Prevalence of Inappropriate Antibiotic Use Behaviors and Related Factors Among Chinese Antibiotic Users: A Cross-Sectional Online Survey | BMC Infectious Diseases


This study was approved by the ethics committee of Tongji Medical College, Huazhong University of Science and Technology (number: 2018IECS175). All participants were informed of the purpose of this study and informed consent was obtained from the electronic signatures of all participants. The data was collected anonymously. All methods were performed in accordance with the Declaration of Helsinki.

Study design and sample size

A cross-sectional survey was designed and conducted among Chinese antibiotic users from July 1, 2018 to September 30, 2018, based on China’s largest online survey platform (Questionnaire Star, Questionnaire Star is a professional services platform for electronic questionnaire design and data collection, which has been widely used by researchers. This study focused on the following three aspects of inappropriate usage behaviors: SMA, SSA, and NAAT. The NAAT included four types of non-adherence behaviors including no antibiotics, increased antibiotic dose, decreased antibiotic dose, and discontinued antibiotics. To ensure the stability and reliability of the survey results, the sample size should be as large as possible. In our study, the maximum sample size was calculated with the minimum prevalence of these target behaviors. We used the formula:(n={z}^{2}p(1-p)/{d}^{2})where not is the sample size, p is the prevalence of the research target, z is the normal deviation (1.96) and D is the margin of error (D= 0.1p). When determining the parameter p , we took the prevalence of target behaviors among audiences over the past 6 months as a criterion according to previous studies. Among them, the prevalence of non-adherence behavior with proactive antibiotic dose escalation was the lowest at 8.3% to 22.0% [17, 19]. Therefore, we took the median value and set the confidence interval (CI) at 95% to calculate the sample size of 2,152. Considering the possibility of invalid surveys (about 15%), at least 2,532 participants should be surveyed in each region.

According to China Health Statistical Yearbook (2018) [20], the population that responded to the online questionnaire was divided into three regions: eastern, central and western China. To ensure the representativeness of the survey samples in each region, the administrator would close the network link and end the questionnaire survey when the number of survey samples in each region reaches 2,532 participants.


To reflect the prevalence of inappropriate antibiotic use behaviors among Chinese antibiotic users, we selected three main outcomes: percentage of SMA, percentage of SSA, and percentage of NAAT. In this study, SMA was defined as the answer “yes” to the question: “In the past 6 months, have you self-administered antibiotics without a doctor’s prescription?” SSA was defined as the “yes” response to the question: “In the past 6 months, have you stored any antibiotics at home for future use?” » NAAT was measured according to four types of non-adherence behaviors that were developed from previous studies [21]: (1) Have you ever missed taking medication during antibiotic treatment? (2) Have you ever increased the dose yourself during antibiotic treatment? (3) Have you ever reduced the dose yourself during antibiotic treatment? (4) Once the symptoms disappear, do you immediately stop the course of antibiotics? Each item measures a specific type of nonadherence behavior and dichotomous responses (yes/no) are captured. The item is scored 0 points if the answer is “Yes” and scored 1 point if the answer is “No”. Total scores range from 0 to 4, the higher the score, the higher the adherence of the antibiotic user. Total scores ≤ 2 are considered “non-adherence”, and total scores > 2 are considered “adherence”.

To identify relevant determinants of inappropriate SMA, SSA, and NAAT usage behaviors, we also collected demographic and sociological characteristics, including gender, age, place of residence (urban/rural), educational level, education (college or below/high school/college or above), self-rated economic status (good/fair/poor), self-rated health status (good/fair/poor), and knowledge of antibiotics. Antibiotic knowledge is assessed by asking 10 questions divided into three sections: knowledge of the role of antibiotics, antibiotic use and antibiotic resistance. These 10 questions are estimated using a scoring system, with a score of 1 for a correct answer and 0 for an incorrect answer. The total knowledge scores range from 0 to 10. We divided the total antibiotic knowledge scores into three levels as follows: (1) high level: scores from 8 to 10; (2) average level: 3 to 7 scores; (3) low level: 0–2 scores. In the questionnaire, the Cronbach’s α coefficients of the nonadherence behavior scale and the antibiotic knowledge scale were 0.71 and 0.84 (>0.70), respectively. Confirmatory factor analyzes showed that the standardized factor load of each item of the nonadherence behavior scale ranged from 0.52 to 0.57 (>0.40), and that these knowledge scale values antibiotics were all above 0.70. The results of these tests indicated that the questionnaire had good reliability and validity.

Data gathering

We have designed a questionnaire and generated a valid QR code of this questionnaire on the online survey platform. Then, we recruited 50 graduate and undergraduate students from Huazhong University of Science and Technology School of Public Health as investigators in July 2018. Four of them declined the request for distribution of questionnaires, with a participation rate of 92%. After the unified training, the interviewers would get the questionnaire QR code. During the summer holidays, all of them sent electronic questionnaires through their personal social software such as “WeChat”. Respondents scanned the QR code on their mobile phone to complete the questionnaire. The data administrator checked the questionnaire and sorted the data in the background every week. When each region (East, Central, and West China) reached the required minimum survey sample of 2,532, the administrator closed the network link and ended the survey.

Prior to the survey, we conducted a pilot test of the questionnaire to ensure the proper implementation of all steps, including logging respondents into the platform, filling out and submitting the questionnaire. we set the following inclusion criteria that respondents completing the questionnaire must meet: (1) adults aged 18 or older; (2) living in the area for more than 6 months; (3) normal cognitive and comprehension abilities; (4) knowing the term “antibiotic” and having used antibiotics. To ensure that only one survey per respondent can be completed, we have limited one IP address per submission on the online survey platform and required logging in with a personal mobile phone number (in China, the mobile phone number is a real name system) before completing the questionnaire. During the survey, to enhance the enthusiasm of respondents, we paid 3 yuan in cash to each person who completed the survey as an economic incentive. To ensure that respondents read the questionnaire carefully and answer it, we have set three quality inspection questions in different places, namely: “Where is the capital of China?”, “What is that 7 minus 2?” and “What is 1 plus 3?” If the answer to any of these three questions was incorrect, the questionnaire would be marked as invalid. After respondents completed the questionnaires, all questionnaires were automatically entered into a data file, and two researchers independently collated and verified the data to ensure the reliability of the survey data.

During the survey process, 21,874 respondents visited the questionnaire link and 17,062 respondents actually completed the questionnaire. As this was an online survey, the true response rate could not be determined here. Of all the questionnaires, 1,280 questionnaires were excluded due to unqualified quality control, and 256 questionnaires were also excluded due to respondents under the age of 18. Finally, 15,526 valid questionnaires were obtained.

statistical analyzes

A descriptive analysis of participants’ demographic and sociological characteristics, antibiotic knowledge, and various inappropriate use behaviors was conducted. Ranked variables were expressed as frequency and percentage, and continuous variables were expressed as mean and standard deviation (SD). To examine the possible impact of controversial questions Q5 and Q9 of the Antibiotic Knowledge Scale (Table 2) on study results [22, 23], a sensitivity analysis was performed by deleting these two items. When these two items were removed, the total antibiotic knowledge scores moved between 0 and 8. The total antibiotic knowledge scores were redivided into three levels as follows: (1) high level: scores 7–8 ; (2) average level: 3 to 6 scores; (3) low level: 0–2 scores. Additionally, a binary logistic regression model was used to explore factors associated with inappropriate SMA, SSA, and NAAT use behaviors among antibiotic users. The adjusted odds ratio (aOR) and 95% CI for each variable were given. All analyzes were performed using SAS 9.4 (SAS Inc., Cary, NC). The statistical tests were double-tailed; a Pa value


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