Impact of a Mass Media Campaign on Adults ’ Knowledge and Attitudes towards Antibiotic Use

Background & Objective(s): Self-medication with antibiotics is a worldwide problem and a major driver of the emergence of antimicrobial resistance. The objectives were to estimate the frequency, describe pattern and identify possible determinants of self-medication with antibiotics among adults in Misurata and to evaluate the impact of a mass media campaign on their knowledge and attitude regarding self-medication with antibiotics. Methods: In the 1st phase, a cross sectional design was used and 277 adults accompanying patients attending the outpatient clinics of Misurata Central Hospital were interviewed using a predesigned structured questionnaire. Data about pattern of antibiotic use, knowledge and attitude was collected. In the 2nd phase, an intervention design (one group pretest post-test design) was used. A two months mass media campaign in the form of a radio program (one episode/week for eight weeks), a TV episode and written articles in Misurata University magazine about the correct use of antibiotics was launched and its effect was assessed after three months. Results: Among adults using antibiotics, 39.5% used it as self-medication. Several defects in the pattern of antibiotic use was noticed including the duration of use, indication, and course completion. Almost two thirds had poor knowledge about antibiotics, while the majority had neutral or positive attitudes. The mean knowledge and attitude scores regarding antibiotics had significantly increased after the mass media campaign (from 9.03± 3.02 to 18.1± 4.21 and from 23.17± 5.11 to 25.81± 4.83,


INTRODUCTION
he World Health Organization (WHO) has defined self-medication as: "The selection and use of medicines by individuals to treat self-recognized illnesses or symptoms". (1)Self-medication with antibiotics is widespread worldwide, and nearly 50% of the antibiotics used are purchased over-the-counter. (2)A systematic review of adult individuals in households of low-and middle-income countries indicated high prevalence (39%) of antimicrobial self-medication. (3)In Libya, the percentage of self-medication use was 24%.Nearly 50% of interviewed Libyans indicated they would take antibiotics for their own use without a prescription if they believed that they needed to. (4)Inappropriate use of antibiotics in humans, including in self-medication, and agriculture, is one of the drivers of the emergence of antimicrobial resistance. (5)In Libya, a study published in 2011 verified the existence of antibiotic resistance in hospitals and high resistance rates were observed among enteric bacteria against commonly used drugs. (6)tudies have reflected the general public's lack of understanding regarding proper use of antibiotics. (7,8) ocal culture and traditions seem to play an important role in shaping people's beliefs about antibiotics. (4)ass media campaigns are used to expose high proportions of a population to health promotion messages, using the media as an educational tool. (9)The use of traditional mass media in health communication campaigns has the potential to transmit a behavior change message faster and farther than most other communication approaches. (10)Educational interventions focusing on the appropriate use of antibiotics by the public can be T Original Article successful especially when local context and barriers are adequately analyzed and addressed. (11)he objectives of this study were to estimate the frequency and describe the pattern of self-medication with antibiotics among adults in Misurata city, to assess knowledge and attitude of adults regarding antibiotics, to identify factors associated with self-medication with antibiotics and to construct, implement and evaluate the impact of a mass media campaign on their knowledge and attitude regarding self-medication with antibiotics.

METHODS
The study was conducted in the Outpatient Department of Misurata Central Hospital which is the major hospital in Misurata city, Libya and receives patients from all levels of society and all city regions.The setting was selected because this was the culturally accepted way, since it is not culturally accepted to conduct a community based house hold survey, while conducting surveys in hospital settings is more acceptable.A cross-sectional design followed by an intervention approach (one group pre-test post-test design) were used.The target population comprised adults (18 years and above, both sexes, Libyan nationals and Misurata residents) accompanying patients attending the outpatient clinics.Those with medical education (physicians) or a related degree (pharmacists, dentists and nurses) and all support degrees were excluded.
For the cross-sectional phase, the sample size was calculated using Epi-Info Software version 7. Based on a 24% prevalence of self-medication with antibiotics (4) , and a confidence limit of 5%, the minimum required sample size at 95% confidence level was 280 adults.There are ten outpatient clinics in Misurata Central Hospital.The sample was distributed equally between the clinics (28 subjects from each clinic).Adults accompanying patients who attend the hospital clinics were consecutively recruited till the required sample size was completed.
For the intervention phase, all subjects who had poor knowledge scores in the pre-test were included (155 participants).
A pre-designed, structured interviewing questionnaire was used to collect data from the study participants (pretest).The questionnaire consisted of four sections.
-Section I included socio-demographic data such as age, gender, level of education, occupation, address and phone number.-Section II included questions about the pattern of selfmedication with antibiotics such as type of antibiotic used, indication and duration of use, completion of antibiotic course, who recommended self-medication with antibiotics, reasons for self-medication with antibiotics and the main source of information the participants depended on.-Section III consisted of twenty seven 'yes or no' questions about knowledge related to antibiotic use including questions about the role or action of antibiotics, identification of antibiotics, proper way for antibiotic use (whether prescribed or self-medicated), antibiotic resistance and antibiotics side effects.A special scoring system was constructed to assess knowledge.A score of 'zero' was given for each incorrect answer, while a score of '1' was given for each correct answer.The total knowledge score was calculated by summing scores of all questions yielding a total score ranging from 0-27 and was classified into poor (<50% or < 14 points), fair (50%-<70% or 14-<19 points) and good (≥70% or ≥19 points) levels of knowledge.-Section IV consisted of nineteen questions about attitudes related to antibiotic use and 10 questions about parental attitude toward antibiotic use in children (only for participants who have children).This section was divided into 5 categories: a) Attitude towards using antibiotics without prescription as self-medication, b) Attitude towards physician visit for diagnosis and treatment, c) Attitude towards antibiotic administration, d) Attitude towards reusing antibiotics and e) Parental attitude towards antibiotic use for their children.A three point Likert scale was used and a scoring system was constructed to assess attitude.The answer of each attitude question was given a score of '2' for a positive attitude, a score of '1' for a neutral attitude and a score of '0' for a negative attitude.The total attitude score was calculated by summing the scores of all questions yielding a total score ranging from 0-38 and was classified into negative (< 50% or ≤18 points), neutral (50%-< 70% or 19-26 points) or positive (≥70% or ≥27 points) attitudes.The total attitude score for participants who have children ranged from 0-20 and was classified as negative (< 50% or ≤ 9 points), neutral (50%-< 70% or 10-13 points) or positive (≥70% or ≥14 points) attitudes.The questionnaire was designed after extensive literature review on the subject.With respect to the local culture, statements concerning knowledge about and attitudes towards self-medication with antibiotics were developed.For content validity, the knowledge and attitude questionnaire has been revised by three experts in health education who modified the questions accordingly to its final form.
Field testing of the questionnaire was carried out among 20 individuals who were not included in the sample to get their feedback on the clarity of the questions, to estimate the time to fill the questionnaire and to detect any difficulties that may arise during data collection and how to deal with them.Accordingly, modification in the format of some questions and changing some concepts were done.Obtaining the phone number to inform the participants about the time of the radio program, and the date to return for the post-test was very difficult for females due to cultural unacceptance and it was overcome by taking the phone number of a male relative (father, brother, husband, etc.).The results of the pre-test of the study were used to construct the health promotion program (a two months mass media campaign).It consisted of a radio program, a TV episode and written articles in Misurata University magazine."Double edged" was the title of the radio program and the subject of this program was the correct use of antibiotics.The educational content was based on the questions posed in the questionnaire.The program included eight episodes (10 minutes each) broadcasted through a Misurata local radio station.It was broadcasted at 18:30, a time assumed to be the most appropriate for people to listen to the radio and a rerun two times per week.To ensure that the participants have listened to the program, a brochure was given to them after the pre-test in which the exact time of the program and the date to return for the post-test was mentioned.At the end of radio program episodes, one episode was recorded for a Misurata TV channel, which was broadcasted through the Health and People program.In addition, articles about self-medication with antibiotics were written in two issues of the Misurata University magazine and distributed in the city (3000 off prints free).All the program episodes were re-recorded on a CD.Almost 1000 CDs were distributed randomly around the city.
To assess the impact of the intervention, participants with poor knowledge score were contacted by phone and were invited for the post-test and their knowledge and attitudes regarding self-medication with antibiotics were reassessed three months after the end of the program using the same data collection tool (knowledge and attitude questionnaire).

Statistical analysis
Statistical Analysis Software (SAS), Epi info, and Statistical Package for Social Sciences (SPSS) version 16 were used for data analysis.For quantitative variables, mean and standard deviation were calculated.A Chisquare (ꭓ 2 ) test was used for analysis of categorical data.The 0.05 level was used as the cut off value for statistical significance.Multiple regression analysis was used to identify factors affecting self-medication with antibiotics, and factors affecting the adults' knowledge and attitudes regarding antibiotics use.A paired t test was used to compare the mean knowledge and attitude scores before and after the intervention.

Ethical considerations
The study was approved by the Institutional Review Board and the Ethics Committee of the High Institute of Public Health.The researcher complied with the International Ethical Guidelines for Epidemiological Studies.An informed verbal consent was obtained from all participants after explanation of the objectives and benefits of the research and confidentiality was ensured.

RESULTS
A total of 280 questionnaires were distributed, out of which 277 were completed (99%).The age of participants ranged between 18 and 73 years, with a mean of 32.62 ± 11.5 years and a median of 32 years and 175 participants (63.2%) were females.More than half of the participants were married (53.1%), 44.4% were single, 41.2% and 39.4% had secondary and university education, respectively.As for occupation, 25.6% and 24.5% were engaged in clerical work or were students, respectively.
The proportion of adults using antibiotics in Misurata during the previous 6 months was 58.5%.Among those who used antibiotics, 39.5% acquired/used antibiotics without prescription as self-medication.Reasons for practicing self-medication with antibiotics included minor illness that was considered not to be worthy of consulting a physician (37.5%), previous or prior experience (17.2%), confidence in the pharmacist (15.6%), friends' or relatives' advice (10.9%), unavailability of physicians (9.4%) and avoiding crowded waiting rooms of physicians (9.4% each).Sources of advices for self-medication with antibiotics were pharmacists (46.9%), self-decision (30.2%), the advice of relatives or friends (14.1%) and previous prescription (7.8%).
Table 1 shows that during the previous 6 months, for both prescribed and self-medicated antibiotics, the highest proportion of participants used antibiotics once (40.8% and 46.9%, respectively).The difference was not statistically significant.The proportion of participants who used the same antibiotic more than once during the previous six months was lower among participants with prescribed antibiotics (48%) than among those with self-medicated antibiotics (64.7%), with a statistically insignificant difference.The most commonly reported indications for prescribed antibiotics were toothache (23.5%), common cold (18.4%) and urinary tract infection (17.3%), while common cold (49.4%), toothache (20.3%), sore throat (17.2%) and tonsillitis (10.9%) were the most commonly reported indications for self-medicated antibiotics.The association between the indications for antibiotic use and the way of use (prescribed or self-medicated) was statistically significant (ꭓ 2 = 31.329,p= 0.002).The most common sources for obtaining prescribed antibiotics were private pharmacies (81.6%) and governmental pharmacies (18.4%), while self-medicated antibiotics were most commonly obtained from private pharmacies (76.6%) and private medicine cabinets (14.1%), with a statistically significant difference (ꭓ 2 = 21.155,p< 0.001).The table also shows that the proportion of participants who completed the antibiotic course was higher (68.8%) among those with prescribed antibiotics compared to those with self-medicated antibiotics (31.2%).The difference was statistically significant [cOR = 2.27 (95% CI =1.19-4.33),ꭓ 2 = 6.33, p< 0.001].The highest percent (54.6%) of those with prescribed antibiotics reported that they had been taking antibiotics for 4-7 days, while 59.4% of those with self-medicated antibiotics used the antibiotics for 1-3 days.This difference was statistically significant (ꭓ 2 = 25.48,p< 0.001).Amoxicillin and Amoxicillin-Clavulanate were the most commonly used antibiotics by both groups (41.5% and 26.4% among those who took prescribed antibiotics and 25.8% and 54.8% among those with self-medicated antibiotics, respectively).Finally, participants who took prescribed antibiotics mostly knew about antibiotics through physicians (62.2%) while selfmedicating participants were least likely to know about antibiotics through physicians (12.5%).This difference was statistically significant (ꭓ 2 = 61.833,p< 0.001).The total knowledge score of adults regarding antibiotics ranged between 0 and 26 with a mean score of 12.47± 5.161 points.The highest percent (62.5%; 173 participants) had poor knowledge levels with a score between 0 -13 points.The mean attitude score was 24.3 ±5.4 points and ranged from 10-36 points.Only 35.8% had a positive attitude (Figure1).Adults with good and fair knowledge were 4.6 times more likely to be 30 years and above compared to those with poor level of knowledge (OR= 4.6, CI= 2.238-9.587).The second and third variables were the level of education and occupation.Adults with good and fair knowledge were almost three times more likely to have university education and to be unemployed compared to those with poor level of knowledge (OR= 2.939, CI= 1.552-5.564and OR= 2.9, CI= 1.379-6.365,respectively).Two variables were found to significantly affect participants' attitudes: gender (OR= 0.415, CI= 0.186-0.923)and the total knowledge score (OR= 0.360, CI= 0.150-0.868).It could be noticed from table 3 that starting from 20 years of age the proportion using antibiotics as self-medication increased by age.The difference was not statistically significant.The percentage of male participants using antibiotics as self-medication (51.5%) was higher than females (31.2%), with a statistically significant difference (ꭓ 2 = 6.721, p= 0.01).The highest proportion of self-medication with antibiotics was among widowers (75%), followed by single participants (43.1%).Among participants who had university and postgraduate education, 54.5% and 60% used prescribed antibiotics, while 45.5% and 40% practiced self-medication.It is obvious from the table that retired participants (100%) were the highest group using antibiotics without 62.5% 23.1%

Poor
Fair Good prescription followed by academic staff (62.5%).The lowest proportion (22.2%) was among housewives.The association between all these factors and the way of using antibiotics (prescribed or self-medicated) was not statistically significant.It is clear from the table that the highest percentage of self-medication was found among participants with poor levels of knowledge (44.3%).The association between the level of knowledge and the way of using antibiotics was not statistically significant.
Table 3: Distribution of adults using antibiotics according to their sociodemographic characteristics, their knowledge and attitude scores and the way of using antibiotics (Misurata, Libya) The highest percentage of self-medication was found among participants with negative attitude scores (62.9%).It was noted that the proportion using prescribed antibiotics increases with the attitude score.This association was statistically significant (ꭓ 2 = 26.406,p< 0.001).Of the 173 pre-intervention participants who had poor level of knowledge, 155 (89.6%) completed the posttest questionnaire.The dropout/attrition rate was 10.4%.Table 4 shows that the high knowledge score increased by 35.3% and the poor/low knowledge scores decreased by 47% after the intervention.The mean knowledge score increased from 9.03± 3.02 before the intervention to 18.1 ± 4.21 after the intervention.This increase was statistically significant (paired t-test= 30.07, p< 0.001).The percent of positive attitude increased by 39.8% and the percent of negative attitude decreased by 2.2% after the intervention.The mean attitude score increased from 23.17 ± 5.11 before the intervention to 25.81 ± 4.83 after the intervention.This increase was statistically significant (paired t-test = 20.33,p< 0.001).

DISCUSSION
Antibiotic resistance is rising to dangerously high levels worldwide.The emergence and spread of resistance is made worse where antibiotics can be bought for human or animal use without a prescription.In contrast with developed countries, where antibiotics are largely restricted to prescription-only use, antibiotics are often overprescribed by health workers and over-used by the public in countries without standard treatment guidelines. (12)Mass media interventions can produce positive health changes on a large scale by enforcing positive health behaviors among individuals. (9)espite the Libyan antimicrobial policy that restricts the dispensing of antibiotics without prescription, the study revealed that the percentage of antibiotic usage during the previous 6 months of the study was 58.5%, and the rate of self-medication was 39.5%.The rate of self-medication was less than that reported in Alexandria, Egypt, 2015 (53.9%). (13)n the other hand, the rate was higher than that reported in Cairo, Egypt, 2013 (29.8%) (14) and Kuwait, 2015 (27.5%). (15)This substantiates the fact that there is wide variation in self-medication prevalence.The variation between and within countries is due to the use of different definitions of self-medication, differences in the health seeking behavior of people, socio-cultural factors, relative prevalence and the seasonal variation of illnesses. (16)The prevalence found in the present study was higher than that reported in the Euro-Mediterranean region study between 2004 and 2005 including Libya (24%). (4)This finding indicates a potential increase in self-medication with antibiotics among Libyans .
In the present study, about half of self-medicating participants would take antibiotics for a common cold, which demonstrates the public perspective regarding the effectiveness of antibiotics in treating such conditions, making the misuse of antibiotics a repeated behavior which is detrimental in an era of antibiotic resistance.The proportion of people reporting using antibiotics for common cold was in agreement with a study in Iran, 2013 (48%). (17)Physicians continue to prescribe antibiotics in avoidable cases. (18)They would thus contribute in a way to antibiotic abuse.In the present study, there was even abuse in the prescribed medications, which points to the need for revising the educational programs for general practitioners .In the present study, the majority of respondents who selfmedicated identified private pharmacies as the main source of medicine and information.Generally, pharmacy staff do not inquire about patient's allergies, do not explain potential side effects, and dispense parenteral antibiotics for home use, which increases the potential for adverse events.Furthermore, financial concerns often guide selection of low-cost antibiotics and in short durations of treatment.This finding was consistent with the results of other studies. (19,20)In addition, increased availability of over the counter antibiotics at the pharmacy despite the fact that this is against the law, is an important component contributing to self-medication with antibiotics.This gray area of pharmacy practice deserves further investigations to know the relative importance of over-the-counter sales .The current study showed that Amoxicillin-Clavulanate tablets followed by Amoxicillin were the most common antibiotics used in self-medication and could be explained by the fact that they are cheap, easily accessible, have a good safety profile, with broad spectrum antimicrobial activity and a high rate of prescription by physicians led people to recognize these agents.This finding was in agreement with other studies. (17,21,22) My studies reported that age and level of education were among the factors associated with self-medication with antibiotics. (23)In the present study, age and level of education were not associated with self-medication with antibiotics.The current results showed that self-medication with antibiotics was significantly higher in males than female respondents, which was in agreement with the results reported by other studies. (24,25) owever, a number of researchers found no differences between males and females. (26,27) e current findings demonstrated that the general public lacks knowledge and harbors some key misunderstandings about antibiotics, as almost two thirds of the respondents had poor knowledge about antibiotics.In terms of attitude toward antibiotic use, the majority of participants had neutral or positive attitudes.
The present finding revealed a significant increase in the mean knowledge and attitude scores of participants regarding antibiotics after the mass media campaign.These results were in agreement with the findings of Mainous et al., (28) This finding demonstrates the importance of public education campaigns as a successful tool for raising public awareness about antibiotics .

Limitations of the study
As the study was conducted in a local hospital setting, the findings may not be generalized to the whole country or other sectors of health care.First, only Misurata residents were surveyed.Second, more females were included in the study than males, which was not intentional; the plan was not to recruit higher numbers of either gender.The high female-to-male ratio found in this study is not truly representative of the actual gender distribution in the population.It is probable that females accompany patients to the hospital visits at a higher rate than males.Third, the intervention was relatively short-lived to see a substantial change in attitude.Future interventions may benefit from longer periods.

CONCLUSION & RECOMMENDATIONS
The study highlighted the extent of inappropriate use of antibiotics especially their use for treating viral infections and for disease prevention, with inadequate antibiotic knowledge and neutral attitude.Predictors of adults' knowledge were age, level of education and employment status while gender and level of knowledge were found to be the predictors affecting the adults' attitudes.Significant changes in knowledge and attitude occurred during 3 month period following the health promotion mass media program .
Improving communication about antibiotic appropriateness between healthcare professionals and patients in addition to policies for auditing antibiotic prescriptions in the healthcare facilities and monitoring sources of obtaining antibiotics through enforcing strict regulations are needed.Consistent and multifaceted intervention strategies concerning appropriate antibiotic use and the problems of antibiotic resistance are required in order to correct widespread misconceptions on antibiotic use.
) and attitudes (model b) regarding antibiotics as the dependent variables.Three variables were significant in affecting participants' knowledge.The first was age.

Figure 1 :
Figure 1: The total knowledge and attitude scores of adults regarding antibiotic use (Misurata, Libya)

Table 1 : Frequency, pattern and source of information about antibiotic use (prescribed and self-medication) among adults who used antibiotics during the previous 6 months (Misurata, Libya) Frequency, pattern and source of information Way of using antibiotics Prescribed
Table 2 describes the logistic regression results of the factors affecting the adults' knowledge