Antimicrobial stewardship: knowledge, perceptions, and factors associated with antibiotics misuse among consumer’s visiting the community pharmacies in a Nigeria Southwestern State

Background In middle-income countries like Nigeria, the misuse of antibiotics by consumers is posing serious threats to public health. This is contributing to the alarming increase in antimicrobial resistance, which is reducing the effectiveness of antibiotics against common infections. This study therefore aimed to assess the knowledge, perceptions, and factors associated with antibiotics misuse among consumers visiting selected community pharmacies. Methods This cross-sectional study conducted in Ibadan, Nigeria, aimed at determining factors influencing antibiotics misuse among consumers. The questionnaires were completed by 509 consumers. The analysis was done using SPSS version 26 and the results were presented using descriptive statistics. The associations between categorical variables were analysed using Pearson’s Chi-square with statistical significance set at p < 0.05. Results Results showed that 95.9% of the consumers believed that antibiotics prevent bacterial growth, and 60.7% thought they treat all infections. However, 57.4% were unaware of antibiotic resistance, while only 14.7% had adequate knowledge about antibiotics. Most of the consumers, 72.5% had used antibiotics in the last 12 months and, amoxicillin 42.4% was the most commonly used with, malaria 38.9% as the primary condition for which antibiotics were used. Some of the significant factors influencing antibiotics misuse included delays in test reports (p-value = 0.007), the belief in antibiotics’ quick relief (p-value = 0.001), proximity of the pharmacy to their house or workplace (p-value = 0.028), amongst others. Conclusion Most of the consumers had inadequate knowledge about rational antibiotic use which contributed to their misuse of antibiotics. Thus, targeted educational interventions are needed to improve knowledge and promote appropriate antibiotic use among consumers. Policies regulating the dispensing and selling of antibiotics with adequate counselling should be further enforced.


Introduction
Antibiotics are substances that are used for inhibiting and treating infections caused by specific bacteria.They play an important role in treating bacterial infections, including life-threatening ones [1].However, microorganisms are becoming less susceptible to antibiotics and by implication, infections are becoming difficult to treat because of antibiotics resistance [1].Antibiotic resistance is a natural process [2], but the misuse and overuse of antibiotics have contributed to the constant surge in resistance, which is a global threat to human health [3].
Antibiotics resistance does not necessarily mean that the human body is resistant to antibiotics, instead, this phenomenon occurs when the growth of microbes is no longer inhibited or destroyed by antibiotics [1].The continuous increase in the rate of antibiotic resistance is alarming and this poses imminent danger to the therapeutic effectiveness of antibiotics.As a result of this surge, resistant bacteria have become widespread [4].This has also led to increased hospitalization rates, higher cost of health care, prolonged stay in hospital and faster mortality rates [5].According to the United Nations (UN) ad hoc Interagency Coordinating Group (IACG), antibiotic-resistant infections currently cause approximately seven hundred thousand deaths yearly, and by 2050, this number could reach ten million annual deaths if urgent and effective measures are not taken to curb its spread [5].It is therefore necessary to put in place strategies that will address and curb the dangers being posed to public health by antibiotic resistance.
The unethical antibiotics use by consumers has been favoured by community pharmacists dispensing these drugs without valid prescriptions [6].In many middleincome countries, antibiotics are available over the counter [2,7].
Many patients resort to antibiotic misuse due to factors such as lack of funds for doctor consultations, long wait times at hospitals, high costs of laboratory tests, and the unavailability of medical doctors [8].Studies have shown that 75% of antibiotic requests and 60% of consultations with community pharmacists worldwide resulted in the sale of antibiotics without a valid prescription [8,9].
Misuse of antibiotics such as failure to finish the antibiotic therapy, skipping of doses, reusing leftover medicines, and excessive use by consumers, have contributed to the widespread menace of antibiotic resistance globally [10].This irrational use of antibiotics is posing danger to the health of the masses [8].Based on a WHO report, about half of all medicines are prescribed, dispensed, or sold in ways that are inappropriate [11].Unethical use of antibiotics is one of the topmost reasons for their reduced efficacy and effectiveness thus making common illnesses more difficult to treat [8,11].
Although some research studies have reported the prevalence of antibiotic resistance in Nigeria, however, there is still inadequate information on the factors responsible for resistance in the country.Previous studies have identified cases of Staphylococcus aureus which is methicillin-resistant and Escherichia coli which is fluoroquinolone-resistant in Nigerian communities [12,13].Additionally, increased rates of antibiotic resistance have been observed among clinical specimens from a tertiary hospital in Nigeria [14].However, only a small percentage of rational antibiotics use studies have been conducted in community pharmacies [15].
Given the global increase in antibiotic resistance, which is predominantly due to misuse of antibiotics.The aim of this study was to assess the knowledge, perceptions, and factors associated with antibiotics misuse among consumers visiting selected community pharmacies in Ibadan, Nigeria.

Study design and setting
This study was a questionnaire-guided cross-sectional survey that assessed the factors associated with antibiotic misuse among consumers visiting the community pharmacies in Ibadan.It was conducted in Ibadan, the capital city of Oyo State in Southwestern Nigeria.Oyo State is one of the 36 states in Nigeria, covering a landmass of 27 249 square kilometres.Ibadan has a population of about 3.6 million people, while the entire population of Oyo State is approximately 5.6 million people.

Data collection instrument
The questionnaire used for the study was designed by the researchers after a thorough review of similar studies [8,9,16], as well as utilizing researchers' proficiency.The designed questionnaire consisted of five sections.Section A focused on gathering socio-demographic data such as age, sex, marital status, educational level, ethnic group, occupation, residential area settlement, and the proximity of the pharmacy to their homes.Section B assessed the knowledge level of consumers about antibiotics and antibiotics resistance.In Section C, consumers were asked to provide their general perception regarding the use of antibiotics.Section D assessed the attitudes of consumers towards the use of antibiotics.Section E investigated the factors associated with antibiotic use among consumers.

Inclusion and exclusion criteria
Eligible participants were consumers above 18 years that visited the community pharmacies during the study period.Those below the age of 18 and adults who were unwilling to participate in the research were excluded.

Sample size determination
For the selection of community pharmacies in this study, simple random sampling technique was employed bearing in mind the centrality of the location and popularity Akande-Sholabi and Oyesiji Journal of Pharmaceutical Policy and Practice (2023) 16:120 in terms of patronage.At least one pharmacy was chosen from each of the 11 local governments in Ibadan.The managers of these selected pharmacies were then approached to provide an approximate count of the daily number of consumers they serve.By aggregating and averaging these estimates, an overall average of 1300 customers per month was determined.With a confidence level of 95% and a margin of error of 5%, the Yamane sample size formula [17] was utilized, resulting in a sample size of 314 for the consumer population.To account for a potential non-response of 10% and ensure an adequate sample size, the target sample population for consumers was adjusted to approximately 340.The number of consumers to be interviewed at each community pharmacy was proportionally allocated based on the estimated average number of customers per day.

Sampling and data collection procedure
For the consumers, consecutive method of sampling was used.The study was conducted in selected community pharmacies in Ibadan, with at least one community pharmacy from each local government area.From each of the community pharmacies, the superintendent pharmacists were approached and the scope of the study was explained to them in order to seek their permission to carry out the study in their premises.In total, 24 community pharmacies gave their consent.Subsequently, consumers visiting the pharmacies to purchase medication, refill their prescriptions, or seek health-related advice were approached.The study objectives were explained to them, and their informed consent was obtained from those who agreed to participate.Each consumer was interviewed using a questionnaire, which took not more than 20 min to complete.For respondents who did not understand English, a translated questionnaire was used, and their responses were back-translated.Consumers from each consented pharmacy were consecutively approached until the desired sample size was reached, with an average of 20 consumers interviewed per consented community pharmacy.

Pre-test and content validation
The questionnaires underwent a thorough review by two clinical pharmacists to ensure the comprehensiveness and clarity.Additionally, a pre-test was conducted with consumers from the local community to assess the questionnaires' ease of understanding.Based on the feedback received during the pre-test and the content validation process, slight adjustments were made to improve the questionnaires.The revised version of the questionnaires was then used to assess the knowledge, perception, attitude of consumers towards antibiotics uses and factors associated with antibiotics misuse among the consumers who visited the community pharmacies in Ibadan during the study period.

Statistical analysis
After the questionnaires were collected, they were carefully checked for accuracy and assigned serial codes.Data entry, cleansing, and analysis were performed using the Statistical Package for Social Science (SPSS) version 26.Descriptive statistics, such as frequency counts, percentages, and means, were used to summarize and present the results and inferential statistics such as Pearson's Chi-square was used to explore the association between statistical variables.The internal consistency/reliability of the 9-item knowledge and 7-item perception questions was determined using Cronbach alpha test, with a value of 0.68.For the consumers, their socio-demographic characteristics were summarized using descriptive statistics and presented in a table.Their knowledge about antibiotics and antibiotics resistance was assessed by assigning a score of "one" for each correct answer, while a score of "zero" was assigned for each incorrect answer.The overall scores for knowledge and perception questions were categorized as "good" or "poor" based on the respondents' scores in each domain.The cut-off point for determining a "good" level of knowledge and perception was set at above 70%.Scores below the cut-off point were classified as "poor" knowledge and perception.The binary categorization for scoring the knowledge of the respondents was derived from Bloom's cut-off criteria and other similar propositions [16,18].
The questions used to assess their attitudes towards rational antibiotics use were analysed using descriptive statistics.Also, the factors influencing their use of antibiotics were identified using descriptive statistics where the 4-point Likert was converted to binary outcome of agree versus disagree such that the percentages of those who chose "strongly agree" or "agree" were considered as agree and the percentages of those who chose "strongly disagree" or "disagree" were considered as disagree.Pearson's Chi-square test was used to evaluate the association between some socio-demographic characteristics and their knowledge, and also the association between their knowledge and factors associated with antibiotics use.The level of statistical significance was set at p < 0.05.

Demographic characteristics of respondents
A total of 520 questionnaires were distributed among consumers visiting pharmacies in Ibadan to evaluate the factors contributing to inappropriate antibiotic dispensing.Among these, 509 questionnaires were adequately completed, resulting in 97.9% response rate.Out of the participants (258, 50.7%) were male, while 251 (49.3%) were female.Most of the participants were single (384, 75.4%), aged between 18-30 years (374, 73.5%), and resided in urban areas (400, 78.6%).A significant percentage of the respondents had attained tertiary education (424, 83.3%) (details in Table 1).

Knowledge and perception of the respondents about antibiotics
A larger percentage of the consumers (488, 95.9%) expressed agreement that antibiotics have the ability to prevent or eliminate bacterial growth.Additionally, 309, 60.7% of them claimed that antibiotics can effectively treat all types of infections, including viral and fungal infections.Also, 247 (48.5%) respondents believed that antibiotics can be used to treat uncomplicated malaria.Interestingly, more than half of the respondents (292, 57.4%) admitted to not being aware of antibiotic resistance, while 342 (67.2%) acknowledged that antibiotic resistance refers to a phenomenon where bacteria lose their sensitivity to antibiotics.To assess their understanding of antibiotics and antibiotic resistance, they were presented with nine item questions, and (75, 14.7%) demonstrated adequate knowledge, whereas (434, 85.3%) had inadequate knowledge in this domain (details in Table 2).
Consumers' perception of antibiotics was evaluated using a set of seven item questions, and the results showed that most of the respondents, (379, 74.5%), held a positive perception while only a few, (130, 25.5%), had a negative perception.Based on the appropriateness of purchasing antibiotics without a doctor's prescription, 433 respondents (85.1%) agreed that it is not suitable to do so whereas nearly half of them, (251, 49.3%), believed that antibiotic resistance is incapable of spreading to other individuals and causing death (details in Table 3).

Antibiotic usage by consumers, recommendations sources, and the use of prescription for its purchase
A significant majority of respondents (369, 72.5%) reported to have used antibiotics within the last 12 months.Among those respondents, slightly above half (297, 58.3%) acquired antibiotics through a prescription, while 144 (28.3%) obtained antibiotics without a prescription.The primary sources of antibiotic prescriptions or recommendations were pharmacists (38.6%) and doctors (37.1%).A smaller proportion of respondents (13.1%) engaged in self-medication, while 10.2% relied on recommendations from family and friends.In rare cases, 0.6% obtained antibiotics from a nurse, and 0.4% received them from a patent medicine personnel (details in Table 4).

Duration of antibiotic use and reasons for discontinuation among consumers
Among the respondents, 264 (60.7%) reported using antibiotics for up to 5 days, while 87 (20%) used them for a duration of 7 days, and 46 (10.6%) used antibiotics for only 2 days.When asked about the reasons for discontinuing antibiotic use, completing the prescribed course was mentioned by 34.6%, stopped when they felt better by 35.8%, stopped based on the advice of a healthcare provider by 21.6%, and 19.8% stopped when their symptoms resolved.Other reasons included experiencing side effects (4.3%), perceiving the medication as ineffective (4.1%), and forgetting to take a dose (5.5%) (details in Table 6).

Reported side effects of some antibiotics used by consumers
Some respondents experienced side effects from using antibiotics.Side effects reported included dry throat, rashes, diarrhoea, heartburn, and cough as a result of amoxicillin.Diarrhoea, stomachache, and side pain were reported as side effects of amoxicillin + clavulanic acid.Bitter mouth, dry mouth, and weakness were reported as side effects of ciprofloxacin.Additionally, other side effects were also reported (details in Table 7).

Factors associated with antibiotics use among consumers
When respondents were queried about their reasons for purchasing or using antibiotics, a variety of factors   8).

Association between knowledge and some socio-demographic characteristics of consumers
Table 9 shows the association between knowledge of the consumers and their various socio-demographic characteristics.The table examines the variables of gender, age group, educational level, occupation, and proximity of residence to the pharmacy.The focus is on identifying any statistically significant associations with poor knowledge (score < 70%) and good knowledge (score ≥ 70%).It was observed that there was no statistically significant association between gender, age groups, educational level, and proximity of residence with knowledge level (p-value = 0.246, p-value = 0.302, p-value = 0.295, and p-value = 0.089).
However, when examining the occupation variable, a statistically significant association was observed.The occupation of consumers was found to have a significant impact on their knowledge level (p-value = 0.011).Specifically, professionals, public/civil servants, artisans, business personnel, and students had higher levels of good knowledge, while unemployed individuals had a higher percentage of poor knowledge.

Association between knowledge and factors associated with antibiotics use among consumers
Table 10 examines the association between knowledge levels and various factors influencing the purchase or use of antibiotics among consumers.The results revealed several statistically significant associations with knowledge level.Individuals with poor knowledge were more likely to indicate that laboratory reports took longer before they were ready (p-value = 0.007), believed in the fast symptom relief of powerful antibiotics (p-value = 0.001), used antibiotics based on past prescriptions (p-value = 0.000), considered the proximity of the pharmacy to their house or workplace as a determining factor (p-value = 0.028), used antibiotics when feeling sick (p-value = 0.001), took the initiative to use antibiotics for minor illnesses (p-value = 0.000), and expressed a lack of trust in physicians and nurses leading to self-purchasing of antibiotics (p-value = 0.039).Conversely, individuals with good knowledge were less likely to hold these beliefs or engage in such behaviours.

Discussion
Findings from this study underscore the irrational use of antibiotics by consumers and a significant gap in their knowledge about rational antibiotics use even though a larger percentage of them have tertiary education.These results differ from studies conducted in Tanzania, where individuals with higher education levels demonstrated better understanding of antibiotic use [8,[18][19][20].
More than half of the respondents were of the belief that antibiotics could treat all infections, including viral and fungal infections, and held misconceptions such as the belief that antibiotics can prevent diarrhoea or act as a preventive measure after unprotected sex.These perceptions align with previous research highlighting similar misconceptions which stem from limited knowledge, societal influences, and a desire for quick health solutions [21][22][23][24][25][26].However, it is necessary to address these beliefs due to their potential consequences, such as the misuse and overuse of antibiotics, which are contributory factors to the global challenge of antibiotic resistance.
One of the threats posed by antibiotic resistance is a high mortality rate.Unfortunately, about half of the respondents in this study believed that antibiotic resistance cannot spread to other people and cannot cause death.This wide knowledge gap is a contributory factor to the irrational use of antibiotics.While most of them understood that antibiotic resistance occurs when bacteria are no longer sensitive to antibiotics and acknowledged that misuse can increase resistance, some respondents claimed to have never heard about antibiotic resistance.This lack of awareness aligns with similar findings in a study by Khan et al. in 2022 where consumers had poor knowledge of antibiotic use and limited understanding of antibiotic resistance [27].
The top five antibiotics reportedly used by consumers in this study in the last 12 months were amoxicillin, ampicillin, ciprofloxacin, tetracycline, and metronidazole.The widespread use of amoxicillin can be attributed to its affordability and availability as an over-the-counter medicine in pharmacies which has enabled individuals to self-medicate with it for common infections.Also, the frequent use of tetracycline and metronidazole suggests their utilization for the prevention or treatment of diarrhoea, as about a third of respondents believed antibiotics are most effective for preventing diarrhoea, which is also one of the top seven ailments for which consumers used antibiotics in this study.Similar misuse of amoxicillin has been reported in Indonesia, while Ampiclox (ampicillin-cloxacillin) was found to be the most misused antibiotic among consumers in Lagos and Ilorin, Nigeria [28][29][30].
Malaria emerged as the most common reason for antibiotic use among consumers, despite the fact that it is caused by protozoa (Plasmodium) and not bacteria.Alarmingly, close to half of the consumers believed that antibiotics are used to treat uncomplicated malaria.Well, malaria which is a life-threatening disease with high prevalence in tropical regions is best treated with antimalarial medicines, however, some antibiotics like macrolides and tetracycline have proven to be effective in its treatment [16,31].Nonetheless, the irrational use of antibiotics for uncomplicated malaria is setting them up for resistance to bacteria.This is in contrast with a study done by Gabriel et al. [32] where 60.5% of respondents correctly believed that malaria is not treatable with antibiotics whereas, in the Northern zone of Tanzania, 68.4% of the participants agreed that antibiotics can be used in the treatment of malaria [19].Cold, cough, sore throat and catarrh were among the top five ailments for which consumers used antibiotics.However, these ailments are primarily viral and self-limiting, and do not require antibiotics for treatment [33,34].This misuse of antibiotics aligns with the knowledge gap identified in this study, where 68% of consumers were of the opinion that antibiotics could be used to treat these illnesses.Some studies conducted in different countries, including Britain, South Korea, Mongolia, and Qatar, have identified poor consumer knowledge about the effectiveness of antibiotics for coughs and colds.A higher percentage of respondents in these studies claimed ignorance about the fact that antibiotics are not effective against most coughs and colds.Such widespread misuse  of antibiotics for viral infections contributes to the spread of antibiotic resistance [35][36][37][38][39]. Therefore, it is necessary to educate the public on the differences between viral and bacterial infections so as to combat antibiotic resistance effectively.
A concerning trend was observed in this study, with nearly half of the consumers obtaining antibiotics with prescriptions or recommendations from pharmacists, while over a quarter acquired antibiotics without any prescription.The roles of pharmacists in the healthcare team are distinct from those of the physicians.However, it is unfortunate that many pharmacists now prescribe antibiotics, which are Prescription Only Medicines, to patients.This practice has contributed to the proliferation of antibiotic resistance due to improper disease management.Several studies have reported the involvement of community pharmacists in promoting self-medication with antibiotics by dispensing them without prescription [40][41][42].Moreover, pharmacists have been identified as key players in dispensing incomplete doses of antibiotics to boost sales [43].These practices call for proper patient education on rational antibiotic use and stricter regulations on the prescription and dispensing of antibiotics.
In addition to obtaining antibiotics from pharmacies, some consumers engaged in self-medication or received recommendations from friends and family.This practice could explain why approximately 10.6% of the respondents used antibiotics for only two days, despite antibiotic therapy typically requiring longer durations.This is consistent with the study done in Ilorin, Nigeria, where 23% of respondents took antibiotics for only 2 days [30].
Incomplete antibiotic dosage regimens contribute to the increase in antibiotic resistance and the transmission of resistant bacteria.Incomplete antibiotic dosage regimens can lead to the emergence of antibiotic resistance in the body due to sub-inhibitory concentrations of the antibiotics.Moreover, incomplete treatment can result in recurring infections that become difficult to treat [44,45].Thus, patient education on rational antibiotic use is crucial to address this issue.Regarding antibiotic discontinuation, most respondents reported stopping antibiotic use when they felt better or when their symptoms disappeared.Some individuals discontinued use due to the side effects of the drugs.Some of the reported side effects included dry throat, rashes, diarrhoea, heartburn, and cough which were associated with amoxicillin.Ciprofloxacin was associated with side effects like weakness and a bitter and dry mouth.These common side effects align with those reported in a study carried out in North Central Nigeria [30].Although the severity of these side effects was not investigated in this study, however, they could contribute to consumers prematurely stopping antibiotic regimens.The premature discontinuation of antibiotic therapy can lead to incomplete eradication of bacteria, allowing the surviving bacteria to develop resistance to the antibiotic.It is necessary for consumers to finish the entire course of antibiotics as prescribed by healthcare professionals.
Additionally, this study revealed that consumers engage in misuse of antibiotics, such as self-medication, using incomplete therapy, and using antibiotics for conditions not caused by bacteria.Interestingly, despite a larger percentage of respondents having tertiary education, a significant knowledge gap was observed among consumers visiting pharmacies.This emphasizes the need for increased public enlightenment and awareness  programmes, which can be effectively implemented by pharmacists within the pharmacy setting.
To further understand the factors contributing to antibiotics misuse by consumers, they were asked about their reasons for buying or using antibiotics, and several responses were recorded so as to shed more light on the factors responsible for antibiotic misuse.
A considerable number of respondents displayed a strong inclination to choose antibiotics due to the delay in receiving laboratory reports.This suggests that the waiting period for test results may drive individuals to resort to self-medication with antibiotics [46].Another notable factor is the belief that antibiotics are powerful drugs that provide rapid symptom relief.This belief, held by a significant portion of the respondents, may stem from a lack of understanding about the right use of antibiotics and their specific indications.This misconception can contribute to the misuse of antibiotics even in the absence of bacterial infection [2].Addressing this misconception is crucial in combating antibiotic resistance.
The influence of healthcare providers is evident, as some individuals reported using antibiotics based on past prescriptions from doctors or other healthcare providers.This highlights the importance of responsible prescribing practices and patient education.Healthcare professionals play a crucial role in communicating the rationale behind antibiotic prescriptions, ensuring that patients understand the necessity and appropriate duration of treatment [47].
Additionally, nearly half of the respondents mentioned the convenience of having a nearby pharmacy as a factor that facilitated their access to antibiotics.This finding suggests that the accessibility and proximity of pharmacies influence consumer choices, potentially enabling easy access to antibiotics.It underscores the need for stricter regulations and the enforcement of prescriptiononly policies to prevent the inappropriate sale of antibiotics [48].
A significant proportion indicated that they had a phobia of injections.This fear may lead individuals to prefer antibiotic use over receiving injectable medications, highlighting a personal factor influencing their decision-making process.Also, approximately one-third of respondents expressed a preference for using antibiotics rather than paying hefty consultation fees.This financial consideration reflects a tendency to prioritize cost-effectiveness over seeking professional medical advice, potentially leading to inappropriate antibiotic use [49].
Furthermore, the belief that minor illnesses and its symptoms can be managed by taking the initiative to use antibiotics is another significant factor contributing to their misuse.This is similar to the research conducted in the Northern zone of Tanzania where over half of the participants believed that antibiotics can be used to treat minor illnesses [19].This self-perception of the ability to determine the necessity of antibiotics may stem from a lack of understanding about the risks associated with inappropriate use and the potential development of antibiotic resistance.Thus, enhancing public knowledge on the proper use of antibiotics and the importance of seeking professional advice for proper diagnosis is crucial in addressing this issue [39].
Moreover, a smaller proportion (13.8%) admitted to occasionally mixing antibiotics with other herbal preparations.This practice raises concerns about the potential interaction between antibiotics and herbal remedies, emphasizing the need for proper guidance from healthcare professionals.
A considerable number of respondents claimed that after reporting their complaints to pharmacists, they found it comfortable to use the antibiotics provided.This suggests that the reassurance and recommendations received from pharmacists are crucial in the decisionmaking process regarding antibiotic use [50].However, a small percentage of respondents demonstrated a notable distrust in physicians and nurses, leading them to purchase antibiotics without professional advice.This lack of trust in healthcare providers contributes to self-medication practices and hinders appropriate antibiotic use.Thus, strengthening the patient-provider relationship and promoting trust through effective communication can discourage self-medication and empower patients to make informed decisions [51].
To combat antibiotic misuse, a comprehensive and collaborative approach involving healthcare professionals, policymakers, technology developers, and the public is crucial.Healthcare professionals should focus on patient education and communication to improve understanding of proper antibiotic use [51].Policy interventions, such as stricter enforcement of prescription-only regulations, are necessary to regulate antibiotic availability and discourage self-medication [49].Technological advancements, including digital health tools, can support patient adherence and informed decision-making [52].Targeted public awareness campaigns tailored to specific populations can address misconceptions and promote responsible antibiotic use [47].By implementing these strategies, antibiotic stewardship can be enhanced and the risks associated with antibiotic resistance can be curbed so as to safeguard the efficacy of these life-saving medications for the future.

Limitations of the study
The nature of this research gives room for both response and recall bias.It is possible that respondents may have provided answers that were influenced by their current circumstances or personal biases.Moreover, the study solely relied on data from community pharmacies and did not capture responses from individuals who obtained their antibiotics from other sources, such as hospitals or online platforms.Furthermore, the translated questionnaire was not revalidated.Hence, the findings from this research may not be fully representative of the broader population, and caution on generalization.
Despite these limitations, this study has provided valuable insights into the knowledge, perception, and attitude of consumers towards rational antibiotic use and the factors influencing their misuse of antibiotics.By addressing these factors and paying close attention to the findings, it is possible to enhance patient care and curb the spread of antibiotic resistance in Nigeria.

Conclusion
This study highlights important findings about the knowledge, perception, and attitudes of consumers in relation to the use of antibiotics.Most of the consumers had poor knowledge about antibiotics, which is a contributory factor to their misuse of these medications.In addressing this, it is paramount to increase awareness campaigns about the dangers associated with antibiotics misuse.Also, educating them on proper antibiotic use is equally important so as to ensure that they understand the right indications, dosages, and duration of treatment.By addressing these gaps in knowledge, the spread of antibiotic resistance can be effectively curbed.Policies regulating the dispensing and selling of antibiotics with adequate counselling should be further enforced.

Table 1
Demographic characteristics of the respondents (n = 509)

Table 4
Antibiotic usage by consumers, recommendations sources, and the use of prescription for its purchase

Table 5
Antibiotic utilization among consumers and associated medical conditions for the use in the last 12 months

Table 6
Duration of antibiotic use and reasons for discontinuation among consumers

Table 7
Reported side effects of some antibiotics used by consumers (n = 22)

Table 8
Factors associated with antibiotics use among consumers (n = 509)

Table 9
Association between knowledge and some socio-demographic characteristics of consumers (n = 509) Statistically significant at p < 0.05 X 2 = Chi-square *

Table 10
Association between knowledge and factors associated with antibiotics use among consumers (n = 509) * Statistically significant at p < 0.05 X 2 = Chi-square