Received: 17 July 2022 | Accepted: 15 September 2022

DOI: 10.1111/nuf.12803

RESEARCH ARTICLE

A national online survey of Filipinos' knowledge, attitude, and

awareness of antibiotic use and resistance: A cross‐sectional
study

Daniel Joseph E. Berdida PhD, RN, RM1 | Rizal Angelo N. Grande EdD, RN2 |
Violeta Lopez PhD, RN, FACN3 | Sheryl H. Ramirez PhD, RN4 |
Muhmin Michael E. Manting MSc5 | Marc Matthew E. Berdida BSN, RN, RM6 |
Christopher B. Bañas MAN, RN, RM1

1
College of Nursing, University of Santo
Tomas, Manila, Philippines Abstract
2
Mental Health Nursing Department, College Background: Antibiotic resistance is one of the 21st century's most challenging
of Nursing, University of Ha'il, Ha'il City, Saudi
Arabia
clinical and public health issues. However, this health issue remains underreported in
3
School of Nursing, Midwifery and Social the Philippines.
Sciences, Central Queensland University, Aim: This study examined Filipinos' knowledge, attitude, and awareness regarding
Rockhampton, Queensland, Australia
4
antibiotic use and resistance and the associated predictive variables of antibiotic
University Research Innovation and
Extension, Universidad de Manila, Manila, resistance.
Philippines Methods: A cross‐sectional design and Strengthening the Reporting of Observa-
5
Department of Biological Sciences, Mindanao
tional Studies in Epidemiology guidelines were used in this study. Convenience
State University—Iligan Institute of
Technology, Iligan City, Lanao del Norte, sampling of 3767 participants completed the Eurobarometer survey on antibiotic
Philippines
resistance from October 2021 to February 2022. χ2 and regression analysis were
6
Northwestern Memorial Hospital, Chicago,
used to analyze the data.
Illinois, USA
Results: Most participants were familiar with the popular types of available
Correspondence antibiotics. Males and healthcare workers had a higher percentage of correct
Daniel Joseph E. Berdida, PhD, RN, RM, St.
Martin de Porres Bldg., College of Nursing, responses on antibiotic resistance knowledge. Participants had moderate to high
University of Santo Tomas, España Blvd., knowledge levels of antibiotic resistance. Age, educational attainment, profession,
1015, Manila, Philippines.
Email: [email protected] and antibiotic use in the previous year, and household members taking antibiotics were
[email protected]; significant predictors of the level of knowledge of antibiotic resistance. There was a
Twitter: @BerdidaJoseph
significant difference in participants' sex, age, and educational attainment in their
attitudes toward acquisition, hygienic practices, and the role of health professionals
in antibiotic resistance.
Conclusion: Government agencies and policymakers should consider the identified
predictors when establishing policies on antibiotic resistance. This will ensure that
antibiotic use is safe and effective.

KEYWORDS
antibiotic resistance, antimicrobial resistance, attitude, awareness, Filipinos, knowledge,
Philippines

Nursing Forum. 2022;1–15. wileyonlinelibrary.com/journal/nuf © 2022 Wiley Periodicals LLC. | 1

2 | BERDIDA ET AL.

1 | INTRODUCTION In contrast, the people in lower‐middle and low‐income nations had poor
knowledge and awareness of antibiotic use and resistance.10,12,14,17,20
Worldwide, nurses play a critical role in medication administration Both high and low knowledge and awareness of antibiotic usage and
safety.1 In the Philippines, the Nursing Act of 20022 emphasized that resistance existed in upper‐middle‐income countries.9,18,19 Thus, the
one of the vital functions and responsibilities of a Filipino nurse is to higher a country's income, the more its population is aware and
provide health education as part of health promotion activities. As an knowledgeable of antibiotics.
outcome, Filipino nurses' involvement in the prevention of antibiotic AMR is one of the most challenging clinical and public health
resistance (AR) can be achieved through their function as health problems in the 21st century.6,7 Bacterial infections become more
educators, among other things. Patients will be better guided on the difficult to treat as they develop AR. In the Philippines, the
proper use of antibiotics. Thus, the incidence of AR will be reduced if Department of Health (DOH) reported 76,892 cases of AR in 2017,
patients are provided with comprehensive information on antibiotic representing a 6% increase from 2016.29 We observed that there had
3
usage through nurse health education programs. been changes in Filipinos' knowledge about antibiotics,30 as
Antibiotics are drugs used to fight bacteria. AR occurs when evidenced by published articles on antibiotic use.20,31–33 Each study
bacteria and fungi develop the ability to resist the drugs used to conducted in different areas of the Philippines revealed similarities,
eradicate them, allowing the pathogens to live and thrive.4 AR all related to a lack of knowledge of antibiotic use resulting in cases of
develops in bacteria, not among humans or animals. These AR AR. Nevertheless, each study shows unique findings that are distinct
bacteria infect humans and animals, and their infections are more from the others. For example, a 2018 study in Manila revealed that a
5,6
challenging to treat than nonresistant bacteria. In 2022, the significant proportion of patients with dengue fever who presented
Antimicrobial Resistance Collaborators published a systematic review to the hospital had already taken antibiotics.31 The lowest income
on the 2019 worldwide burden of antimicrobial resistance (AMR) in group had a higher likelihood of using antibiotics than other groups
bacteria.7 This review reported that the six‐leading antibiotic‐ with the same condition, according to the findings.
resistant microorganisms associated with deaths are Escherichia coli, Another case in 2019 happened in Bulacan, a province just north
Staphylococcus aureus, Klebsiella pneumoniae, Streptococcus pneumo- of Manila.32 Poor understanding of antibiotic use and adequate
niae, Acinetobacter baumannii, and Pseudomonas aeruginosa; and their knowledge of antimicrobials were identified in the study of the
number is growing worldwide.7 Globally, as of 2019, an estimated surveyed population. The study found that participants' inability to
4.95 million deaths were associated with AMR, including the 1.27 complete the prescribed antibiotic therapy was due to a lack of
7
million deaths due to AR. financial resources to purchase the prescribed antibiotic therapy. Like
Antibiotic knowledge refers to understanding antibiotic informa- the 2018 study in Manila,31 the study in Bulacan correlates to the
tion in a detailed or factual manner, while antibiotic awareness refers lack of knowledge of the use of antibiotics for viral infections; hence,
8,9
to an individual's personal relevance to antibiotic information. AR is there is a need to educate the public on the appropriate use of
caused by antibiotic misuse, linked to a lack of information about antibiotics for certain illnesses.32
6,10
using antibiotics correctly. Several factors and reasons contribute In 2022, a study was conducted in Isabela,33 a province in the
to a lack of knowledge and awareness about antibiotic use, including northwest portion of Luzon Island, Philippines. Similar to previous
illiteracy, doctors failing to offer adequate instructions and non- studies on AR, surveyed participants had a poor understanding of
compliance with provided instructions.11,12 Published studies on antibiotic use. In the study, age, gender, and educational attainment
antibiotic knowledge regarding use and resistance in several were found to be predictors of antibiotic knowledge. Those between
countries, including Cyprus,13 Ethiopia,14 Italy,15 Germany,16 18 and 35 years old, men, and those with a vocational degree have a
Ghana,10,17 Kosovo,18 Malaysia,19 Nepal,12 Philippines,20 Singapore,11,21 greater knowledge of antibiotic use.
22 8,23 24
Netherlands, Thailand, and Trinidad and Tobago ; all correlate The alarming increase in AR reported in the Philippines over the
it with age, sex, higher educational attainment, and employment as last five years29,30 necessitates revisiting this problem, particularly
their predictors. when novel infections such as COVID‐19 and other reported
The Centers for Disease Control and Prevention25 estimate that diseases are re‐emerging. In numerous ways, COVID‐19 has
each year in the United States, antibiotic‐resistant bacterial infections influenced the worldwide population's perspective on the use of
cause at least 2 million infections and 23,000 fatalities. In the US, antibiotics.34 Even before the emergence of COVID‐19, many people
25
indiscriminate antibiotic use is the most significant cause of AR. The worldwide have used antibiotics knowingly or unintentionally
general US population and some medical professionals believe because they perceive that when they contract an infection,
26,27
antibiotics are not without adverse effects or complications. regardless of the causative microorganism, they should take
There are still portions of the US population unaware and have low antibiotics immediately.6,7 Then came COVID‐19, whose effects on
28
knowledge of antibiotic use and resistance. a person's health and the best treatment are poorly understood.
Knowledge and awareness concerning antibiotic use and resist- People would simply assume that antibiotics are the only therapeutic
ance were correlated with the income levels of various countries. The choice because they are unfamiliar with how the condition should be
population of high‐income countries reported a high level of managed.35 During the COVID‐19 pandemic, the lack of a compre-
13,15,16
awareness and knowledge regarding antibiotic use and resistance. hensive understanding of the virus intensified antibiotic usage and
BERDIDA ET AL. | 3

misuse, leading to increased AR.36 Therefore, this study examined programs. This document offers therapeutic recommendations for
Filipinos' knowledge, attitude, and awareness regarding antibiotic use common infectious infections in the community and hospitals to help
and resistance and the AR's associated predictive variables. clinicians optimize antibiotic treatment.30,50 Additionally, the Manual
of Procedures for Primary Health Care Settings was implemented in
2019 to address concerns in antimicrobial usage at the community
1.1 | Background level and to complete the DOH AMS initiatives across the country.30
This manual helps health professionals and workers perform AMS‐
Antimicrobials' efficacy in fighting infections has increased global related responsibilities in Primary Health Care settings and monitor
population life expectancy.37 However, as medical and pharmaceuti- and evaluate health facilities' performance according to the AMS's
cal advancements continue, new problems have emerged regarding objectives.30
antibiotic use and resistance, causing more harm than good from The Filipino culture and belief system are critical in perpetuating
antibiotics.38,39 AMR in the Philippines. Cultural barriers, Filipino attitudes and
The WHO6 declared AMR as a public health priority. The actions regarding health compliance, such as their concept of self‐
World Health Assembly developed and disseminated the AMR and medication and the belief in “albularyo” (Filipino traditional healers)
AR global action plan in 2015.6 This international action plan has that they use alone or in conjunction with modern treatment,
five strategic objectives. This plan includes improving awareness contribute to the prevalence of AMR in the Philippines.51 Addition-
and understanding of AMR, strengthening surveillance and ally, Filipinos' lack of knowledge about antibiotic use includes self‐
research, reducing the incidence of infection, optimizing the use medication without physician advice, lack of information about the
of antimicrobial medicines, and ensuring sustainable investment in harmful effects of antibiotic misuse, antibiotic sharing, and antibiotics
countering AMR.6 readily available in “sari‐sari stores” (small convenience stores in
The indiscriminate and extensive use of antibiotics is a significant Filipino neighborhoods) were reported factors contributing to AR.20
contributor to AR.39,40 Indiscriminate antibiotic use involves doctors' Only a few studies, to our knowledge, have investigated
41
inappropriate prescription, self‐medication, overuse, not complet- antibiotic misconceptions (e.g., antibiotic sharing, self‐medication,
ing the entire course of treatment,42 sharing medication with others, and informal antibiotic distribution),20,31 knowledge, attitude, and
retaining part of a treatment course for a later date, and obtaining awareness,32,33 but not primarily AR knowledge and perception, as
antibiotics from pharmacies without a prescription.20,43 Additionally, well as predictive variables for AR, among Filipinos. In contrast, the
the unregulated dumping of antibiotic waste products by pharma- purpose of our study was to investigate Filipinos' knowledge,
ceutical companies into the wastewater contributes to the increasing attitude, and awareness regarding antibiotic usage and resistance,
case of AR worldwide.39,44 The large quantities of antibiotics as well as their associated predictive characteristics.
contaminate rivers, lakes, and seas, affecting the food sources (e.g.,
fish, crops, poultry). Once ingested, these contaminated food sources
predispose humans to an increased risk of AR.45 The same situation 2 | METHODS
happened in countries like India,45 China,46 and Pakistan.47
Healthcare workers (HCWs [e.g., nurses, doctors, midwives, 2.1 | Study design
pharmacists]) and patients play a crucial role in preventing the spread
of AR by adhering to appropriate antibiotic use.48 Moreover, A cross‐sectional design was used to assess participants' knowledge,
healthcare workers significantly contribute to the public's knowledge attitude, and awareness of antibiotic use and resistance. We followed
of AR.31 They also served as the most credible antibiotic use and the Strengthening the Reporting of Observational Studies in
18,49
resistance information source. Thus, to help solve the AR Epidemiology (STROBE) guidelines for cross‐sectional studies. This
problems, healthcare workers and the general population must guideline helps authors explain their work before submitting it to
ensure that these drugs are used appropriately.6 Given the magnitude journals and must complete the 22 checklist items. STROBE is not a
of the AR problem and the reality that resolving it will require validation tool for the study or a framework for conducting an
collective efforts, it is critical that the public understands the issue of observational study.52
AR, its ramifications, and solutions to address this global health
problem.
The Philippines' DOH launched the Antimicrobial Stewardship 2.2 | Ethical considerations
(AMS) program, National Antibiotic Guidelines (NAG), and Manual of
Procedures for Primary Health Care Settings to address the rising The ethics review committee of a government‐owned university
cases of AR and a lack of knowledge in the use of appropriate granted ethical authorization to our study following the submission of
30
antibiotics among Filipinos. The AMS program was established in all relevant protocols and documents (ERC‐UdM‐2021‐018;
2016 to improve patient outcomes, prevent future financial hardship approved: 11/04/2021). The study's objectives, participants' rights,
due to healthcare costs, and protect the public's welfare.30,50 In benefits, possible risks of participation, and withdrawal from the
2018, the NAG was created to enhance antimicrobial stewardship survey, were all thoroughly explained to the participants. This
4 | BERDIDA ET AL.

information was provided in the survey's introduction to ensure that The Eurobarometer 79.4 included 51 questions.54 This survey
potential participants were adequately informed. The authors instrument is divided into five parts and comprises dichotomous replies
considered the online survey submission to be implied consent to and multiple‐choice questions. The first part inquired whether the
participate in the survey. No identifying data such as name, address, participant or any family members had ever taken antibiotics or are now
email, or contact numbers were collected during the survey. taking them. This part also yielded information on the reasons for taking
certain antibiotics. This information was used to determine the general
awareness of participants about antibiotic use. The participants' specific
2.3 | Participants and sampling awareness of antibiotic use and misuse (e.g., types of antibiotics,
antibiotics make one recover faster when having a cold) was the focus
This study used convenience sampling to recruit participants. Social of the second part. We assessed the level of knowledge about the
media platforms (e.g., Facebook, WhatsApp, and Twitter) were adverse effects (e.g., antibiotics often cause side effects such as diarrhea)
utilized to identify participants. Snowball sampling was employed to and AR (e.g., resistance can spread from person to person) in the third and
enhance participant response. This technique includes distributing fourth parts. The knowledge of AR was evaluated using 10 “agree‐
the Google survey form to their family, friends, and coworkers. disagree” items. Participants' attitudes towards antibiotic access or AR
Participants were eligible based on the following criteria: (a) Filipinos (e.g., if I get an infection, I often wait and see, i.e., rest and take it easy,
residing in the Philippines at the time of data collection; (b) were at and see if the infection goes away on its own) and perceptions of the
least 18 years old, (c) had access to social media and the internet, or roles of health care professionals (e.g., doctors always conduct a thorough
someone else did; (d) had used both prescribed and non‐prescribed examination regarding whether a patient is in need of antibiotics or not)
oral antibiotics, and (e) that they were willing to participate. were all assessed in part five.
Participants who had access to social media platforms, online forums,
friends, family members, or anyone else with access to social media
were encouraged to fill out and circulate the forms. 2.5 | Data collection
The required sample size was determined using an online sample
size calculator.53 The minimum required sample size was 1857 after The online survey instrument allowed the participants to administer it
using a statistical power of 95%, an effect size of 0.01, and an alpha themselves. Participants could not submit the online form if they did
of 0.05. A total of 4172 online survey forms were received. After not answer all items. This setting of the survey form allowed
rigorous survey forms inspection, data cleaning, and validation, 3767 participants to withdraw from the study anytime they felt they could
(90.3% response rate) online forms were determined to be complete not complete the survey. We collected data for 6 months, from
and acceptable for analysis. Consequently, our sample satisfied the October 2021 to February 2022.
required sample size. The collected data were anonymously retrieved and stored in a
password‐protected Google drive account. The researchers can only
access this online repository system. The online survey forms do not
2.4 | Instruments require the participants to share personal data (e.g., names, social media
accounts, email, or birthdays). Each participant's data was assured of
This study utilized a survey instrument to evaluate the population's complete anonymity and confidentiality. Participants did not receive any
knowledge, awareness, and attitudes toward antibiotic use and gifts or monetary compensation during data collection.
resistance. The first part collected the demographic profiles. This
included age, sex, educational attainment, employment status, and
religion. The second section of the survey form adopted the 2.6 | Data analysis
Eurobarometer 79.4 survey on AR.54 This instrument has been used
to assess antibiotic use and resistance among Europeans22 and the Data was encoded using Microsoft® Excel 2007 and analyzed using
Ghanaian population.10 SPSS, Version 23.0 for Windows. Descriptive statistics were used to
The original English instrument was translated into Filipino summarize the demographic profiles of the participants as well as
(Tagalog) using semantic equivalence methods.55 It was subsequently their responses to the different items of the questionnaire.
validated by three Filipino (Tagalog) language specialists utilizing Frequency and proportion were used for categorical variables.
backward‐forward translation. Thereafter, the translated instrument The χ2 test (or Fisher Exact test) was used for categorical data,
was pilot tested among 150 Filipinos (students [n = 36], employed while regression analysis was performed for multivariate data. The
[n = 33], retired [n = 30], professionals [n = 27], and jobless [n = 24]). significance threshold was set at .05.
For the Eurobarometer 79.4 AR survey instrument, the pilot test got Our regression tables included statistical controls for sex, age,
a Cronbach α of .92, showing strong reliability. 56
Pilot test educational attainment, and occupation. Females were used as the
participants were not included as actual study participants. The reference category for sex, and the 18–21 age group was used as the
pilot‐tested instrument was then distributed to the study reference for age. The comparison groups for educational attainment
participants. and occupation were high school graduates and health workers,
BERDIDA ET AL. | 5

respectively. Three educational attainments were measured: high a higher percentage of correct answers than non‐HCW. It is worth
school graduate, college undergraduate, college graduate, and noting that for item 3, “if one feels better after only partially
master's or doctorate. Antibiotic use was divided into four categories completing an antibiotic course, one can terminate the therapy
in the previous year: none, once, 2–5 occurrences, and more than five immediately,” the proportion of participants with correct responses
occurrences. Regression analysis was conducted based on partici- decreases with increasing educational attainment.
pants' knowledge level, awareness, attitudes, and perceptions of AR.

3.4 | Regression estimates of participants' general

3 | RESULTS awareness of AR based on knowledge levels

3.1 | Participants' demographic profile For the knowledge items, scores were computed, determined for
each respondent, and summed up (Table 3). The first group, the “low
The study included 3767 participants. There were 2384 (64%) knowledge,” had a maximum of four correct answers (n = 1911,
females and 1383 (36%) males. Participants were evenly divided into 50.7%), and the second group, the “moderate knowledge,” had up to
three age groups: 18–21 years (1856, 49.3%), 22–25 years (450, seven correct answers (n = 1587, 42.1%). The third group, the
11.9%), and over 25 years (1461, 38.8%; the group's oldest “highest knowledge,” had more than seven correct answers
participant was 69 years old). The participants were divided into (n = 269, 7.1%).
groups according to their educational attainment. College under- Regression analysis was conducted to determine the general
graduates (2181, 57%) were the most common participants. This was awareness of AR based on participants' knowledge levels (Table 3). As
followed by college graduates (1050, 27.9%), high school graduates shown in the table, a regression analysis was carried out to determine
(296, 7.8%), and master's or doctorate holders (240, 6.4%). The the predictors of knowledge of AR. In this study, a person's age,
majority of the participants (2747, 72.9%) were non‐healthcare educational attainment, profession, antibiotic use in the previous
workers, while 1020 (27.1%) were healthcare workers. year, and having anyone in the household taking antibiotics were
significant contributors to the knowledge level on AR.

3.2 | Participants' awareness of antibiotics use and

misuse 3.5 | Participants' general attitudes toward
antibiotic acquisition and the use of hygienic practices
The participants' awareness of antibiotic use and misuse is shown in to prevent AR and its spread
Table 1. As depicted in the table, most participants have a basic
understanding of the various types of available antibiotics. This AR can be reduced by changing participants' attitudes toward
knowledge differed significantly among age groups, sexes, and antibiotic use, illnesses, and hygiene practices (Table 4). These were
occupations, but not significantly according to educational attain- computed using χ2 testing and reported relative to the participants'
ment. Moreover, less than half of the participants were aware that demographic profiles. In total, 69.2% (2605/3767) of respondents
antibiotics are ineffective against the common cold, with statistical said they wait and see when they have illnesses (i.e., resting without
significance noted between sex, age groups, and educational medication and later monitoring if the infection goes away). In
attainment (p < .05). A marginally significant result was noted for addition, 92.2% (3475/3767) of participants employ hand hygiene to
the profession (p = .075). Responses to the two items, “the body can prevent the spread of common illnesses. Notably, most of them
fight mild infections on its own without antibiotics (agree)” and “whether (95.4%, 3592/3767) (Table 4) purchased antibiotics from pharmacies
it is good to acquire antibiotics from relatives, without having to be using doctor's prescriptions. There was a significant difference noted
examined by a doctor (disagree)” were not substantially different in the proportion of participants who answered the statement
(p > .05) among the different types of educational attainment. correctly “if I get an infection, I often wait and see, i.e., rest and take it
Responses to the question “leftover antibiotics can be saved for easy, and see if the infection goes away on its own,” according to age
personal future use or to give to someone else (disagree)” were not (χ2 = 62.436; p < .0001) and educational attainment (χ2 = 74.549;
significantly different according to sex (p = .982). p < .0001). For the item, “I usually use hand hygiene (hand washing
or alcohol hand rub) to reduce the risk of spreading common
infections, such as influenza,” a significant difference in the
3.3 | Participants' knowledge of adverse antibiotic proportion of participants who got it correctly was noted according
effects and AR to sex (χ2 = 13.249; p < .0001), age (χ2 = 77.707; p < .0001), and
educational level (χ2 = 84.794; p < .0001). Similarly, for the item,
Table 2 shows the participants' knowledge of adverse antibiotic “I always use doctor's prescription to purchase antibiotics from
effects and AR. Males had a higher percentage of correct responses pharmacy,” a significant difference in the proportion of participants
in most of the items than females. Similarly, in most items, HCW had who got it correctly was noted according to sex (χ2 = 36.758;
 6
|

TABLE 1 Participants' awareness of antibiotics use and misuse (n = 3767)

Sex n (%) Age (in years) n (%) Educational attainment n (%) Occupation n (%)

High‐ College College Masters'/

Male Female 18–21 22–25 >25 school undergra‐duate graduate Doctorate HCW Non‐HCW
Item (n = 1383) (n = 2384) (n = 1856) (n= 450) (n = 1461) (n = 296) (n = 2181) (n = 1050) (n = 240) (n = 1020) (n = 2747)

Chloramphenicol, Clindamycin, 1249 (90.3) 2109 (88.5) 1644 (88.6) 367 (81.6) 1347 (92.2) 233 (78.7) 1912 (87.7) 977 (93.0) 236 (98.3) 1011 (99.1) 2347 (85.4)
cloxacillin, ampicillin are types
of antibiotics. (correct choice)

χ2 3.082 41.460 75.648 143.800

p .079 <.0001 <.0001 <.0001

Antibiotics make one recover 517 (37.4) 761 (31.9) 572 (30.8) 204 (45.3) 502 (34.4) 6 (2.0) 816 (37.4) 330 (31.4) 126 (52.5) 369 (36.2) 909 (33.1)
faster when having a cold.
(Disagree)

χ2 11.646 34.328 186.059 3.160

p .001 <.0001 <.0001 .075

The body can usually fight mild 999 (72.2) 1638 (68.7) 1322 (71.2) 285 (63.3) 1030 (70.5) 177 (59.8) 1540 (70.6) 749 (71.3) 171 (71.3) 714 (70.0) 1923 (70.0)
infections on its own without
antibiotics. (Agree)

χ2 5.183 11.032 16.127 0.000

p .023 .004 .001 .998

Left over antibiotics can be saved 854 (61.7) 1473 (61.8) 1054 (56.8) 292 (64.9) 981 (67.1) 236 (79.7) 1281 (58.7) 618 (58.9) 192 (80.0) 666 (65.3) 1661 (60.5)
for personal future use or to
give to someone else.
(Disagree)

χ2 0.001 39.236 86.492 7.343

p .982 <.0001 <.0001 .007

It is good to acquire antibiotics 1279 (92.5) 2135 (89.6) 1577 (85.0) 432 (96.0) 1405 (96.2) 288 (97.3) 1898 (87.0) 1022 (97.3) 206 (85.8) 921 (90.3) 2493 (90.8)
from relatives, without having
to be examined by a doctor.
(Disagree)

χ2 8.816 138.090 110.938 0.185

p .003 <.0001 <.0001 .667

Note: %=n/N; p ≤ .05—significant, p > .05—not significant; correct answer category is given after the statement in parenthesis.
BERDIDA
ET AL.
 BERDIDA

TABLE 2 Participants' knowledge of adverse antibiotic effects and antibiotic resistance (n = 3767)

Sex Age (in years) Educational attainment Occupation

ET AL.

High‐ College College Masters'/

Male Female 18–21 22–25 >25 school undergraduate graduate Doctorate HCW Non‐HCW
Items (n = 1383) (n = 2384) (n= 1856) (n = 450) (n = 1461) (n = 296) (n= 2181) (n = 1050) (n = 240) (n = 1020) (n = 2747)

1. Antibiotics often cause side 43.0% 55.6% 49.9% 67.3% 47.3% 32.1% 51.9% 48.5% 76.3% 55.4% 49.3%
effects such as
diarrhea. (True)

2. Antibiotics cause negative 15.0% 23.2% 25.1% 15.1% 15.6% 23.0% 21.3% 17.7% 18.3% 17.5% 21.3%
effects on the body's own
bacterial flora. (True)

3. If one feels better after only 22.7% 21.3% 33.7% 9.6% 10.5% 40.9% 27.9% 8.1% 3.3% 27.0% 7.8%
partially completing an
antibiotic course, one can
terminate the therapy
immediately. (False)

4. Bacteria can become resistant 80.6% 77.9% 81.5% 81.8% 74.7% 46.3% 82.1% 77.2% 97.5% 84.7% 76.7%
to antibiotics. (True)

5. The more antibiotics we use 70.4% 62.1% 62.9% 73.6% 65.4% 35.1% 66.7% 67.4% 78.3% 77.6% 60.5%
in society, the higher is the
risk that resistance develops
and spreads. (True)

6. People can become resistant 77.2% 74.2% 76.0% 80.0% 72.9% 58.1% 78.4% 68.7% 97.1% 72.6% 82.5%
to antibiotics. (True)

7. Antibiotic use for animals can 28.7% 17.9% 14.9% 9.6% 34.6% 20.9% 14.8% 35.0% 30.0% 30.0% 18.9%
reduce the possibility of
effective antibiotic
treatment for humans. (True)

8. Resistance can spread from 37.2% 29.3% 28.7% 44.2% 33.0% 34.1% 29.7% 34.7% 42.1% 45.2% 27.4%
animals to humans. (True)

9. Resistance can spread from 38.9% 43.3% 39.1% 59.1% 39.6% 39.9% 37.5% 50.2% 45.0% 51.1% 38.2%
person to person. (True)

10. People traveling outside 31.4% 37.7% 32.7% 45.3% 35.8% 35.8% 33.1% 44.8% 14.2% 35.9% 35.2%
their home country risk
bringing resistance upon
return to their
country. (True)

Note: Correct answer category is given after the statement (True/False). Scores are in percentages.
|
7
8 | BERDIDA ET AL.

T A B L E 3 Regression estimates of
Low knowledge Moderate knowledge High
(n = 1911) (n = 1587) knowledge (n = 269) participants' general awareness of
Demographic profile B SE B SE B SE antibiotic use based on knowledge levels
(n = 3767)
Sex (female reference)

Male −0.169* 0.076 0.084 0.077 0.091 0.163

Age (18–21 reference)

22–25 −0.671*** 0.137 0.931*** 0.146 −0.615* 0.251

>25 −1.273*** 0.148 1.214*** 0.149 0.702** 0.266

Educational attainment
(highschool graduate)

College undergraduate 0.563** 0.196 −1.062*** 0.231 0.313 0.290

College graduate 0.353 0.191 −0.253 0.204 −0.930** 0.325

Master's/Doctorate −0.207 0.152 0.742*** 0.160 −2.400*** 0.285

Occupation (HCW
reference)

Non‐health worker −0.343*** 0.096 −0.067 0.098 1.399*** 0.173

Antibiotic use within the

last 12 months (never
reference)

Once 0.008 0.087 0.133 0.088 −0.989*** 0.198

2–5 times 0.326** 0.102 −0.199* 0.104 −1.044*** 0.236

>5 times 0.401*** 0.114 −0.102 0.117 −2.287*** 0.312

Anyone in your household

taking antibiotics at the
moment (Yes reference)

No −0.431*** 0.099 −0.319** 0.102 2.899 0.215

Constant 0.648 0.183 −0.992 0.191 −2.093 0.215

2
Cox & Snell R 0.047 0.063 0.091
2
Negelkerke R 0.063 0.085 0.226

Abbreviation: SE, standard error.

*p ≤ .05; **p < .01; ***p < .001.

p < .0001), age (χ2 = 27.687; p < .0001), and educational attainment AR. There was a significant difference noted in the proportion of
2
(χ = 62.876; p < .0001). participants who answered correctly the statement “doctors always
conduct a thorough examination regarding whether a patient needs
antibiotics or not,” according to age (χ2 = 62.436; p < .0001), and
3.6 | Participants' perceptions of the role of educational attainment (χ2 = 59.149; p < .0001). For the item,
healthcare professionals in antibiotic use and “Doctors prescribe antibiotic when a patient expects it,” a significant
resistance difference in the proportion of participants who answered it correctly
was noted according to sex (χ2 = 15.985; p < .0001), age (χ2 = 43.732;
Table 5 shows that some participants across sex, age, educational p < .0001), and educational attainment (χ2 = 9.467; p = .024). Similarly,
attainment, and occupation reported that: doctors do not conduct a for the item, “when antibiotics are prescribed, the doctor takes time
thorough examination to determine whether a patient requires to provide information on how they should be used, in an
antibiotics, doctors do not take the time to explain how antibiotics understandable manner,” a significant difference in the proportion
should be used, and pharmacy personnel does not take the time to of participants who got it correctly was noted according to sex
explain how antibiotics should be used. (χ2 = 84.911; p < .0001), age (χ2 = 28.062; p < .0001), and educational
Table 5 reveals the distribution of participants according to their attainment (χ2 = 35.188; p < .0001). And lastly, for the item, “phar-
perception of the role of health professionals in antibiotic use and macy staff take their time to inform me on how antibiotics should be
 BERDIDA
ET AL.

TABLE 4 Participants' general attitudes toward antibiotic acquisition and the use of hygienic practices to prevent antibiotic resistance and its spread (n = 3767)

Sex n (%) Age (in years) n (%) Educational attainment n (%)

College Masters'/
Statements on antibiotic use and misuse Male Female 18–21 22–25 >25 High‐school under‐graduate College graduate Doctorate
(correct responses) (n = 1383) (n = 2384) (n = 1856) (n = 450) (n = 1461) (n = 296) (n = 2181) (n = 1050) (n = 240)

If I get an infection, I often wait and see, that 977 (70.6) 1628 (68.3) 1354 (73.0) 242 (53.8) 1009 (69.1) 142 (48.0) 1544 (70.8) 765 (72.9) 154 (64.2)
is, rest and take it easy, and see if the
infection goes away on its own. (Yes)

χ2 2.275 62.436 74.549

p .131 <.0001 <.0001

I usually use hand hygiene (hand washing or 1247 (90.2) 2228 (93.5) 1648 (88.8) 410 (91.1) 1417 (97.0) 254 (85.8) 1962 (90.0) 1024 (97.5) 235 (97.9)
alcohol hand rub) to reduce the risk of
spreading common infections, such as
influenza. (Yes)

χ2 13.249 77.707 84.794

p <.0001 <.0001 <.0001

I always use doctor's prescription to purchase 1281 (92.6) 2311 (96.9) 1768 (95.3) 409 (90.9) 1415 (96.9) 257 (86.8) 2110 (96.7) 991 (94.4) 234 (97.5)
antibiotics from pharmacy. (Yes)

χ2 36.758 27.687 62.876

p <.0001 <.0001 <.0001

Note: %=n/N; p ≤ .05—significant, p > .05—not significant; correct answer category is given after the statement in parenthesis.
|
9
 10
|

TABLE 5 Participants' perceptions of the role of healthcare professionals in antibiotic use and resistance (n = 3767)

Sex n (%) Age (in years) n (%) Educational attainment n (%)

College Under‐ College Masters'/
Male Female 18–21 22–25 >25 High‐school graduate Graduate Doctorate
Statements (n = 1383) (n = 2384) (n = 1856) (n = 450) (n = 1461) (n = 296) (n = 2181) (n= 1050) (n = 240)

Doctors always conduct a thorough examination 1305 (94.4) 2248 (94.3) 1663 (89.6) 441 (98.0) 1449 (99.2) 296 (100) 2005 (91.9) 1020 (97.1) 232 (96.7)
regarding whether a patient is in need of
antibiotics or not. (Agree)

χ2 0.007a 152.867 59.149

a
p .934 <.0001 <.0001a

Doctors prescribe antibiotic when a patient expects 3 (0.2) 39 (1.6) 42 (2.3) 0 0 24 (1.1) 18 (1.7) 0
it. (Disagree)

χ2 15.985 43.732 09.469

a
p <.0001 <.0001 .024

When antibiotics are prescribed, the doctor takes 1318 (95.3) 2375 (99.6) 1797 (96.8) 447 (99.3) 1449 (99.2) 296 (100) 2120 (97.2) 1047 (99.7) 230 (95.8)
time to provide information on how they should
be used, in an understandable manner. (Yes)

χ2 84.911 28.062 35.188

p <.0001 <.0001 <.0001

Pharmacy staff take their time to inform me on how 847 (61.2) 1486 (62.3) 1165 (62.8) 206 (45.8) 962 (65.8) 208 (70.3) 1328 (60.9) 625 (59.5) 172 (71.7)
antibiotics should be used. (Yes)

χ2 0.440 59.852 21.964

p .507 <.0001 <.0001

Note: %=n/N; p ≤ .05—significant, p > .05—not significant.

a
Fisher Exact test; correct answer category is given after the statement in parenthesis.
BERDIDA
ET AL.
BERDIDA ET AL. | 11

used,” there was a significant difference noted in the proportion of doctor's prescription and adhere to the pharmacist's or doctor's
participants who answered correctly according to age (χ2 = 59.852; instructions on how to use the antibiotics. According to a study
p < .0001), and educational attainment (χ2 = 21.964; p < .0001). conducted among Singaporeans, most have a favorable view of
antibiotics and are aware of AMR, drug resistance, and AR. However,
they perceive the transmission of resistant bacteria negatively to
4 | DISC US SION other people and believe that AR affects only those who take
antibiotics regularly.11 AR occurs when an antibiotic is not taken
Filipinos' knowledge and perception of AR and its associated predictive according to the prescribed dosage or when the recommended
variables were assessed in our study. The majority of Filipinos surveyed dosage is exceeded or decreased as well as when taken as needed
were undergraduate students. Tangcharoensathien et al.8 and Zajmi regardless of the time interval between doses even if prescribed
18
et al. discovered that educated individuals with a college degree or doses are followed.6,40,58
higher understand proper antibiotic use compared to noncollege degree Corollary to our findings, Raupach‐Rosin et al.16 revealed that
individuals. Similarly, a Ghanaian survey found that a higher education having a college degree, working as a healthcare worker, and obtaining
level was associated with several correct responses to antibiotic use and information from sources such as the internet and newspapers all
resistance.10 Across sex, age, and educational attainment, some of the predict an acceptable level of knowledge and awareness about
reasons for the problem with antibiotic use are that physicians do not antibiotic use. A study in Trinidad and Tobago discovered that
thoroughly examine patients to determine whether they require educational attainment is a predictor of antibiotic use,24 correlating
antibiotics, and pharmacists do not educate them on proper antibiotic with our findings. Individuals who are more educated are more aware
use.10 Being a healthcare worker and having a high level of education that an antibiotic‐resistant infection cannot occur if they follow their
makes a person more knowledgeable about antibiotic use.16,49 While in doctor's antibiotic prescription.24 Antibiotic use can be predicted by
a systematic review of the general Thai population, education level is geographic location and educational attainment,59 crediting our findings.
linked to antibiotic usage knowledge, uneducated people can become In a 2017 study in the Philippines, most Filipinos clearly understood
aware of antibiotic use through social media and information antibiotic use for bacterial infections.20 Regrettably, Filipinos,20 Malay-
23,57
campaigns. Conversely, even though Nepali patients have used sians,19 and Trinidadians24 also mistakenly believed that antibiotics
and been prescribed antibiotics, they are unaware of the antibiotic class might be used to cure viral diseases like the common cold and cough.
as a medication, its uses, and its essential components.12 Females and Furthermore, most participants are unaware that antibiotics have side
young adult participants made up the majority of our current study. effects and that even those not allergic to antibiotics are not immune to
Zajmi et al.18 noted that females abuse antibiotics at a higher rate than their side effects.20 However, our study found that currently, Filipinos
males. In Romania, most participants sought physician advice before know that antibiotics are only indicated for bacterial infections. Patients
using antibiotics rather than using an old prescription and seeking advice receiving a particular antibiotic may experience its side effects
from others who are not physicians or healthcare workers.58 regardless of whether they have an allergy to that antibiotic. The
In contrast to our findings, where the majority of participants overwhelming majority of the surveyed participants in the study of Ali
scored item 3, “if one feels better after only partially completing an et al.24 and Milani et al.41 understand that antibiotics should only be
antibiotic course, one can terminate the therapy immediately,” used when prescribed and that physicians should only prescribe when
Italians' score is significantly lower (only 4%) on the statement “to necessary, which is similar to our findings, where 95.4% understand that
stop treatment when they feel better.”15 The same report found that antibiotics should only be used with a doctor's prescription.
over 70% of participants correctly answered seven out of nine Health education is an essential responsibility of nurses in
questions on antibiotic use resistance, indicating high knowledge.15 medication administration and lowering the risk of AR.1,3 Our study
The same results were found among students in Ghana, where revealed that 50.7% of participants had a limited understanding of
students enrolled in healthcare programs possessed a high level of antibiotic side effects and AR. Numerous individuals are oblivious to
knowledge.17 Patients in Ghana also have shown a direct relationship the causal role of inappropriate use and non‐adherence in anti-
between the use of antibiotics, age, and education level.59 Most microbial resistance and its effect on future healthcare expenses.51
Ethiopian patients surveyed regarding antibiotic use were aware of Accordingly, in response to the prevalence of AR in the country and
and believed in antibiotic use and physician advice.14 Similarly, the World Health Organization's 2015 Global action plan,6 the
Singaporeans heard the term antibiotics (97.5%), but only a third Philippines' Department of Health has intensified surveillance and
correctly answered a knowledge test about antibiotic use.21 People monitoring of the incidence of AR in various Philippine hospitals and
who have a college degree are more aware of how antibiotics work primary health care centers.29,50
13
than people who have not finished at least a college degree. The problem with AR requires a multi‐sectoral and multi‐
Our data indicate that males have more AR knowledge despite institutional solution, necessitating the involvement of several local
having a more significant proportion of females than males. Ilktac and national government agencies. The Philippine legislature passed
et al.13 corroborate our findings in their study of the Cypriot several house bills and laws regulating the administration and
population, the majority of whom are male and have completed distribution of prescription drugs, particularly antibiotics, in the
college, who reported that they purchase antibiotics only with a Philippines.20,60
12 | BERDIDA ET AL.

When patients are appropriately informed by their physicians Any additional constructs revealed by the data cannot be tested using
and nurses about antibiotic use, there is a high likelihood that the the same instrument. Moreover, recall bias and social desirability bias in
prevalence and incidence of AR will decrease dramatically. The self‐report instruments could affect data validity due to underestimation
primary obligation of the public to reduce AR is to adhere to their or overestimation. Second, we utilize a cross‐sectional study design,
physician's instructions and prescriptions.16,19 From primary health which can only assess the state of the variables during a specific period
care facilities to tertiary hospitals, a nationwide initiative to advocate and cannot provide findings of previous or future changes in the studied
the safe use of antibiotics can be implemented. Other healthcare variables. Third, the sample size cannot represent various demographics
professionals, such as pharmacists, are also tasked with providing the of the nationwide population of the Philippines. Finally, we conducted
general population with accurate antibiotic usage instructions. this study during the COVID‐19 pandemic, which may have influenced
Finally, more global health networks, like the 2015 WHO Global Filipinos' responses to the questionnaire because they were in a
Action on AR,6 that share the most effective strategies for dealing with situation where information about health, medications, and disease was
antimicrobial resistance in low‐ and middle‐income countries like the more prominent and impactful. Thus, the generalizability of our results
Philippines, will help move the global goal of AR eradication forward. must be interpreted with caution.
Therefore, we suggest that other instruments, such as question-
naires that measure compliance and knowledge of other medications
5 | I M PL I C A T I O N S T O N U R S I N G routinely prescribed with antibiotics among Filipinos, be conducted
PR AC TI C E to determine essential traits or attributes related to AR knowledge
and perception. This survey should be conducted with a larger sample
Nurses adhere to the nursing law of their country or the country of Filipinos or perhaps undertaken on a wide scale in other countries
where they are licensed to practice. In each of these nursing laws to accurately represent public awareness and misconceptions about
governing the practice of the nursing profession, the administration AR. A different study design, such as a pure experimental or quasi‐
of medications, including antibiotics, is also regulated. experimental design, could be used to find a more causal pattern of
2
The Philippine Nursing Act of 2002 specifies the obligations and the variables. Finally, a post‐COVID‐19 pandemic study on this same
responsibilities of Filipino nurses for medication administration. In topic should be undertaken to determine whether there are any
this regard, nurses are responsible for managing and supervising the disparities in how Filipinos respond during and after a pandemic.
therapeutic and adverse effects of medication, adherence to
medication safety guidelines, patient medication self‐management,
patient education and information about medication, prescriptions, 7 | CONCLUSION
medication safety, and coordination of care on medication adminis-
tration.3 Additionally, the International Council of Nurses' Code of Amid a pandemic, our study of AR among Filipinos is vital and
Ethics61 also demands that nurses exercise due prudence in pertinent. According to the findings, health care workers have a fuller
performing nursing actions, including administering medications. knowledge of antibiotic use than the general people, which is not
Nurses and healthcare workers have critical responsibilities surprising. Additionally, education, job, previous antibiotic use, and
to incorporate various AR prevention measures into their health whether or not a family member uses antibiotics are all predictors of
education4,25,62 such as adherence to treatment regimens,16 proper AR knowledge and perception. The Philippines' DOH and other
handwashing,63 avoiding antibiotic sharing,20 and secure consultation agencies accountable for the safe antibiotic usage, distribution, and
and prescription from a physician,64 as revealed in the findings. Setting prescription among Filipinos should consider the identified predictors
up a more systematic and accurate monitoring and documentation when establishing policies. This ensures that antibiotic use in the
system for AR in the clinical setting is essential for hospital Philippines is both safe and effective.
administrators, doctors, and nurses to be aware of the prevalence of
antibiotics in the clinical setting and respond appropriately to AR cases. A UT H O R C O N T R I B U TI O NS
Additionally, our findings indicate that it is necessary for local and Study design: Daniel Joseph E. Berdida, Rizal Angelo N. Grande, and
national health policymakers in the Philippines to implement a program Violeta Lopez. Data collection: Daniel Joseph E. Berdida, Rizal Angelo
to develop antibiotic use guidelines and standards. N. Grande, Sheryl H. Ramirez, Muhmin Michael E. Manting, Marc
Matthew E. Berdida, and Christopher B. Bañas. Data analysis: Daniel
Joseph E. Berdida, Rizal Angelo N. Grande, Violeta Lopez, Sheryl H.
6 | L IM I TAT I ONS AND Ramirez, Muhmin Michael E. Manting, Marc Matthew E. Berdida, and
R E C O MM E N D A T IO N S Christopher B. Bañas. Manuscript writing: Rizal Angelo N. Grande,
Daniel Joseph E. Berdida, and Violeta Lopez.
Our study is limited concerning some aspects and variables studied.
First, we used self‐report assessment instruments to determine Filipinos' ACKNOWLEDGME NT S
knowledge and perceptions of AR. While the instrument we employed is We would like to express our gratitude to Ma. Grace C. Rosales,
highly reliable and valid, it can only measure the variables created for it. MSPH for her assistance and expertize in statistics. Also, we are
BERDIDA ET AL. | 13

indebted to Danilo Berdida, Josephine Berdida, and Franz Dominique changes from 2017. BMC Public Health. 2021;21(1):2188. doi:10.
E. Berdida for their help during the data gathering. This study did not 1186/s12889-021-12237-y
9. Trevethan R. Deconstructing and assessing knowledge and aware-
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ness in public health research. Front Public Health. 2017;5:194.
commercial, or not‐for‐profit sectors. doi:10.3389/fpubh.2017.00194
10. Effah CY, Amoah AN, Liu H, et al. A population‐base survey on
CO NFL I CT OF INTERES T knowledge, attitude and awareness of the general public on
antibiotic use and resistance. Antimicrob Resist Infect Control.
The authors declare no conflict of interest.
2020;9(1):105. doi:10.1186/s13756-020-00768-
11. Guo H, Hildon ZJ, Lye DCB, Straughan PT, Chow A. The associations
D A TA A V A I L A B I L I T Y S T A T E M E N T between poor antibiotic and antimicrobial resistance knowledge and
The data that support the findings of this study are available from the inappropriate antibiotic use in the general population are modified
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corresponding author upon reasonable request.
11010047
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ETHICS STATEME NT antimicrobial resistance in Nepal: a nationwide survey. Sci Rep.
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