This study reveals the inadequate knowledge and inappropriate perception on antibiotic use among the public in the state of Perak, Malaysia. While respondents’ knowledge of antibiotics resistance was satisfactory, most remained ignorant to the types of infection and illnesses which antibiotics can treat. Respondent’s knowledge and perception improved significantly post-intervention and was sustained after two weeks. The employment of focused one-on-one educational intervention may provide additional benefits in addition to a mass awareness campaign. Consistent with local and foreign studies, targeted educational interventions have shown great effectiveness in improving public knowledge, and perception on antibiotic use and resistance [15, 28,29,30].
Pre-intervention, 36% of the respondents were not aware that self-medication behaviour, such as taking leftover antibiotics or purchasing antibiotics without doctor’s consultation, accelerates the process of antibiotic resistance. The post-intervention evaluation showed significant improvement, in which 60% of the respondents acknowledged that the use of antibiotics without professional clinical judgments may contribute to antibiotic resistance. Comparatively, a previous study in Jordan with a similar intervention reported a less pronounced improvement (11%)  compared to this study, in which the sociodemographic information of the respondents was not noted. Hence, we could not confirm whether level of education or other sociodemographic characteristics contributed to this difference in the effectiveness of the intervention between the two studies.
In terms of knowledge on antibiotic use, the majority of the respondents were not able to identify illnesses treatable by antibiotics [31,32,33,34]. Similar public awareness surveys reported that 61% and 75% of respondents from China and India, respectively, believed antibiotics could treat illnesses of a viral origin, such as a cold and the flu .
In a recent local study, 52.7% respondents agreed that antibiotics could work on viruses . To address this, we incorporated antibiotic indication and taglines, such as ‘Viruses and Bacteria: What’s got you sick?’ into our education material. At baseline, one quarter of the respondents (25.6%) in this study were aware that antibiotics were not effective against viruses. A significant improvement was observed post-intervention, where more than 80% of the respondents answered correctly. The reduction of antibiotic demand for a typical viral infection in the European Antibiotic Awareness Day campaign evaluation suggested continuous education regarding infections of viral and bacterial origin should be prioritised in future antibiotic awareness campaigns .
While knowledge of antibiotics was significantly associated with prudent antibiotic use, public perception was equally important. Three-quarters of the respondents perceived that they did not have a role in curbing antibiotic resistance before the intervention. Respondents were worried about the consequences of antibiotic resistance (KR1&PU4) but were not convinced that they could help in the fight against it. These findings were similarly reported in a previous survey, where around three-quarters of respondents in Vietnam, Indonesia, and China agreed that there was little they could do in the antibiotic resistance fight . Our intervention significantly enhanced the individual awareness in responsibility for combating antibiotic resistance, hence this message should be emphasised in future awareness campaigns.
Furthermore, more than half of the respondents had inappropriate expectations for antibiotics when having fever, sore throat, or runny nose. Similar responses were observed in Poland, where 41% of respondents expected antibiotics for flu while 23% expected antibiotics when having sore throat . Misaligned beliefs and demands for antibiotics by patients may exert pressure on healthcare providers, hence leading to inappropriate prescription to meet the patients’ satisfaction [35, 36]. The educational material in this study contained several key facts on the ineffectiveness of antibiotics against viral infections and significant improvement was observed after the intervention. Incorporation of key facts, such as ‘Cold? Flu? Take care without antibiotics! Antibiotics don’t kill viruses and don’t treat viral illnesses’ in previous awareness campaigns demonstrated effectiveness in reducing the expectations of antibiotics in treating viral respiratory infections .
It is important to note that respondents with at least one family member working as a healthcare professional possessed better antibiotic knowledge and perception at baseline. Public preference to seek informal advice from family and friends rather than formal healthcare was observed in previous studies [37, 38]. These observations were in-line with previous recommendations and highlighted social network support as one of the measures in promoting public health [39, 40]. The importance of community influence was also crucial, as demonstrated by the introduction of the Antibiotic Guardian campaign in the United Kingdom, which effectively reduced antibiotic resistance and encouraged sharing of knowledge [41,42,43]. In Malaysia, the ‘Know Your Medicine Ambassador’ programme, showed an 81.4% increase in awareness on quality use of medications . Therefore, integrating antibiotic-related information into the ‘Know Your Medicine’ programme may be beneficial in promoting prudent antibiotics use.
This study has several strengths. Our intervention tool (an educational leaflet) was designed to address several knowledge gaps among the Perak state population, based on a previous study by Choo et al. . Unlike previous educational leaflets, our focus was to target the misconception of antibiotic effectiveness on upper respiratory infection, especially, and the public’s ability to identify viral infections in which respondents were found to be lacking . Instead of conventional modalities via a lecture-style distribution of generic information, we adopted a more focused, individualised, and interactive counselling approach that increased the effectiveness of the message delivered [45, 46]. We also developed the leaflets in the three major languages: Malay, English, and Chinese, in order to overcome the language barrier which is a common challenge in a multiracial country like Malaysia.
This study had its limitation: the findings only reflected the population in Perak (i.e. the state level) and not the entire country. We calculated the sample size based on previous literature21, which assumed a substantial increase in the mean knowledge score. This resulted in a smaller sample size, which might have affected the power of our study. Due to the fact that the questionnaires were available in multiple languages and majority of the respondents had a higher level of education, the intervention’s impact might have been skewed towards a more effective direction. While previous literature found that better knowledge was associated with more prudent antibiotic use24, we did not assess the participants’ practice of using of antibiotics; hence, we could not affirm this relationship. Non-response bias may present, as those who did not respond to the questionnaire may differ in terms of attitude towards antibiotics and willingness to acquire new information, compared to those who responded.
The impact of face-to-face interactive and targeted educational intervention was proven in this study. In the future, expanding the coverage of the antibiotic awareness campaign through a digital or online interactive web-based medium may be useful to enhance public awareness—further studies are certainly warranted.