Public Knowledge and Belief Regarding Antibiotic Use and Antimicrobial Resistance in Qatar

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INTRODUCTION
The invention of antibiotics was a revolution in medical science. Antibiotics make surgery safer for those with immunosuppressive conditions, children and the elderly can quickly recover from bacterial infections 1 . The antibiotics should be accessible with a physician's prescription even though self-medication is prevalent. A systematic review shows that the prevalence of self-medication in the Middle East area ranges from 19% to 82% 2 . Self-medication can be caused by a variety of factors, including poor public knowledge and belief towards antibiotics, easy access to antibiotics in many places, and lack of policies regarding appropriate antibiotic usage 3 . The most common health problems for which people were urged to use antibiotics to treat coughs, colds, and viral respiratory infections, which are self-limiting and caused by viruses 4 . This highlighted the lack of knowledge about the role of antibiotics, which may lead to self-medication and non-compliance with antibiotic treatment 5 . Also, people have a tendency to use leftover medication based on their previous personal experience, which is the foremost cause of resistance 6 .
Antibiotic resistance can have a significant impact on increasing mortality among hospitalized patients. The pathogenic bacteria acquire resistance genes to a specific antibiotic, and that antibiotic becomes ineffective in clinical use 3 . Antibiotic resistance enables the bacteria to overcome the virulence necessary to fight against the immune system of the host 7 . According to the Global Antimicrobial Resistance and Use Surveillance System (GLASS) report released by the World Health Organization (WHO), Escherichia coli resistance rates to ciprofloxacin have increased from 8.4% to 92.9% and Klebsiella pneumonia resistance rates have increased from 4.1% to 79.4% 8 . Nowadays, antibiotic resistance is becoming a worldwide problem that requires globally coordinated efforts. Although the WHO has developed a variety of plans worldwide for the fight against antibiotic resistance called the "Global action plan on antimicrobial resistance" (GAP), Global Antimicrobial Resistance and Use Surveillance System (GLASS), and Global Antibiotic Research and Development Partnership (GARDP) [8][9] . Recent studies have shown a dramatic increase in antimicrobial resistance, especially in resource-limited countries 10 .
A recent study conducted in Qatar revealed that taking antibiotics without consultation (82%), not completing the course of antibiotics (45%), and purchasing antibiotics from the pharmacy without a prescription (23%) are the common inappropriate practices 11 . Similarly, a recent systematic review in Saudi Arabia shows a high prevalence of antibiotic misuse in the country 12 . A national-based study from Japan shows similar findings, 11.7% of the participants agreed about the use of leftover antibiotics, 23.6% of them have adjusted the doses of antibiotics by themselves, and 30% of the participants demanded their physician for antibiotics during episodes of cold 13 . Many studies supported that lack of knowledge about the use of antibiotics is predominant and self-medication with the help of pharmacists is a very common practise [14][15] .
Antibiotic misuse results in antibiotic resistance, treatment failure, increased inpatient hospitalization, as well a huge financial burden. Health professionals can play a crucial role in preventing antibiotic resistance because they prescribe antibiotics in routine clinical practice 13 . The community-based educational programs revealed that antibiotic-related knowledge and behaviors including the use, importance of compliance with dose, consequences of self-medication, and antibiotic resistance, had dramatically improved. However, the beliefs remained unchanged [16][17] .
The appropriate use of antibiotics is influenced by public knowledge, attitudes, and behaviors. In Qatar, there is a scarcity of information on public awareness, beliefs, and practices regarding the use of anti-biotics. Moreover, gaining a better understanding of how the public perceives antibiotic usage, as well as their belief toward them, is crucial in implementing antibiotic stewardship program. In this context, the present study used to explore the knowledge and belief of the diverse population of Qatar regarding antibiotic use and antimicrobial resistance.

METHODS
Study design: The current study adopted a crosssectional research design to collect information on the knowledge and beliefs of the public regarding the use of antibiotics and antimicrobial resistance from September to November 2018.
Sample Population and recruitment: The study was conducted on patients and visitors in two large emergency departments of public hospitals in Qatar using a purposive sampling method. People who had previously consumed antibiotics were enrolled in the study. The study excluded participants with language barriers during face-to-face interviews. The research team collected the data from the participants after explaining the purpose of the study and provided adequate time to clarify their queries.
Sample Size: Assuming awareness of antibiotics was 65.0% (19) with 5% absolute error, keeping 95% confidence interval (C.I.) and design effect 2 to avoid biases of clustering, the sample size was 728. Sample size (n) was calculated using the formula, n= {Design effect* N(p(1-p)} / {d2/Z2 1-α/2*(N-1) +p*(1-p)}, where N is Qatar general population with awareness of antibiotics, p is proportion of awareness and d is 5% absolute error. Assuming a 35% incomplete survey, the study recruited approximately 1,350 participants while they waited in the emergency room. Finally, a total of 1000 subjects were used to collect the of this study.
The instrument for data collection: The data was collected from the participants through structured interviews using an adapted questionnaire from WHO and CDC [18][19] after obtaining their permission. A similar questionnaire was used in WHO's multicountry public awareness survey and the CDC's tool was used in some other studies 8,20-21 .
The questionnaire consists of a three-section in which section A is comprised of eight questions in which demographic characteristics (5 items) and practice of the participants (3 items). Section B covers knowledge assessment items of antibiotics (6 items), and antibiotic resistance (11 items). In this section, a combination of true and false, multiplechoice, and closed-ended questions are included. The participants with correct responses had a score of '1' while those with the wrong answer had a score of '0'. The total score of Knowledge Domain was generated by summing up the scores obtained from sections B. The minimum and maximum possible scores were 0 and 17, respectively, and the knowledge domain was further divided into five subdomains. Section C had 14 items that elicited the responses of the participants on belief towards antibiotic and antimicrobial resistance. The response was marker over five-point Likert's scale in which "Strongly disagree", "Disagree", "Neither agree nor disagree", "Agree" and "Strongly agree" as "-2", "-1", "0", "+1" and "+2", respectively 26 . The lowest and highest possible scores were -28 and +28, respectively, in the belief section. The score was converted to a scale ranging from 0 to 100, in which 0 means the worst possible score and 100 means the best possible score. The total obtained score was categorized as low (<50%), moderate (50-70%), and high (>70%) in knowledge and belief [22][23] .
Statistics: Descriptive analyses were used to calculate the prevalence of dichotomous variables and means and standard deviations for continuous variables describing participant background. Knowledge and beliefs regarding antibiotic and antimicrobial resistance were described using mean and SD. Student t-tests and ANOVA were used for continuous variables and Chi-square tests for categorical variables to check the relationship. Internal consistency and reproducibility were performed for the reliability of the questionnaire. Cronbach's α coefficient was used to see the homogeneity of question items in each domain index for internal consistency. Coefficients of 0.7 and above were considered to be internally consistent for the questionnaire 24 . Each domain score in the form of an index variable at pre-and post-level was also calculated using intraclass correlation 25 . Pvalue 0.05 (two-tailed) is considered a significant level. The STATA 16.0 statistical package is used for the analysis. The scores gained from all items within two domains of the questionnaire, knowledge, and belief in Cronbach's Alpha, were 0.48 and 0.91 respectively. The domain belief (0.91) was under acceptable limits of 0.60 -1.00 26 in turn indicating good internal consistency, whereas the knowledge domain (0.48) had low internal consistency.

RESULTS
The response was collected from 1000 participants who visited the emergency department during the study period. Table: 1, showing the sociodemographic characteristics of the study participants. Most of the study participants were males (76.4%), and the majority of the participants belong to the age group between 26 and 45 years (66.6%) and were predominantly of Asian ethnicity (75.9%). Less than 40% of the respondents held bachelor's degrees (39.8%) and a large proportion of the study participants (60.6%) were professional workers. Nearly half of the participants (49 %) had taken antibiotics within six months of study period. Interestingly, 77.6% of participants had purchased their antibiotics from the pharmacy as prescribed by the physician (71.2%).
Most respondents (42%) had moderate knowledge about antibiotics, and 36.5% of the participants had a low level of knowledge regarding antibiotics and antimicrobial resistance. The majority of the participants (53.4%) possess positive beliefs regarding antibiotics and antimicrobial resistance ( Table 2).
More than 50% of respondents answered correctly in two out of five domains: "Knowledge on antibiotic access" (Q5, Q6), and "Knowledge about antibiotic resistance" (Q7-Q11). In the domain of "knowledge on bacteria",56.9% of respondents answered that bacteria are germs that could cause colds and flu. In "knowledge on antibiotics", more than 58.5% correctly answer the question of when you should stop taking antibiotics once you have begun treatment. In the domain of "knowledge on the effect of antibiotic misuse", the question of antibiotic resistance is an issue in other countries that had the lowest score (42.8%) ( Table 3).   In terms of the belief regarding antibiotic use and antimicrobial resistance, the overall mean score of belief of the participants was 66.57±23.13, which was significantly lower in males (8.58±12.5) compared with females (11.51±14.0; P= 0.002). In terms of education, the belief score is significantly associated with the education level, the higher positive belief score was found among graduates (11.75±12.5) followed by participants with higher secondary school education (

DISCUSSION
Antibiotic resistance is a growing public health concern all over the world. The general public's knowledge is a crucial element in combating antimicrobial resistance. The current study assesses the knowledge and beliefs regarding antibiotics and antimicrobial resistance among the general population of Qatar. The National Action Plan of Qatar was established to improve antimicrobial stewardship in all healthcare settings across the country. Qatar has a strong antibiotic policy, and it is impossible to obtain antibiotics without a physician's prescription. However, the study is relevant as the Qatar population consists of a large number of expatriates communities 27 and there is a possibility of not completing prescribed course and saving medicine for future use.
Many international studies focused on public knowledge of antibiotic use and antimicrobial resistance, which indicates that a wide range of knowledge gaps exist on the effectiveness of antibiotics for viral infections [5][6][15][16][28][29] . According to the present study, a high percentage of respondents do not understand the difference between viral and bacterial infections as well as the indications for antibiotic treatment. The participants (64.8%) believed that the antibiotic was effective against viral infections. This misconception may be due to patients not being informed whether their infection is bacterial or viral.
The present study shows that only 13.2% of the participants had good knowledge of the proper use of antibiotics and the consequences of antimicrobial re-sistance, which is in line with the previous studies conducted in Malaysia 29 . The literature supported the factors influencing self-medication, such as the use of leftover medication, over-the-counter purchases, and the use of antibiotics offered by friends and family 30. The majority of our study participants (71.2%) took antibiotics prescribed by their doctors, which is consistent with another study 31 . However, this will not exclude the possibility of self-medication with the left-over antibiotics from previous therapy, which is supported by a Eurobarometer survey in Poland 32 . According to studies conducted in the Middle East, antibiotics are often shared among family and friends or administered based on recommendations from relatives 5,16 . A promising finding of the present study was that the majority of participants (60%) stated that they were not keeping the remaining antibiotics for future use.
Antibiotic resistance is an emerging health concern among the general public. The most important factor that promotes antimicrobial resistance (AMR) is the inappropriate usage of antibiotics, which has been supported by several international studies 31,33 . Our study found a similar result, with 52.1% expressing concern regarding antimicrobial resistance. The literature has widely discussed the importance of following a physician's antibiotic regimen. The present study revealed that more than half of respondents (58.5%) completed their prescribed antibiotic regimen and mostly young adults (47.8%) which was consistent with the Jordanian study 16 . The study found that 61% of participants consented to complete the antibiotic course that was prescribed to them. However, these results are not comparable to the findings of many other studies 29,32,34 . Consequently, this kind of behavior can result in the development of resistant strains and complications during their future treatment.
Education programs can improve the public's knowledge of, belief, and adherence to antibiotics. In the long term, multifaceted approaches and constant reinforcement are necessary to reduce misinformation regarding antibiotics and their proper use. The government can initiate the campaign with the support of healthcare professionals through various platforms such as social media, television, and newspapers to disseminate information on the correct use of antibiotics. An awareness camp should be provided on a community basis to strengthen the knowledge that everyone has the power to influence through their actions, thus helping them understand their role in preventing bacterial resistance. Notably, ongoing research is focused on developing new antimicrobial drugs to combat resistant bacteria. Despite these efforts, it is essential to ensure that existing antibiotics remain effective.

STRENGTHS AND LIMITATIONS
To our knowledge, the present research is the first study to assess the public knowledge and belief re-garding antibiotic use and antimicrobial resistance in Qatar. However, the study has certain limitations. The random selection of participants within the study population was not feasible in our research settings. The study's generalizability is restricted because the purposive sampling method was used to collect the data from the participants. Qatar has a multi-ethnic culture with more than 45 different nationalities. Hence, a design effect was applied to adjust for clustering in the sample data. The research team was unable to understand more than five common languages in Qatar. People who were unable to deal with the interview due to language barriers or illiteracy were excluded from the research. Finally, we excluded all the participants who had never heard of antibiotics in their lifetime.

CONCLUSION
Our study showed that the public knowledge regarding the appropriate use of antibiotics and antimicrobial resistance is still a concern, especially the scope of antibiotics in the treatment of mild illnesses like the flu and cold. These misconceptions may contribute to self-medication and inappropriate use of antibiotics. Even though Qatar has a strong antibiotic policy and a National Action Plan for Qatar, which were established to improve antimicrobial stewardship in all healthcare settings across the country, more active interventions are needed to tackle the issues raised by the inappropriate usage of antibiotics. Moreover, this study suggested constructive engagement of healthcare professionals especially physicians, nurses, and pharmacists to encourage their patients about the judicious use of antibiotics.

RECOMMENDATIONS
Our study recommended a public awareness program to influence the knowledge and practice of the people regarding antibiotic use and the consequences of misuse. Further studies are required to determine whether public awareness programs can enhance knowledge and beliefs about antibiotic use and antimicrobial resistance.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE
The Ethical approval was obtained from the IRB of the Medical Research Center (MRC), protocol #17129/17 from 28 November 2017 to 2018 period. Participation in the study was voluntary, and the identity & confidentiality of the subjects was maintained throughout the study.