Psychological and Behavioral Factors Associated with Antibiotic Use and Perceptions of Antimicrobial Resistance among University Students in Sialkot, Pakistan

Abstract

Antimicrobial resistance (AMR) is influenced not only by microbial factors but also by human decisions regarding antibiotic use. Understanding the psychological and behavioral determinants of inappropriate antibiotic use is crucial for strengthening antimicrobial stewardship. This study assessed antibiotic-related attitudes, AMR risk perception, and antibiotic-use behaviors among university students in Sialkot, Pakistan, focusing on the knowledge-attitude-behavior gap. A cross-sectional online questionnaire was completed between 19 and 27 June 2026 by 506 respondents (293 females, 57.9%; 213 males, 42.1%). The questionnaire assessed demographics, antibiotic related knowledge, attitudes, AMR perceptions. Descriptive frequencies and percentages were calculated and chi-square test examined gender differences in behaviors. Participants showed favourable attitude towards responsible antibiotic use, with all respondents agreeing that doctors should prescribe antibiotics only when clinically necessary. However, inappropriate practices remained common. Non-prescription antibiotic use was reported by 55.3% of females and 75.1% of males (χ² = 20.89, p < 0.001) while premature discontinuation after fever subsided was reported by 80.9% and 91.5% respectively. Concern about AMR affecting themselves or family members was reported by 64.6% females and 72.8% males. Healthcare professionals were the main source of AMR information (31.4% females;52.1% male), while university education was prominent among females (22.9% vs.12.7%). Overall, a clear knowledge-attitude behavior gap was evident as favorable attitudes and AMR concern did not consistently translate into appropriate antibiotic-use practices. These findings highlight the need for university-based behavioral interventions addressing risk perception, social influences, perceived behavioral control, and treatment adherence alongside conventional awareness-raising approaches to promote responsible antibiotic use.