Antibiotics have saved millions of lives and changed the history of infectious diseases. However, in recent years, antibiotic resistance has become a major global public health problem [1]. Antibiotic resistance challenges the treatment of common infectious diseases and increases mortality rates and treatment costs [2]. Each year, approximately 700,000 deaths occur due to resistant infections [3].

Antibiotic resistance is a natural phenomenon. However, insufficient antibiotic use, poor patient adherence to antibiotics, and insufficient antibiotic regulation increase its prevalence [4]. The main reason for the development of resistance is the insufficient use of antibiotics, especially in developing countries where the use of antibiotics is often not well regulated, which allows self-treatment [5]. Worldwide, more than 50% of antibiotics are purchased from pharmacies or street vendors without a prescription [6].

In general, the Jordanian community has a lack of awareness regarding the use of antibiotics [7]. The public impression of antibiotic use is affected by socioeconomic considerations [5]. The number of Jordanians who use antibiotics inappropriately and access antibiotics without a prescription has increased. Moreover, they often fail to finish the course of therapy, indicating that antibiotics are being misused. There is a real need for an evaluation study to be carried out in Jordan to avoid the occurrence of bacterial resistance among children. This evaluation should lead to the recommendation of necessary solutions if there is a problem in knowledge, attitudes, and practices (KAP) [7].

Previous studies have shown poor KAP toward antibiotic use among parents of children, where KAP was linked with the sociodemographic status of parents. For example, a cross-sectional study conducted among 239 parents in the United Arab Emirates revealed that 54.4% had a lack of knowledge regarding effectiveness, the role, and indications of antibiotics [8]. 67.2% of the parents believed that antibiotics are used to treat viral infections, and 44.5% believed that misuse of antibiotics could lead to antibiotic resistance. Furthermore, a cross-sectional study among 320 parents in Malaysia revealed that parents’ KAP was significantly linked with parental education level and family income [9].

Due to the high prevalence of infectious diseases in children [10], they receive a lot of antibiotics, but parents often administer these drugs inappropriately [7, 10], which is influenced by their knowledge, attitudes, and practices towards these drugs [10]. Some studies indicate important gaps in parents' knowledge of antibiotics: parents believe that these drugs can treat viral infections [8], that antibiotics should be used whenever a child has a fever, and that shorter courses of antibiotics are better for the health of their children [8, 9].

Generally, children consume a large number of antibiotics to treat infections, most of which are acute respiratory infections. There are many reasons for inappropriate antibiotic use in children. In some cases, it may be because the child has previously suffered from an infection that should have been treated with antibiotics, and then, when a similar viral infection develops, it cannot be cured without antibiotics [9]. In addition, antibiotics are started even in cases where the infection is thought to be viral due to the poor geographical conditions of the area where the physician works, lack of equipment, the fear that the patient will not be able to reach the physician easily, or the sick child will not be brought to control [7, 10]. Furthermore, the indifference of parents in pediatric patients and the pressure on pediatricians to prescribe antibiotics also lead to inappropriate antibiotic use [11]. As a result, the administration of antibiotics provides minimal benefit, and sometimes even harm (side effects, resistance, etc.) [12, 13].

There is a shortage of research conducted to assess KAP among parents regarding antibiotic use in Jordan, whether among Jordanian nationals or Syrian refugees. Currently, Syrian refugees constitute a good proportion of Jordanian society; there are approximately 660,000 registered Syrian refugees in Jordan [22]. Hence, the objectives of this study were to (1) assess knowledge, attitudes, and practices towards antibiotic use to treat acute respiratory infections among Jordanian and Syrian refugee parents who have children under five years old; (2) examine the relationship between KAP toward antibiotic use and parental socio-demographic variables, and to find the differences between Jordanian and Syrian refugee parents in terms of their KAP toward antibiotic use.

This section presents the research methodology used to conduct this study, which includes research design, population, setting, sampling and sampling method, measurement, data collection and analytics procedures, and ethical considerations.

This study was conducted to assess the KAP toward antibiotic use. Close to half of the parents believe that once a child has a fever, antibiotics must not be given. This finding is in contrast with the study that was conducted in Saudi Arabia which revealed that the majority of parents had good knowledge about the use of antibiotics with the febrile child. The finding of this study indicated that less than half of parents reported adequate knowledge regarding the administration of antibiotics for a viral infection such as cold, flu, or sore throat as the illness is self-limited. The same study in Saudi Arabia by Alwahhabi et al. [12] showed that less than half of parents had a good knowledge about ARI causes, such as the virus. It is noteworthy that a small percentage of parents are well aware that antibiotics do not help children to recover quickly in cases where they are suffering from flu-like symptoms. This finding is slightly lower in percentage than a Palestinian study by Zyoud et al. which showed that almost 25% of the sample disagreed with giving antibiotics to children to help them recover faster from flu-like conditions [14]. These results resembled the findings of a study conducted in United Arab Emirates by Salama et al. which showed that approximately 50% of participants agreed that antibiotic resistance develops because of antibiotics misuse [8].

The analysis indicated that Jordanian and Syrian parents scored 46 out of 70 for attitude. The level of attitude in this study is lower than in a study in Greece by Lakshmi et al. where most mothers (92%) reported a moderately good overall attitude [15]. This may be because the study was conducted in a Western country, where the population enjoys a higher quality of life than that of most people in Jordan. Additionally, the Jordanian population needs a comprehensive national campaign to educate parents about the use of antibiotics. Furthermore, in the current study, Syrian parents were found to have a lower attitude score than Jordanian parents. This can be explained based on the demographic data of this study, including the lack of health insurance for Syrian children and the low level of income, which promotes self-medication without doctor consultation. According to a study conducted in United Arab Emirates by Salama et al. [8], parents without health insurance and with low incomes have a strong tendency to administer medicine at home or buy an antibiotic from the pharmacy to save money.

In the current study, one third of participants reported that among the reasons for administering the antibiotic without a doctor’s consultation is that sometimes there was not enough time to visit the doctor or no money to pay the fee, particularly among Syrian parents. This may be attributed to the unavailability of health insurance for their children in comparison to Jordanian children who have health insurance from the Jordanian MOH until the age of six years. Furthermore, more than half of parents thought that sometimes or often they considered their child's condition not serious enough to warrant a visit to the doctor, so they administered an antibiotic on their own responsibility. In concordance, a study in Palestine Zyoud et al. showed that 24.7% of parents used antibiotics as self-medication due to financial difficulties or insufficient time. In addition, 50.6% would give antibiotics to their children because they believed symptoms were not as harmful as they thought [14]. The data suggested that most parents strongly disagreed and disagreed with changing pediatricians because they didn’t prescribe as many antibiotics as they thought they should. This finding is somewhat relevant to a result of a study in Oman by Al Hashmi et al. [16] which showed that 66% of responders disagreed about changing physicians for this reason. Additionally, the results showed that more than half of parents (57%) agreed and strongly agreed that they would change their pediatrician since he/she keeps prescribing antibiotics. The results of the current study are more promising than the results of a study in Oman Al Hashmi et al. which showed only 22.9% agreed with switching doctors if they consistently prescribed antibiotics. In this study, most parents (73.5%) strongly disagreed and disagreed that they would reuse any leftover antibiotics whenever the child exhibits ARI symptoms. The result reflects the findings of a study conducted in Oman by Al Hashmi et al. which showed that 75.8% of participants disagreed with utilizing the remaining antibiotics [16]. The result of this study revealed that both Jordanian and Syrian parents reported a practice score of 17.5 out of 25 toward the use of antibiotics to treat ARI. In comparison, an Egyptian study by Mansour et al. found that more than half of parents (53.3%) reported inappropriate practices toward antibiotic use with ARI [17]. However, the Jordanian parents reported better practices than the Syrian parents. The reason may be attributed to the fact that the Jordanian sample in this study had a higher education level. For example, the majority of Jordanian mothers (83.9%) had a college or higher level of education, while less than 25% of Syrian mothers had a college or higher level of education. Likewise, the percentage of highly educated fathers in the Jordanian sample is higher than in the Syrian one. To support this, a study in Puerto Rico by Hernández-Díaz et al. showed that the correct behavior toward antibiotic uses correlates with the higher education level of parents [18]. Hence, inappropriate practice might be due to many factors, such as not allocating enough time from the attending physician to educate parents and the lack of health education specialists in health institutions.

In terms of knowledge, the results revealed no significant relationship between knowledge of antibiotics and any demographic data (parents' education level, family income, number of children, or gender), which is compatible with the finding of a study in Jordan by Abu Hammour et al. that discovered no significant differences in parent’s knowledge scores depending on gender or educational level [19]. However, this result is contrary to the result of a study conducted in Greece by Panagakou et al. which found there was a positive relationship between knowledge of antibiotics and parents' level of education level, family income, and the number of children [20]. For attitude, the findings showed that there was a significant relationship between attitude toward antibiotics and parent’s gender. Mothers were found to have a better attitude than fathers, which is confirmed by a study in Greece by Panagakou et al. [20]. There was a significant positive relationship between attitudes toward the use of antibiotics and the father’s/mother’s level of education, which agrees with the study in Greece by Panagakou et al. which confirmed that low level of education may lead to negative attitudes about antibiotics use [20].

For practices, the findings showed that there was a significant positive relationship between practice toward antibiotics and mother’s level of education. This finding was confirmed by the study in Greece by Panagakou et al. [20]. However, there was no significant relationship between practice and father’s education which disagrees with the findings of a study in Malaysia by Teck et al. [9]. Although both parents are caregivers of the children, the mother is the person who is most attached to the child and the one who spends the most time with them. Therefore, the best level of her education prepares her for reading and searching for answers regarding the health of her child. This may be an explanation for the relationship of a mother’s high education level with her positive attitudes and practices. Furthermore, this explanation is supported by a study in Jordan by Al-Azzam et al. [21], which showed that low-income people and people with lower levels of education had higher intentions to use antibiotics.

Obviously, limitation of this study is that the results do not represent the Jordanian community as whole, due to the setting of the study which confines to Irbid city in the northern part of Jordan. Likewise it does not represent the Syrian community comprehensively because there is a big portion of them living in the refugee camps or inside other Jordanian cities, therefore, their socio-economic conditions may differ from those in Irbid city.

There is a shortage of research conducted to assess KAP among parents regarding antibiotic use in Jordan, whether among Jordanian nationals or Syrian refugees. Currently, Syrian refugees constitute a good proportion of Jordanian society; there are approximately 660,000 registered Syrian refugees in Jordan [22]. Hence, the objectives of this study were to (1) assess knowledge, attitudes, and practices towards antibiotic use to treat acute respiratory infections among Jordanian and Syrian refugee parents who have children under five years old; (2) examine the relationship between KAP toward antibiotic use and parental socio-demographic variables, and to find the differences between Jordanian and Syrian refugee parents in terms of their KAP toward antibiotic use.

Overall, the knowledge and attitudes of parents about ARI and the use of antibiotics by both Jordanian and Syrian parents in the city of Irbid are limited. Parental education and income levels were mainly correlated with KAP. Jordanian parents recorded higher attitude and practice scores than Syrian parents. Thus, there is a clear need to improve the awareness of parents through health education and to improve health insurance policies. Health education should target parents with low socio-economic status in general and Syrian refugee parents in particular.

Currently, there is a strong and urgent need to impose a law prohibiting the dispensation of antibiotics without a prescription from pharmacies because of their possible side effects, the most important of which is bacterial resistance. In line with the recommendations of the World Health Organization to reduce bacterial resistance, infection prevention and control policies, programs, and implementation should be improved [23]. Decision-makers should create a national health policy that regulates the purchase of antibiotics from the pharmacy without a medical prescription. This policy should also regulate medical prescriptions in public and private hospitals and in healthcare centers. Furthermore, serious attention should be paid to developing a children's health insurance policy for Jordanians and Syrians. It is also important to provide a highly qualified specialist physician to diagnosis infectious diseases correctly before antibiotic prescription.