Knowledge,attitudes,and practices on antibiotic use and antimicrobial resistance among graduating health care professionals at Debre Tabor University,Ethiopia: a cross-sectional study with implications for antimicrobial stewardship education

Abstract

Background:

Rational use of antimicrobials is a key strategy for preventing antimicrobial resistance (AMR) and relies primarily on the knowledge and practices of future health care professionals.

Objectives:

To assess the knowledge, attitudes, and practices of graduating health care students regarding antibiotic use and AMR at Debre Tabor University.

Design:

An institution-based cross-sectional study was employed.

Methods:

The study was conducted from March to April 2025 among graduating students at the College of Health Sciences. A validated self-administered questionnaire was used to assess knowledge, attitude, and practice (KAP). Scores were categorized using previous studies and modified Bloom’s cut-off criteria (⩾80% = good; <80% = poor). Data were analyzed using descriptive statistics, chi-square tests, pearson correlation, and logistic regression, with p-values < 0.05 considered statistically significant.

Results:

Antibiotic use in the past year was reported by 75.2% of participants, with ciprofloxacin and amoxicillin being the most commonly used agents. Overall, 55.8% showed good knowledge, 41.3% had a positive attitude and 51.4% reported good practices. While awareness of AMR was high, only 32.5% correctly identified antimicrobial stewardship (AMS). A total of 68% of students purchased antibiotics without a prescription, and 69.9% discontinued treatment once symptoms improved. Significant differences in KAP across departments were observed (p < 0.005). Knowledge was positively correlated with attitude (r = 0.31, p = 0.001), and attitude with practice (r = 0.29, p = 0.002), whereas knowledge was not significantly associated with practice. Knowledge and Attitude levels were independent predictors of good attitude and practice, respectively. Additionally, birthplace, department of study, prior antibiotic use, AMR training, and family health background were associated with KAP outcomes, respectively.

Conclusion:

The study showed that 55.8% of respondents had good knowledge, but attitudes (41.3%) and practices (51.4%) were lower, highlighting a clear knowledge–practice gap and the need for strengthened AMS training.

Keywords

Antibiotic resistance Debre Tabor University Ethiopia health science students knowledge attitude and practice

Introduction

Antibiotics are powerful agents used to treat a wide range of bacterial infections and have significantly contributed to increased life expectancy when used appropriately.¹ Their therapeutic effects are mediated by disrupting essential bacterial cell components or inhibiting pathways critical for bacterial replication.² For decades, penicillin and its derivatives have been widely used in the management of bacterial infections. Globally, increased awareness and improved access to modern pharmaceuticals have led to a steady rise in antibiotic consumption, which is projected to double by 2030.³

The World Health Organization (WHO) defines antimicrobial resistance as the reduced effectiveness of a previously effective antimicrobial agent against a specific infectious pathogen.⁴ The rapid emergence of antibiotic-resistant microbes, largely driven by the overuse and misuse of antibiotics, represents an urgent and growing threat to global public health.⁵ This phenomenon is influenced by multiple factors, including self-medication, inappropriate dosing, poor adherence to treatment regimens, lack of diagnostic support, and improper prescribing and dispensing practices.^6,7

Antibiotic resistance affects individuals across all age groups and poses serious challenges to the veterinary, agricultural, and healthcare sectors. It is among the most urgent global public health threats, contributing to millions of deaths worldwide.^8,9 According to WHO estimates, AMR is responsible for approximately 25,000 deaths annually in Europe.¹⁰ Beyond its impact on human health, AMR also imposes a substantial economic burden, with studies predicting global financial losses of up to USD 100 trillion by 2050.¹¹

Antibiotics, as a key class of therapeutic agents, are particularly susceptible to indiscriminate use, which is a primary driver of the emergence of AMR microorganisms.¹² Such misuse has significant consequences, including prolonged hospitalization, increased healthcare costs, and a higher risk of mortality, thereby affecting both public health and the economy.¹³ AMR diminishes the effectiveness of first-line agents, often forcing reliance on alternative therapies that may be less effective and more toxic.¹⁴

Although AMR is a global threat, its incidence and prevalence are disproportionately high in low- and middle-income countries.¹⁵ In Ethiopia, multiple studies have reported that a wide range of bacterial strains have developed resistance to commonly used antibiotics, largely due to frequent and inappropriate use.^16,17 Therefore, urgent interventions are required to address this critical issue, particularly in Africa, where AMR remains closely associated with high morbidity and mortality.¹⁸

In many resource-limited countries, particularly in rural areas, shortages of well-trained healthcare professionals contribute to the imprudent use of antimicrobials.¹⁹ Additionally, insufficient public knowledge, attitudes, and awareness regarding antibiotic use and resistance, coupled with easy access to antibiotics and weak regulatory enforcement, play a central role in the rise of AMR.²⁰ These factors ultimately lead to irrational antibiotic use, thereby increasing the risk of resistance²¹ and contributing to the emergence of potentially drug-resistant infections.²²

A key strategy to curb the emergence and spread of antibiotic resistance is the prevention of irrational antimicrobial use. Educational programs targeting both healthcare professionals and the general public are essential to improve awareness of prudent antibiotic use.²³ In addition, promoting awareness of and participation in antimicrobial stewardship (AMS) programs is vital, as these initiatives support the rational prescribing, dispensing, and optimal use of antimicrobials.²⁴

In Ethiopia, health professional training is delivered through discipline-specific undergraduate programs with varying durations and curricular emphases. At Debre Tabor University, the Doctor of Medicine and Pharmacy programs span 6 and 5 years, respectively, while Nursing, Midwifery, Anesthesia, and Medical Laboratory Science are 4-year programs. Despite shared foundational courses in microbiology, pharmacology, and infectious diseases, the emphasis on AMR and AMS differs across disciplines.

Healthcare students represent a critical group with the potential to significantly influence community awareness regarding the appropriate use of antibiotics.²⁵ Accordingly, their knowledge, attitude, and practice (KAP) related to antibiotic use and resistance play a key role in shaping future trends in antimicrobial resistance. Numerous KAP-based studies on antibiotic use and resistance have been conducted among diverse populations in various countries.²⁶ However, evidence specifically focusing on graduating health science students has not yet been reported in this setting. This study, therefore, aimed to assess their knowledge, attitudes, and practices regarding antibiotic use and resistance, given their future role in ensuring rational antibiotic use. The findings of this study may help identify existing gaps and inform the development of targeted strategies and evidence-based policies to promote rational antibiotic use and mitigate AMR.

Methods and materials

Study area and period

The study was conducted at the College of Health Sciences, Debre Tabor University, located in the South Gondar Zone of the Amhara National Regional State, Ethiopia. The college is approximately 100 km from Bahir Dar, the capital of the Amhara Region, and 667 km from Addis Ababa, the capital of Ethiopia. The College of Health Sciences at Debre Tabor University was established in 2013, 5 years after the founding of the university, and currently comprises eight schools and departments: Medicine; Social and Public Health; Comprehensive Nursing; Pediatric and Child Health Nursing; Midwifery; Anesthesia; Medical Laboratory Sciences; Pharmacy; and Biomedical Sciences. Data collection was conducted between March and April 2025.

Study design and study population

An institution-based cross-sectional study was conducted at the College of Health Sciences, Debre Tabor University. The survey targeted undergraduate health science students graduating in the 2025 academic year. According to data from the university registrar’s office, a total of 225 Bachelor of Science students were expected to graduate during this period, representing six departments: Medicine, Pharmacy, Nursing, Midwifery, Anesthesia, and Medical Laboratory Science.

Inclusion and exclusion criteria

Inclusion criteria

All registered graduating health science students who were present during the study period and provided informed consent were included in the study.

Exclusion criteria

Students who were absent on the day of data collection, seriously ill, involved in the pilot study, unwilling to participate, or unable to understand or complete the questionnaire independently were excluded.

Sample size determination and sampling technique

The sample size was calculated using the single-population proportion formula, assuming a 95% confidence level, 5% margin of error, 50% prevalence, and a 5% non-response rate, yielding a minimum required sample size of 403 participants. Since only 225 students were available during the study period, a census approach was employed, and all eligible students were invited to participate.

Data collection procedure

At the beginning of the study, a compulsory course was identified in each department, and students were consecutively invited to complete the questionnaire immediately after the session. Prior to data collection, the purpose and objectives of the study were thoroughly explained to all potential participants, and those who agreed provided written informed consent. The questionnaire was then distributed and completed within 5–10 min. Participation was voluntary, and students could withdraw at any time. Confidentiality was strictly maintained, with no personal identifiers recorded. The data collectors closely monitored the process to prevent the use of reference materials, discussion among participants, or multiple submissions. To minimize potential bias, two data collectors who were unfamiliar with the students conducted the survey. Questionnaires with incomplete responses were considered invalid and recorded as non-responses.

Data collection instrument

Data were collected using a validated, self-administered questionnaire developed by the investigators following an extensive review of related studies, with minor modifications.^{14,18,20,24,26–30} The instrument included both positively and negatively worded items to minimize response bias, with negatively worded items reverse-coded during analysis. The English-language questionnaire consisted of 45 items organized into five sections. The first section contained eight items on participants’ demographic characteristics. The second section comprised five items addressing medical history, antibiotic use, the names and sources of antibiotics in the past year. The third section included 12 items assessing knowledge of antibiotics (identification, therapeutic roles, side effects, and AMR), with correct responses scored as 1 and incorrect or “I don’t know” responses scored as 0 (total score: 0–12). The fourth section assessed attitudes toward antibiotic use and resistance using 10 items rated on a 5-point Likert scale ranging from “Strongly Disagree” (1) to “Strongly Agree” (5), with negatively worded items reverse-scored (total score: 10–50). The final section evaluated practices using 10 items scored as 0 (“Never”), 1 (“Sometimes”), and 2 (“Always”), with inappropriate practices reverse-scored, yielding a total score ranging from 0 to 20 (Supplemental File 1).

To standardize interpretation, all scores were converted to percentages. Scores ⩾80% were classified as good and <80% as poor, based on modified Bloom’s cut-off criteria and previous studies.^14,25,31 Accordingly, participants scoring ⩾10, ⩾40, and ⩾16 in the knowledge, attitude, and practice domains, respectively, were classified as good, while those with lower scores were classified as poor.

Data quality assurance

The data collection tool was reviewed by subject matter experts to assess content validity, relevance, and accuracy. A pilot test was conducted on 5% of students from each department to evaluate the clarity and comprehension of both positively and negatively worded questions. Feedback from experts and the pilot test was used to refine the final structured questionnaire. Students who participated in the pilot test were excluded from the main survey, and their responses were not included in the final analysis. Internal consistency and reliability were assessed using Cronbach’s alpha, yielding coefficients of 0.78 for knowledge, 0.85 for attitude, and 0.75 for practice, indicating acceptable reliability. Reverse-coded items were accounted for to ensure scoring accuracy and consistency across positive and negative questions.

Data processing and analysis

Data were checked for completeness and accuracy. Incomplete questionnaires were excluded and considered non-responses. Data were entered and coded using Epi-Info and exported to IBM SPSS version 27 for analysis. Descriptive statistics, including frequencies and percentages for categorical variables and means with standard deviations for continuous variables, were used to summarize the data and are presented in tables, figures, and narrative form. The chi-square test was used to assess differences in knowledge, attitude, and practice levels across departments. Pearson correlation analysis was performed to examine the relationships among knowledge, attitude, and practice scores. Binary logistic regression analysis was conducted to identify factors associated with knowledge, attitude, and practice levels. Variables with a p-value < 0.25 in the bivariate analysis were entered into the multivariable logistic regression model. Model fit was assessed using the Hosmer–Lemeshow goodness-of-fit test. Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were reported, and a p-value < 0.05 was considered statistically significant.

For attitude assessment, five-point Likert-scale responses were integrated into three categories: disagree (strongly disagree/disagree), uncertain, and agree (agree/strongly agree).

Study variables

The outcome variables were the levels of knowledge, attitudes, and practices regarding antibiotic use and resistance among graduating health care students. The independent variables included sociodemographic characteristics (gender, age, place of birth, religion, and monthly income), academic factors (department, duration of study), prior AMR training, previous antibiotic exposure, and having relatives served in health care.

Reporting guidelines

The reporting of this study conforms to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement,³² and the completed STROBE checklist is provided (Supplemental File 2).

Results

Study participants

Among the 225 graduating health professionals assessed for eligibility, 15 were excluded due to ineligibility, refusal to participate, or other reasons. A total of 210 participants were enrolled, of whom 206 completed the questionnaire and were included in the final analysis. The overall response rate was 95.8%.

Sociodemographic characteristics of study participants

Among the 206 participants, the majority (60.2%) were male and aged 20–24 years (73.4%), while those older than 30 years were underrepresented (2.9%). Most participants (66.5%) identified as Orthodox Christians and were born in rural areas (61.2%). Across departments, medicine had the highest representation (20.9%), whereas anesthesia had the lowest (13.1%). Nearly half of the respondents (48.5%) reported having relatives working in health-related fields. Most participants had studied at the university for 4 years (62.6%), and the majority (84.0%) reported a monthly income below 3000 ETB (Table 1).

Table 1.

Sociodemographic characteristics of graduating health science students at Debre Tabor University, March–April 2025 (n = 206).

Variables	Category	Frequency (%)
Gender	Male	124 (60.2)
	Female	82 (39.8)
Age (year)	20–24	151 (73.4)
	25–30	49 (23.7)
	>30	6 (2.9)
Religion	Orthodox	137 (66.5)
	Muslim	42 (20.4)
	Protestant	18 (8.7)
	Others	9 (4.4)
Place of birth	Urban	80 (38.8)
	Rural	126 (61.2)
Department	Medicine	43 (20.9)
	Pharmacy	34 (16.5)
	Nursing	40 (19.4)
	Midwifery	30 (14.6)
	Anesthesia	27 (13.1)
	Medical Laboratory	32 (15.5)
Relatives working in a health-related field	Yes	100 (48.5)
	No	106 (51.5)
Duration of stay in university (year)	4	129 (62.6)
	5	34 (16.5)
	6	43 (20.9)
Monthly income (ETB)	<1500	111 (53.9)
	1500–3000	62 (30.1)
	>3000	33 (16.0)

The estimated national average monthly income in Ethiopia is approximately 6500–10,000 ETB.

ETB, Ethiopian Birr.

Participants’ self-reported antibiotic use and utilization patterns

Among the 206 respondents, 75.2% (n = 155) reported antibiotic use within the past year. The frequency of use varied, with nearly half (46.1%, n = 95) using antibiotics 1–2 times, followed by 23.8% (n = 49) reporting 3–5 uses and 5.3% (n = 11) reporting more than five times. The most common clinical indication was gastroenteritis (30.1%), followed by cough (22.8%), while fever/headache was the least frequently reported illness (9.7%; Figure 1).

Figure 1.

Distribution of self-reported illnesses leading to antibiotic use among graduating health science students (n = 206).

Ciprofloxacin (35.4%) and amoxicillin (32.5%) were the most commonly utilized antibiotics, whereas doxycycline (4.5%) was the least used (Figure 2). Most participants obtained antibiotics from hospital pharmacies (54.9%), while smaller proportions reported using leftover antibiotics (11.7%) or obtaining them from other sources (2.9%; Figure 3).

Figure 2.

Distribution of antibiotic use among graduating health science students of Debre Tabor University (n = 206).

Figure 3.

Sources of antibiotics among graduating health science students at Debre Tabor University, March–April 2025 (n = 206).

Knowledge of respondents on antibiotic use and resistance

The knowledge of respondents is summarized in Table 2. Nearly all respondents recognized that paracetamol is not an antibiotic (91.3%) and that irrational antibiotic use contributes to resistance (96.6%). The majority also understood that antibiotics are effective against bacterial infections (88.3%) but not viral infections (77.2%). Only two-thirds (67.5%) understood that antibiotic resistance affects the wider community, not just individual users. Understanding of antimicrobial stewardship was limited, with only one-third (32.5%) correctly identifying it as the proper use of antibiotics.

Table 2.

Knowledge regarding antibiotic use and resistance among graduating health science students at Debre Tabor University, March–April 2025 (n = 206).

Knowledge variable/statement	Yes n (%)	No n (%)	Don’t know n (%)
Penicillin or amoxicillin is an antibiotic (1)	175 (85.0)	13 (6.3)	18 (8.7)
Paracetamol is an antibiotic (2)	14 (6.8)	188 (91.3)	4 (1.9)
Antibiotics are useful for treating bacterial infections (3)	182 (88.3)	15 (7.3)	9 (4.4)
Antibiotics are useful for treating viral infections (4)	40 (19.4)	159 (77.2)	7 (3.4)
Antibiotics are indicated to relieve pain/inflammation (5)	64 (31.1)	135 (65.5)	7 (3.4)
Antibiotics may cause super infection or secondary infections (6)	135 (65.5)	31 (15.0)	40 (19.5)
Antibiotics may cause allergic reactions (7)	186 (90.3)	7 (3.4)	13 (6.3)
Antibiotic resistance is the loss of activity of an antibiotic (8)	160 (77.7)	33 (16.0)	13 (6.3)
Inappropriate/irrational use of antibiotics results in ABR (9)	199 (96.6)	5 (2.4)	2 (1.0)
Self-medication could contribute to antibiotic resistance (10)	170 (82.5)	20 (9.7)	16 (7.8)
ABR is only a problem for people who take antibiotics (11)	36 (17.5)	139 (67.5)	31 (15.0)
Antimicrobial stewardship means using antibiotics properly (12)	67 (32.5)	130 (63.1)	9 (4.4)

Data are presented as number (percentage). For positively worded items (1, 3, 6–10, 12), a correct response was “Yes”; for negatively worded items (2, 4, 5, 11), a correct response was “No.”

ABR, antibiotic resistance; n, number of respondents.

Attitude of respondents toward antibiotic use and resistance

The attitudes of participants toward antibiotic use and resistance are depicted in Table 3. A large proportion agreed that completing the full course of antibiotics is essential (77.2%) and rejected the practice of keeping leftover antibiotics for future illnesses (80.6%). Understanding of the impact of narrow-spectrum antibiotics was limited, with only about half (49.5%) disagreeing that their use increases resistance. A majority of participants (81.5%) also recognized that adherence to hospital antibiotic policies reduces antibiotic resistance, and most (92.2%) supported including antibiotic use and resistance in the curriculum.

Table 3.

Attitude towards antibiotic use and resistance among graduating health science students of Debre Tabor University, March–April 2025 (n = 206).

Attitude variable/statement	Disagree n (%)	Uncertain n (%)	Agree n (%)
Full course of antibiotic therapy is essential, even when feel patients better (1)	40 (19.4)	7 (3.4)	159 (77.2)
Keeping leftover antibiotics for other illnesses is acceptable (2)	166 (80.6)	11 (5.3)	29 (14.1)
Antibiotic resistance is a serious global problem (3)	8 (7.1)	22 (19.5)	83 (73.4)
Skipping antibiotic doses doesn’t contribute to antibiotic resistance (4)	127 (61.7)	46 (22.3)	33 (16.0)
Using narrow-spectrum antibiotics increases the risk of antibiotic resistance (5)	102 (49.5)	29 (14.1)	75 (36.4)
Local irrational antibiotic use does not affect global resistance (6)	146 (70.9)	24 (11.6)	36 (17.5)
Antibiotic use in livestock should be strictly monitored to reduce ABR risk (7)	40 (19.4)	49 (23.8)	117 (56.8)
Following the hospital antibiotic policy reduces ABR development (8)	117 (56.8)	16 (7.8)	168 (81.5)
Antibiotic resistance is a major global health threat (9)	13 (6.3)	33 (16.1)	160 (77.6)
Antibiotic use and resistance should be included in the curriculum (10)	190 (92.2)	5 (2.5)	11 (5.3)

Data are presented as number (percentage). For positively worded attitude statements (items 3, 7–10), “Agree” was considered the correct response. For negatively worded attitude statements (items 1, 2, 4–6), “Disagree” was considered the correct response.

ABR, antibiotic resistance; n, number of respondents.

Practice of respondents toward antibiotic use and resistance

The antibiotic-use practices of respondents are illustrated in Table 4. Most participants (63.6%) sometimes used antibiotics for the common cold or sore throat. A majority (84.9%) never doubled doses after missing an antibiotic, while about half (53.9%) sometimes discontinued antibiotics once they felt better. More than half (58.3%) sometimes purchased antibiotics without a prescription, and nearly three-quarters (72.3%) reported never attending training or seminars on antibiotic resistance.

Table 4.

Practice on antibiotic use and antimicrobial resistance among graduating health science students at Debre Tabor University, March–April 2025 (n = 206).

Practice variable/statement	Never n (%)	Sometimes n (%)	Always n (%)
I take antibiotics for common cold or sore throat (1)	60 (29.1)	131 (63.6)	15 (7.3)
If I miss an antibiotic dose, I double the next dose (2)	175 (84.9)	29 (14.1)	2 (1.0)
I discontinue antibiotics when I feel better (3)	66 (32.0)	111 (53.9)	29 (14.1)
I purchase antibiotics without a prescription (4)	62 (30.1)	120 (58.3)	24 (11.6)
I keep leftover antibiotics at home for future use (5)	77 (37.4)	109 (52.9)	20 (9.7)
I buy previously prescribed antibiotics for similar infections (6)	71 (34.5)	118 (57.3)	17 (8.2)
I inform others about the risks of non-prescribed antibiotics (7)	37 (17.9)	131 (63.7)	38 (18.4)
I share residual antibiotics with others when they get sick (8)	57 (27.6)	127 (61.7)	22 (10.7)
I discourage others from self-medicating with antibiotics (9)	51 (24.8)	120 (58.3%)	35 (16.9)
I attend training or seminars on antibiotic resistance (10)	149 (72.3)	55 (26.8)	2 (0.9)

Data are expressed as frequency (percentage). Items 1–6 and 8 are negatively worded, where “Never” indicates the correct practice. Items 7, 9, and 10 are positively worded, where “Always” indicates the correct practice.

n, number of participants.

Overall respondents’ knowledge, attitude, and practice status

The mean knowledge score was 9.37 ± 1.63 (range 5–12), with slightly more than half of respondents (55.8%) having good knowledge. The mean attitude score was 38.35 ± 4.37 (range 30–49), but fewer than half of respondents (41.3%) demonstrated a good attitude. The mean practice score was 15.35 ± 2.50 (range 10–19), with just over half of respondents (51.4%) reporting good practices (Table 5).

Table 5.

Summary of knowledge, attitude, and practice scores and levels of respondents (n = 206).

Domain	Measure	Category	N (%)	Mean ± SD
Knowledge	Score	—	—	9.37 ± 1.63
	Level	Good	115 (55.8)	—
		Poor	91 (44.2)	—
Attitude	Score	—	—	38.35 ± 4.37
	Level	Good	85 (41.3)	—
		Poor	121 (58.7)	—
Practice	Score	—	—	15.35 ± 2.50
	Level	Good	106 (51.4)	—
		Poor	100 (48.6)	—

Scores are presented as mean ± standard deviation (SD). Levels were categorized based on predefined cutoff values, with scores ⩾80% classified as good and scores <80% classified as poor.

Distribution of knowledge, attitude, and practice across departments

Among participants, knowledge scores were highest in pharmacy (79.4%) and medicine (79.1%), and lowest in medical laboratory science (34.4%). Attitude scores were most favorable in pharmacy (73.5%) and least favorable in anesthesia (25.9%). For practice, pharmacy (73.5%) achieved the best performance, whereas midwifery (30.0%) had the poorest performance. Significant differences were observed across departments for knowledge, attitude, and practice (Table 6).

Table 6.

KAP profile of respondents by academic department.

Variable	Knowledge level		Attitude level		Practice level
Department	Good = n (%)	Poor = n (%)	Good = n (%)	Poor = n (%)	Good = n (%)	Poor = n (%)
Medicine	34 (79.1)	9 (20.9)	12 (27.9)	31 (72.1)	17 (39.5)	26 (60.5)
Pharmacy	27 (79.4)	7 (20.6)	25 (73.5)	9 (26.5)	25 (73.5)	9 (26.5)
Nursing	21 (52.5)	19 (47.5)	16 (40.0)	24 (60.0)	29 (72.4)	11 (27.6)
midwifery	11 (36.7)	19 (63.3)	11 (36.7)	19 (63.3)	9 (30.0)	21 (70.0)
Anesthesia	11 (40.7)	16 (59.3)	7 (25.9)	20 (74.1)	9 (33.3)	18 (66.7)
MLS	11 (34.4)	21 (65.6)	14 (43.8)	18 (56.2)	17 (53.1)	15 (46.9)
χ² (df)	18.7 (5)		15.6 (5)		18.2 (5)
p value	0.002*		0.008*		0.003*

Data are presented as frequency (n) and percentage (%). Differences in KAP levels across departments were assessed using Pearson’s chi-square test. χ² values, degrees of freedom (df), and p-values are indicated.

Denotes statistically significant differences (p < 0.05).

KAP, knowledge, attitude, and practice.

Correlation between knowledge, attitude, and practice of respondents

Pearson correlation analysis showed significant positive correlations between knowledge and attitude (r = 0.31) and between attitude and practice (r = 0.29). In contrast, the relationship between knowledge and practice was weak and not significant (r = 0.12; Table 7).

Table 7.

Pearson correlation matrix of knowledge, attitude, and practice scores among study participants (n = 206).

Variables	Knowledge score	Attitude score	Practice score
Knowledge score	1.00	r = 0.31**, p = 0.001	r = 0.12, p = 0.205
Attitude score	r = 0.31**, p = 0.001	1.00	r = 0.29**, p = 0.002
Practice score	r = 0.12, p = 0.205	r = 0.29**, p = 0.002	1.00

r, Pearson’s correlation coefficient.

Correlation is significant at the 0.01 level.

Factors associated with knowledge, attitude, and practice towards antibiotic use and resistance

Multivariate analysis identified several independent predictors of knowledge, attitude, and practice regarding antibiotic use and resistance, with all models demonstrating acceptable fit (p > 0.05; Table 8). Medical and pharmacy students (p < 0.05), along with those reporting prior antibiotic use (p = 0.042) and previous AMR training (p = 0.027), were significantly more likely to demonstrate good knowledge. Furthermore, being a pharmacy student (p = 0.040), having a family member in a health-related field (p = 0.036), and possessing good knowledge (p = 0.007) were positively associated with a positive attitude. Interestingly, while a family health background (p = 0.036) and a positive attitude (p = 0.004) were associated with better practices, a rural place of birth was a negative predictor of good practice (p = 0.029).

Table 8.

Multivariable logistic regression analysis of factors associated with knowledge, attitude, and practice levels of respondents, March–April 2025 (n = 206).

Variable	Knowledge level			Attitude level		Practice level
Variable	Category	AOR (95% CI)	p value	AOR (95% CI)	p value	AOR (95% CI)	p value
Birthplace	Urban	1.15 (0.71, 2.86)	0.562	1.18 (0.75, 1.86)	0.641	Reference	—
	Rural	Reference	—	Reference	—	0.51 (0.28, 0.96)	0.029*
Department	Medicine	7.42 (1.52, 36.17)	0.013*	Reference	—	Reference	—
	Pharmacy	7.19 (1.47, 33.58)	0.012*	8.10 (1.07, 31.42)	0.04*	1.29 (0.68, 2.04)	0.527
	Nursing	1.73 (0.54, 5.59)	0.357	2.31 (0.23, 23.17)	0.48	0.94 (0.54, 1.87)	0.763
	Midwifery	1.02 (0.64, 3.68)	0.870	1.40 (0.14, 14.35)	0.76	1.27 (0.71 – 2.39)	0.045
	Anesthesia	1.36 (0.27, 6.92)	0.714	1.20 (0.12, 14.97)	0.89	0.86 (0.43, 1.56)	0.608
	Medical lab	Reference	—	1.62 (0.23, 11.96)	0.64	1.05 (0.61, 1.96)	0.836
Family in health field	Yes	1.19 (0.74, 1.92)	0.480	Reference	—	2.92 (1.07, 8.34)	0.036*
	No	Reference	—	0.28 (0.10, 0.83)	0.02*	Reference	—
Hx of antibiotics	Yes	2.84 (1.05, 8.71)	0.042*	1.15 (0.74, 1.96)	0.545	0.89 (0.59, 1.62)	0.612
	No	Reference	—	Reference	—	Reference	—
AMR training	Yes	3.75 (1.16, 13.1)	0.027*	1.09 (0.68, 1.79)	0.392	1.10 (0.68, 1.79)	0.701
	No	Reference	—	Reference	—	Reference	—
Knowledge level	Poor	—	—	Reference	—	Reference	—
	Good	—	—	4.01 (1.46, 10.99)	0.007*	1.63 (0.77, 3.46)	0.203
Attitude level	Poor	—	—	—	—	Reference	—
	Good	—	—	—	—	3.26 (1.45, 7.31)	0.004*

Each column represents a separate multivariable logistic regression model. Variables with p < 0.25 in the bivariate analysis were entered into the multivariable logistic regression model.

Indicates statistical significance at p < 0.05.

AMR, antimicrobial resistance; AOR, adjusted odds ratio; CI, confidence interval; Hx, History; Lab, Laboratory.

Discussion

Rational use of antimicrobials is a key strategy for preventing AMR and relies primarily on the health professionals’ knowledge and behavior.³³ Therefore, this study aimed to assess the knowledge, attitudes, and practices of graduating health science students at Debre Tabor University.

In this study, most students were aged 20–24 years, with a few participants older than 30 years, reflecting the typical age distribution of university populations. A similar age pattern was reported in a study from the University of Zambia.³⁴ Male students constituted a higher proportion, in line with Ethiopian higher educational statistics showing higher male enrollment.³⁵

The overall prevalence of antibiotic use among students in this study was 75.2%, exceeding the 25.7% and 65.9% reported in Malaysia³⁰ and Ethiopia,³⁶ respectively. These disparities may be linked to differences in study populations, access to antibiotics, levels of health awareness, public health interventions, and variations in antibiotic use recall periods. Despite strong participant engagement (95.8%), the findings revealed a notable knowledge–practice gap and generally poor attitudes toward appropriate antibiotic management among future healthcare providers.

In the present study, 55.8% of participants demonstrated good knowledge regarding antibiotic use and AMR. This proportion is lower than the 87.5% reported in Italy,³⁷ 91.1% in Colombia,⁴ and 74.5% in Ethiopia,³⁸ but higher than the 42.4% in Bangladesh,²⁸ 41.8% in Zambia,²⁴ and 45% in Ethiopia.³⁹ It is comparable to findings from Nigeria¹⁴ and Ethiopia,⁴⁰ where 58.4% and 52.5% of students, respectively, demonstrated good knowledge, suggesting a consistent pattern of moderate knowledge among graduating health students in the region. These variations may reflect differences in curriculum emphasis, study populations, assessment tools, and access to updated learning resources. Interpreted in light of participants’ academic training, this pattern may be explained by the structure of the health science curriculum, which includes core modules in medical microbiology and pharmacology but primarily emphasizes mechanisms of action and antimicrobial spectra, with limited focus on the public health implications of resistance.

Although a large majority of students correctly identified that paracetamol is not an antibiotic (91.3%) and that antibiotics are effective against bacteria (88.3%), important gaps remain. Only about two-thirds recognized that AMR affects the broader community, and knowledge of AMS was notably low (32.5%). These findings speculate that, while foundational knowledge is adequate, key concepts related to stewardship and the societal impacts of AMR are insufficiently emphasized. This gap may be attributed to a teaching approach that prioritizes theoretical clinical management over integrated stewardship training. Similar shortcomings have been reported in Ghana (35.2%),⁴¹ Sudan (30.7%),⁴² and other Ethiopian institutions (64.8%),⁴³ indicating that stewardship education remains limited across many African training settings and warrants urgent pedagogical reform.

The current study found that 73.4% and 77.6% of participants recognized antibiotic resistance as a serious global and public health threat, respectively. These findings are consistent with studies conducted at the University of Rwanda (69.3%)¹⁸ and in Yemen (76.9%).⁴⁴ However, misconceptions regarding antibiotic spectrum persisted, as 36.4% of students incorrectly believed that narrow-spectrum agents contribute more to resistance, a pattern also reported in China (31.2%),²⁷ Uganda (40.4%),⁴⁵ and Ghana (32.9%).⁴⁶ The strong support for including antibiotic use and resistance in the curriculum (92.2%) underscores the perceived need to strengthen formal education to address these gaps.

The overall attitude of respondents was poor, with only 41.3% demonstrating a positive outlook toward antimicrobial use and resistance. This proportion is considerably lower than reports from Nepal (67.5%), India (89.4%), and Nigeria (62%),^14,47,48 but higher than findings from Malaysia³⁰ and Zambia,²⁴ where only 22.6% and 20.8% of respondents, respectively, possessed a positive attitude. This heterogeneity may arise from differences in training approaches, study populations, methodologies, healthcare contexts, and the thresholds applied to define positive attitudes. The low level of attitude observed in this study may stem from limited practical exposure, inadequate emphasis on responsible antibiotic use, and minimal engagement with stewardship initiatives.

Concerning antibiotic use, practices were poor, with only 51.4% of participants demonstrating good practice. Over half reported purchasing antibiotics without a prescription, stopping treatment once symptoms improved, using leftover antibiotics, or storing them at home. These findings align with studies from the United Arab Emirates (52.3%),⁴⁹ Malawi (56.7%),⁵⁰ and a systematic review done in Africa (58.1%).⁵¹ However, the level of good practice observed here was lower than that reported in Germany (66.8%)⁵² and Georgia (62.1%),⁵³ where stricter regulations and stronger antimicrobial stewardship limit non-prescription antibiotic access. In Ethiopia and many low-resource settings, weak enforcement of prescription regulations and easy access to antibiotics through community pharmacies likely drive inappropriate practices.

A large proportion of students reported using antibiotics for cough (22.8%) and sore throat (20.4%), indicating persistent misconceptions, as these conditions are typically viral and self-limiting. This knowledge–practice gap was particularly evident among medical students, who demonstrated relatively good knowledge (79.1%) but the lowest level of good practice (39.5%), consistent with findings from South Africa (43.6%).⁵⁴ One possible explanation is that participants may not reliably distinguish viral from bacterial infections, leading to inappropriate antibiotic use despite adequate knowledge. Additional factors such as professional self-reliance, easy access to antibiotics, prior clinical exposure, and habitual behaviors may also contribute to this discrepancy. Furthermore, approximately three-quarters of participants had not attended any AMR training or seminars, similar to reports from India (72.9%),²⁶ China (70.4%),²⁷ Thailand (68.1%),²⁰ and East Africa (79.2%).²⁵ This lack of continuing education may hinder the translation of knowledge into practice, highlighting the need for behavioral and stewardship-focused AMS interventions.

The study showed significant positive correlations between knowledge and attitude, and between attitude and practice, consistent with findings from the University of Gondar, Ethiopia.³⁹ These results suggest that improving students’ knowledge of AMR may enhance their attitudes, which in turn promotes appropriate practice. Multivariate analysis further confirmed that a good attitude significantly increased the likelihood of good practice. However, the direct relationship between knowledge and practice was weak and insignificant (r = 0.12, p = 0.205), indicating that knowledge alone may not ensure appropriate antibiotic use. This disconnect may be influenced by factors such as the widespread availability of antibiotics without prescription, self-medication practices, academic pressure to recover quickly, and gaps in the practical application of theoretical knowledge. These findings emphasize the need for behavioral and stewardship-focused AMS interventions that go beyond knowledge-based education to improve practice.

In this study, medical and pharmacy students had significantly higher odds of good knowledge, likely reflecting greater curricular exposure to antimicrobial use and stewardship, aligned with reports from Bangladesh,²⁸ Indonesia,⁵⁵ and Ethiopia.³⁹ Prior antibiotic use and previous AMR training were also associated with better knowledge, indicating the contribution of personal experience and formal education, as similarly reported across 27 European universities.⁵⁶ Having a family member in a health-related field was positively associated with attitude, possibly due to informal access to reliable health information, consistent with findings from Wollega University, Ethiopia.³⁶ Pharmacy students demonstrated a more positive attitude, which may be attributed to stronger curricular emphasis on AMR and stewardship, as documented in Pakistan,⁵⁷ South Africa,⁵⁴ and Ethiopia.⁵⁸ Moreover, good knowledge was significantly associated with a positive attitude, suggesting that improved understanding enhances risk perception and promotes responsible attitudes. This finding is in line with studies conducted in Ethiopia.^39,59 Regarding practice, students from rural areas were less likely to exhibit good practice than their urban counterparts, evidence in concordance with previous studies in Ethiopia^36,58 and possibly reflecting disparities in access to health information and healthcare services. Having a family member in a health-related field was also associated with better practice, likely due to greater incidental exposure to health-related information, as reported in China²⁷ and Ethiopia.³⁶ Furthermore, a positive attitude was a significant predictor of good practice, supported by evidence from similar studies in Ethiopia³⁸ and Jordan.⁶⁰ This highlights the role of attitudinal factors in translating knowledge into appropriate behaviors.

Implications for practice and policy

The findings highlight the need to strengthen AMS in undergraduate health education to bridge the knowledge–practice gap. Improving antibiotic use among graduating healthcare professionals requires multifaceted interventions, including the integration of practical, competency-based AMS training into undergraduate curricula. Assessing faculty may also help identify gaps in training and mentorship that influence students’ practices. Furthermore, incorporating AMR and AMS competencies into licensing and professional certification processes could reinforce rational use and promote sustained adherence to stewardship principles. At the policy level, stricter prescription enforcement, improved supervision of community pharmacies, and expanded AMR-focused continuing education are essential to promote rational use and curb AMR in Ethiopia and similar low-resource settings.

Limitations and future directions for research

This study has some limitations. Its single-center, cross-sectional design limits generalizability and prevents causal inference. The reliance on self-administered questionnaires may have introduced recall and social desirability biases. The use of a specific cutoff for “good” scores may hinder comparisons with studies using different metrics, and omitted variables might have restricted the identification of additional factors associated with AMR. Furthermore, terms such as “irrational use” may have introduced leading-language bias, so future work should adopt neutral, descriptive phrasing. The relatively small sample size compared to the initially calculated requirement may have reduced the statistical power of the study and contributed to wider confidence intervals in some estimates. Future research should include questions specifically assessing participants’ ability to distinguish bacterial from viral infections to better evaluate diagnostic knowledge. Additionally, studies should employ multi-center, longitudinal, or interventional designs with larger samples and consider weighted scoring systems to emphasize clinically significant items and better assess participants’ knowledge and behavior regarding antimicrobial use.

Conclusion

This study revealed that 55.8% of graduating health care students at Debre Tabor University exhibited good knowledge towards antibiotic use and AMR, while only 41.3% and 51.4% demonstrated a positive attitude and appropriate practices, respectively. The observed knowledge–practice gap and the strong influence of attitude on practice indicate that knowledge alone is insufficient to ensure appropriate use. Strengthening undergraduate AMS education through practical and behavioral training is essential to promote responsible use and prepare future healthcare professionals to combat AMR. Future research should include multi-center studies with larger and more diverse populations, as well as longitudinal or interventional designs, to better understand behavioral and contextual determinants and to evaluate the effectiveness of stewardship interventions.

Supplemental Material

sj-docx-1-tai-10.1177_20499361261448476 – Supplemental material for Knowledge, attitudes, and practices on antibiotic use and antimicrobial resistance among graduating health care professionals at Debre Tabor University, Ethiopia: a cross-sectional study with implications for antimicrobial stewardship education

Supplemental material, sj-docx-1-tai-10.1177_20499361261448476 for Knowledge, attitudes, and practices on antibiotic use and antimicrobial resistance among graduating health care professionals at Debre Tabor University, Ethiopia: a cross-sectional study with implications for antimicrobial stewardship education by Yared Andargie Ferede, Tilaye Arega Moges, Muluken Adela Alemu, Samuel Berihun Dagnew, Achenef Bogale Kassie, Tigabu Eskeziya Zerihun, Addisu Melake Bayafers and Woretaw Sisay Zewdu in Therapeutic Advances in Infectious Disease

Supplemental Material

sj-docx-2-tai-10.1177_20499361261448476 – Supplemental material for Knowledge, attitudes, and practices on antibiotic use and antimicrobial resistance among graduating health care professionals at Debre Tabor University, Ethiopia: a cross-sectional study with implications for antimicrobial stewardship education

Supplemental material, sj-docx-2-tai-10.1177_20499361261448476 for Knowledge, attitudes, and practices on antibiotic use and antimicrobial resistance among graduating health care professionals at Debre Tabor University, Ethiopia: a cross-sectional study with implications for antimicrobial stewardship education by Yared Andargie Ferede, Tilaye Arega Moges, Muluken Adela Alemu, Samuel Berihun Dagnew, Achenef Bogale Kassie, Tigabu Eskeziya Zerihun, Addisu Melake Bayafers and Woretaw Sisay Zewdu in Therapeutic Advances in Infectious Disease

Footnotes

Acknowledgements

The authors sincerely thank Debre Tabor University for providing the necessary resources to conduct this study. We are also grateful to the department coordinators and heads for granting permission to engage their students in the research. Finally, we extend our heartfelt appreciation to all the students who participated and cooperated during the study. The authors also acknowledge the use of Open AI’s Chat GPT for language refinement and editorial assistance; all AI-generated content was thoroughly reviewed and verified by the authors for accuracy and clarity.

Declarations

ORCID iDs

Yared Andargie Ferede

Tilaye Arega Moges

Samuel Berihun Dagnew

Woretaw Sisay Zewdu

Supplemental material

Supplemental material for this article is available online.

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