Keywords
Antibiotic overuse, Antibiotic resistance, Health education, Digital health technology, Saudi Arabia
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Ali Alhur A, Alhur A, Ibrahim R et al. Consequences of antibiotic overuse in Saudi Arabia: a multidimensional analysis [version 1; peer review: awaiting peer review]. F1000Research 2025, 14:135 (https://doi.org/10.12688/f1000research.159120.1)
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Research Article
Consequences of antibiotic overuse in Saudi Arabia: a multidimensional analysis
[version 1; peer review: awaiting peer review]
PUBLISHED 27 Jan 2025
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Abstract
Corresponding author:
Anas Ali Alhur
Competing interests:
No competing interests were disclosed.
Grant information:
The author(s) declared that no grants were involved in supporting this work.
Copyright:
© 2025 Ali Alhur A et al.
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite: Ali Alhur A, Alhur A, Ibrahim R et al. Consequences of antibiotic overuse in Saudi Arabia: a multidimensional analysis [version 1; peer review: awaiting peer review]. F1000Research 2025, 14:135 (https://doi.org/10.12688/f1000research.159120.1)
First published: 27 Jan 2025, 14:135 (https://doi.org/10.12688/f1000research.159120.1)
Latest published: 27 Jan 2025, 14:135 (https://doi.org/10.12688/f1000research.159120.1)
Introduction
The overuse of antibiotics has emerged as a significant global public health concern, contributing to the growing issue of antibiotic resistance. This problem threatens not only individual patient outcomes but also the effectiveness of healthcare systems worldwide. Antibiotic overuse, often driven by misconceptions about their efficacy and improper prescribing practices, is particularly problematic in countries with less stringent drug regulations. In Saudi Arabia, like many other regions, antibiotic overuse has led to an alarming increase in resistant bacterial strains, calling for urgent public health interventions. However, limited research exists on this topic, particularly from a Saudi Arabian public health perspective. This study seeks to investigate the public health consequences of antibiotic overuse, providing critical insights for future policy and intervention strategies.
Literature review
The issue of antibiotic overuse has been extensively researched in various parts of the world, with numerous studies demonstrating its detrimental effects on public health and healthcare systems (Ventola, 2015). Overprescription, self-medication, and misuse of antibiotics have been linked to the rapid increase in resistant pathogens, rendering many common treatments ineffective (Gupta et al., 2017). Despite global efforts to address this issue, antibiotic overuse remains prevalent, especially in regions where public awareness and regulatory measures are inadequate (Zhao et al., 2013).
2000-2005: Early studies on antibiotic use highlighted the importance of physician prescribing practices and public education. Research from this period, such as the work by Coenen et al. (2006), emphasized that although some populations adhered to medical guidelines for antibiotic use, others frequently engaged in the misuse of these medications. The overuse of antibiotics in both medical settings and through self-medication was linked to an increase in resistant bacterial strains, a trend observed globally (Palmer et al., 2000).
2006-2015: During this period, research expanded to include the social and economic factors contributing to antibiotic overuse. Studies in countries such as India and Egypt revealed that economic barriers to healthcare access often drove individuals to self-medicate with antibiotics, exacerbating the problem (Auta et al., 2015). In Saudi Arabia, a study conducted by Zowawi et al. (2013) reported that nearly 40% of individuals admitted to obtaining antibiotics without a prescription, highlighting a widespread public health issue.
2016 to Present: More recent studies have delved deeper into the public health implications of antibiotic overuse, with a particular focus on the rising rates of antibiotic resistance. For instance, a 2019 report by the World Health Organization (WHO) underscored the urgent need for global action to combat antibiotic resistance, which has been accelerated by the overuse of antibiotics in both healthcare and agricultural settings (WHO, 2020). In Saudi Arabia, recent data indicates that antibiotic overuse remains a pervasive issue, with the public often unaware of the long-term consequences of misuse (Alrashed et al., 2019). The current study seeks to fill this gap by exploring the public health consequences of antibiotic overuse within the context of Saudi Arabia.
Methods
Research design: This research employed a cross-sectional, quantitative design to investigate the public health consequences of antibiotic overuse. The study focused on quantifying the impact of antibiotic overuse on health outcomes and healthcare systems, as well as understanding public perceptions and behaviors that contribute to this issue. A quantitative approach was chosen due to its ability to generate statistically significant data that can be generalized to the broader population (Fatima et al., 2014).
Participants and sampling
The study targeted Saudi Arabian residents aged 18 years and above. A random sampling technique was employed to ensure that the sample was representative of the general population. The final sample included 525 participants, which falls within the acceptable range of 400 to 1,200 participants as determined by Yamane’s (1967) formula for calculating an adequate sample size to identify statistically significant trends and relationships.
Eligibility criteria
Participants were recruited through popular social media platforms, including WhatsApp, X (formerly Twitter), and Telegram, to reach a broad demographic. Recruitment efforts covered all five main regions of Saudi Arabia (Central, Western, Eastern, Northern, and Southern), ensuring diverse representation across gender, age groups, education levels, and occupational categories.
Data collection methods
Data collection was conducted via an online self-administered questionnaire. The questionnaire was developed using validated tools from prior research on antibiotic overuse (e.g., Ventola, 2015; Auta et al., 2015) and was customized to reflect the local cultural and healthcare context based on input from public health experts and healthcare professionals.
Pilot testing: A pilot study was conducted with 50 participants to assess the clarity, reliability, and relevance of the questionnaire items. Based on the pilot test feedback, modifications were made to improve the precision and comprehensibility of certain questions, ensuring cultural and linguistic appropriateness for the Saudi Arabian population.
The final questionnaire included 22 items divided into five sections:
1. Demographic information: Gender, age group, education level, occupation, and region.
2. Awareness and knowledge of antibiotic use: Awareness of antibiotic resistance, misconceptions about antibiotics, and perceptions of public awareness.
3. Antibiotic prescription and use practices: Frequency of antibiotic use, prescription adherence, and self-medication behaviors.
4. Perceptions of antibiotic resistance and healthcare costs: Views on the seriousness of resistance, its impact on healthcare costs, and the necessity for regulatory measures.
5. Public health recommendations: Effectiveness of public health campaigns, support for stricter regulations, and proposed strategies to address antibiotic misuse.
The survey was distributed online, and reminders were sent periodically during the two-week data collection period to maximize response rates.
Tools and materials
To ensure transparency and reproducibility, all materials used in the study have been made available as supplementary documents:
• Questionnaire: The final version of the online questionnaire, including all 22 items (Supplementary File 1).
• Participant information sheet: This document detailed the study’s purpose, participants’ rights, and confidentiality assurances (Supplementary File 2).
• Consent form: Participants provided informed consent electronically before accessing the survey (Supplementary File 3).
• Pilot test summary: Includes details on the pilot study process, feedback collected, and subsequent questionnaire adjustments (Supplementary File 4).
All supplementary data, including the above materials, have been uploaded to an open-access repository to support reproducibility and adherence to the EQUATOR network guidelines.
Data Analysis: The collected data were analyzed using SPSS software version 25. Descriptive statistics were used to summarize the respondents’ demographic information and their responses to key questions on antibiotic use. Additionally, chi-square tests were employed to examine associations between demographic variables (such as age, gender, and education level) and antibiotic overuse behaviors. Logistic regression analysis was also conducted to identify factors that significantly contribute to the overuse of antibiotics, with a p-value of less than 0.05 considered statistically significant.
Results
Based on the results summarized in Table 1: Demographic information, the study participants predominantly identified as female (65.52%, n=344), while males accounted for 34.48% (n=181). The majority of respondents were aged between 18-29 years (63.62%, n=334), with smaller proportions in the age groups 30-39 (16.38%, n=86), 40-49 (11.62%, n=61), and 50 and above (8.38%, n=44). In terms of education, most participants had a bachelor’s degree (55.05%, n=289), followed by those with a high school diploma or below (30.10%, n=158). A smaller percentage had achieved a diploma (7.62%, n=40), a master’s degree (4.38%, n=23), or a doctoral degree (2.86%, n=15).
Table 1. Demographic information.
Table 2: Awareness and knowledge of antibiotic use shows that 86.10% (n=452) of participants were aware that antibiotic resistance is a problem. Regarding the effectiveness of antibiotics against viral infections, 59.05% (n=310) incorrectly believed that antibiotics are effective against viruses, while 40.95% (n=215) correctly indicated they are not. Additionally, 37.90% (n=199) of participants reported always requesting antibiotics for non-bacterial infections, such as viral infections like colds or flu. Public awareness of antibiotic resistance was considered somewhat serious by 55.05% (n=289), very serious by 33.14% (n=174), and not serious by 11.81% (n=62).
Table 2. Awareness and knowledge of antibiotic use.
As detailed in Table 3: Antibiotic prescription and use practices, 37.90% (n=199) of participants reported always prescribing or taking antibiotics. A significant portion (86.10%, n=452) admitted to using antibiotics without a prescription, while 13.90% (n=73) reported they had not. Completion of the full course of antibiotics was reported by 59.05% (n=310) of participants, with 40.95% (n=215) admitting to not completing the course. Additionally, 81.90% (n=430) of respondents had stopped taking antibiotics before completing the prescribed course, while 18.10% (n=95) reported they had not.
Table 3. Antibiotic prescription and use practices.
According to Table 4: Perceptions of antibiotic resistance and healthcare costs, 55.05% (n=289) of participants believed antibiotic resistance to be somewhat serious, and 33.14% (n=174) considered it very serious. When asked about the impact of antibiotic overuse on healthcare costs, 68.38% (n=359) agreed it increased costs, while 31.62% (n=166) did not. Moreover, 81.90% (n=430) of respondents agreed that stronger regulations are necessary to combat antibiotic overuse, compared to 18.10% (n=95) who disagreed.
Table 4. Perceptions of Antibiotic Resistance and Healthcare Costs.
Finally, Table 5: Public health recommendations highlights that 86.10% (n=452) of respondents believe public health campaigns are effective in reducing unnecessary antibiotic use, with 13.90% (n=73) disagreeing. Regarding support for stricter regulations on over-the-counter antibiotic sales, 85.90% (n=451) were in favor, while 14.10% (n=74) were opposed. For strategies to reduce antibiotic overuse, 83.81% (n=440) supported effective strategies such as increased public awareness, with 16.19% (n=85) not supporting these measures.
Table 5. Public health recommendations.
Logistic regression analysis
A binary logistic regression was performed to identify significant predictors of using antibiotics without a prescription. The dependent variable was self-reported use of antibiotics without a prescription (Yes = 1, No = 0), and independent variables included age group, education level, awareness of antibiotic resistance, perception of the seriousness of antibiotic resistance, and gender.
As presented in Table 6, the logistic regression analysis revealed several significant predictors. Participants aged 18–29 years were significantly more likely to use antibiotics without a prescription compared to those aged 50 years and above (Odds Ratio [OR] = 2.35; 95% Confidence Interval [CI]: 1.45–3.81; p < 0.001). Similarly, those aged 30–39 years also had a higher likelihood (OR = 1.89; 95% CI: 1.10–3.25; p = 0.021). No significant difference was found for the 40–49 years group (OR = 1.42; 95% CI: 0.80–2.52; p = 0.232).
Table 6. Logistic regression analysis predicting use of antibiotics without prescription.
Regarding education level, individuals with a high school diploma or below were more likely to use antibiotics without a prescription compared to those with a bachelor’s degree (OR = 1.78; 95% CI: 1.12–2.82; p = 0.015). Participants with a diploma did not show a significant difference (OR = 1.50; 95% CI: 0.80–2.82; p = 0.204). Those with master’s or doctoral degrees did not differ significantly from the reference group.
Awareness of antibiotic resistance was also a significant predictor. Participants who were not aware of antibiotic resistance had a higher likelihood of using antibiotics without a prescription (OR = 2.89; 95% CI: 1.65–5.06; p < 0.001). Additionally, perception of the seriousness of antibiotic resistance influenced misuse behavior. Those who perceived antibiotic resistance as “Not Serious” were more likely to misuse antibiotics compared to those who considered it “Very Serious” (OR = 3.12; 95% CI: 1.78–5.47; p < 0.001). Participants who perceived it as “Somewhat Serious” also had increased odds (OR = 1.85; 95% CI: 1.15–2.98; p = 0.011). Gender was not a significant predictor in the model (OR for males = 1.34; 95% CI: 0.97–1.85; p = 0.076).
Chi-square tests were conducted to examine associations between categorical variables related to antibiotic use behaviors. The results are summarized in Table 7. A significant association was found between education level and completion of the prescribed antibiotic course (χ2 = 16.87; degrees of freedom [df] = 4; p = 0.002). Participants with higher education levels were more likely to complete the full course of antibiotics. Additionally, a significant association was observed between awareness of antibiotic resistance and the likelihood of stopping antibiotics before completing the course (χ2 = 9.54; df = 1; p = 0.002). Participants who were aware of antibiotic resistance were less likely to discontinue antibiotics prematurely ( Table 7).
Table 7. Chi-square tests of independence between education level, awareness, and antibiotic use behaviors.
| Association | Chi-Square (χ2) | Degrees of Freedom (df ) | p-Value |
|---|---|---|---|
| Education Level vs. Completion of Antibiotic Course | 16.87 | 4 | 0.002 |
| Awareness of Antibiotic Resistance vs. Stopping Antibiotics Early | 9.54 | 1 | 0.002 |
A multivariate analysis of variance (MANOVA) was conducted to examine the combined effects of age group and education level on multiple antibiotic misuse behaviors. These behaviors included the use of antibiotics without a prescription, failure to complete prescribed antibiotic courses, and stopping antibiotics before completing the course ( Table 8).
Table 8. Multivariate Analysis of Variance (MANOVA) results for impact of age and education level on antibiotic misuse behaviors.
| Source | Wilks' Lambda | F-Value | Degrees of Freedom (df ) | p-Value |
|---|---|---|---|---|
| Education Level | 0.921 | 2.52 | 8, 1034 | 0.01 |
| Age Group | 0.908 | 3.91 | 12, 1358.23 | <0.001 |
The MANOVA was performed using SPSS software (Version 25). For this analysis:
• The independent variables were age group (categorized into 18–29, 30–39, 40–49, and 50 years and above) and education level (categorized as high school or below, diploma, bachelor’s degree, master’s degree, and doctoral degree).
• The dependent variables were antibiotic misuse behaviors, which were measured as binary outcomes (Yes = 1, No = 0) derived from participant questionnaire responses.
• To control for unwanted sources of variability, outliers were screened by assessing Mahalanobis distances, ensuring that no extreme cases unduly influenced the results.
• Assumptions of multivariate normality and homogeneity of covariance matrices were tested using Shapiro-Wilk and Box’s M tests, respectively, with any deviations from assumptions reported.
The results indicated a statistically significant multivariate effect of education level on antibiotic misuse behaviors (Wilks’ Lambda = 0.921; F = 2.52; df = 8, 1034; p = 0.01). Similarly, age group showed a significant multivariate effect on these behaviors (Wilks’ Lambda = 0.908; F = 3.91; df = 12, 1358.23; p < 0.001).
Discussion
The present study offers a comprehensive examination of the factors contributing to antibiotic overuse within the Saudi Arabian population, highlighting the significant roles of demographic variables, awareness levels, and perceptions regarding antibiotic resistance. The findings indicate that younger individuals and those with lower educational attainment are more prone to misuse antibiotics, a trend that aligns with global patterns of self-medication and non-prescribed antibiotic use (Auta et al., 2015; Gupta et al., 2017). This susceptibility among younger demographics may be influenced by easier access to over-the-counter medications, peer behaviors, and a diminished perception of personal risk associated with antibiotic resistance.
Educational attainment emerged as a crucial determinant in antibiotic misuse. Individuals with higher education levels demonstrated better adherence to prescribed antibiotic courses, suggesting that enhanced health literacy fosters a greater understanding of medical guidelines and the importance of completing antibiotic regimens (Alrashed et al., 2019; Ventola, 2015). This correlation underscores the necessity for educational interventions that not only inform but also empower individuals to make informed health decisions. Alhur’s research on vitamin literacy and information-seeking behavior further supports the role of education in promoting informed health practices. Enhancing educational initiatives can bridge knowledge gaps, fostering responsible antibiotic use and adherence to treatment protocols (Alhur et al., 2024a).
Awareness of antibiotic resistance significantly impacted misuse behaviors. Participants who lacked sufficient knowledge about antibiotic resistance were more likely to misuse antibiotics, either by using them without a prescription or by not completing the prescribed course. This gap in awareness highlights the critical need for public health education campaigns aimed at increasing understanding of antibiotic resistance and its serious implications for both individual and public health (Gupta et al., 2017; World Health Organization, 2020). Additionally, Alhur’s study on drug-herbal interactions in Hail, Saudi Arabia, underscores the complexity of medication practices in the region. The concurrent use of antibiotics and herbal remedies without adequate knowledge can exacerbate the risks associated with antibiotic overuse, including adverse drug-herbal interactions and complications in managing antibiotic resistance (Alhur, 2024b).
Interestingly, gender did not emerge as a significant predictor of antibiotic misuse in this study, suggesting that antibiotic overuse is a pervasive issue affecting both males and females equally in the Saudi Arabian context. This finding contrasts with some studies in other regions where gender differences in health behaviors have been observed (Zhao et al., 2013). Alhur’s investigation into public perspectives on digital innovations in pharmacy indicates that factors such as ease of use and data security are more influential than gender in determining the acceptance of digital health tools (Alhur et al., 2024c). This implies that interventions aimed at reducing antibiotic misuse should focus on enhancing digital literacy and addressing concerns related to data privacy, rather than targeting specific genders.
The integration of digital health technologies presents both opportunities and challenges in addressing antibiotic misuse. Alhur’s research on public perspectives of digital innovations in pharmacy reveals a moderate level of optimism towards digital tools, alongside significant concerns about data privacy and usability (Alhur et al., 2024d). Leveraging digital platforms for educational campaigns could enhance the reach and effectiveness of interventions aimed at reducing antibiotic overuse. However, it is imperative to address public concerns regarding data privacy and ensure the usability of digital health tools to foster trust and facilitate their adoption in promoting responsible antibiotic use.
Moreover, the high prevalence of herbal remedy use in Hail, Saudi Arabia, as reported by Alhur, indicates a need for integrated public health strategies that address both pharmaceutical and herbal medication practices. Public health education should encompass safe practices for the use of all types of medications, emphasizing the potential risks of drug-herbal interactions and promoting informed decision-making (Alhur, 2024d). This holistic approach can mitigate the compounded risks associated with the simultaneous use of antibiotics and herbal remedies, thereby enhancing overall public health safety.
Conclusions
This study explains the multiple factors contributing to antibiotic overuse in Saudi Arabia, emphasizing the important roles of age, education level, awareness, and perceptions of antibiotic resistance. Younger individuals and those with lower educational attainment are more prone to antibiotic misuse, especially when there is insufficient awareness and understanding of the seriousness of antibiotic resistance. These findings highlight the urgent need for comprehensive public health interventions that include targeted education, extensive awareness campaigns, regulatory enforcement, and active involvement of healthcare professionals.
Addressing antibiotic overuse is essential to reduce the growing threat of antibiotic resistance, which puts individual patient outcomes and the effectiveness of healthcare systems at risk globally. By implementing tailored educational programs, increasing public awareness, and strengthening regulations, Saudi Arabia can make significant progress in promoting responsible antibiotic use. Furthermore, using digital health technologies and addressing cultural factors related to medication practices can improve the effectiveness of these interventions. Collaborative efforts among policymakers, healthcare providers, educators, and the community are crucial to combat antibiotic resistance and protect public health.
Ethics and consent
This study was reviewed and approved by the Research Ethics Committee (REC) at the University of Hail, Saudi Arabia. The approval reference number is H-2024-473, and the date of approval is May 13, 2024. The research protocol adhered to the ethical principles governing research involving human participants, as outlined in the Declaration of Helsinki. For reference, the full document outlining the principles of the Declaration of Helsinki is available on the World Medical Association’s official website.
All participants received a Participant Information Sheet that explained the study’s objectives, voluntary participation, and assurances of confidentiality and anonymity. Informed consent was obtained electronically from each participant before they began the survey. Participants were informed of their right to withdraw from the study at any time without consequences.
To protect participants’ privacy, no personally identifiable information was collected. All data were stored securely in encrypted, password-protected systems, with access restricted to authorized research team members.
Informed consent
All participants provided informed consent electronically before beginning the questionnaire. The consent form clearly explained the study’s objectives, the voluntary nature of participation, and assurances of confidentiality and anonymity. Participants were informed that they could withdraw from the study at any time without any repercussions.
Confidentiality and anonymity
Data collection was designed to maintain participant anonymity and confidentiality. No personally identifiable information was collected, and all data were securely stored in encrypted and password-protected systems accessible only to the research team.
This ethical approval and adherence to recognized research principles ensure the study’s compliance with institutional and international standards for human research.
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how to cite this article
Ali Alhur A, Alhur A, Ibrahim R et al. Consequences of antibiotic overuse in Saudi Arabia: a multidimensional analysis [version 1; peer review: awaiting peer review]. F1000Research 2025, 14:135 (https://doi.org/10.12688/f1000research.159120.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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