Public knowledge of antibiotics, self-medication, and household disposal practices in Jordan

ABSTRACT

Background

This study aimed to assess public understanding of antibiotics, self-medication, and drug disposal practices.

Methods

A cross-sectional self-administered online survey was undertaken in Jordan.

Results

The study was completed by 1,105 participants. When asked about their knowledge of antibiotics, rational antibiotic use, and disposal practices, 16% percent believed they should discontinue antibiotics once they felt better, and 12% agreed to take the same antibiotics prescribed to others for the same illness. Self-medication with antibiotics was practiced by 44% of the participants. Prior experience, healthcare costs, and pharmacy location were all major determinants of self-medication. Only 6.4% of unneeded antibiotics were returned to the pharmacy, 60% were kept at home, and 26.6% were disposed of at home. Almost half of those who kept the antibiotics said they would use them again, and one-third said they would give them to friends and family. Respondents who had used antibiotics within the previous 6 months (p = 0.052) and relied on medication leaflets (p = 0.031) and physician recommendations (p = 0.001) were less likely to self-medicate with antibiotics.

Conclusions

The study highlighted areas of inappropriate use of antibiotics, self-medication and the improper antibiotic disposal that can inform antimicrobial stewardship.

KEYWORDS:

• Self-medication
• antibiotic resistance
• antibiotic disposal
• COVID-19
• antimicrobial stewardship

1. Introduction

Antibiotics are considered the main management response to treat potentially severe bacterial diseases, and contribute to millions of lives being saved [1]. However, it is well-known that the inappropriate use of various antibiotics results in a rise in antimicrobial resistance (AMR) [2–5]. AMR is one of the main hazards affecting global health with approximately 700,000 deaths annually [6]. Self-medication with antibiotics is a driver for the development of antimicrobial resistance in low and middle income countries (LMICs) and adds to other drivers such as incorrect dosing, incorrect treatment duration, and lack of access to effective medications [7–12]. Recent findings on understanding of AMR in LMICs, demonstrated limited knowledge and understanding[8,13,14]. Other high-income Middle Eastern countries had low antibiotic knowledge, which resulted in poor antibiotic identification, seeking antibiotics without a prescription, and failing to complete their antibiotic medication course [15–17]. The World Health Organization (WHO) defines self-medication as ‘the act of persistent, irrational, and inappropriate consumption of medications without prescriptions, supervision, or medical advice in an attempt to treat recurrent, chronic, or self-diagnosed illness’ It has been reported that the rate of self-treatment with medications can reach up to 90% in some societies [7,18].

Old prescriptions refilling, using medications remaining after treatment of a previous disease or sharing medications between family and friends are other forms of self-medication [19–21]. Improper drug disposal behaviors can contribute to irrational use of medicine (IUM) practices such as inappropriate treatment, drug wastage, medication errors, AMR, intoxication, and unnecessary self-medication [22–25]. A clear indication for the use of antibiotics in the treatment of coronavirus disease-2019 (COVID-19) patients should be determined, i.e. a secondary bacterial super-infection [26,27]. Even though viral infections, including COVID-19, cannot be treated or prevented with antibiotics, a rise in antibiotic use alongside an increase in COVID-19 cases has been reported in several studies [26,28–30]. The emergence of the COVID-19 pandemic has contributed to increased fear, anxiety, depression, and stress in the general population [31–33]. Accordingly, measures including the use of masks, social distancing, and isolation were introduced to decrease transmission of the virus [34]. COVID-19 pandemic-induced psychological distress was significantly positively related to self-medication and preventative use of antibiotics increased in an emotional response to perceived health risks [35,36].

Educating healthcare professionals and the general public on the proper use of antibiotics is one way to promote the responsible use and knowledge of antibiotics. Antibiotic use, including when to provide them and when to avoid them, should be emphasized to healthcare providers [8,37–39]. The public should be aware of the importance of only taking antibiotics when prescribed by a healthcare practitioner, and the consequences of antibiotic overuse or misuse. The public should be provided with adequate resources to provide individuals with quick and easy access to primary healthcare. There should be warnings about controversial advertising and social media influence in which patients become attracted to a specific antibiotic, which may result in dissatisfaction due to a doctor’s refusal prescribe, and patients potentially obtaining the medication elsewhere [7,40–42]. Previous research has emphasized the importance of policymakers enacting strict regulations to limit the availability of antibiotics as over-the-counter (OTC) medications [42–44]. Furthermore, recent studies suggest that measures should be followed to ensure that antibiotics are used effectively, such as encouraging medical practitioners to use evidence-based criteria when prescribing antibiotics and implementing antibiotic stewardship programs [43,45]. Due to a lack of research focusing on antibiotic self-medication and drug disposal practices [46,47], the purpose of this study was to assess the public understanding of antibiotics, antibiotic self-medication, and drug disposal practices during the late stage of the COVID-19 outbreak in Jordan. Furthermore, the study evaluated the effectiveness of the awareness campaign on people’s understanding of antibiotics and self-medication practices.

2. Materials and methods

2.1. Overview of study

To achieve the study’s objectives, a quantitative approach was primarily used. Based on a review of the literature and validated items from WHO multi-country survey study (, Google Forms was utilized to generate a link to the survey questionnaire, which was then posted on Facebook® pages. The survey was designed to assess participants’ knowledge of antibiotics, self-medication with antibiotics, antibiotic disposal practices, and the relationship between antibiotic self-medication and several independent variables. The study was approved by the Jordan University of Science and Technology’s Institutional Review Board (IRB, Reference: 56/140/2021).

2.2. Study design and setting

A convenience sample approach was used to conduct a cross-sectional, observational study among Jordan’s general public. A self-administered online questionnaire was posted on Facebook pages for the public to complete. Although Facebook pages are generally self-selected and may not be representative of the Jordan population in terms of age, gender, or other demographic criteria, and may not necessarily indicative of the population as a whole. Thus, self-identification is currently the method for researchers to identify eligible participants in an online survey. However, to recruit eligible participants for this study, we used instructions in online advertisements to discourage people who do not meet the criteria from completing the survey. Participants were selected based on their ability to understand and speak Arabic, aged 18 or older, and willingness to participate voluntarily. Raosoft® software was used to estimate a sample size of almost 1,000 participants, with a 95% confidence level and a 3% margin of error [48].

2.3. Respondents, recruitment procedures, and data collection

We conducted an anonymous online survey of members of public Facebook users and groups. Facebook represent Jordan’s largest social network from January 1 to 1 April 2022, which was regarded as the late stage of Jordan’s COVID-19 pandemic. During the COVID-19 pandemic, the online survey was used to obtain data from a large number of individuals without the requirement for physical interaction. In addition, the online survey was used to obtain information from those who were unable to participate in traditional surveys owing to travel constraints or safety concerns. Despite the simple process for accessing social network services via smartphones, tablets, and computers [49], paid advertisements on Facebook- a form of online advertising that allows researchers to target specific Facebook users whose profiles indicated that they lived in Jordan and who matched on specific demographics [50]. Free advertising approaches such as posts on relevant Facebook pages (e.g. groups with a general interest in chronic diseases), were also used to increase the number of people exposed to the study particularly those who are difficult to reach or contact.

A brief description of the study was included in the recruitment adverts, along with a link to the online survey. We used free advertising approaches to directly recruit individuals who participated in chronic disease Facebook groups because this study aimed to survey the general public who could possibly self-medicate with antibiotics or engage in antibiotic disposal practices. It was not possible to calculate a response rate for this study due to the dynamic nature of the number of platform users and a lack of information about the denominator, i.e. the number of potential participants came across the survey information and decided not to respond to it. However, the total number of Facebook participants for whom the sample size was calculated was 30,000.

Throughout the Facebook advertisements, interested and eligible individuals were redirected to the online-survey website, and responses to the study survey were automatically collected using Google Forms®. The purpose of the current study, as well as its benefits and risks, were outlined in the online invitation, and participants were assured that their anonymity and confidentiality would be protected from unauthorized access. Participants were given the option of agreeing or disagreeing to participate voluntarily in the study. SPSS® software was then used to analyse the data that had been collected and organized using Google Forms.

2.4. Survey instrument

This study used a 35-item online questionnaire. The final survey was developed with the assistance of faculty members from the Antibiotic Stewardship Programs (ASPs) at King Abdullah University Hospital, Jordan and a comprehensive literature review on public knowledge, attitudes, and behaviors regarding antibiotics [5,10,15,19,51–55]. An eight-item list of demographics (age and gender; residence; family structure; education; employment status; total household income and health insurance) was included in the first part of this survey. The survey asked four questions about medication and COVID-19 history. The Single Item Literacy Screener (SILS) by Morris et al., (2006) [56] was used to report how frequently participants sought assistance in reading the instructions and leaflets from their doctor or pharmacy, using a five-point Likert scale: (5 = never; 4 = rarely; 3 = sometimes; 2 = often; 1 = always). In this study, scores of 4 or 5 were considered adequate health literacy, while a score of 3 or lower was considered inadequate. Antibiotic knowledge was assessed using the validated Antibiotic resistance: multi-country public awareness survey [57] of the World Health Organization (WHO), which is available in English; however, a previously translated version used in a similar setting was employed [58]. The final survey was pilot tested by 25 participants primarily to assess survey readability and comprehension, which was then delivered in Arabic.

2.5. Statistical analysis

Data obtained via Google Forms was automatically organized into columns and rows, and missing and duplicate data were avoided by selecting ‘required item’ and ‘limit to 1 response,’ respectively. A histogram was also used to locate and remove outliers from the data. The data were then directly downloaded into an excel sheet and transferred to SPSS® (Statistical Package for the Social Sciences) version 26.0 computer software to analyze the data collected in this study. The percentages and frequencies of antibiotic knowledge, participants’ behaviour regarding antibiotic use and self-medication, and antibiotic disposal practices were reported using descriptive analysis. Antibiotic knowledge was classified as adequate or inadequate [58], and antibiotic self-medication was classified as appropriate or inappropriate (self-medication). Following univariate logistic regression, variables with p < 0.25 were included in the multiple logistic regression model, which was then used to identify factors associated with self-medication practices. In order to be considered statistically significant, analyses had to have a p-value of less than 0.05.

3. Results

In total, 1,105 participants replied to the online survey. The mean age of the participants was 34.5 ± 10.5 years, ranging from 18 to 60 years. The majority of participants were female (64%) and married (58.3%); 52.6% had a bachelor’s degree or higher, and 73.5% had medical insurance. Almost half of the participants earned less than (JOD) 500 ($700) each month, lived in cities, and were unemployed. Eighteen percent of individuals stated that they had a chronic condition, and nearly forty percent stated that they had been infected with COVID-19. Table 1 summarizes the respondents’ sociodemographic characteristics.

Table 1. Frequency distribution of participants’ sociodemographic characteristics (N = 1,105).

Variables		Frequency (%)
Gender
	Male	398 (36)
	Female	707 (64)
Age (years)
	18 to 30	480 (43.4)
	31 to 40	350 (31.7)
	41 to 65	275 (24.9)
Social Status
	Single/Divorced	403 (36.5)
	Married (no kids)	56 (5.1)
	Married (with kids)	588 (53.2)
	Extended family	58 (5.2)
Academic Level
	Prior to high school	113 (10.2)
	High school	202 (18.3)
	Student in university/college	208 (18.8)
	Bachelor’s degree	449 (40.6)
	Postgraduate	133 (12)
Insurance
	Insured	812 (73.5)
	Non-insured	293 (26.5)
Income (JOD monthly)
	Less than 500	547 (49.5)
	501–1,000	383 (34.7)
	1,001–1,500	107 (9.7)
	More than 1,500	68 (6.2)
Living Area
	Urban	608 (55)
	Suburban/Rural	497 (45)
Employment
	Unemployed	616 (55.7)
	Medical-related	128 (11.6)
	Nonmedical-related	306 (27.7)
	Retired	55 (5)
Existence of chronic diseases
	Yes	200 (18.1)
	No	905 (81.9)
COVID-19 infection history
	Yes	439 (39.7)
	No	666 (60.3)
Health literacy
	Adequate	747 (67.6)
	Inadequate	358 (32.4)

Almost 15.8% of participants believed that once they felt better, they should discontinue antibiotic use. Nearly 12% agreed that they would take the same antibiotics that had been prescribed to a friend or family member for the same illness, while this is an improper practice. Over one third (35.6%) of participants answered that it was ‘acceptable’ to purchase the same medication or request it from a doctor if they became ill and that the same drugs helped them recover previously when they experienced the same symptoms. When respondents were asked which of a list of bacterial or viral infections may be treated with antibiotics, over half of the participants correctly identified bladder infection or urinary tract infection (65.2%) and skin or wound infection (53.4%) as antibiotic-treatable diseases. However, only a limited number chose gonorrhea (11.8%) and malaria (9.6%) as antibiotic-treatable infections. Of note, participants believed antibiotics were used to treat sore throats (77%) as well as colds and flu (46.2%) and fever (26.3%). Table 2 summarizes the participants’ knowledge about antibiotics.

Table 2. Participants knowledge regarding antibiotics use (N = 1,105).

Items		Correct Answer*	Frequency (%)
When do you think you should stop taking antibiotics?
	When you feel better	False	175 (15.8)
	When you have taken all of the antibiotics as directed	True	908 (82.2)
	Don’t know	False	22(2)
It’s okay to use antibiotics that were given to a friend or family member, as long as they were used to treat the same illness
	True	False	133 (12)
	False	True	880 (79.6)
	Don’t know	False	92 (8.3)
It’s okay to buy the same antibiotics, or request these from a doctor, if you’re sick and they helped you get better when you had the same symptoms before”
	True	False	393 (35.6)
	False	True	588 (53.2)
	Don’t know	False	124 (11.2)
Do you think antibiotics can be used to treat these conditions? (% of Correct Answer)
	1. HIV/AIDS	False	64 (5.8)
	2. Gonorrhoea	True	130 (11.8)
	3. Bladder infection or urinary tract infection (UTI)	True	720 (65.2)
	4. Diarrhoea	False	184 (16.7)
	5. Cold and flu	False	511 (46.2)
	6. Fever	False	291 (26.3)
	7. Malaria	True	106 (9.6)
	8. Measles	False	70 (6.3)
	9. Skin or wound infection	True	590 (53.4)
	10. Sore throat	False	851 (77)
	11. Body aches	False	149 (13.5)
	12. Headaches	False	165 (14.9)
	13. Corona virus	False	224 (20.3)

*Correct answer indicates if the answer provided by participants was true or false.

When asked about antibiotic use, the percentage of respondents in this survey who reported using antibiotics in the preceding month, the previous 6 months, and a year ago was determined (42.2%, 23.3%, and 8.1%, respectively; Table 3). When respondents were sorted to include only those who had self-medicated of antibiotics in the preceding month, the previous 6 months, and a year ago, comparable percentages were observed. Almost 46% of participants in this study reported self-medication with antibiotics, with the majority obtaining the antibiotics and seeking medical advice primarily from pharmacies (68.3%) without consulting prescribing physicians, and 21.4% obtaining antibiotics from friends or family (Table 3). According to participants, the factors responsible for self-medication were prior experience (38.3%), proximity to a pharmacy (19.8%), and economical reasons (18.5%). According to the findings of this study, product information leaflets (67.5%) and the internet (47.3%) were the most frequently used sources of antibiotic information. The majority of participants stated that they received antibiotic use counselling from both pharmacists and doctors, and they became acquainted with the term “antimicrobial resistance (Table 3).

Table 3. Participants behavior on antibiotics use and self-medication (N = 1,105).

Items	Frequency (%)
Did you get a doctor’s prescription before taking the antibiotic (Self-medication)?
Yes	619 (56)
Yes, but it was an old medicine prescription	54 (4.9)
No, I bought it directly from the pharmacy	256 (23.2)
No, I obtained it from friends	26 (2.4)
No, I obtained it from my family	150 (13.6)
When was the last time you were administered antibiotics?
Last month	466 (42.2)
Last six months	257 (23.3)
Last year	90 (8.1)
More than a year or never	292 (26.4)
When was the last time you took antibiotics without a prescription?
Last month	228 (46.9)
Last six months	108 (22.2)
Last year	33 (6.8)
More than a year or never	117 (24.1)
What are the most common reasons for taking antibiotics without first consulting a doctor (without a prescription)?
I don’t want to interact with the medical professionals.	30 (6.2)
Financial considerations (doctor’s fees)	90 (18.5)
The distance between medical centers or hospitals	41 (8.4)
The pharmacy is close to my house	96 (19.8)
I have prior experience	186 (38.3)
I consult my friends	24 (4.9)
I do not have enough time to see a doctor or go to the hospital.	61 (12.6)
If you are looking for more information about how to use the antibiotics you will be using, where you get it from?
Product information leaflets (package inserts)	746 (67.5)
Information provided on the drug labelling	214 (19.4)
The internet	523 (47.3)
Pharmacists	421 (38.1)
Doctors	366 (33.1)
From whom have you received advice about the appropriate use of antibiotics?
Doctors	723 (65.4)
Pharmacists	734 (66.4)
Have you ever heard of the term ‘antimicrobial resistance’?
Yes	735 (66.5)
No	370 (33.5)
Prior to the COVID-19 pandemic, did you believe antibiotics are effective against infections caused by viruses?
Yes	672 (60.8)
No	433 (39.2)
Following the COVID-19 pandemic, do you believe antibiotics are effective against infections caused by viruses?
Yes	570 (51.6)
No	535 (48.4)

When compared to the previous month’s antibiotic users, adequate antibiotic knowledge was substantially more prevalent among respondents who reported using antibiotics in the preceding 6 months or longer (adjusted OR = 8.19, 95% CI: 1.190–2.535, p-value = 0.004; Table S1). Furthermore, respondents who reported receiving antibiotics via medical prescription were more likely to have adequate antibiotic knowledge (adjusted OR = 1.83, 95% CI: 1.362–2.451, p-value = <0.0001) than those who self-medicated. Those who had heard about antibiotic resistance knew more about antibiotics than those who had not (adjusted OR = 1.97, 95% CI: 1.459–2.654, p-value = <0.0001). Respondents who disagreed that antibiotics are beneficial against viral infections were more likely to have adequate knowledge of antibiotics than those who agreed with the opposite statement (adjusted OR = 5.38, 95% CI: 3.783–7.647, p-value = <0.0001; Table S1).

When participants were asked to provide an appropriate disposal strategy for unused antibiotics, only 6.4% indicated that they return unused antibiotics to the pharmacy, the majority (60%) reported keeping them at home, and 26.6% indicated that they dispose of antibiotics at home (Table 4). Almost half of those who selected to retain the antibiotics at home confirmed they would use them again and keep them in their medicine cabinet, and one-third said they would be willing to share them with friends and family. The most prevalent method of disposing of unwanted antibiotics was through household waste (77.2%), followed by flushing with water supply (22.8%; Table 4).

Table 4. Antibiotic disposal practices and perceptions of unused antibiotics.

Items	Frequency (%)
When dealing with unused antibiotics, what is your most common course of action?
Return them to the pharmacy.	71 (6.4)
Keep them at home.	663 (60)
At home, I get rid of them.	294 (26.6)
Share them with your friends/family	61 (5.5)
Others (never taken or finished the course of antibiotic)	16 (1.4)
The option that accurately describes why antibiotics should be kept at home (select more than one option)
Keep them for the next time.	352 (53.1)
I keep them in case my family or friends require them.	243 (36.7)
I’m not sure what to do with them.	111 (16.7)
They should be stocked in the medicine cabinet at home.	333 (50.2)
Please choose one of the following methods for disposing of an antibiotic at home
Regular household waste	227(77.2)
Flushing down the toilet or sink	67(22.8)

3.1. Factors associated with participants’ self-medication of antibiotics

A number of factors related to antibiotic self-medication were identified using univariate analysis (e.g. age groups and gender distributions), socioeconomic status and educational attainment levels, health insurance coverage, monthly income and location, employment status, the presence of chronic diseases, the history and protective measures taken against the COVID-19 infection, health literacy, knowledge of the most recent use of antibiotics, and the sources of antibiotic information, antibiotics and methods of antibiotic disposal (Table S2). The multiple logistic regression model including variables with p< 0.25 showed that health insurance coverage (adjusted OR = 1.67, 95% CI: 1.251–2.229, p = 0.001) and adequate antibiotic knowledge (adjusted OR = 1.605, 95% CI: 1.224–2.105, p = 0.001) were associated with a higher likelihood of using antibiotics as prescribed by doctors, according to this study (Table 5).

Table 5. Multiple logistic regression of sociodemographic and other factors associated with participants’ antibiotic self-medication.

Variables	Antibiotics use (appropriate vs self-medication)
	Standardized β (S.E.)	Adjusted OR (95% CI)	p-Value
Academic Level
Prior to high school	−0.155(0.284)	0.857(0.491–1.494)	0.355
High school	−0.135(0.253)	0.874(0.532–1.436)	0.466
Student in university/college	−0.012(0.256)	0.988(0.599–1.631)	0.43
Bachelor’s degree	−0.029(0.229)	0.972(0.62–1.522)	0.554
Postgraduate	Ref.
Insurance
Insured	0.513 (0.150)	1.67(1.251–2.229)	0.001
Non-insured	Ref.
Existence of chronic diseases
Yes	0.256 (0.174)	1.291(0.922–1.808)	0.137
No	Ref.
Protective measures against COVID-19
0–2 actions	−0.071(0.164)	0.931(0.675–1.284)	0.663
3–4 actions	0.048(0.159)	1.049(0.768–1.433)	0.765
4 or more actions	Ref.
Knowledge of antibiotics
Adequate	0.473 (0.159)	1.605(1.224–2.105)	0.001
Inadequate	Ref.
When was the last time you took antibiotics?
More than a year	1.055(0.186)	2.872(1.996–4.132)	<0.0001
Last year	0.506(0.25)	1.659(1.016–2.707)	0.043
Last six months	0.32(0.165)	1.378(0.998–1.902)	0.052
Last month	Ref.
If you are looking for more information about how to use the antibiotics, where you get it from?: (Ref. = No)
Product information leaflets (package inserts)	0.319(0.137)	1.375(1.053–1.797)	0.031
Doctors	0.505(0.137)	1.656(1.266–2.168)	0.001
Antibiotic Disposal
Share them with others	−0.96(0.421)	0.383(0.168–0.875)	0.023
Get rid of them at home	−0.642(0.342)	0.526(0.269–1.03)	0.062
Keep them at home	−1.221(0.326)	0.295(0.156–0.558)	<0.0001
Return them to pharmacy	Ref.

*Protective measures included, but were not limited to, uptake of the COVID-19 vaccine, social isolation, taking vitamins, eating healthy foods, using herbal products, exercising, and wearing a mask.

Those respondents who reported using antibiotics at least six months ago (adjusted OR = 1.378, 95% confidence CI:0.998–1.902, p = 0.052) and relied on product information leaflets (adjusted OR = 1.375, 95% CI:1.053-1.797, p = 0.031) and physicians (adjusted OR = 1.656, 95% CI: 1.266-2.168, p = 0.001) for obtaining more information about antibiotics, were also less likely to engage in antibiotic self-medication than those who recently used antibiotics and those who relied on drug labeling, Internet, or pharmacists to obtain more information. Respondents who returned unused antibiotics to the pharmacy were more likely to use antibiotics appropriately than those who shared them (adjusted OR = 0.383, 95% CI: 0.168-0.875, p = 0.023), disposed of them at home (adjusted OR = 0.526, 95% CI: 0.269-1.03, p = 0.062), or kept them at home (adjusted OR = 0.295, 95% CI: 0.156-0.558, p <0.0001; Table 5).

4. Discussion

4.1. Participants knowledge regarding antibiotics use

Inappropriate use of antibiotic therapy has been documented in 70% to 90% of COVID-19 patients worldwide [59–61]. Compared to earlier research, participants were more aware of antibiotic use as the COVID-19 pandemic progressed [58,62], possibly due to increased awareness efforts among people in Jordan regarding inappropriate antibiotic use. Recent findings on the level of understanding of antibiotics in LMICsrelated to the appropriate usage of antibiotics, use of leftover antibiotics, and awareness related to antibiotic resistance, have been reported[8]. This necessitates investment in public health initiatives to raise AMR awareness and understanding, as well as to ensure access to healthcare services and treatments. The majority of participants in this study correctly stated that they must cease taking antibiotics once they have completed the course as prescribed and that it is risky to offer antibiotics to a friend or family member to treat the same ailment [58]. The proportion of correct answers in this study was higher than in the WHO multi-country survey study [57]. Zaidi et al., (2020) and Mboya et al., (2020) observed that 55% and 58.6% of their participants misunderstood the need to complete an antibiotic course when symptoms improved [51,63]. Other high-income Middle Eastern countries reported low antibiotic knowledge, which resulted in poor antibiotic identification, seeking antibiotics without a prescription, and failing to complete their antibiotic medication course [8,15,17]. These discrepancies could be explained by Jordanians having greater access to health insurance, which is associated with higher socioeconomic status and education, both of which are associated with a better understanding of antibiotic effectiveness. Although discontinuing antibiotics sooner than expected is an unacceptable practice, growing evidence supports the opposite. Longer antibiotic courses are more likely create the selective pressure required to drive antimicrobial resistance [64–67]. Furthermore, studies have shown that for the majority of common uncomplicated infections treated in the community setting, short courses of antibiotics are equally effective as longer courses [68–72].

Compared to the findings of the multi-country survey study (43%) [57], and a recent study in Jordan (34.1%) [58], Jordan (34.1%) [58] and Northern Tanzania (51%) [63], nearly one-third of participants (35.6%) in this study believed that if they were sick and the same antibiotics helped them get well, it was alright to buy them or ask the doctor for them again, which may contribute to the resistance problem. Further antibiotic awareness campaigns in Jordan are required to improve antibiotic seeking and consumption practices. Participants in the current study gave more correct answers than in previous surveys [40,41] for identifying conditions treatable with antibiotics, particularly cold and flu (46.2% vs 43.2%) [58] and fever (26.3% vs 24.6%) [58], suggesting a slight increase in antibiotic knowledge among people due to a continuous educational campaign throughout the COVID-19 pandemic that may help minimize the harmful effects of antibiotics misuse. A slightly higher proportion of participants in the current study were unable to identify UTI and wound infections as antibiotic treatable conditions, which could be attributed to the widespread use of antibiotics during COVID-19 and the frequent use of terms such as ‘antibiotic resistance’ and ‘germs’ rather than specifically mentioning the most common causative agents of infectious diseases [73]. Compared to a year before [58], fewer participants thought antibiotics helped against COVID-19, which is consistent with prior research and may be due to participants’ speedy recovery from COVID-19-like symptoms [74,75]. Because COVID-19 is a viral disease with few individuals having bacterial co-infection [76–78], the current study emphasizes the importance of increasing awareness about the rational use of antibiotics and their effectiveness against bacterial infection.

4.2. Participants’ antibiotic use and self-medication behavior

According to the study’s findings, 42.2%, 23.3%, 8.1%, and 26.4% of respondent had used antibiotics within the previous month, six months, year, and more than a year. In contrast to Waaseth et al., (2019) [79,80], our findings consistently suggest that participants who reported using antibiotics in the previous 6 months or longer had greater antibiotic knowledge than those who reported using antibiotics in the previous month. The findings suggested that a lack of information about antibiotic use was significantly associated with higher consumption of these antibiotics, which could also be attributed to inappropriate antibiotic prescribing by physicians, OTC sales, and a lack of standardized antibiotic dispensing policies, all of which are common in LMICs [47,55–59]. In this study, the proportion of individuals who self-medicated with antibiotics (44%) is higher than in most developing countries, which may exacerbate antibiotic resistance and treatment failure [15,62,81–86]. According to studies from LMICs, the public frequently obtains antibiotics due to a lack of public awareness about inappropriate use, as well as following the advice of non-authorized personnel and using them as OTC medicines, which is also a factor in leftover antibiotics as reported in similar other studies [41,43,44], resulting in unnecessary storage and waste [41–44]. This study confirmed the accessibility and availability of antibiotics without prescription in Jordan, as approximately 23% of all participants stated that they obtained antibiotics from a pharmacy, which is consistent with previous findings [87–91]. Providing individuals with easy and quick access to primary healthcare centers [7,42, 1300,1400] can reduce easy access to antibiotics as OTC medicines and promote antibiotic prudence. Compared to the 44% of participants in this study who reported self-medication practices, the percentage was lower, 30%, in a prior study conducted in a comparable setting [58]. Early in the course of the pandemic, the Jordan implemented measures such as quantity metrics to track the volume and cost of antibiotics, and comply with WHO guidelines to promote antibiotic stewardship, as well as delivering continuous antimicrobial stewardship training to healthcare workers to improve antimicrobial prescribing and dispensing behaviours. Furthermore, more than 73% in the later study reported receiving antibiotic information from healthcare practitioners [58], compared to 65% in this study, which could be attributed to the advent of online learning and a rise in Internet usage, as people might become better at finding information online, as shown in the current study (47.3%). This information-seeking behavior, however, may not be as useful as a doctor-to-patient interaction. Prior experience, healthcare costs, and pharmacy proximity were also identified as major reasons for self-medication in this study.

4.3. Antibiotic disposal practices among participants

Antimicrobial storage at home is common in many developing countries, resulting in irrational antibiotic use, antibiotic resistance, and toxicities [8,9,92]. The practice of safely and responsibly disposing of unused or expired medications, antimicrobial drugs, and other medical products contributes to the reduction of antimicrobial resistance, which is a growing global health concern. In this study, returning medications to a pharmacy was the least commonly adopted method of antibiotic disposal. Comparable percentages were recorded in Nigeria, Serbia, India, and other countries [53,93,94], suggesting that most households may store unnecessary medicines and that many drugs remain unused. In Western and Northern Europe, Australia, New Zealand, and the UK [54,95–98] it is reported that unused antibiotics are commonly returned to the pharmacy. Due to the scarcity of Middle Eastern studies, antibiotic disposal should not be overlooked since patients’ value medical prescriptions as a result of their visits to public health centers [99]. Over half of the participants in this study keep antibiotics at home in case they need them in the future. The public’s lack of knowledge about antibiotics may be what leads to improper storage and waste of medicines. This adds to evolving evidence that people in LMICs may use expired medicines [100,101].Other studies reported that antibiotics are among the many prescriptions that are commonly discarded by both patients and pharmacists, in the trash, sink, and toilet[41,102,103]. It’s possible that this practice has persisted in part because there is no formal program in place to address this type of waste, a take-back initiative is therefore warranted. Education of both healthcare personnel and patients on the appropriate use of antimicrobials, monitoring of antimicrobial use, and the adoption of methods to reduce antimicrobial misuse are all enhanced by the introduction of an antimicrobial stewardship program. Moreover, inappropriate antibiotic disposal may damage the ecosystem by allowing trace amounts of active medications to infiltrate the food chain, exposing people, and leading to drug resistance [104–106]. More research is needed to investigate the policy for disposing of unused and expired antibiotics in order to raise public awareness about the rational use of antibiotics and proper return procedures.

4.4. Factors associated with self-medication with antibiotics

A lack of insurance coverage, according to the study’s findings, was highlighted as a positive motivator for self-medication. This study showed that medical insurance can possibly safeguard the public from inappropriate antibiotic use, resistance, unnecessary storage, and drug waste. Previous research [58,107–110] has linked medical insurance and self-medication. According to the findings of this study, national health programs should be adopted to limit patients’ excessive number of prescriptions, irrational antibiotic usage, and inappropriate disposal practices. Our results show that effective community-based programs to raise public awareness and emphasize medication control are needed. Low-knowledge participants were more likely to self-medicate with antibiotics due to a lack of understanding of the indications for antibiotic use and the perception that antibiotics ought to be effective in all conditions previously encountered or about which they complained [58,62,63,87,111–113]. Public awareness of this issue, along with healthcare practitioners’ direction, would increase compliance and decrease inappropriate prescribing.

Participants who had taken antibiotics in the past year or longer were also less likely to use antibiotics on their own than participants who had taken antibiotics in the past few months. Almost 35% of those surveyed indicated they received no advice from doctors or pharmacists, and nearly 53% of those who self-medicated declared they obtained their antibiotics from pharmacies. Others reached similar conclusions [58,114], suggesting that the effects of community healthcare professionals in antibiotic optimization were effective at improving appropriate antibiotic use and avoiding irrational antibiotic use during the early stages of the COVID-19 pandemic, which could be attributed primarily to a lack of potential benefits of antibiotic action to treat or curb COVID-19 spread. Although the COVID-19 pandemic appeared to influence changes in self-medication antibiotic use, other factors such as difficulty accessing community pharmacies due to the lockdown, delays in receiving healthcare services, and insufficient stock of antibiotics may also have played a role during the early stages of the COVID-19 pandemic [115]. More research is needed to study the importance of antibiotic stewardship measures on raising public awareness activities and enforcing rational antibiotic usage and regulating their availability during pandemics. Patients who mentioned product information leaflets and physicians as their primary sources of knowledge were less likely to self-medicate with antibiotics, showing that reading about adverse effects and precautions in prescription leaflets may discourage patients from self-medicating [116]. Although participants received prescription counseling from physicians and pharmacists, the previous finding may reflect physicians’ higher motivation to reduce drug hazards and resistance challenges caused by inappropriate antibiotic self-medication.

Contrary to previous studies [54,95–98,117], only a small proportion of participants in this project returned unused antibiotics to pharmacies, and those who did were less likely to engage in antibiotic self-medication than those who shared them with friends and family or kept them at home for future use. This highlights the importance of raising public awareness of the harmful effects of inappropriate antibiotic sharing, keeping, and disposal on the environment and public health. Antibiotic return campaigns should be emphasized to avoid improper disposal of unwanted drugs.

5. Study limitations

Due to a lack of Internet access and non-users of social media, some age groups and social characteristics were underrepresented in the sample, which may have compromised its generalizability. Because the survey was self-administered, recall bias may have occurred as a result of the study’s design. Furthermore, the discovered associations do not imply causality. Further, there was a risk of sampling bias since people who were exposed to Facebook advertising about ‘antibiotics self-medication and disposal’ were more likely to respond if they viewed this as a serious problem.

6. Conclusions

The consumption of antibiotics has been associated with the availability, accessibility, and inappropriate use of antibiotics, as well as the development of antibiotic resistance. According to the World Health Organization’s practical guide on the disposal of unused and expired medicines, there are still shortcomings and a lack of progress in this area, particularly in developing countries. The aim of this study was to assess public understanding of antibiotics, self-medication with antibiotics, and drug disposal practices during the late stage of COVID-19 outbreak. The study findings showed that the proportion of individuals who use antibiotics for self-medication is high, highlighted the need to improve public awareness and knowledge of appropriate antibiotic use. According to the study, returning antibiotics to a pharmacy was the least common approach for disposal, and unused antibiotics were reported to be thrown in the household waste, most likely due to a lack of policies and awareness about return policies. Antibiotic self-medication can be reduced by teaching people about the risks of taking antibiotics without a prescription. Antibiotics are ineffective against viruses, and taking antibiotics without a prescription increases the risk of AMR. Furthermore, encouraging individuals to return unused or expired medications to a pharmacy or healthcare provider for proper disposal can help to improve antibiotic disposal practices. In addition, healthcare professionals including community pharmacists should be further informed and supported about appropriate antibiotic disposal practices. Through public awareness campaigns, the public can be educated on the subject of AMR and antibiotic disposal. These efforts should emphasize the importance of using antibiotics only when prescribed by a healthcare practitioner, who should be encouraged to provide patients with clear instructions on when and how to take antibiotics. The study added to the body of knowledge about the inappropriate use of antibiotics and their improper disposal as a potential driver of antimicrobial resistance and, as a result, the anticipated environmental and public health risks, highlighting areas for antimicrobial stewardship improvement. Future research should address certain elements for antimicrobial usage post the onset of COVID-19 pandemic, including the number of antibiotic prescriptions, the types of antibiotics provided, the duration of antibiotic use, and the appropriateness of antibiotic use. In addition, we may assess the prevalence of antibiotic resistance in the Jordanian community.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or material discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or mending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/14787210.2023.2182770

Additional information

Funding

This paper was not funded.