Hrev_master [page 94] [Healthcare in Low-resource Settings 2023; 11:11647] Maternal knowledge and prescribing practices of antibi- otics for childhood infections: a cross-sectional survey in Jordan Ruaa Abdeljawad,1 Osama Abu-Hammad,2 Omayyah Dar-Odeh,1 Farhan Alkouz,1 Raghad Abdeljawad,3 Abdalla Abu-Hammad,4 Rahaf Abdeljawad,3 Najla Dar-Odeh2 1Private Practice, Amman, Jordan; 2School of Dentistry, University of Jordan, Amman; 3School of Medicine, The Hashemite University, Alzarqa; 4School of Medicine, University of Jordan, Amman, Jordan Abstract This article aims to assess the knowl- edge and practices of Jordanian mothers regarding antibiotic consumption by their children. A questionnaire was distributed to mothers during hospital visits in February- May 2020. Questions were on socio-demo- graphics; knowledge of antibiotic indica- tions/complications; and prescribing prac- tices. A total of 1926 mothers participated. Most mothers were aware that antibiotics are not indicated for viral infections (72.0%), and that abuse leads to complica- tions like antibiotic resistance (82.1%). However, their knowledge regarding antibi- otic complications was not satisfactory par- ticularly complications of obesity (11.7%), caries (29.9%), and allergy (43.4%). The most important clinical indications for antibiotics were perceived to be otitis media (89.8%), and sore throat (44.4%). A propor- tion of 21.7% admitted self-prescribing, significantly among families of ≤2 children, and poor antibiotic knowledge (p<0.01). Lower antibiotic knowledge scores were impacted mostly by grandparents who self- prescribe antibiotics (p<0.01). Jordanian mothers show satisfactory knowledge of pediatric antibiotic consumption, however, their knowledge of complications is not suf- ficient. Antibiotic self-prescribing is identi- fied mainly in families with lower income and less antibiotic knowledge, therefore these families should be identified and tar- geted in antibiotic awareness campaigns. Introduction Children may use substantial amounts of antibiotics due to their high susceptibility to infections, particularly those affecting the upper respiratory tract. Exposure of chil- dren to factors that predispose them to infections is promoted by the surrounding environment such as nurseries, daycare facilities, and schools which facilitate the spread of antibiotic-resistant bacteria.1 Although a substantial proportion of child- hood illnesses are viral in origin, it is esti- mated that 78% of children with acute upper respiratory tract infections (AURIs) receive antibiotic prescriptions that are mostly based on broad-spectrum antibi- otics.2 Misuse of antibiotics in children has been associated with the development of several complications particularly antibiotic resistance which has many serious conse- quences including increased mortality.3,4 Situated in the heart of a turbulent Middle East, Jordan represents a politically stable country that continues to host refugees, immigrants, and workforce from neighboring countries such as Palestine, Syria, Iraq, Egypt, Yemen, and more recent- ly Sudan.5 It is estimated that more than 40% of the Jordanian population, or 3.8 million, are children; approximately 30% of these are of non-Jordanian origin. This may represent a real challenge for the national healthcare system which may be burdened by the fluctuating demographics and the associated challenges of drug prescribing and use. Previous research in Jordan and the neighboring countries of the Eastern Mediterranean showed several alarming findings regarding antibiotic abuse includ- ing their unjustified use for viral infections, parental pressure in prescribing, and exces- sively long antibiotic courses.2,6,7 It is esti- mated that approximately 77.5% of pre- scriptions to the outpatient pediatric popula- tion are antimicrobials.8 It was also con- cluded that pneumococcal carriage rate and resistance among 2- to 4-year-old children reached an alarming rate.9 Another impor- tant finding was the noticeable impact of social factors and parental involvement in treatment plans which were identified in this geographic region.10 Since antibiotics are among the most commonly used drugs by the pediatric pop- ulation, and considering the influence of mothers in the consumption of antibiotics, and shaping prescribing practices of clini- cians, it is crucial to investigate their knowl- edge and self-prescribing practices of antibiotics. Therefore, this cross-sectional survey aims to evaluate the knowledge and prac- tices of Jordanian mothers regarding antibi- otic consumption by their children. Materials and Methods The study was a questionnaire-based cross-sectional survey. The questionnaire was a modified version of a similar ques- tionnaire used in a previous study.11 It was composed of 36 closed-ended questions and organized into three sections. The first sec- tion consisted of six questions on socio- demographics. The second section consist- ed of 19 knowledge questions answered by (Yes, No, Don’t know), and eight questions on appropriate antibiotic uses answered by (Yes, No). There were five knowledge ques- Healthcare in Low-resource Settings 2023; volume 11:11647 Correspondence: Najla Dar-Odeh, School of Dentistry, University of Jordan, Amman, Jordan. Tel.: +962.792005197 E-mail: najla_dar_odeh@yahoo.com Key words: antibiotics; awareness; children; Jordan; parents; practices; self-prescribing. Ethics approval: ethical approval was obtained from the Ibn Alhaitham Hospital, Amman, Jordan. Availability of data and material: data are available upon request from the corresponding author. Conflict of interest interest: authors declare no conflict of interest. Contributions: Conceptualization, Ruaa A.; N. D-O, O A-H: Data Curation, O. D-O; Formal analysis: O A-H; Investigation, F. A., Raghad A.;. Writing-original draft, Ruaa A.A. A-H; Rahaf A; Writing-review and editing, N. D-O, O A-H; All authors have read and agreed to the published version of the manuscript. Received: 9 August 2023. Accepted: 3 November 2023. Early view: 10 November 2023. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2023 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2023; 11:11647 doi:10.4081/hls.2023.11647 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affili- ated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guar- anteed or endorsed by the publisher. Non -co mmerc ial us e o nly tions on five types of common childhood medications and whether these constitute antibiotics. These types included the fol- lowing drug categories with common local- ly recognized brand names (Penicillins: Augmentin, Amoclan, Curam; Cephalosporins: Suprax, Cefix, Omnicef; Macrolides: Zomax, Azicure; Non-steroidal anti-inflammatory agents: Brufen/ Aspirin; Corticosteroids: Decadron, Predone). The third section consisted of prescribing aspects specifically antibiotic storage for future use and self-prescribing by parents and grandparents. Questionnaire items were entered onto Google Forms and a link was created. Ethical approval was obtained from the Ibn Alhaitham Hospital, Amman, Jordan. Mothers who attended the hospital for treatment of their children were invited in a consecutive order to participate in the study. Those who gave their consent received the link for the questionnaire on their smartphones and they were guided throughout the questionnaire by the investi- gators without influencing their responses. Invitation of the participants and the ques- tionnaires were completed in four months from February 1st, 2020 to May 31st, 2020. Knowledge and practice answers were scored by assigning one mark for each appropriate answer (whether yes or no) while the incorrect and the “don’t know” answers were marked by “zero”. Questions about understanding antibiotics and their [Healthcare in Low-resource Settings 2023; 11:11647] [page 95] Article Table 1. Sociodemographic characteristics of mothers (N=1926) participating in the sur- vey and their families. Sociodemographic characteristics No (%) Marital status Married 1905 (98.9) Divorced 19 (1.0) Widowed 2 (0.1) Residence Urban 1713 (88.9) Rural 213 (11.1). Health insurance Yes 1425 (74.0) No 501 (26.0) Monthly household income (JOD) Low (<500) 476 (24.7) Moderate (500-1000) 732 (38.0) High (>1000) 718 (37.3) Education of parents Mothers Fathers School 189 (9.8) 396 (20.6) College 209 (10.9) 191 (9.9) University 1310 (68.0) 1048 (54.4) Postgraduate 218 (11.3) 291 (15.1) JOD, Jordanian Dinar (equivalent to 1.41 USD). Table 2. Knowledge and prescribing practices of antibiotics for children among participating mothers. Knowledge and practice items Frequency (%) Yes No Don’t know Knowledge: indications, advantages, complications ABs are useful for viral infections 438 (22.7) 1386 (72.0)* 102 (5.3) ABs are indicated for bacterial infection 1583 (82.2)* 187 (9.7) 156 (8.1) ABs abuse complicates treatment 1582 (82.1)* 177 (9.2) 167 (8.7) ABs abuse causes bacterial resistance 1596 (82.9)* 258 (13.4) 72 (3.7) Expensive ABs are more effective 336 (17.4) 1353 (70.2)* 237 (12.3) New ABs are more effective 516 (26.6) 614 (31.7) 809 (41.7) ABs may induce obesity in children 226 (11.7)* 473 (24.6)* 1227 (63.7) ABs may induce dental caries 575 (29.9)* 414 (21.5) 937 (48.7) ABs may induce sensitivity 835 (43.4)* 347 (18.0) 744 (38.6) ABs may induce diarrhea 1342 (69.7)* 188 (9.8) 396 (20.6) ABs enhance child recovery 1216 (63.1)* 631 (32.8) 79 (4.1) ABs ease flu 269 (14.0) 1563 (81.2)* 94 (4.9) ABs abuse makes future use difficult 1456 (75.6)* 272 (14.1) 198 (10.3) ABs should be stopped after recovery 171 (8.9) 1733 (90.0)* 22 (1.1) Palatable ABs are better 330 (17.1) 1548 (80.4)* 48 (2.5) Knowledge: These medications are ABs Penicillins 1551 (80.5)* 375 (19.5) 0 Cephalosporins 1441 (74.8)* 485 (25.2) 0 Macrolides 1069 (55.5)* 857 (44.5) 0 Corticosteroids 269 (14.0) 1657 (86.0)* 0 NSAIDS 113 (5.9) 1813 (94.1)* 0 Prescribing Practices I have a background on childhood infections 1397 (72.5) 528 (27.5) NA I use ABs for sore throat 855 (44.4) 1071 (55.6) NA I use ABs for flu 105 (5.5) 1821 (94.5) NA I use ABs for diarrhea 152 (7.9) 1774 (92.1) NA I use ABs for fever 699 (36.3) 1227 (63.7) NA I use ABs for otitis media 1729 (89.8) 197 (10.2) NA I use ABs for dental pain and caries 236 (12.3) 1690 (87.7) NA I prescribe Abs to my children 417 (21.7) 1509 (78.3) NA Grandparents prescribe ABs to my children 460 (23.9) 1466 (76.1) NA I store ABs for future use 417 (21.7) 1509 (78.3) NA ABs: Antibiotics; NA: Not applicable; Penicillins: Augmentin, Amoclan, Curam; Cephalosporins: Suprax, Cefix, Omnicef; NSAIDS: Brufen/ Aspirin; Corticosteroids: Decadron, Predone; and Macrolides: Zomax, Azicure. *Correct statements Non -co mmerc ial us e o nly indications were marked for all participants and were calculated as knowledge scores for antibiotics. The sum of all marks for each participant comprised the total score in antibiotics knowledge. Statistical analysis was performed using the IBM SPSS soft- ware version 21.0 (Armonk, NY: IBM Corp). Analysis was done to obtain descrip- tives in the form of frequencies and percent- ages. Cross-tabulation was performed to determine significant associations between sociodemographics on the one hand and antibiotic knowledge scores and self-pre- scribing practices on the other hand. The level of significance was set at P≤0.05. Multiple linear regression was carried out to investigate significant factors influencing knowledge scores. Results Socio-demographics of the sample A total of (1926) mothers participated in the survey. Sociodemographic characteris- tics of marital status, number of children in the family, education status of parents, availability of medical insurance, and other sociodemographics of the sample are pre- sented in Table 1. Most of the sample were married (98.9%), urban dwellers (88.9%), had health insurance (74.0%), and had mod- erate-high income (75.3%). A higher per- centage of mothers than fathers (90.2% ver- sus 79.4%) had higher education. Items related to knowledge and practice about antibiotics use among children are shown in Table 2 together with the respons- es of participants. Knowledge scores ranged from a mini- mum (3) to a complete score of (27) with a mean value of (19.4±3.4). Accordingly, scores ≤18 were considered low, while scores >18 were considered high scores. Knowledge items with the highest correct response rate (>82%) were: ABs are indi- cated for bacterial infection, AB abuse com- plicates treatment, and AB abuse causes bacterial resistance. On the other hand, knowledge items with the highest “Don’t know” response rate were: antibiotics may induce obesity and dental caries in children (63.7% and 48.7% respectively) (Table 2). Approximately 22.0% of the sample practiced antibiotic self-prescribing for their children and storing medications for future use. A higher percentage of grandpar- ents (23.9%) than mothers (21.7%) pre- scribed antibiotics to their grandchildren (Table 2). The practice of self-prescribing was cross-tabulated with sociodemographic factors and total knowledge scores. Results are presented in (Table 3). Health insurance was found to be the only variable not signif- icantly correlated to self-prescribing behav- ior (p=0.068). Having ≤2 children, low antibiotic knowledge scores, parents’ uni- versity education level, urban residence, low-middle income, and self-prescribing grandparents were all significantly associat- ed with the practice of antibiotic self-med- ication among participants (p<0.05) (Table 3). Results of cross-tabulation between antibiotic knowledge scores and sociode- mographic factors are displayed in Table 4. There were significantly higher antibi- otic knowledge scores when: parents’ edu- cation was university (p=0.000 for both), urban residence (p=0.002), having health insurance (p=0.002), non-prescribing grandparents (p=0.000) and moderate-high household income (p=0.000) (Table 4). For the regression model (Table 5) an “ENTER” method was implemented and independent variables were identified as follows: Monthly household income, Number of children in the family, Prescribing grandparents, Health insurance, Residence, Mother’s education, and Article Table 3. Cross-tabulation of sociodemographics with the practice of antibiotic self-medication among participating mothers. Sociodemographics Do you prescribe ABs to your children? p No N=1509 (%) Yes N=417 (%) Number of Children in the family 1-2 1121 (74.3) 246 (59) 0.000 > 2 388 (25.7) 171 (41) AB knowledge ranks Low (≤18) 442 (29.3) 249 (59.7) Good (> 18) 1067 (70.7) 168 (40.3) 0.000 Mother education School 122 (8.1) 67 (16.1) 0.000 College 153 (10.1) 56 (13.4) University 1051 (69.6) 259 (62.1) Higher education 183 (12.1) 35 (8.4) Father education School 262 (17.4) 134 (32.1) 0.000 College 144 (9.5) 47 (11.3) University 868 (57.5) 180 (43.2) Higher education 235 (15.6) 56 (13.4) Residence Rural 144 (9.5) 69 (16.5) 0.000 Urban 1365 (90.5) 348 (83.5) Health insurance No 378 (25) 123 (29.5) 0.068 Yes 1131 (75) 294 (70.5) Grandparent/s prescribe/s ABs No 1172 (77.7) 294 (70.5) 0.003 Yes 337 (22.3) 123 (29.5) Monthly household income Low 316 (20.9) 160 (38.4) 0.000 Middle 572 (37.9) 160 (38.4) High 621 (41.2) 97 (23.3) [page 96] [Healthcare in Low-resource Settings 2023; 11:11647] Non -co mmerc ial us e o nly Father’s education. The “ENTER” method used forced all variables into the regression model. The results of multiple linear regression are shown in Table 5. Significant variables in the model were: monthly income, prescribing grandparents, father’s education, and mother’s education (p<0.01). All other variables were not sig- nificant (p>0.05). Regression analysis showed an R-value of 0.325, R2=0.106, and adjusted R2=0.102 (close to the R square value indicated that the sample size was sat- isfactorily sufficient). Durban Watson test value of 1.919 indicated that 10.6% of the variability in antibiotics knowledge scores could be accounted for by variations of independent variables in the model. Durban Watson test value was > 1.5 indicating that we do not have meaningful serial correla- tion or multicollinearity between independ- ent variables. ANOVA results indicated an F=58.270 and p<0.001. Coefficients in the regression model are shown in Table 5. Coefficients (B weights) show that grand- parents’ contribution to medication had the highest impact on AB knowledge scores which was a negative effect, indicating that prescribing grandparents were associated with knowledge scores that were lower by 0.904 score) followed by monthly income then mother’s education and finally father’s education. All entered variables were signif- icant at p≤0.001. Tolerance of more than 0.2 for all included variables indicated that multicollinearity is not an issue in this regression model. Article Table 4. Cross-tabulation of sociodemographic characteristics with antibiotic knowledge scores among participating mothers. AB Knowledge score ranks of mothers p Low (%) Good (%) No of children 1-2 475 (68.7) 892 (72.2) 0.116 > 2 216(31.3) 343 (27.8) Marital status Widow 1(0.1) 1 (0.1) 0.528 Married 681(98.6) 1224 (99.1) Divorced 9(1.3) 10 (0.8) Mother education School 116(16.8) 73 (5.9) 0.000 College 80(11.6) 129 (10.4) University 440(63.7) 870 (70.4) Higher education 55(8) 163 (13.2) Father education School 203(29.4) 193 (15.6) 0.000 College 82(11.9) 109 (8.8) University 334(48.3) 714 (57.8) Higher education 72(10.4) 219 (17.7) Residence Rural 97(14) 116 (9.4) 0.002 Urban 594(86) 1119 (90.6) Health insurance No 208(30.1) 293 (23.7) 0.002 Yes 483(69.9) 942 (76.3) Grandparents participating in medication No 480(69.5) 986 (79.8) 0.000 Yes 211(30.5) 249 (20.2) Monthly income Low 254(36.8) 222 (18) 0.000 Middle 262(37.9) 470 (38.1) High 175(25.3) 543 (44) Table 5. Coefficients in the regression model. Independent Unstandard. Coeff. Standard. t Sig. 95.0% Conf. Correlations Collinearity variables B Std. Coeff. Intervalfor B Statistics Error Beta Lower Upper Zero-order Partial Part Tolera VIF (Constant) 15.19 0.579 26.23 0 14.05 16.32 Monthly income 0.708 0.117 0.161 6.07 0.000 0.479 0.936 0.269 0.137 0.131 0.660 1.515 No. of children 0.000 0.075 0 0.003 0.998 0.148 0.147 0.008 0 0.000 0.884 1.131 Self-prescribing Grandparents 0.904 0.175 0.113 5.16 0.000 1.248 0.560 0.156 0.117 0.111 0.969 1.032 Residence 0.448 0.250 0.041 1.79 0.073 0.042 0.939 0.108 0.041 0.039 0.881 1.136 Health insurance 0.066 0.178 .008 .370 .712 .416 .284 .071 .008 .008 .884 1.131 Mother’s education 0.426 0.116 0.095 3.67 0 0.198 0.654 0.209 0.083 0.079 0.694 1.442 Father’s education 0.308 0.094 0.088 3.27 0.001 0.124 0.493 0.226 0.075 0.071 0.647 1.547 a, Dependent Variable: Antibiotics knowledge scores. [Healthcare in Low-resource Settings 2023; 11:11647] [page 97] Non -co mmerc ial us e o nly [page 98] [Healthcare in Low-resource Settings 2023; 11:11647] Discussion This study was conducted on a large sample of Jordanian mothers, the primary caregivers for children in Jordan to explore their knowledge of antibiotics, awareness of antibiotic uses and complications, and final- ly the self-prescribing practices towards their children. A close look at the sociode- mographics of this sample indicates that more than 75% of the sample were settled financially and socially being mostly mar- ried, educated, with health insurance, and urban dwelling. It was interesting to identi- fy that more mothers had college or higher education than fathers. This is undoubtedly a close representation of the actual data that report that approximately 56% of students in Jordanian universities are women.12 Perhaps that is why most respondents had good knowledge about the uses and compli- cations of antibiotics as most of them believed that antibiotics are not indicated for viral infections and that antibiotics should be used for bacterial infections. This reflects that Jordanian mothers have accept- able levels of awareness regarding the main uses of antibiotics. This was further con- firmed by >80% of the sample who acknowledged that antibiotic abuse is a problem that results in increasing antibiotic resistance and complicating treatment out- comes. It was important to explore mothers’ knowledge of the possible complications of antibiotic use. Their knowledge is expected to increase their appreciation of the treat- ment outcomes that could be adverse mak- ing its avoidance necessary. However, not all participants were aware of some antibi- otic complications known to affect the pedi- atric population. Whereas most participants agreed with the fact that antibiotics may induce diarrhea and sensitivity, a substantial proportion did not recognize that antibiotics may induce obesity or dental caries. This is perhaps related to the acute and prevalent nature of antibiotic-associated diarrhea which is estimated to be 11%.13 Whilst, any antibiotic is capable of inducing diarrhea, the most common agent involved is amoxi- cillin followed by clindamycin because of the spectrum of action and widespread use.14 Further, antibiotics use in children may be associated with the risk of develop- ing allergies and asthma.15 The association between asthma and antibiotic use has been debatable for a long period, however, in the past decade more studies emerged that con- cluded that excessive use of systemic antibiotics in infancy may play a role in the development of asthma in children.16,17 Therefore, the association between antibiot- ic use in children and allergy and asthma cannot be overlooked. Other complications associated with less awareness among our sample included obesity and dental caries, probably due to the common belief of their association with nutritional and lifestyle factors. An association between antibiotic use on the one hand and obesity and dental caries on the other hand has been suggested previously.18,19 A recent meta-analysis reported that early-life antibiotic exposure was associated with the risk of childhood overweight or obesity in a dose-response manner.19 Children who are exposed to antibiotics early in their life may be at risk of changing the composition of their intes- tinal microbiota, with subsequent adverse long-term effects like obesity.20 Therefore, with the high prevalence of obesity among children in Jordan,21 more studies are war- ranted to investigate the role of antibiotics and other childhood medications as a con- tributory factor to obesity. On the other hand, several dental problems associated with pediatric antibiotic use are identified, and these when associated with the poor oral health practices common among chil- dren in the Eastern Mediterranean region22 would worsen the oral health outcomes. It was also shown that exposure to amoxicillin during early infancy may predispose to den- tal defects in the form of defective enamel.23 Participants were generally knowledge- able about the antibiotic brand names pre- scribed to children locally in Jordan. However, a small percentage identified cor- ticosteroids (14%) and NSAID analgesics (6%) as antibiotics probably because of their anti-inflammatory nature, and their versatile applications in the management of childhood infections.24 Regarding the effectiveness of antibi- otics and associated factors, the study revealed that seven out of 10 respondents did not perceive that there was a relation between the cost of antibiotics and their effectiveness. On the other hand, 30% of respondents did not consider that new antibiotics are more effective as opposed to a slightly higher proportion of 40% who expressed uncertainty about the compara- tive effectiveness of new antibiotics. These results suggest that our respondents have a keen understanding of the price-quality relationship of drugs. However, it is worth noting that multiple studies have indicated that higher-priced drugs are often associat- ed with higher efficacy judgment.25 Clearly, new antibiotics have been developed to tar- get more resistant strains of bacteria. Nevertheless, this does not imply that the older antibiotics are any less effective than the new ones against the original strains of bacteria.26 Participants used antibiotics to treat a variety of childhood infections and dis- eases. The most frequently cited diseases were otitis media followed by sore throat, while the least frequently cited diseases for antibiotics use were dental pain, diarrhea, and flu in descending order. This generally indicates good practice since operative treatment, for dental pain,27 and palliative treatment for flu are the appropriate meas- ures that should be followed rather than antibiotic consumption. One in five of the participants practiced self-medication with their children. Self- medication with antibiotics is a serious common practice in Jordan and other Eastern Mediterranean populations.10 A recent systematic review reported that the prevalence of antibiotic self-medication among children was highest in the Middle East and lowest in Europe.28 It was noticed that small families (≤2 children), and low- middle income were significantly associat- ed with this practice. This is consistent with recent systematic reviews that concluded that low income and having more than one child were associated with this practice.29 Unfortunately, the non-prescribed dispens- ing of antibiotics in Jordan is not yet well- controlled, which facilitates obtaining med- ications for self-prescribing parents. This may have serious implications particularly that this practice was significantly associat- ed with participants who had low antibiotic knowledge scores. Expectedly, there was a significant association between higher antibiotic knowledge scores and favorable socioeconomic status in terms of education, residence, health insurance, and monthly income. Education is usually paralleled by socioeconomic well-being, and both are generally associated with improved access and retrieval of required information about childhood medications. It was important to explore grandparents’ involvement in the child’s treatment plan because of the pri- mary role that grandparents in Arabic soci- eties play in contributing to their grandchil- dren’s upbringing issues such as health aspects. Albeit the small difference, a higher percentage of grandparents than parents participated in self-medication. On the other hand, prescribing grandparents were signif- icantly associated with prescribing mothers and mothers who had low antibiotic knowl- edge scores. This was confirmed by regres- sion analysis which showed that self-pre- scribing grandparents had the strongest association with low knowledge scores of mothers followed by other less significant factors such as monthly income, and par- ents’ education. This confirms previous findings of the essential role of the family in promoting health behaviors including appropriate drug use.30 This study therefore showed that good antibiotic knowledge and Article Non -co mmerc ial us e o nly [Healthcare in Low-resource Settings 2023; 11:11647] [page 99] non-self-prescribing go hand in hand to leave the practice of prescribing to physi- cians to promote patient safety and avoid the anticipated side effects of antibiotic abuse. The study has limitations. It was a sin- gle-center study conducted in a private city hospital. However, a large sample of moth- ers with different socioeconomic profiles has participated. The cross-sectional self- perceived nature of the survey may repre- sent another limitation. However, the anonymous nature of the questionnaire and the assistance that researchers provided to participants during the completion of the survey are two main factors that helped pro- vide reliable responses. Conclusions Jordanian mothers seem to have satis- factory knowledge of antibiotics consumed by their children. However, their knowledge of complications is not sufficient, and some of them show poor practices in obtaining the medication and practicing self-medication. Most parents showed their interest in improving their education on antibiotics issues, and this could be utilized to design parent-oriented interventions that increase the awareness of parents and improve antibi- otic use among the pediatric population. References 1. Nyquist AC, Gonzales R, Steiner JF, et al. Antibiotic prescribing for children with colds, upper respiratory tract infec- tions, and bronchitis. 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