use of antibiotics
25.9% took antibiotics within the past 4 weeks.
Most obtained the medications after consultation with doctors (n=38, 24.1%).
Others purchased antibiotics from retail pharmacy without prior consultation.
The most common causes for taking antibiotics:
fever (n=62, 39.5%)
respiratory tract infections (n=46, 29.1%)
urinary tract infections (n=25, 15.8%)
skin problems or wounds (n=16, 10.4%)
pain or inflammation (n=9, 5.4%)

14. Results PART III - Knowledge of antibiotic use (Table II)
Knowledge score ranged from 0 to 12 points.
Mean(SD) score of 6.30(3.32).
Most were not aware that antibiotics were not effective against coughs and colds (n=121, 76.6%) and viral infections (n=103, 65.2%).
Many knew that antibiotics could kill bacteria that normally live on the skin and gut (n=103, 65.1%) and antibiotics could cause allergic reactions (n=103, 65.1%).

15. Table II: Proportion of inappropriate responses for knowledge statements
Aspects
No.
Statement
Frequency
Percentage (%)
Role of antibiotics 1
Antibiotics are medicines that can kill bacteria 11
7.0 2
Antibiotics can be used to treat viral infections
103
65.2 3
Antibiotics work on most colds and coughs
121
76.6
Good bacteria 4
Antibiotics can kill bacteria that normally live on the skin and gut (digestion tract) 55
34.8 5
Bacteria that normally live on the skin and in the gut are good for your health 98
62.0
Identification of antibiotics 6
Antibiotics are the same medications used to relieve pain and fever such as aspirin and paracetamol (Panadol) 61
38.6 7
Penicillin is an antibiotic 77
48.7
Adverse effects 8
Antibiotics may cause allergic reactions 9
Antibiotics do not cause side effects 74
46.8 10
Overuse of antibiotics can cause the antibiotics to lose effectiveness in long term 86
54.4
Administration of antibiotics
It is okay to stop taking an antibiotic when symptoms are improving 82
51.9 12
Taking less antibiotics than prescribed is more healthy than taking the full course prescribed 78
49.4

16. Results PART IV - Attitude towards antibiotic use (Table III)
Attitude score ranged from 0 to 8 points.
Mean(SD) score of 4.39(2.20).
Many participants:
Take antibiotics when they have cold (n=101, 64.0%).
Expect doctors to prescribe antibiotics for common cold (n=97, 61.4%).
NEVERTHELESS, majority take antibiotics according to instructions (n=156, 98.73%).

17. Table III: Proportion of inappropriate responses for attitude statements
Frequency
Percentage (%) 1
When I get cold, I will take antibiotics to help me get better more quickly
101
64.0 2
I expect antibiotic to be prescribed by my doctor if I suffer from common cold symptoms 97
61.4 3
I normally stop taking an antibiotic when I start feeling better 75
47.5 4
If my family member is sick I usually will give my antibiotic to them 27
17.1 5
I normally keep antibiotic at home in case of emergency 26
16.4 6
I will use leftover antibiotics for a respiratory illness (runny nose/flu) 18
11.4 7
I will take antibiotic according to the instructions on the label
1.3 8
I normally will look at the expiry date of antibiotic before taking it 19
12.1

18. Discussion Demographic characteristics:
Despite the different geographic locations, they were similar to Lim and Teh (2012) in Putrajaya.
Except that ours had more respondents and family members who worked in healthcare-related occupation.
25.9% took antibiotics within the past 4 weeks of the survey:
Consistent with Oh et al.(2010) in Penang (28.9%).
In contrast to Lim and Teh (2012) - only 16.5%.
Common reasons for taking antibiotics were fever and respiratory tract infections:
In agreement with Oh et al.(2010) and Lim and Teh (2012).

19. Discussion
Education level, healthcare-related job and employment status contributed significantly to knowledge and attitude towards antibiotics:
Oh et al. (2010) - education level had huge impact on knowledge and attitude with other associated factors were age and race.
Lim and Teh (2012) - education level and healthcare- related occupation were strongly related with both variables.

20. Discussion LESS KNOWLEDGEABLE when it comes to the role of antibiotics
Most were not aware that antibiotics would not be effective for coughs and colds (76.6%):
Showed misconception about the indication of antibiotics in treating infections.
Comparable to Lim and Teh (2012) – 82.0%.
Lower percentages were reported in studies outside of Malaysia % used antibiotics for a cold or flu in Namibia (Pereko, Lubbe & Essack, 2015), 54.5% took antibiotics for common cold in Kuwait (Awad & Aboud, 2015).

21. Discussion
Most thought that antibiotics could treat viral infections (65.2%):
Consistent with Pereko, Lubbe and Essack (2015) – 64.0% assumed that antibiotics could kill viruses.
The rates reported by Oh et al. (2010) and Lim and Teh (2012) were more alarming (83.0% and 86.6%, respectively).
Could be due to the frequent prescribing of antibiotics for viral respiratory tract infections and common flu which prompted the misconception (Gonzales, Steiner & Sande, 1997).

22. Discussion
Many respondents correctly answered that antibiotics could kill bacteria that normally live on the skin and gut (65.1%) and knew that antibiotics could cause allergic reactions (65.1%):
Could be due to the positive outcome of Know Your Medicine campaign (Pharmaceutical Services Division, 2017).
Might also explain why majority take antibiotics according to instructions (98.73%) .

23. Discussion High prevalence of INAPPROPRIATE ATTITUDE
Many take antibiotics to get better quickly (64.0%):
Many expect doctors to prescribe antibiotics for common cold (61.4%):
Comparable to Oh et al. (2010).
Overprescribing of antibiotics could trigger negative attitude.
Antibiotics have been shown to be prescribed under pressured clinical context to please patients’ expectations.
Some general practitioners prescribe antibiotics to maintain doctor-patient relationships even though when they feel that they are not necessary (Kumar, Little & Britten, 2003).

24. Study limitations
Single center study – findings cannot be generalized to population
Selection bias – convenience sampling
Response bias – self-administered questionnaire

25. Conclusion
Overall, patients attending outpatient pharmacy in HRPZ II, Kelantan showed an average level of knowledge and attitude towards antibiotics.
They were significantly influenced by education level, employment status and healthcare-related occupation.
We managed to identify the areas of misconceptions and negative attitude regarding rational use of antibiotics.
Future awareness campaign and educational program should focus on these issues to improve the appropriate use of antibiotics.

26. Acknowledgement
We would like to thank all pharmacists in HRPZ II, Kelantan who were directly or indirectly involved with this study.

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