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Abstract

Objectives

Antibiotic resistance threatens global health, underscoring healthcare students’ critical role in mitigation efforts. This study evaluated their knowledge, attitudes, and practices toward antibiotic resistance and use.

Methods

A validated, self-administered, paper-based questionnaire was developed following an extensive literature review and administered to final-year medical, dental, Pharm D, and pharmacy students at the University of Jordan from October 2022 to March 2023.

Results

Descriptive, nonparametric, and logistic regression analyses were conducted on 263 eligible questionnaires. Students demonstrated adequate knowledge (4.30/5) and positive attitudes (4.19/5), but poor practices (4.78/6). Most felt responsible for resistance (89.73%) and reported efforts to combat self-medication (77.95%). However, irresponsible antibiotic use was noted (78.33%). Females scored higher in practice (5.29) than males (4.70, P = 0.01). Students using leftover antibiotics had lower attitudes (3.50) than those who obtained antibiotics via prescriptions (4.25) or directly from pharmacies (4.55). Enrollment in pharmacy and dental majors increased the odds of inadequate knowledge (P = 0.004) and poor practices (P = 0.02), respectively. Positive attitudes significantly predicted adequate knowledge (P < 0.001) and good practices (P = 0.001).

Conclusions

Knowledge and practices varied across healthcare majors, highlighting educational gaps. Systematic interdisciplinary clinical exposure paired with periodic discussions could enhance interprofessional knowledge sharing, inform decision-making, and foster trust between disciplines. Male students’ poorer practices may stem from an unmet need for career-oriented education that aligns with their career trajectories; incorporating internships could improve their engagement to education and prudent behaviors. Despite limitations in generalizability and potential sampling bias, these findings align with existing literature, suggesting relevance beyond the study sample.

Keywords

antibiotic resistance antimicrobial stewardship‌healthcare students health education knowledge attitudes practices awareness

Introduction

Antibiotic resistance is accelerating at an alarming rate, and the prevalence of resistant bacterial pathogens threatens the efficacy of existing antibiotics.¹ Antibiotic-resistant infections have spread globally,¹ with approximately 700,000 annual deaths attributed to multidrug-resistant infections,² with severe consequences including prolonged hospitalizations, higher mortality rates, and increased reliance on costly second- and third-line treatments. This demand has led to shortages of essential antibiotics and rising healthcare costs.³ In the healthcare sector, antibiotic resistance is fostered by the overuse and misuse of antibiotics and poor infection control.^4,5 Complex scientific, economic, and licensing factors pose additional barriers to antibiotic development and innovation.⁶ For instance, antibiotic discovery faces lengthy preclinical assessments, high costs, and low success rates, as only 1 in 15 preclinical candidates achieves approval.⁷ Even approved antibiotics often lose efficacy within 2–3 years due to rapid resistance emergence.⁷ Nontraditional approaches are prioritized, yet deemed insufficient by the World Health Organization.^5,7 Currently, only 6 of 27 antibiotics in clinical trials against priority pathogens demonstrate true novelty in chemical class, target, mechanisms of action, or cross-resistance.^7,8 Hence, many countries have developed National Action Plans (NAP) to delay crises or reduce their impacts.⁹ Furthermore, the WHO finalized a global development and stewardship framework based on a tripartite collaboration between the Food and Agriculture Organization and the World Organization for Animal Health, which aims to preserve existing antimicrobials while developing and distributing new quality antimicrobial medicines, vaccines, and diagnostics.¹⁰

Strengthening the healthcare system involves a set of essential pillars: infection prevention and control (IPC), patient and medicine safety, and antimicrobial stewardship (AMS).¹¹ The latter aims to optimize antimicrobial use regarding indication, drug choice, dosing, duration, and route while ensuring sustainable access to quality healthcare.¹² Healthcare providers serve as essential frontline stewards in the fight against antibiotic resistance. They fulfill this critical role by appropriately prescribing antibiotics based on their specialized knowledge and expertise. Additionally, they educate their patients about the proper use of these medications.¹² Furthermore, the education and training of healthcare students, including primary and continuous training, are among the core elements of AMS.¹³

In the Middle Eastern and North African (MENA) region, several NAPs have been developed to tackle antibiotic resistance.⁹ Despite their presence, studies have highlighted inadequate implementation due to insufficient AMS education and training among healthcare professionals^14–17 and the public.^18–20 Furthermore, the implementation of Universal Health Coverage (UHC), which implies the full coverage and continuum of timely access to affordable and geographically accessible quality healthcare, is also a burden in many countries across the region.^21,22

Jordan's NAP

Jordan is a lower-middle-income country located in the Eastern Mediterranean region.²³ According to national mortality statistics from 2018, communicable diseases (including maternal, perinatal and nutritional conditions) represented Jordan's second leading cause of death (n = 1145), with respiratory tract infections (RSTIs) accounting for 45.2% of these fatalities (n = 518).²⁴ In alignment with global efforts and national priorities to address communicable diseases, Jordan has implemented an NAP to combat antimicrobial resistance (AMR). The 2018–2022 NAP identified critical gaps, including insufficient public awareness campaigns, inadequate training for healthcare providers, and weak enforcement of AMR-related policies.²⁵ To address these challenges, the 2023–2025 monitoring and evaluation plan, through a One Health approach, focuses on expanding public awareness initiatives, strengthening AMS programs, improving IPC measures, and reinforcing governance.²⁶ The existing literature underscores the urgency of these measures, particularly the need for improved AMS education and training among healthcare professionals,^27–30 and for better implementation of AMS to ensure the adherence to Jordan's NAP.^27,28,30

Health education research to curb antibiotic resistance

Since healthcare students are the future gateway keepers against antibiotic resistance, ensuring their optimal education and adherence to AMS principles is paramount. Therefore, several studies have been conducted worldwide to assess healthcare students’ knowledge, attitudes, and practices related to antibiotic resistance and antibiotic use.^31–34 To the best of our knowledge, no study has conducted a comparative assessment of final-year healthcare students undergoing the critical transition into the workforce, a phase that imposes additional psychological burdens,³⁵ with comprehensive assessments based on subgroup differences, particularly in the MENA region, where evidence indicates inappropriate antibiotic use among healthcare providers. By adopting a comparative approach, this study aims to formulate targeted recommendations that foster equitable educational and professional opportunities across healthcare disciplines. These findings provide critical insights into subgroup differences among healthcare students that may shape their contributions to antibiotic resistance. Identifying gaps in knowledge, attitudes, and practices enables formulating evidence-based recommendations for curricular improvements, contributing to global efforts against antibiotic resistance.

This study explored medical, dental, Pharm D, and pharmacy students’ knowledge, attitudes, and practices related to antibiotic resistance and use in Jordan, examined their associations by sociodemographic characteristics and patterns of antibiotic use, and explored potential predictive factors for antibiotic use.

Methods

Study design and setting

A cross-sectional survey-based design was used to collect data from final-year medical, dental, Pharm D, and pharmacy students at the University of Jordan, a public institution in Amman, the capital of Jordan, and its affiliated teaching hospital, Jordan University Hospital. During the 2022–2023 academic year, the university enrolled 46,590 undergraduate students.

Population and sample

The target population comprised final-year students specializing in medicine, dentistry, Pharm D, and pharmacy at the university. No exclusion criteria were applied, and final-year students were selected because they have acquired nearly all the theoretical and practical antimicrobial knowledge necessary for transitioning into the workforce. Thus, the study findings would reflect their behaviors as future healthcare professionals, making curricular recommendations most relevant at this stage.

According to the University of Jordan's Admission and Registration Unit, the number of final-year students in medicine, dentistry, Pharm D, and pharmacy was 411, 167, 132, and 172, respectively. Males comprised 33.12% of the total population, distributed as follows: 47.93%, 29.30%, 17.42%, and 19.05% across these majors.

Although proportional stratified sampling was initially considered to ensure representative subgroup distribution, its implementation was not feasible due to time constraints and limited research staff. Consequently, a convenience sampling approach was employed within each stratum. Despite this limitation, efforts were made to maintain representativeness by stratifying participants by academic major and utilizing faculty assistance to facilitate recruitment.

The sample size was calculated from a population of 882 students based on the multivariate analysis of variance (MANOVA): Global Effects using a priori G*Power software (G*Power Software for Windows, Kiel, Germany).³⁶ The analysis was performed to compare students’ knowledge, attitudes, and practices across four study majors using a medium effect size of f² (V) = 0.0625, power of 0.8, and type-1 error (α) of 0.05. A proportion of 20% was added to the estimated sample size of 88, yielding a total of 106 to account for expected incomplete reporting, data loss, or other study-related issues. The number of participants in each stratum was determined based on their proportions in the target population, with medical, dental, Pharm D, and pharmacy students representing 46.60%, 18.93%, 14.97%, and 19.50% of the sample, respectively.

Study instrument

Two experts in public health developed the questionnaire following an extensive literature review of similar published studies that assessed the knowledge, attitudes, or practices related to antibiotic resistance and use. The literature search was confined to articles with questionnaires published in English in PubMed and Scopus. The items were supplemented by additional insights drawn from authoritative public health sources such as the Center for Disease Control.^28,37–46 Only pre-validated questionnaires were included in the synthesis of questionnaire items, and the study authors developed additional items to suit the study population and objectives. The questionnaire consisted of four sections: knowledge (10 items), attitudes (eight items), practices (seven items), and sociodemographic characteristics (15 items).

The first section, “knowledge,” contains questions assessing students’ ability to define antibiotic resistance (items 1 and 2), their agreement on specific factors related to antibiotic use that are associated with resistance (items 3 to 7), and their understanding of the possible consequences related to antibiotic resistance (items 8 to 10). Answers were based on a five-point Likert agreement scale, with scores ranging from 1 (strongly disagree) to 5 (strongly agree). Three negative items (4, 5, and 9) were reverse-coded.

The second section, “attitudes,” contains questions exploring students’ views on the narrowing pipeline of antibiotic development (item 1), their attitudes toward factors related to antibiotic use that are associated with resistance (items 2 to 7), and their sense of responsibility in influencing antibiotic resistance (item 8). Answers were based on a five-point Likert agreement scale, with scores ranging from 1 (strongly disagree) to 5 (strongly agree), while item 3 was reverse-coded.

The third section, “practices,” investigates students’ behaviors related to their preference for antibiotic use in specific scenarios (items 1 and 2), the execution of their role in influencing the judicious use of antibiotics among their friends, families, and community (items 3 to 6), and their behaviors following knowledge gained on antibiotic resistance (item 7). The answers were based on a six-point Likert frequency scale, with scores ranging from 1 (never) to 6 (always). Negative items (1, 2, and 4) were reverse-coded.

The fourth section, “sociodemographic characteristics,” includes questions about a respondent's gender, income, major, paternal education, maternal education, having relatives working in healthcare, and their use of antibiotics in the past year.

Cut-off values of the knowledge, attitude, and practice mean scores

The Knowledge, Attitude, and Practice outcome variables were dichotomized using an 80% threshold of the total possible scale scores.⁴⁷ For knowledge and attitude assessments (5-point Likert scales), scores ≥4 (80% of 5 points) were classified as indicating adequate knowledge or positive attitudes, respectively. The practice scale (6-point Likert scale) used a cutoff of ≥4.8 (80% of 6 points) to define good practices. The minimum possible score was 1 and the maximum was 5 for both knowledge and attitude scales, while the practice scale ranged from a minimum of 1 to a maximum of 6.

Validity and reliability assessment of the questionnaire

The draft questionnaire was submitted to a panel of four family and community medicine and community health nursing experts at the University of Jordan to verify face and content validity. Based on constructive feedback, minor rewordings and amendments to scale items were made. The questionnaire's reliability and internal consistency were evaluated through a pilot study involving 30 participants within the same sampling frame, analyzed using SPSS (version 20).⁴⁸ The average time for questionnaire completion was 11 min. Cronbach's alpha values of 0.710 (knowledge) and 0.756 (attitudes) indicated high reliability. Given these robust consistency metrics, the pilot data were retained in the final analysis to maximize statistical power and maintain sample representativeness.

Data collection procedure and ethical considerations

Data were collected between October 2022 and March 2023 following approval from the Institutional Review Board (IRB) of the University of Jordan (Approval No. 101-2022) using self-administered, paper-based questionnaires.

Initial in-person data collection involved researchers directly approaching students in faculty buildings and hospital wards, with hospital-based recruitment conducted exclusively outside clinical sessions. However, the response rate was suboptimal due to participants’ demanding schedules. To improve participation, the administrative faculty provided formal support by:

Facilitating access to academic schedules: (including faculty-based and hospital-based lectures), ensuring data collection did not interfere with clinical training;

Identifying mixed-cohort lectures: (eg, lectures attended by Pharm D/pharmacy students or by fourth-/fifth-year cohorts); and,

Advising on optimized screening protocols during these lectures, where students were instructed to self-report their academic level and major on top of questionnaires, an approach that ensured only eligible final-year participants were included.

The research objectives, ethical considerations, and principal investigators’ contact details were clearly outlined in the informed consent form and through verbal communication from the research team. All participants provided verbal consent after reviewing written study information, with questionnaire return constituting final consent. During the 10- to 20-min data collection window, participants could withdraw freely. Strict anonymity was maintained (no identifiers collected). Participation was entirely voluntary, with no impact on academic standing or incentives offered, and only principal investigators collected completed questionnaires. All data collected remained secure and accessible exclusively to the research team.

Statistical analysis

The paper analyzes the associations between three endpoint variables (knowledge, attitudes, and practices) against a set of candidate determinants (ie, sociodemographic characteristics and patterns of antibiotic use in the past year). The data were analyzed using SPSS software version 20.⁴⁸ P values <0.05 were considered significant (with 95% confidence intervals [CI], two-tailed). Univariate descriptive frequency statistics were employed using counts and percentages. While in the bivariate analysis, inferential nonparametric Mann–Whitney U and Kruskal–Wallis tests were employed to assess associations between mean score outcome variables and candidate determinants, given the non-normal distribution of mean score outcome variables (Shapiro–Wilk test: (knowledge (P < 0.001), attitudes (P < 0.001), and practices (P < 0.001)). When the analyses showed significant associations, pairwise post hoc comparisons were performed using the independent samples Kruskal–Wallis one-way ANOVA test (significance level is at Adjusted P values <0.05, two-tailed). Mean scale variables were summarized with medians and interquartile ranges (IQR) in the bivariate analysis. In the univariate analysis, however, means and standard deviation (SD) were more informative, given the categorical nature of the raw data.

Significantly associated determinants were entered into the multivariate logistic regression analysis to control for confounding (enter model). Multicollinearity in each regression model was ruled out based on variance inflation factors below 2. Notably, variable categories pertaining to the source of antibiotics used in the past year were combined into “medical prescription” and “other” to address the very low sample sizes obtained in specific categories.

Handling missing values

In the total sample of 263 students, there were 15 cases with missing values in the knowledge ordinal constructs (5.70%), 4 in the attitude constructs (1.52%), and 3 in the practice constructs (1.14%). When calculating mean scores, missing values were imputed by series means using SPSS.⁴⁸ A sensitivity analysis was conducted to assess the potential bias arising from this method. This involved replacing the missing values in constructs with extreme upper-limit and lower-limit values, and then conducting bivariate and multivariate analyses for each resulting mean. The results were consistent with the original findings of this research, except for the association between “course completion” and “students’ practice mean scores”, which became statistically insignificant. However, this finding was discussed in the context of existing literature.

Results

Response rate

Of the 315 questionnaires distributed, 263 were considered eligible for inclusion, yielding a response rate of 83.49%. The ineligible questionnaires (52 respondents) were mainly collected from lectures that included students from different academic majors or levels at the faculty of pharmacy, having students from outside the target population. With data saturation achieved, the final study sample comprised 263 final-year students, distributed as follows: 56 medical (21.29%), 58 dental (22.05%), 89 Pharm D (33.84%), and 60 pharmacy students (22.81%).

Baseline characteristics

The majority of respondents were female (78.91%), with female distribution across majors as follows: 14.06% in medical, 17.58% in dental, 28.52% in Pharm D, and 18.75% in pharmacy programs. Also, 94.33% of students fell within the 20 to 25-year-old age group, and 39.53% reported having a family member working in the healthcare field, of whom 13.31% were medical healthcare professionals. Over the past year, 125 students (60.98%) had used antibiotics; 92.56% completed the treatment course, and 72.95% used antibiotics based on a medical prescription (Table 1).

Table 1.

Sociodemographic characteristics of last-year healthcare students at The University of Jordan, October 2022–March 2023 (N = 263).

Sociodemographic characteristics		n (% VALID)	Missing valuesn (%)
Gender (n = 256)	Female	202 (78.91)	7 (2.66)
	Male	54 (21.09)
Birth date (n = 247)	1994–1997	14 (5.67)	16 (6.08)
	1998–2002	233 (94.33)
Major (n = 263)	Medicine	56 (21.29)	0 (0.00)
	Dentistry	58 (22.05)
	Pharm D	89 (33.84)
	Pharmacy	60 (22.81)
Household income “expressed in Jordanian Dinars/month” (n = 106)	<700	54 (50.94)	157 (59.70)
	≥700	52 (49.06)
Maternal level of education (n = 254)	Tawjihi^a or less	48 (18.90)	9 (3.42)
	Bachelor's degree	165 (64.96)
	Graduate studies	41 (16.14)
Paternal level of education (n = 252)	Tawjihi^a or less	43 (17.06)	11 (4.18)
	Bachelor's degree	124 (49.21)
	Graduate studies	85 (33.73)
Family members working in healthcare(n = 253)	No	153 (60.47)	10 (3.80)
Family members working in healthcare(n = 253)	Yes	100 (39.53)
Career (n = 74)	Medical	35 (13.31)	36 (13.69)
	Other	39 (14.83)
Use of antibiotics in the past year(n = 205)	No	80 (39.02)	58 (22.05)
Use of antibiotics in the past year(n = 205)	Yes	125 (60.98)
Reason for use (n = 69)	Unspecified	11 (15.94)	114 (43.35)
	Respiratory	16 (23.19)
	Ear, Nose, Throat (ENT)	7 (10.14)
	Oropharyngeal-tonsillar	13 (18.84)
	Odontogenic	8 (11.59)
	Urinary	7 (10.14)
	Skin-soft tissue	2 (2.90)
	Gastro-enterology	5 (7.25)
Completion of the course of treatment(n = 121)	No	9 (7.44)	62 (23.57)
Completion of the course of treatment(n = 121)	Yes	112 (92.56)
Source of access to the antibiotic(n = 122)	Medical prescription	89 (72.95)	61 (23.19)
	Leftover	5 (4.10)
	Pharmacy	26 (21.31)
	Other	2 (1.64)

Tawjihi: The General Secondary Education Certificate Examination in Jordan.

Knowledge, attitudes, and practices of healthcare students

Knowledge

Table 2 shows the mean knowledge score of students is adequate: 4.30 (0.54) out of 5 (cut-off value at score ≥ 4), The highest mean knowledge scores were demonstrated for items 1 (4.61 (0.81)) and 2 (4.78 (0.62)), which assess students’ ability to define antibiotic resistance. However, the lowest mean scores were seen among items underpinning students’ understanding of specific factors associated with antibiotic resistance.

Table 2.

Students’ answers to knowledge items related to antibiotic use and resistance, October 2022–March 2023, Jordan (N = 263).

#	Knowledge item^a	1 (%)	2 (%)	3 (%)	4 (%)	5 (%)	Mean (SD)
1	Antibiotic resistance is a phenomenon by which a bacterium no longer responds to the antibiotic designed against it.	2.30	1.15	3.45	19.54	73.56	4.61 (0.81)
2	Bacteria can become resistant to antibiotics	1.14	0.38	2.28	11.79	84.41	4.78 (0.62)
3	Not completing the course of an antibiotic can lead to antibiotic resistance	2.30	2.68	9.96	21.46	63.60	4.41 (0.94)
4	Prescribing antibiotics inconsistently with clinical guidelines can be acceptable ^b	36.54	17.31	19.23	15.38	11.54	3.52 (1.41)
5	Taking antibiotics for shorter than recommended durations is rational ^b	39.38	27.03	17.37	13.13	3.09	3.86 (1.17)
6	Prescribing antibiotics for conditions where an antibiotic is not indicated can lead to antibiotic resistance	3.80	3.80	7.98	17.49	66.92	4.40 (1.04)
7	Self-medication (using antibiotics available at home) without medical advice can lead to antibiotic resistance	2.66	3.42	8.37	18.63	66.92	4.44 (0.97)
8	Antibiotic-resistant infections could make medical procedures like surgery, organ transplants, and cancer treatment much more dangerous	1.95	2.33	15.18	19.07	61.48	4.36 (0.95)
9	Antibiotic-resistant infections can be treated easily, just like normal infections ^b	53.64	29.50	7.66	3.83	5.36	4.22 (1.10)
10	The treatment of antibiotic-resistant infections is more costly.	2.67	2.29	14.89	21.76	58.40	4.31 (0.99)
	Overall Knowledge						4.30 (0.54)

1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree.

Reverse coded item.

Attitudes

Table 3 shows that students demonstrated an overall positive attitude with a mean score of 4.19 (0.53) out of 5 (cut-off value at score ≥ 4). The highest attitude mean score (4.60 (0.79)) was observed for the item assessing students’ sense of responsibility in influencing antibiotic resistance. In contrast, the lowest mean score (3.48 (1.09)) was for the item concerning the narrowing pipeline of antibiotic development.

Table 3.

Students’ answers to attitude items related to antibiotic use and resistance, October 2022–March 2023, Jordan (N = 263).

#	Attitude item^a	1 (%)	2 (%)	3 (%)	4 (%)	5 (%)	Mean (SD)
1	New antibiotics will be developed in the future that will keep up with the problem of antibiotic resistance.	3.83	12.64	37.93	22.61	22.99	3.48 (1.09)
2	I realize that antibiotic use in minor or self-limited illnesses can contribute to resistance	2.66	3.80	15.21	35.36	42.97	4.12 (0.98)
3	I think that prescribing/dispensing broad-spectrum antibiotics when equally effective narrower-spectrum antibiotics are available is acceptable^b	40.08	19.85	19.47	12.60	8.02	3.71 (1.32)
4	I think that prescribing/dispensing an antibiotic when medically not indicated can contribute to resistance	3.05	2.29	6.49	27.10	61.07	4.41 (0.94)
5	In my view, patients/clients buying antibiotics from the pharmacy without a prescription contribute to resistance	1.52	1.90	7.98	22.81	65.78	4.49 (0.84)
6	In my opinion, patients/clients using antibiotics from previously unfinished leftover prescriptions contribute to antibiotic resistance	0.00	1.53	13.03	24.90	60.54	4.44 (0.78)
7	I have no doubt that patients/clients not finishing a prescribed course of an antibiotic can contribute to resistance	3.80	4.94	16.73	19.01	55.51	4.17 (1.11)
8	As a student in the medical line and also a member of the society, I have a role to play in decreasing the prevalence of antibiotic resistance	1.14	1.52	7.60	15.21	74.52	4.60 (0.79)
	Overall Attitude Mean						4.19 (0.53)

1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree.

Reverse coded item.

Practices

Table 4 shows that students exhibited poor overall practices with a mean score of 4.78 (1.10) out of 6 (cut-off value at mean scores ≥ 4.80). Students demonstrated the highest practice mean score (5.11 (1.33)) for the item investigating the impact of knowledge gained about antibiotic resistance on the frequency of prudent practices. However, the lowest mean score (4.41 (1.49)) was observed for the item assessing the frequency of using antibiotics in the presence of cough and sore throat.

Table 4.

Students’ answers to practice items related to antibiotic use and resistance, October 2022–March 2023, Jordan (N = 263).

#	Practice item^a	1 (%)	2 (%)	3 (%)	4 (%)	5 (%)	6 (%)	Mean (SD)
1	In the presence of cough and sore throat, antibiotics are my first-choice treatment ^b	28.52	25.86	23.19	10.27	4.56	7.60	4.41 (1.49)
2	When I feel better or symptoms disappear, I don’t finish the antibiotic course^b	57.03	12.17	9.13	8.75	3.80	9.13	4.83 (1.67)
3	I have made efforts to protect family and friends from antibiotic resistance	1.52	6.84	14.83	15.97	23.57	37.26	4.65 (1.37)
4	It is not my role or responsibility to influence other people to properly use antibiotics ^b	54.62	16.54	6.54	5.77	7.69	8.85	4.78 (1.71)
5	When someone is going to self-medicate with antibiotics, I try to persuade them not to do it	1.90	6.46	13.69	10.27	22.43	45.25	4.81 (1.40)
6	I have informed family and friends about the risks associated with self-medication and the use of nonprescribed antibiotics	0.38	7.60	13.69	12.55	14.83	50.95	4.87 (1.38)
7	I have taken greater precautions when using antibiotics after learning about antibiotic resistance	0.00	9.51	6.08	7.98	17.11	59.32	5.11 (1.33)
	Overall Practice Mean							4.78 (1.10)

1 = never, 2 = rarely, 3 = sometimes, 4 = often, 5 = most, 6 = always.

Reverse coded item.

Relationships between students’ knowledge, attitudes, and practices and their sociodemographic characteristics and patterns of antibiotic use in the past year

Mann–Whitney U and Kruskal–Wallis analyses were conducted to explore the associations between students’ knowledge, attitude, and practice mean scores and their sociodemographic characteristics and patterns of antibiotic use in the past year (Table 5). The Kruskal–Wallis test showed a statistically significant association between students’ knowledge and their major (P = 0.001). Post hoc pairwise comparisons revealed that medical students reported higher knowledge scores (4.60 (4.00-4.90)) than pharmacy students (4.20 (3.80-4.60), P = 0.001) and dental students (4.10 (3.90-4.70), P = 0.05). Also, post hoc pairwise comparisons showed that significantly lower attitude scores were found among students who used leftover antibiotics at home (3.50 (3.00-3.63)) compared with those who bought antibiotics directly from the pharmacy (4.50 (4.18-4.75), P = 0.001) or based on a medical prescription (4.25 (4.00-4.63), P = 0.01). Based on the Mann–Whitney U test, significantly higher practice scores were found among females (5.29 (4.29-5.71), P = 0.01) and among students who completed the course of antibiotics used in the past year (4.14 (3.29-5.00), P = 0.02). Post hoc analyses found that dental students reported significantly lower practice scores (4.07 (3.29-5.29)) than Pharm D (5.29 (4.71-5.71), P < 0.001), pharmacy (5.29 (4.57-5.57), P = 0.004), and medical students (5.29 (4.36-5.57), P = 0.02).

Table 5.

Relationship between students’ sociodemographic characteristics and their knowledge, attitude, and practice mean scores, October 2022–March 2023. Results of Mann–Whitney U and Kruskal–Wallis tests, Jordan (N = 263).

			Endpoint variables
			Knowledge		Attitudes		Practices
Sociodemographic characteristic		(% valid)	Median (IQR)	P value	Median (IQR)	P value	Median (IQR)	P value
Gender (n = 256)	Female	78.91%	4.30 (3.90, 4.70)	0.647	4.25 (3.88, 4.63)	0.429	5.29 (4.29, 5.71)	0.014
Gender (n = 256)	Male	21.09%	4.50 (3.90, 4.70)		4.25 (3.75, 4.50)		4.70 (3.71, 5.43)
Birth date	1994–1997	5.67%	4.35 (3.90, 4.80)	.665	4.19 (4.00, 4.50)	.902	5.00 (4.14, 5.57)	.532
	1998–2002	94.33%	4.30 (4.00, 4.70)		3.88 (4.63, 5.29)		5.29 (4.14, 5.57)
Major (n = 263)	Medicine	21.29%	4.60 (4.00, 4.90)	0.001	4.38 (4.13, 4.56)	0.056	5.29 (4.36, 5.57)	0.000
Major (n = 263)	Dentistry	22.05%	4.10 (3.90, 4.70)		4.06 (3.63, 4.50)		4.07 (3.29, 5.29)
	Pharm D	33.84%	4.40 (4.00, 4.80)		4.38 (3.88, 4.63)		5.29 (4.71, 5.71)
	Pharmacy	22.81%	4.20 (3.80, 4.60)		4.25 (3.88, 4.56)		5.29 (4.57, 5.57)
Household income (Jordanian Dinars/month) (n = 106)	<700	50.94%	4.55 (4.19, 4.80)	0.114	4.28 (4.00, 4.63)	0.589	5.07 (4.14, 5.71)	0.470
Household income (Jordanian Dinars/month) (n = 106)	≥700	49.06%	4.50 (4.00, 4.70)		4.44 (4.13, 4.63)		5.29 (4.64, 5.64)
Use of antibiotics in the past year (n = 205)	No	39.02%	4.50 (4.00, 4.80)	0.187	4.25 (3.88, 4.63)	0.586	5.29 (4.43, 5.57)	0.751
Use of antibiotics in the past year (n = 205)	Yes	60.98%	4.30 (4.00, 4.70)		4.38 (4.00, 4.63)		5.29 (4.14, 5.71)
Course completion (n = 121)	No	7.44%	4.50 (4.00, 5.00)	0.589	3.63 (3.50, 4.75)	0.245	4.14 (3.29, 5.00)	0.021
Course completion (n = 121)	Yes	92.56%	4.30 (4.00, 4.70)		4.38 (4.00, 4.63)		5.43 (4.43, 5.71)
Source of the antibiotic (n = 122)	Medical prescription	72.95%	4.30 (4.00, 4.70)	0.394	4.25 (4.00, 4.63)	0.003	5.29 (4.43, 5.71)	0.482
	Leftover	4.10%	4.00 (3.50, 4.70)		3.50 (3.00, 3.63)		4.14 (3.29, 5.71)
	Pharmacy	21.31%	4.55 (4.10, 4.80)		4.50 (4.18, 4.75)		5.43 (5.00, 5.57)
	Other	1.64%	3.90 (3.20, 4.60)		4.31 (4.13, 4.50)		4.29 (3.86, 4.71)

Predictors of knowledge, attitudes, and practices

In Table 6, the multivariate logistic regression results show, after adjusting for confounding factors, that having positive attitudes significantly increases the odds of having adequate knowledge (odds ratio [OR] = 4.56, 95% confidence interval [CI] 2.35-8.85, P < 0.001) and good practices (OR = 3.67, 95% CI 1.67-8.03, P = 0.001). Furthermore, pharmacy students had the lowest likelihood of adequate knowledge (OR = 0.25, CI 0.10-0.65, P = 0.004). Dental students had the lowest likelihood of good practices (OR = 0.33, CI 0.13-0.84, P = 0.02).

Table 6.

Multivariate logistic regression of factors predicting Students’ knowledge, attitudes, and practices related to antibiotic resistance and use, October 2022–March 2023, Jordan (N = 263).

Variable		Knowledge				Attitudes				Practices
		OR	95% CI		p Value	OR	95% CI		p value	OR	95% CI		p value
			Lower	Upper			Lower	Upper			Lower	Upper
Knowledge ^a(n = 263)	Deficient (ref.)					1.00				1.00
Knowledge ^a(n = 263)	Adequate	—	—	—	—	3.50	1.64	7.50	0.001	1.70	0.75	3.83	0.203
Attitudes ^b(n = 263)	Negative (ref.)	1.00								1.00
Attitudes ^b(n = 263)	Positive	4.56	2.35	8.85	0.000	—	—	—	—	3.67	1.67	8.03	0.001
Practices ^c(n = 263)	Poor (ref.)	1.00				1.00
Practices ^c(n = 263)	Good	1.93	1.00	3.75	0.052	4.19	2.07	8.51	0.000	—	—	—	—
Gender(n = 256)	Male (ref.)	n.a^d								1.00
Gender(n = 256)	Female									0.84	0.36	1.94	0.678
Major(n = 263)	Medicine (ref.)	1.00				n.a^d				1.00
	Dentistry	1.02	0.37	2.81	0.971					0.33	0.13	0.84	0.020
	Pharm D	0.66	0.26	1.66	0.374					2.33	0.96	5.67	0.063
	Pharmacy	0.25	0.10	0.65	0.004					1.91	0.70	5.26	0.209
Antibiotic course completion(n = 121)	No (ref.)	n.a^d				n.a^d				1.00
	Yes									2.24	0.46	10.91	0.319
	No use of antibiotics in the past year									1.92	0.39	9.50	0.424
Source of antibiotic used(n = 122)	Medicalprescription (ref.)	n.a^d				1.00				n.a^d
	Other					0.77	0.27	2.18	0.619
	No use of antibiotics in the past year					0.76	0.35	1.65	0.487

The cut-off point for adequate knowledge is at mean scores ≥ 4.00 of 5; knowledge is considered deficient at values < 4.00 of 5.

The cut-off point for positive attitudes is at means scores ≥ 4.00 of 5; attitudes are considered negative at values < 4.00 of 5.

The cut-off point for good practices is at mean scores ≥ 4.80 of 6; practices are considered poor at values < 4.80 of 6.

No regression analysis was conducted between the two variables due to the lack of significant associations found based on nonparametric analyses.

Discussion

In this study, we investigated the knowledge, attitudes, and practices regarding antibiotic resistance and use among final-year medical, dental, Pharm D, and pharmacy students in Jordan. As future healthcare professionals, comparing these student groups may be a reference for future curricular enhancement.

Students’ knowledge, attitude, and practice scores

Analyses of the overall mean scores and distributions revealed that students had adequate knowledge and positive attitudes toward antibiotic resistance and use, but poor practices. The study found that 84.41% of students understood that unnecessary antibiotic prescriptions contribute to resistance, and a substantial proportion (89.73%) believed in their role in mitigating antibiotic resistance. These sentiments were highlighted in their practices, as most students frequently made efforts to protect their family and friends from antibiotic resistance (76.80%), persuaded their community not to self-medicate (77.95%), and informed them about the risks associated with irresponsible antibiotic use (78.33%). Furthermore, 57.03% of students reported that they never stopped taking antibiotics when their symptoms disappeared. Similarly, a study from Jordan reported that 61.0% of undergraduate Pharm D and pharmacy students always completed the entire course of treatment.³³ Despite these promising findings, only 28.52% and 25.86% of the students reported rarely using antibiotics for cough or sore throat, respectively, indicating the need for curricular advancements for RSTIs.

RSTIs

Regional and global patterns of inappropriate antibiotic use

Inappropriate antibiotic use for RSTIs is prevalent across the Middle East and globally. In the Middle East, two multicountry cross-sectional online surveys found inappropriate antibiotic use for RSTI indications; one observed such behaviors in around half the sample of medical students, while the other observed them in approximately a quarter of a sample of multi-level pharmacy and Pharm D students.^46,49 Similarly, a multicenter study in Saudi Arabia found that around a quarter of a sample of fourth-year to sixth-year dental students and interns would prescribe antibiotics for viral infections, a practice linked to gaps in knowledge that improved with academic seniority.⁵⁰ In the global context, findings from Nepal found that almost half the sample of multilevel medical and dental students also self-medicated with antibiotics for the treatment of sore throat, accompanied by a runny nose.⁵¹ On the contrary, A multicenter cross-sectional report found that only 8% of Colombian medical students regard antibiotics as the first-line agents in cough and sore throat, highlighting regional disparities influenced by healthcare education and policies.³¹

Healthcare policies and legal frameworks

The effectiveness of antibiotic stewardship programs is intrinsically linked to national regulatory frameworks, with significant variations observed across countries. In Nepal, unregulated antibiotic dispensing has led to widespread self-medication practices, exacerbating antimicrobial resistance.⁵² In contrast, both Saudi Arabia and Colombia implemented stringent regulatory measures in 2018, including prescription-only antibiotic access, comprehensive public awareness campaigns, and strict penalties for violations such as pharmacist license suspension or termination.^53,54

Nevertheless, surveys in these two countries showed heterogeneous prescribing behaviors,^31,50 suggesting variability in policy enforcement or the depth of educational interventions. For example, a Saudi study found that while 75% of students were aware of antibiotic resistance, only 54.7% understood its public health threat. Crucially, this deeper awareness was associated with nearly double the reduction in antibiotic misuse (51.32%) compared to basic awareness alone (27.96%).⁵⁵

Jordan's regulatory landscape and challenges

Jordan faces significant antibiotic misuse, driven by systemic gaps identified in its 2018–2022 NAP, including weak policy enforcement, insufficient healthcare training, and limited public awareness.²⁵ A retrospective analysis of 92,968 family medicine clinic visits (2017) revealed that antibiotics constituted 25% of all prescriptions, with 51.13% for RSTIs, yet only 28.8% were clinically justified.²⁷ This aligns with broader regional trends and underscores Jordan's urgent need for in-depth awareness interventions that influence collective behavioral change to mitigate antibiotic resistance within the sheets of society.

Students’ perceptions of educational influences on their practices

Educational interventions emerged as a critical but underutilized tool for improving AMS. Only 59.32% of our sample highly credited the impact of academic input on influencing their practices, a proportion similar to that from a survey of fourth-to sixth-year medical students in Warsaw (53.40%), which also indicated educational insufficiencies.⁵⁶ Curricular advancements should focus on exploring root causes that drive inappropriate behaviors, as this would likely prevent their persistence in future clinical practice. Qualitative assessments from Egypt, Spain, and Norway revealed that fear of negative therapeutic consequences contributes to inappropriate antibiotic use among healthcare practitioners,^57–59 especially when a past traumatic outcome triggers these feelings.⁵⁸ To mitigate this, healthcare education must strike a balance between rigorous therapeutic training and psychological support, empowering them to navigate clinical decisions safely and effectively, especially given the high mortality rates associated with these infections.²⁴

Associations between baseline characteristics and mean knowledge, attitude, and practices

Gender disparities in education

In terms of sociodemographic characteristics, gender disparities were evident in this sample, with males disproportionate to the target population (21.09% in the sample compared to 33.12% in the population), particularly in the medical and dental majors (35.71% and 21.05%, respectively). Medical students may be absent due to elective rotations outside the country, making their exact representation uncertain. However, the disproportion among dental students might reflect lower engagement in education and attendance among males, which aligns with their reduced engagement in prudent antibiotic practices observed in this study. Our analysis also revealed that females exhibited significantly higher practice mean scores than males (P = 0.01). These findings align with Saudi Arabian, Middle Eastern, and Serbian surveys of healthcare students.^49,60,61 In contrast, multicountry Asian and Sudanese surveys reported higher knowledge scores among male pharmacy students, potentially due to sampling biases favoring female participation.^62,63

Social identity attributes provide additional insights into gender differences in academic engagement. An analysis of the Add Health dataset,⁶⁴ which tracked 20,000 adolescents until their early adulthood, found that gender gaps in attitudes are predicted by males’ perceived ‘attainable’ social identity.⁶⁵ Male students had substantive lower aspirations of attaining college, despite expressing their desire, making them less likely to enroll. These aspirations are strongly linked to male students’ social identities, suggesting that so-called “behavioral deficits” are, in fact, a consequence of an undermined social identity quest. Although the study differs in terms of age and academic discipline, its findings align with another analysis of large-scale international surveys and statistical reports,^66–68 which suggests that standardized education models across genders may not sufficiently accommodate diverse learning needs across genders, and that directly addressing males’ academic weaknesses may be less effective than creating opportunities to capitalize on their strengths and interests.⁶⁹ One proposed solution is career-oriented internships, as exemplified by the University of Jordan's School of Pharmacy, which leverages stakeholder networks to provide internships across various pharmacy sectors.⁷⁰ Such experiential learning opportunities may help reduce gender disparities in both education and practice by aligning educational structures with students’ aspirations and career trajectories.

Use of antibiotics within the past year

Regarding antibiotic use in the past year, 72.95% of students used prescribed antibiotics, aligning with findings from Serbia (71.5%)⁷¹ and Mali (81.2%)⁷² among medical students. The latter study also found that self-medication was more prevalent among senior students and indicated deficient overall knowledge that may underpin overconfidence.⁷² In addition, pairwise post hoc comparisons found that students who used leftover antibiotics at home had significantly lower positive attitude scores than students who bought antibiotics using a medical prescription (P = 0.01) or from the pharmacy (P = 0.001). Conversely, a Serbian study among final-year medical and nonmedical students found no association.⁷¹ A multicenter survey among Sudanese medical students found that self-medication is inversely associated with academic year advancements and income level.⁷³ The latter is unsurprising given that income can facilitate access to timely and quality medical care that is affordable and geographically accessible, according to the principles of the UHC.²¹ This is particularly relevant in Sudan's urban areas, where 61.80% of the population lives in poverty, driving reliance on pharmacies for self-medication due to financial, geographical, and time barriers to quality healthcare access.⁷⁴ Thus, public health policies addressing self-medication require a nuanced approach considering sociodemographic indicators, ensuring that interventions do not unintentionally marginalize disadvantaged populations from essential healthcare services.

Multivariate regression analysis

Discordance between knowledge and practice

Multivariate logistic regression analysis revealed that positive attitudes predicted adequate knowledge and good practices. However, adequate knowledge was not a predictor of good practices. This discordance is well-documented in the literature.^75–77 Hence, tackling practices is better achieved by addressing attitudes and vice versa. The following paragraphs discuss how training enhancements, including early, hands-on, case-based theoretical, and interdisciplinary clinical training, might address these incompetencies. For instance, a cross-sectional survey in Colombia found that medical students who perceived their training as excellent had significantly higher knowledge, attitude, and practice scores.³¹ Training enhances students’ competence by fostering critical thinking, decision-making, and interpersonal relationships, while enabling them to handle attitudinal factors (eg, fear and anxiety) prudently.^78,79

Interprofessional gaps across healthcare disciplines

Medical students

Medical students achieved the highest median scores in knowledge (4.60 [4.00-4.90]), attitude (4.38 [4.13-4.56]), and practice (5.29 [4.36-5.57]), likely due to their rigorous training. At the University of Jordan, medical students undergo 40 weeks of annual clinical training starting in their fourth year, with specialty systems beginning as early as the second year.^80,81 This aligns with findings from Egypt, where medical students demonstrated superior knowledge and lower self-medication rates.⁷⁶ Similar trends were observed in Colombia.³¹ However, discrepancies exist in the literature. For instance, Polish medical students showed knowledge-attitude gaps, possibly due to including junior students.⁵⁶ Conversely, in Bangladesh, seniority inversely correlated with knowledge and attitudes,⁷⁷ a pattern likely influenced by context-specific systemic barriers, including inadequate IPC infrastructure (eg, clean water access), financial strains⁷⁷ (eg, high out-of-pocket costs accounting for 44.31% of healthcare expenditures), and antibiotic market dynamics ($45.08 M in Q2 2022).^82,83 Such infrastructural and economic barriers may hinder optimal antibiotic practices, warranting further policy research on these linkages.

Pharm D and pharmacy students

This study found that pharmacy students were less likely to have adequate knowledge (P = 0.004). Notably, pharmacy students, unlike other students in the sample, lacked clinical training in hospital wards or outpatient clinics. Furthermore, while pharmacy and Pharm D students share foundational coursework in Therapeutics and pharmacy field training, their career pathways diverge substantially: Pharm D students receive extensive clinical training focused on patient management, including specialty clerkships during their sixth year,⁸⁴ while pharmacy students concentrate on pharmaceutical sciences and dispensing.⁸⁵ This curricular divergence likely explains pharmacy students’ inferior antibiotic stewardship knowledge versus Pharm D peers and other healthcare students.

Our finding contrasts with a multicountry Middle-Eastern survey that found an increased likelihood of adequate knowledge among pharmacy students compared to Pharm D students. Nevertheless, the study employed a different cut-off categorization and included students from all academic years.⁴⁹ In fact, surveys in Cyprus and Spain found that medical students demonstrated significantly higher knowledge of pharmacological agents³⁴ and antibiotic resistance⁸⁶ than other healthcare students, likely due to their infectious disease training.⁸⁶ However, pharmacy students excelled in understanding antibiotic effectiveness for specific microbes,³⁴ highlighting the need to integrate theoretical education with practical training for optimal competency.

The literature reported variable knowledge levels among pharmacy students, ranging from deficient^62,87 to adequate,⁸⁸ and curricular enhancements have been recommended for pharmacists^62,87,88 and healthcare students in general.⁸⁹ Structured clinical exposure would reinforce pharmacy students’ theoretical knowledge. The University of Toronto provided a successful example of how early, experiential clinical training, with consistent feedback, can enhance hands-on experience and decision-making skills, leading to informed prescribing practices.⁷⁸ In Jordan, Pharm D programs have begun implementing simulation labs for clinical training;⁹⁰ moreover, pharmacy students would benefit from incorporating case-based theoretical learning, expanded clinical placements, and standardized AMS modules.

Dental students

Our findings also revealed that dental students had significantly lower odds of demonstrating good antibiotic prescribing practices (P = 0.02). This aligns with global literature highlighting gaps in their education and training, including: The need for further education on antibiotic use and resistance,^91,92 limited confidence,^91,93 deficits in interdisciplinary training,⁹⁴ and in managing pediatric endodontic infections.⁹⁵ These professional gaps may stem from curriculum limitations inherent in traditional dental education, which maintains a strong oral health focus while providing less emphasis on systemic pharmacological principles and AMS.

A multicenter cross-sectional survey in Saudi Arabia found that dental interns exhibited poor prescribing behaviors, particularly for systemic conditions.⁵⁰ Furthermore, a scoping review on the challenges of dental education found that students rarely receive adequate performance assessments during interdisciplinary training.⁹⁴ Interdisciplinary cooperation is influenced by social dynamics, acting as either an opportunity for interprofessional learning or a barrier when peer pressure and hierarchy interfere.⁹⁶ A collaborative learning environment mimicking real-world clinical challenges can prepare students across disciplines to integrate, developing new insights while blending their knowledge. The variability of healthcare professionals’ knowledge and experience backgrounds may drive them to perceive prudent practices differently.¹⁸ Therefore, standardized interdisciplinary education on antibiotics for all healthcare students would enhance decision-making and mutual understanding.⁹⁷

Growing evidence highlights the effectiveness of interprofessional educational workshops,^97,98 e-learning modules,⁹⁹ and teamwork and knowledge sharing in enhancing AMS and healthcare outcomes.¹⁰⁰ At the university level, fostering interfaculty collaboration might provide valuable insights for curricular enhancement strategies, yielding better outcomes than isolated efforts. These collective efforts can focus on standardizing healthcare students’ core competencies, developing early, supervised, interdisciplinary clinical training in their syllabi to help them grow together and work together, and incorporating social support courses that emphasize the importance of solidarity and collaboration across healthcare disciplines, who are the building blocks of tomorrow's healthcare systems.⁹⁷

Limitations

This study has several limitations that should be considered when interpreting the findings. The primary limitation is potential sampling bias, particularly the underrepresentation of medical students (20.83% in the sample compared to 46.60% in the population). This discrepancy resulted from limited access to medical students relative to other healthcare student groups. However, the sample size was deliberately increased to account for subgroup differences.

Additionally, the survey-based cross-sectional design introduces the potential for self-reporting bias. This was partially mitigated by ensuring anonymous responses and triangulating data with existing literature. Furthermore, the questionnaire did not include items on students’ intravenous (IV) history or grade point average (GPA), both of which may influence knowledge, attitudes, and practices. However, given that students’ knowledge, an essential component of GPA, was discordant with their practices, attitudes may be a more significant predictor of behavior in this field.

Another limitation is the exclusion of nursing students, who play a key role in antibiotic administration and patient education. Additionally, the sampling frame was confined to final-year medical, dental, Pharm D, and pharmacy students at the University of Jordan, which may limit the generalizability of the findings. Nevertheless, the results align with broader literature, suggesting their relevance beyond this specific population.

Recommendations

A summary of recommendations based on key findings is presented in Table 7. In brief, the findings highlight students’ difficulties in translating knowledge into practice, underscoring the need for curricular improvements.

Table 7.

Summary of key recommendations based on major study findings.

Education
#	Recommendation	Implementation	Justification	Projected outcome
1	Early, supervised, interdisciplinary clinical training	Interfaculty rotations with joint case discussions	Theory-practice gaps, especially in RSTIs.	Clinical training bridges theory-practice gaps.
		Discipline-specific supervision	Interprofessional gaps among disciplines are possibly linked to clinical training insufficiencies.	Interprofessional learning builds trust, allows knowledge sharing, and reduces social barriers among the future stakeholders of the healthcare system.
			RSTI's are the leading cause of death among communicable diseases in Jordan.	Clinical training reduces fear of handling high-mortality cases.
			Fear is a major driver of misuse among practitioners, especially when triggered by a traumatic healthcare event.
2	Gender-tailored education	Career-focused internships	Gender disparities in antibiotic use might be influenced by social identity influences rather than academic achievement or inherent skill. Therefore, directly addressing male students’ poor practices may be ineffective.	Improved male students’ knowledge, attitudes, and practices, while aligning with their career aspirations.
2	Gender-tailored education	Social identity-aware mentoring
Public Health Policy
#	Recommendation	Implementation	Justification	Projected outcome
1	Targeted AMS awareness campaigns	Public health-focused AMS awareness	Addressing the discordance between knowledge and practice through attitude-oriented interventions.	Collective community behavioral change.
			The prevalence of self-medication was inversely associated with attitudes.	Collective community behavioral change.
			Evidence of almost doubled mitigation in antibiotic misuse practices among students who were aware that antibiotic resistance is a public health problem.	Reduced rates of antibiotic-resistant infections among different sheets of the society.
2	UHC-integrated access solutions	Holistic approach (financial, geographic, IPC)	Reports demonstrate that inappropriate antibiotic use is more prevalent in areas where barriers financial / geographical / or IPC measures undermine access to quality healthcare.	Improving affordability and accessibility to quality healthcare while promting IPC measures would decrease self-medication and inappropriate antibiotic demand.
Research
#	Recommendation		Implementation	Projected outcome
1	Vignette-based cross-sectional surveys		Control questions related to systemic diseases	Identify precise deficits in knowledge application
1	Vignette-based cross-sectional surveys		Control questions related to systemic diseases	Assess whether similar insufficiencies persist in other domains than infectious diseases.
2	Longitudinal follow-up studies		Pre-/post-clinical training assessments	Measure how students’ knowledge, attitudes, and practices change over time.
2	Longitudinal follow-up studies		Pre-/post-clinical training assessments	Confirm attitudinal mediation effects between knowledge and practices.
3	Mixed-method studies		Student/faculty interviews	Reveal hidden curriculum gaps and gender-specific stressors
3	Mixed-method studies		Male-specific focus groups	Reveal hidden curriculum gaps and gender-specific stressors
4	Bias-minimized sampling		Targeted outreach to underrepresented groups	Improve generalizability by capturing diverse socioeconomic strata
4	Bias-minimized sampling		Multimodal data collection (online/in-person)

Education

Early interprofessional clinical training: Mandate early interdisciplinary rotations with structured case discussions to bridge knowledge-practice gaps and reduce decision-making anxiety (eg, fear of treatment failure or resistance development).

Gender-responsive curricula: Address male students’ unique needs through career-aligned internships and mentorship programs via widespread collaborations with the healthcare industry.

Public health policies

Behavioral campaigns: Frame antibiotic resistance as a public health crisis (not just clinical) to maximize impact.

UHC integration: Subsidize prescriptions, expand primary care, and strengthen IPC programs in underserved areas to decrease perceived need for self-treatment.

Research

Vignette-based assessments: Identifying specific training gaps using clinical scenarios.

Longitudinal designs: Monitoring how students’ knowledge, attitudes, and practices change over time, exploring additional upstream and downstream factors associated with the knowledge, attitude, and practice pathway, and confirming attitudinal mediation effects.

Mixed-method studies: Exploring knowledge-translation barriers (eg, clinical inexperience, confidence gaps) and optimal training structures via student/faculty interviews, with a male-specific focus on career-related stressors.

Sampling bias mitigation: Through expanded recruitment (eg, multimodal outreach) targeting underrepresented groups.

Conclusion

This study highlights persistent gaps between healthcare students’ knowledge and clinical practices, calling for educational reforms: Early clinical rotations to bridge pharmacy students’ theory-practice divide, interdisciplinary training to strengthen dental competencies, and gender-responsive internships addressing male students’ educational needs and career aspirations. Standardizing AMS training through interfaculty collaboration and expanding partnerships between universities and the healthcare industry will develop a workforce capable of translating knowledge into practice.

Supplemental Material

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Footnotes

Acknowledgments

We thank Dr Sireen Alkhaldi for the continuous guidance, support, and encouragement. The shared knowledge and expertise significantly contributed to the quality of this research. We appreciate the dissertation committee (Prof. Zeinab Hassan, Dr Lana Alhalaseh, and Dr Mamdouh El-Hneiti) for their valuable comments, insights, and guidance in improving and refining this work. The authors also acknowledge the editor and anonymous reviewers’ valued time, effort, and constructive feedback invested in the quality and depth of this manuscript. Authors deeply recognize the internal support provided by the University of Jordan faculties and staff, with special gratitude to Prof. Areej Othman, Prof. Mahmoud Alhussami, and Dr Hamza Alduraidi for their expertise and support during the validity assessment, as well as to Prof. Khawla Abu Hammour, Dr Dina Taimeh, Dr Bassam Amro, Prof. Ibrahim Al-Abbadi, Dr Oqba Al-Kuran, and Prof. Yusuf Al-Hiari for their support during data collection. We also thank Dr Nezar Al-Labadi for the valuable knowledge and expertise imparted and the statistical analysis of raw data. Acknowledgment is extended to Pharm D training supervisors for their help with data collection, and to all the students who participated in this study. We thank Elsevier Language Services for the English language editing of the manuscript. We used the STROBE cross-sectional checklist when writing our report.¹⁰¹

This paper is dedicated to the memory of Prof. Mohammad Issa Saleh, whose commitment to research ethics deeply inspired me, in honor of his generous administrative guidance during data collection and technical support. His impact on my scientific journey continues to resonate.

Author Note

This paper has been edited in English by Elsevier Language Services.

ORCID iDs

Sara R. Homsi

Sireen M. Alkhaldi

Zaid R. Homsi

Ethical Considerations

Ethical approval for this study was obtained from the University of Jordan IRB (Approval No. 101-2022, ref. 19/2022/549).

Consent to Participate

Informed consent was obtained verbally before participation.

Author Contributions

Sara R. Homsi: all tasks of research conduct and manuscript preparation. Sireen M. Alkhaldi: all tasks of research conduct and manuscript preparation. Hana A. Taha: questionnaire validation, writing—original draft, and writing—review and editing. Zaid R. Homsi: data collection, writing—original draft, and writing—review and editing. All authors have read the final manuscript draft and approved it for submission.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Data will be made available upon reasonable request.

Supplemental Material

Supplemental material for this article is available online.

References

Antimicrobial resistance. World Health Organization. Accessed January 18, 2024. https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance

World Health Organization. No time to wait: Securing the future from drug-resistant infections. Report to the Secretary-General of the United Nations. Geneva: WHO; 2019. Accessed May 2, 2024. https://www.who.int/publications/i/item/no-time-to-wait-securing-the-future-from-drug-resistant-infections

Chinemerem Nwobodo

Ugwu

Oliseloke Anie

, et al. Antibiotic resistance: the challenges and some emerging strategies for tackling a global menace. J Clin Lab Anal. 2022;36(9):e24655. https://doi.org/10.1002/jcla.24655

Rump

Timen

Hulscher

, et al. Infection control measures in times of antimicrobial resistance: a matter of solidarity. Monash Bioeth Rev. 2020;38(S1):47–55. https://doi.org/10.1007/s40592-020-00119-9

Shelke

Bankar

Bandre

, et al. An overview of preventive strategies and the role of various organizations in combating antimicrobial resistance. Cureus. 2023;15(9):e44666. https://doi.org/10.7759/cureus.44666

World Health Organization. 2023 antibacterial agents in clinical and preclinical development: an overview and analysis. Geneva: WHO; 2024. Accessed April 26, 2025. https://www.who.int/publications/i/item/9789240094000 WHO

Lack of innovation set to undermine antibiotic performance and health gains. World Health Organization. Accessed April 26, 2025. https://www.who.int/news/item/22-06-2022-22-06-2022-lack-of-innovation-set-to-undermine-antibiotic-performance-and-health-gains#:∼:text=Barriers%20to%20development%20of%20new,preclinical%20to%20the%20clinical%20stages

Cardona

Rahman

ASMZ

Novomisky Nechcoff

. Innovative perspectives on the discovery of small molecule antibiotics. NPJ Antimicrob Resist. 2025;3(1):19. https://doi.org/10.1038/s44259-025-00089-0

Library of AMR national action plans. World Health Organization. Accessed January 18, 2024. https://www.who.int/teams/surveillance-prevention-control-AMR/national-action-plan-monitoring-evaluation/library-of-national-action-plans

10.

World Health Organization, World Organization for Animal Health, Food and Agriculture Organization of the United Nations. Global framework for development & stewardship to combat antimicrobial resistance: draft roadmap. Geneva: WHO; 2017. Accessed June 14, 2024. https://www.who.int/publications/m/item/global-framework-for-development-stewardship-to-combat-antimicrobial-resistance-draft-roadmap

11.

Shrestha

Zahra

Cannady

. Antimicrobial stewardship in non-traditional settings: A practical guide. 1st ed. Springer International Publishing; 2023.

12.

World Health Organization. Antimicrobial stewardship interventions: a practical guide. Copenhagen: WHO Regional Office for Europe; 2021. Accessed June 14, 2024. https://www.who.int/europe/publications/i/item/9789289056267

13.

World Health Organization. Health workers’ education and training on antimicrobial resistance: curricula guide. Geneva: WHO; 2019. Accessed June 14, 2024. https://iris.who.int/handle/10665/329380

14.

Khan

Bory

Rego

, et al.

Is enhancing the professionalism of healthcare providers critical to tackling antimicrobial resistance in low- and middle-income countries?

Hum Resour Health. 2020;18(1):10. https://doi.org/10.1186/s12960-020-0452-7

15.

Atif

Ihsan

Malik

, et al. Antibiotic stewardship program in Pakistan: a multicenter qualitative study exploring medical doctors’ knowledge, perception and practices. BMC Infect Dis. 2021;21(1):374. https://doi.org/10.1186/s12879-021-06043-5

16.

Lohiniva

Heweidy

Girgis

, et al. Developing a theory-based behavior change intervention to improve the prescription of surgical prophylaxis. Int J Clin Pharm. 2022;44(1):227–234. https://doi.org/10.1007/s11096-021-01338-8

17.

Ahmed

Khan

Prescription ethics in a low-middle income country: thematic analysis of research from Pakistan. J Pak Med Assoc. 2024;74(11)(Suppl 12):S28–S37. https://doi.org/10.47391/JPMA.AKU-EPP-07

18.

Sharif

Peiravian

Salamzadeh

, et al. Irrational use of antibiotics in Iran from the perspective of complex adaptive systems: redefining the challenge. BMC Public Health. 2021;21(1):778. https://doi.org/10.1186/s12889-021-10619-w

19.

Al-Tarawneh

Ali

Al-Taani

. Public patterns and determinants of antibiotic self-medication and antibiotic knowledge in southern Jordan. Antibiotics. 2024;13(1):98. https://doi.org/10.3390/antibiotics13010098

20.

Saif

Khan

Bukhsh

et al.

Cross-sectional survey to explore knowledge, attitude, practices and impact of an intervention programme related to antibiotic misuse and self-medication among general population of Pakistan. BMJ Public Health. 2024;2(1):e000758. https://doi.org/10.1136/bmjph-2023-000758

21.

Universal health coverage. World Health Organization. Accessed February 5, 2025. https://www.who.int/health-topics/universal-health-coverage#tab=tab_1

22.

Alshehari

Al-Selwi

Agu

Younes

MA.

Measuring progress towards universal health coverage in 22 Middle East and north African countries.

Dialogues Health. 2024;5:100191. https://doi.org/10.1016/j.dialog.2024.100191.

23.

WHO country cooperation strategy at a glance: Jordan. World Health Organization. Accessed February 6, 2025. https://iris.who.int/bitstream/handle/10665/136901/ccsbrief_jor_en.pdf?sequence=1

24.

WHO Mortality Database, Interactive platform visualizing mortality data. World Health Organization. Accessed February 5, 2025. https://platform.who.int/mortality/countries/country-details/MDB/jordan

25.

World Health Organization. National action plan for combating antimicrobial resistance in the Hashemite Kingdom of Jordan 2018-2022. 2018. Accessed April 26, 2025. https://www.who.int/publications/m/item/jordan-national-action-plan-for-combating-antimicrobial-resistance-in-the-hashemite-kingdom-of-jordan

26.

Jordan Center for Disease Control. Monitoring and Evaluation Plan of the National Action Plan for Combating Antimicrobial Resistance (2.0) Framework & Recommended Indicators 2023–2025. 2023. Accessed April 26, 2025. https://jcdc.gov.jo/ebv4.0/root_storage/ar/eb_list_page/amr_me_plan_2023-2025_text_24_oct_v8_-_sm-endo-0.pdf

27.

Alkhaldi

Yaseen

Bataineh

, et al. Patterns of antibiotic prescribing and appropriateness for respiratory tract infections in a teaching hospital in Jordan. Int J Clin Pract. 2021;75(6):e14113. https://doi.org/10.1111/ijcp.14113

28.

Darwish

Baqain

Aladwan

Salamah

Madi

Masri

RMA.

Knowledge, attitudes, and practices regarding antibiotic use and resistance among community pharmacists: a cross sectional study in Jordan. Int J Clin Pharm. 2021;43(5):1198–1207. https://doi.org/10.1007/s11096-021-01234-1

29.

Shallal

Jarrah

Prentiss

, et al. Lessons from the field: supporting infection prevention and control and antimicrobial stewardship in Amman, Jordan. J Infect Public Health. 2023;16(Suppl 1):78–81. https://doi.org/10.1016/j.jiph.2023.10.044

30.

Jarab

Al-Alawneh

Alshogran

, et al. Knowledge and attitude of healthcare prescribers and pharmacists toward antimicrobial stewardship program and the barriers for its implementation. Antimicrob Resist Infect Control. 2024;13(1):35. https://doi.org/10.1186/s13756-024-01382-9

31.

Higuita-Gutiérrez

Roncancio Villamil

Jiménez Quiceno

. Knowledge, attitude, and practice regarding antibiotic use and resistance among medical students in Colombia: a cross-sectional descriptive study. BMC Public Health. 2020;20(1):1861. https://doi.org/10.1186/s12889-020-09971-0

32.

Kandasamy

Sivanandy

Almaghaslah

, et al. Knowledge, attitude, perception and practice of antibiotics usage among the pharmacy students. Int J Clin Pract. 2020;74(11):e13599. https://doi.org/10.1111/ijcp.13599

33.

Al-Qerem

Hammad

Jarab

, et al. Knowledge, attitudes, and practice with respect to antibiotic use among pharmacy students: a cross-sectional study. Eur Rev Med Pharmacol Sci. 2022;26(10):3408–3418. https://doi.org/10.26355/eurrev_202205_28834

34.

Baddal

Lajunen

Sullman

MJM

. Knowledge, attitudes and behaviours regarding antibiotics use among Cypriot university students: a multi-disciplinary survey. BMC Med Educ. 2022;22(1):847. https://doi.org/10.1186/s12909-022-03853-2

35.

Lee

Psychological well-being of nurses with one to five years of clinical experience. SAGE Open Nurs. 2024;10 https://doi.org/10.1177/23779608241255300

36.

University of Kiel. G*Power. Version 3.1.9.7. (Software for Windows). University of Kiel; 17 March 2020 March 17.

37.

Thriemer

Katuala

Batoko

, et al. Antibiotic prescribing in DR Congo: a knowledge, attitude and practice survey among medical doctors and students. PLoS One. 2013;8(2):e55495. https://doi.org/10.1371/journal.pone.0055495

38.

Abbo

Cosgrove

Pottinger

, et al.

Medical students’ perceptions and knowledge about antimicrobial stewardship: how are we educating our future prescribers?

Clin Infect Dis. 2013;57(5):631–638. https://doi.org/10.1093/cid/cit370

39.

Dyar

Pulcini

Howard

, et al. European medical students: a first multicentre study of knowledge, attitudes and perceptions of antibiotic prescribing and antibiotic resistance. J Antimicrob Chemother. 2014;69(3):842–846. https://doi.org/10.1093/jac/dkt440

40.

World Health Organization. Antibiotic Resistance: Multi-Country Public Awareness Survey. World Health Organization; 2015.

41.

Dyar

Hills

Seitz

et al.

Assessing the knowledge, attitudes and behaviors of human and animal health students towards antibiotic use and resistance: a pilot cross-sectional study in the UK. Antibiotics (Basel). 2018;7(1):10. https://doi.org/10.3390/antibiotics7010010

42.

Zhuo

Labbate

Norris

, et al. Opportunities and challenges to improving antibiotic prescribing practices through a one health approach: results of a comparative survey of doctors, dentists and veterinarians in Australia. BMJ Open. 2018;8(3):e020439. https://doi.org/10.1136/bmjopen-2017-020439

43.

Gupta

Vohra

Raghav

. Assessment of knowledge, attitudes, and practices about antibiotic resistance among medical students in India. J Family Med Prim Care. 2019;8(9):2864. https://doi.org/10.4103/jfmpc.jfmpc_504_19

44.

Healthcare Infection Control Practices Advisory Committee (HICPAC). Antibiotic stewardship statement for Antibiotic Guidelines – Recommendations of the Healthcare Infection Control Practices Advisory Committee . 2016. Accessed June 14, 2024. https://www.cdc.gov/hicpac/media/pdfs/antibiotic-stewardship-statement-508.pdf

45.

El-Sokkary

Kishk

Mohy El-Din

, et al. Antibiotic use and resistance among prescribers: current status of knowledge, attitude, and practice in Egypt. Infect Drug Resist. 2021;14:1209–1218. https://doi.org/10.2147/IDR.S299453

46.

Alsayed

Darwish El Hajji

Al-Najjar

MAA

et al.

Patterns of antibiotic use, knowledge, and perceptions among different population categories: a comprehensive study based in Arabic countries. Saudi Pharm J. 2022;30(3):317–328. https://doi.org/10.1016/j.jsps.2022.01.013

47.

Yang

Xie

Chen

, et al. Knowledge, attitude, and practice about antibiotic use and antimicrobial resistance among nursing students in China: a cross sectional study. Infect Drug Resist. 2024;17:1085–1098. https://doi.org/10.2147/IDR.S454489

48.

IBM Corp. IBM SPSS Statistics, Version 20.0. (Software for Windows). New York: IBM Corp, 2011.

49.

Naser

Aboutaleb

Khaleel

, et al. Knowledge, attitude, and practices of pharmacy students in 7 Middle Eastern countries concerning antibiotic resistance: a cross-sectional study. Medicine (Baltimore). 2024;103(36):e39378. https://doi.org/10.1097/MD.0000000000039378

50.

Mubarak

Alwafi

Alharbi

, et al. Knowledge and attitude toward antibiotic prescription among dental students and interns at multiple universities in Saudi Arabia. Cureus. 2024;16(1):e51777. https://doi.org/10.7759/cureus.51777

51.

Mandal

Rauniyar

Rai

, et al.

Self-medication practice of antibiotics among medical and dental undergraduate students in a medical college in eastern Nepal: a descriptive cross-sectional study

. JNMA J Nepal Med Assoc. 2020;58(225):328–332. https://doi.org/10.31729/jnma.4914

52.

Ghimire

Banjara

Marasini

, et al. Antibiotics prescription, dispensing practices and antibiotic resistance pattern in common pathogens in Nepal: a narrative review. Microbiol Insights. 2023;16. https://doi.org/10.1177/11786361231167239

53.

Ministry of Health Warns Against Selling Antibiotics without Prescription. Saudi Arabian Ministry of Health. 2018. Accessed April 26, 2025. https://www.moh.gov.sa/en/Ministry/MediaCenter/News/Pages/news-2018-04-17-004.aspx

54.

Colombia’s experience with control of antimicrobial medicines sales. Pan American Health Organization / World Health Organization. Accessed April 26, 2025. https://www.paho.org/en/health-systems-and-services/colombias-experience-control-antimicrobial-medicines-sales

55.

Bu-Khamsin

Fabella

Al Abdullah

, et al. Association between awareness on antibiotic resistance and antibiotic misuse among Saudi university students. Open Public Health J. 2021;14(1):545–554. https://doi.org/10.2174/1874944502114010545

56.

Sobierajski

Mazińska

Wanke-Rytt

et al.

Knowledge-based attitudes of medical students in antibiotic therapy and antibiotic resistance. A cross-sectional study. Int J Environ Res Public Health. 2021;18(8):3930. https://doi.org/10.3390/ijerph18083930

57.

AbdEl-Aty

Amin

Ahmed

et al.

Exploring factors for antibiotic over-prescription in children with acute upper respiratory tract infections in Assiut, Egypt: a qualitative study. Antimicrob Resist Infect Control. 2024;13(1):2. https://doi.org/10.1186/s13756-023-01357-2

58.

Arnau-Sánchez

Jiménez-Guillén

Alcaraz-Quiñonero

, et al. Factors influencing inappropriate use of antibiotics in infants under 3 years of age in primary care: a qualitative study of the paediatricians’ perceptions. Antibiotics (Basel). 2023;12(4):727. https://doi.org/10.3390/antibiotics12040727

59.

Christensen

Haug

Berild

et al.

Factors affecting antibiotic prescription among hospital physicians in a low-antimicrobial-resistance country: a qualitative study. Antibiotics (Basel). 2022;11(1):98. https://doi.org/10.3390/antibiotics11010098

60.

Nukaly

Aljuhani

Alhartani

, et al. Knowledge of antibiotic use and resistance among medical students in Saudi Arabia. Adv Med Educ Pract. 2024;15:501–512. https://doi.org/10.2147/AMEP.S462490

61.

Horvat

Petrović

Kusturica

et al.

Survey of the knowledge, attitudes and practice towards antibiotic use among prospective antibiotic prescribers in Serbia. Antibiotics (Basel). 2022;11(8):1084. https://doi.org/10.3390/antibiotics11081084

62.

Abubakar

Muhammad

Sulaiman

SAS

et al.

Knowledge and self-confidence of antibiotic resistance, appropriate antibiotic therapy, and antibiotic stewardship among pharmacy undergraduate students in three Asian countries. Curr Pharm Teach Learn. 2020;12(3):265–273. https://doi.org/10.1016/j.cptl.2019.12.002

63.

Abdelkarim

Abubakar

Hussain

, et al. Knowledge, perception, and self-confidence of antibiotic resistance, appropriate antibiotic therapy, and antibiotic stewardship among undergraduate pharmacy students in Sudan. Infect Drug Resist. 2024;17:935–949. https://doi.org/10.2147/IDR.S435190

64.

Harris

Halpern

Whitsel

, et al. The National Longitudinal Study of Adolescent to Adult Health (Add Health), 1994-2018. Carolina Population Center, University of North Carolina at Chapel Hill; 2019. Accessed February 23, 2025. https://addhealth.cpc.unc.edu/

65.

Lundberg

Educational gender gaps. South Econ J. 2020;87(2):416–439. https://doi.org/10.1002/soej.12460

66.

Organisation for Economic Co-operation and Development (OECD). PISA 2022 Results (Volume I): Student Performance. OECD Publishing; 2023. Accessed February 23, 2025. https://www.oecd.org/pisa/publications/

67.

World Values Survey Association. World Values Survey: Round 7 (2017-2022). 2022. Accessed February 23, 2025. https://www.worldvaluessurvey.org/

68.

Organisation for Economic Co-operation and Development (OECD). Education at a Glance 2023: OECD Indicators. OECD Publishing; 2023. Accessed February 23, 2025. https://www.oecd.org/education/education-at-a-glance/

69.

Stoet

Geary

DC.

Gender differences in the pathways to higher education. Proc Natl Acad Sci USA. 2020;117(25):14073–14076. https://doi.org/10.1073/pnas.2002861117

70.

Welcome to the School of Pharmacy the University of Jordan. The University of Jordan. Accessed February 7, 2025: https://pharmacy.ju.edu.jo/Lists/FacultyAbstract/School_FacultyAbstract.aspx

71.

Horvat

Tomas

Kusturica

et al.

Serbian students’ knowledge, attitudes and behaviour towards antibiotic use: is there room for improvement?

Int J Public Health. 2020;65(8):1257–1267. https://doi.org/10.1007/s00038-020-01448-6

72.

Chen

Sidibi

Shen

, et al. Lack of antibiotic knowledge and misuse of antibiotics by medical students in Mali: a cross-sectional study. Expert Rev Anti Infect Ther. 2021;19(6):797–804. https://doi.org/10.1080/14787210.2021.1857731

73.

Elmahi

OKO

Musa

RAE

Shareef

AAH

, et al. Perception and practice of self-medication with antibiotics among medical students in Sudanese universities: a cross-sectional study. PLoS One. 2022;17(1):e0263067. https://doi.org/10.1371/journal.pone.0263067

74.

Sudan - Urban Issues. United Nations Habitat. Accessed February 6, 2025. https://unhabitat.org/sudan-urban-issues

75.

Bano

Gupta

Singh

, et al. Combatting antibiotic resistance: identifying gaps in knowledge, attitude, and practice among medical interns. Cureus. 2024;16(7):e64402. https://doi.org/10.7759/cureus.64402

76.

Emera

El-Baraky

Abbassi

et al.

Knowledge, attitude, and practice towards antibiotics use among medical sector final-year students in Egypt. Med Sci Educ. 2024;34(6):1369–1379. https://doi.org/10.1007/s40670-024-02117-6

77.

Bonna

Mazumder

Manna

, et al. Knowledge attitude and practice of antibiotic use among medical students in Bangladesh: a cross-sectional study. Health Sci Rep. 2024;7(9):e70030. https://doi.org/10.1002/hsr2.70030

78.

Lam

Leis

et al.

Implementing an antimicrobial stewardship medical student elective to impart good antibiotic prescribing habits early in medical training. Antimicrob Steward Healthc Epidemiol. 2023;3(1):e239. https://doi.org/10.1017/ash.2023.522

79.

Wiese-Posselt

Lâm

Schröder

, et al. Appropriate antibiotic use and antimicrobial resistance: knowledge, attitudes and behaviour of medical students and their needs and preferences for learning. Antimicrob Resist Infect Control. 2023;12(1):48. https://doi.org/10.1186/s13756-023-01251-x

80.

Study Plan for the Bachelor’s Degree in Doctor of Medicine. The University of Jordan. Accessed April 25, 2025. https://medicine.ju.edu.jo/Documents/Course%20Syllabus2024/%28MD%29Study%20Plan%20%28PDF%29.pdf

81.

Program Specifications - Doctor of Medicine (M.D). The University of Jordan. Accessed April 26, 2025. https://medicine.ju.edu.jo/Lists/ProgramSpecifications/School_ProgSpic_last_new.aspx?prog=56&categ=12

82.

Out-of-pocket expenditure per capita (current US$) - Bangladesh. The World Bank Group. 2025. Accessed April 27, 2025. https://data.worldbank.org/indicator/SH.XPD.OOPC.PC.CD?locations=BD

83.

Rani

Saha

Ferdous

et al.

Assessment of the Bangladeshi antibiotic market: implications of the WHO AWaRe classification and dosage form availability on antimicrobial resistance. J Infect Public Health 2024;17(12):102587. https://doi.org/10.1016/j.jiph.2024.102587

84.

Study Plan for the bachelor’s degree in Doctor of Pharmacy. The University of Jordan. Accessed April 27, 2025. https://pharmacy.ju.edu.jo/Documents/03%20PharmD%20in%20English%20%D8%AA%D8%B9%D8%AF%D9%8A%D9%84%202023.pdf

85.

Study Plan for the bachelor’s degree in Pharmacy. The University of Jordan. Accessed April 27, 2025. https://pharmacy.ju.edu.jo/StudyPlans/English%20Pharmacy%20study%20plan%202022.pdf

86.

Yuste

Matteo

ABD

Gruber

. Impact of Infectious Diseases training in the perception of antibiotic resistance and rational use of antibiotics among Spanish medical students – a cross-sectional study. BMC Med Educ. 2022;22(1):550. https://doi.org/10.1186/s12909-022-03580-8

87.

Hayat

Jamshed

Rosenthal

, et al. Understanding of pharmacy students towards antibiotic use, antibiotic resistance and antibiotic stewardship programs: a cross-sectional study from punjab, Pakistan. Antibiotics (Basel). 2021;10(1):66. https://doi.org/10.3390/antibiotics10010066

88.

Khan

Shah

, et al. Exploring undergraduate pharmacy students perspectives towards antibiotics use, antibiotic resistance, and antibiotic stewardship programs along with the pharmacy teachers’ perspectives: a mixed-methods study from Pakistan. Front Pharmacol. 2021;12. https://doi.org/10.3389/fphar.2021.754000

89.

Nisabwe

Brice

Umuhire

, et al. Knowledge and attitudes towards antibiotic use and resistance among undergraduate healthcare students at University of Rwanda. J Pharm Policy Pract. 2020;13(1):7. https://doi.org/10.1186/s40545-020-00207-5

90.

Pharmacy - facilities Jordan University of Science and Technology. Accessed February 6, 2025. https://www.just.edu.jo/FacultiesandDepartments/FacultyofPharmacy/Pages/Facilities.aspx

91.

Bajalan

Bui

Salvadori

, et al. Awareness regarding antimicrobial resistance and confidence to prescribe antibiotics in dentistry: a cross-continental student survey. Antimicrob Resist Infect Control. 2022;11(1):158. https://doi.org/10.1186/s13756-022-01192-x

92.

Thanissorn

Park

Wang

et al.

Australian dental students’ knowledge on antibiotics prophylaxis for dental procedures. BMC Oral Health. 2022;22(1):633. https://doi.org/10.1186/s12903-022-02660-x

93.

Holz

Naavaal

Stilianoudakis

et al.

Antibiotics and antimicrobial resistance: evaluation of the knowledge, attitude, and perception among students and faculty within US dental schools. J Dent Educ. 2021;85(3):383–391. https://doi.org/10.1002/jdd.12445

94.

Annamma

Varma

Abuttayem

, et al. Current challenges in dental education- a scoping review. BMC Med Educ. 2024;24:1523. https://doi.org/10.1186/s12909-024-06545-1

95.

Dogan

Toptanci

IR.

Dental students’ knowledge level regarding the use of antibiotics in endodontic infections in pediatric patients. Dent J. 2025;58(1):45–51. https://doi.org/10.20473/j.djmkg.v58.i1.p45-51

96.

Talkhan

Stewart

McIntosh

, et al. Exploring determinants of antimicrobial prescribing behaviour using the theoretical domains framework. Res Social Adm Pharm. 2024;20(4):401–410. https://doi.org/10.1016/j.sapharm.2023.12.009

97.

Barraclough

Patel

Grimes

et al . Interprofessional learning for dental and pharmacy professionals: learning together changes how you work together. Br Dent J. 2022;233(1):45–51. https://doi.org/10.1038/s41415-022-4402-8

98.

Chetty

Swe-Han

Mahabeer

et al.

Interprofessional education in antimicrobial stewardship, a collaborative effort. JAC Antimicrob Resist. 2024;6(2). https://doi.org/10.1093/jacamr/dlae054

99.

Catanzaro

MT.

Antibiotic stewardship for nurses: using e-learning modules to bridge the education gap. Antimicrob Steward Healthc Epidemiol. 2022;2(1):e7. https://doi.org/10.1017/ash.2021.216

100.

Schmid

Schlosser

Gülow

et al.

Interprofessional collaboration between ICU physicians, staff nurses, and hospital pharmacists optimizes antimicrobial treatment and improves quality of care and economic outcome. Antibiotics (Basel). 2022;11(3):381. https://doi.org/10.3390/antibiotics11030381

101.

von Elm

Altman

Egger

Pocock

Gotzsche

Vandenbroucke

. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies.

Supplementary Material

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Healthcare Students’ Knowledge,Attitudes,and Practices Related to Antibiotic Resistance and Use in Jordan: A Cross-Sectional Study

Abstract

Objectives

Methods

Results

Conclusions

Keywords

Introduction

Jordan's NAP

Health education research to curb antibiotic resistance

Methods

Study design and setting

Population and sample

Study instrument

Cut-off values of the knowledge, attitude, and practice mean scores

Validity and reliability assessment of the questionnaire

Data collection procedure and ethical considerations

Statistical analysis

Handling missing values

Results

Response rate

Baseline characteristics

Knowledge, attitudes, and practices of healthcare students

Knowledge

Attitudes

Practices

Relationships between students’ knowledge, attitudes, and practices and their sociodemographic characteristics and patterns of antibiotic use in the past year

Predictors of knowledge, attitudes, and practices

Discussion

Students’ knowledge, attitude, and practice scores

RSTIs

Regional and global patterns of inappropriate antibiotic use

Healthcare policies and legal frameworks

Jordan's regulatory landscape and challenges

Students’ perceptions of educational influences on their practices

Associations between baseline characteristics and mean knowledge, attitude, and practices

Gender disparities in education

Use of antibiotics within the past year

Multivariate regression analysis

Discordance between knowledge and practice

Interprofessional gaps across healthcare disciplines

Medical students

Pharm D and pharmacy students

Dental students

Limitations

Recommendations

Education

Public health policies

Research

Conclusion

Supplemental Material

sj-docx-2-mde-10.1177_23821205251344732 - Supplemental material for Healthcare Students’ Knowledge, Attitudes, and Practices Related to Antibiotic Resistance and Use in Jordan: A Cross-Sectional Study

Supplemental Material

sj-docx-4-mde-10.1177_23821205251344732 - Supplemental material for Healthcare Students’ Knowledge, Attitudes, and Practices Related to Antibiotic Resistance and Use in Jordan: A Cross-Sectional Study

Supplemental Material

sj-docx-5-mde-10.1177_23821205251344732 - Supplemental material for Healthcare Students’ Knowledge, Attitudes, and Practices Related to Antibiotic Resistance and Use in Jordan: A Cross-Sectional Study

Supplemental Material

sj-sav-6-mde-10.1177_23821205251344732 - Supplemental material for Healthcare Students’ Knowledge, Attitudes, and Practices Related to Antibiotic Resistance and Use in Jordan: A Cross-Sectional Study

Footnotes

Acknowledgments

Author Note

ORCID iDs

Ethical Considerations

Consent to Participate

Author Contributions

Funding

Declaration of Conflicting Interests

Data Availability Statement

Supplemental Material

References

Supplementary Material