ORIGINAL ARTICLE
Bali Medical Journal (Bali MedJ) 2025.
Volume 14.
Number 3 : 732-740 P-ISSN.
E-ISSN: 2302-2914
Factors associated with self-medication using antibiotics among adults in Saudi Arabia:
a cross-sectional study Department of Health Informatics.
College of Public Health and Health Informatics.
University of Hail.
Hail.
Saudi Arabia Department of Clinical Pharmacy.
College of Pharmacy.
Qassim University.
Qassim.
Saudi Arabia Community Pharmacy.
United Pharmaceutical Company.
Hail.
Saudi Arabia Department of Clinical Pharmacy.
College of Pharmacy.
King Khalid University.
Abha.
Saudi Arabia Department of Clinical Pharmacy (PharmD).
College of Pharmacy.
Taif University.
Taif.
Saudi Arabia Department of Clinical Pharmacy.
College of Pharmacy.
Umm Al-Qura University.
Makkah.
Saudi Arabia Department of Clinical Pharmacy.
College of Pharmacy.
Al Baha University.
Al Baha.
Saudi Arabia Pharmaceutical Care Department.
IV Pharmacist.
Armed Forces Hospital.
Southern Region.
Khamis Mushait.
Saudi Arabia Department of Pharmacy.
College of Pharmacy.
Shaqra University.
Shaqra.
Saudi Arabia Physical Therapy Department.
Alwatani Alshamil Center.
Jeddah.
Saudi Arabia Department of Clinical Pharmacy.
College of Pharmacy.
Taif University.
Taif.
Saudi Arabia Department of Clinical Pharmacy.
Ghodaf Medical Company.
Taif.
Saudi Arabia Department of Pharmacy.
College of Pharmacy.
Umm Al-Qura University.
Makkah.
Saudi Arabia Emergency Department.
King Fahd Military Medical Complex.
Dhahran.
Saudi Arabia Department of Clinical Pharmacy.
Dr.
Sulaiman Al Habib Medical Company.
Riyadh.
Saudi Arabia *Corresponding to:
Anas Ali Alhur.
Department of Health Informatics.
College of Public Health and Health Informatics.
University of Hail.
Hail.
Saudi Arabia.
alhur@gmail.
Received: 2025-09-12
Accepted: 2025-11-27
Published: 2025-12-28
INTRODUCTION
Antibiotic resistance has emerged as one of the most serious public health issues worldwide, placing increasing pressure on healthcare systems and limiting the effectiveness of widely used treatments.
A major contributor to this problem is the inappropriate use of antibiotics, particularly when individuals take Anas Ali Alhur1*.
Wejdan Mohammed Alharbi2.
Lama Altwalah3.
Jomanah Alghuwainem4.
Hala Algahtni5.
Sara Shabana6.
Seham Mufarreh7.
Shahad Alshahrani8.
Rawan Fayhan9.
Taif Almutairi10.
Mohammed Althomali11.
Raghad Almathkouri12.
Seham Alsuhaymi13.
Abdullah Alqahtani14.
Mohammed Alharbi15
ABSTRACT
Introduction: Self-medication with antibiotics is a common community practice that contributes to inappropriate use and antimicrobial resistance.
Despite regulatory policies in Saudi Arabia restricting non-prescription antibiotic sales, community-level access remains relatively easy, and misuse continues to be reported.
This study aimed to estimate the prevalence of antibiotic self-medication among adults in Saudi Arabia and identify associated demographic, behavioral, and perceptual predictors.
Methods: A cross-sectional online survey was conducted among adults aged Ou18 years or older residing in Saudi Arabia.
A structured questionnaire assessed sociodemographic characteristics, healthcare access, antibiotic knowledge, perceptions, and self-medication behavior.
Descriptive statistics summarized sample characteristics.
Bivariate analyses (NA, t-test, point-biserial correlatio.
examined crude associations, and multivariable logistic regression identified independent predictors.
Internal reliability was assessed using CronbachAos alpha, and model diagnostics included variance inflation factors (VIF).
HosmerAeLemeshow goodness-of-fit, and Nagelkerke RA.
Results: A total of 523 respondents participated.
1% reported using antibiotics without a prescription in the past 12 months.
Individuals who self-medicated had significantly lower antibiotic knowledge scores than non-users .
74 vs.
p < 0.
After adjustment, higher knowledge remained protective .
OR = 0.
73, 95% CI
58Ae0.
, while perceiving antibiotics as easy to obtain increased the odds nearly twofold .
OR = 1.
89, 95% CI
20Ae2.
Support for stricter regulations was associated with lower odds of self-medication .
OR = 0.
58, 95%
CI 0.
36Ae0.
Model diagnostics showed no multicollinearity .
ll VIF < 2.
and acceptable model fit (HosmerAe Lemeshow p = 0.
Findings were consistent across gender and education subgroups.
Conclusion: Self-medication with antibiotics remains widespread among adults in Saudi Arabia.
Knowledge, accessibility perceptions, and regulatory attitudes are key determinants of misuse.
Strengthening public awareness, improving enforcement of prescription-only policies, and supporting community-based antimicrobial stewardship may help reduce inappropriate antibiotic use.
Keywords: antibiotics.
antimicrobial resistance.
cross-sectional study.
Saudi Arabia.
self-medication.
Cite This Article: Alhur.
Alharbi.
Altwalah.
Alghuwainem.
Algahtni.
Shabana.
Mufarreh, .
Alshahrani.
Fayhan.
Almutairi.
Althomali.
Almathkouri.
Alsuhaymi.
Alqahtani.
Alharbi.
Factors associated with self-medication using antibiotics among adults in Saudi Arabia: a cross-sectional Bali Medical Journal 14.
:732-740.
DOI: 10.
15562/bmj.
them without medical guidance or a 1Ae5 Self-medication with antibiotics (SMA) often occurs when people rely on previous personal experiences, recommendations from family members, or leftover medications at home.
4Ae6 Although this approach may appear convenient, it exposes individuals to risks such as using antibiotics for non-bacterial illnesses, taking incorrect dosages, or discontinuing treatment prematurely, all of which contribute to antimicrobial resistance.
International studies consistently report that SMA is a common practice, especially in communities where antibiotics remain readily accessible without stringent regulation.
7Ae10 In many Middle Eastern countries, including Saudi Arabia, social norms favor self-care, and Bali Medical Journal 2025.
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ORIGINAL ARTICLE
misconceptions about antibiotics persist.
For example, many individuals mistakenly believe that antibiotics are effective for viral infections such as colds or influenza, a trend documented in regional and local 11,12 These practices continue despite accumulating evidence linking inappropriate antibiotic use to rising resistance patterns.
In Saudi Arabia.
SMA remains widespread despite the Ministry of Health policies banning the sale of antibiotics without a prescription.
13,14 Several investigations from different regions of the country, including Riyadh.
Dammam.
Medina, and Al-Baha, report SMA prevalence ranging between 30% and 4,10,15 These studies highlight recurring themes: limited public knowledge about appropriate antibiotic use, previous personal success with antibiotics, easy access to antibiotics from community pharmacies, and social influence from friends or relatives.
13,14,16,17 Recent findings by Morsy18 and Malli et al.
14 indicate that even university and healthcare students engage in SMA, suggesting that increased educational attainment alone may not be sufficient to prevent misuse.
While existing evidence outlines the scope of SMA in Saudi Arabia, many studies have focused on specific groups or basic descriptive patterns.
There is limited research that examines how antibiotic knowledge, perceptions of accessibility, and attitudes toward regulation collectively influence SMA among the broader adult Previous Saudi studies rarely incorporate multivariable approaches or explore indirect relationships, such as whether the perception of easy access mediates the effect of knowledge on antibiotic use.
With continuing to rise nationally and globally, and with community-level misuse still prevalent in Saudi Arabia despite regulatory actions, further investigation is urgently needed.
Understanding how knowledge, access, and regulatory perceptions contribute to SMA can support national strategies aimed at promoting responsible antibiotic use.
Therefore, this study aims to assess the prevalence of SMA among adults in Saudi Arabia and to identify the key factors associated with this practice through a combination of descriptive, bivariate, multivariable, and exploratory mediation analyses.
METHODS
Study Design and Setting This study used a cross-sectional survey design to explore factors associated with self-medication with antibiotics among adults in Saudi Arabia.
Data were collected between May and August 2025 through an online questionnaire.
The digital format allowed participants from various regions of the Kingdom to access the survey easily and anonymously.
Study Population and Sampling The target population consisted of Saudi adults aged 18 years and above living in Saudi Arabia during the study period.
Individuals employed in clinical, pharmacy, or health-related fields were excluded to avoid bias related to professional antibiotic knowledge.
Convenience sampling was used due to the online distribution method, which is commonly applied in community-based public health studies.
To ensure adequate statistical power, the sample size was calculated using CochranAos formula, assuming a 50% expected prevalence of self-medication, a 5% margin of error, and a 95% confidence The minimum required sample was 384 participants.
however, 523 adults completed the survey, increasing the precision of the estimates.
Development and Validation of the Questionnaire The questionnaire was developed based on previous research examining antibiotic use, self-medication practices, and antimicrobial resistance in Saudi Arabia and other Middle Eastern It included four main sections, .
consent statement: confirming voluntary, anonymous participation, .
sociodemographic information: including age, gender, marital status, education, employment, income, chronic disease status, and health insurance coverage, .
health behaviors and antibiotic knowledge:
covering physician visits, beliefs about antibiotic effectiveness, awareness of resistance development, and attitudes Bali Medical Journal 2025.
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toward using leftover antibiotics, and .
self-medication practices: including use of antibiotics without a prescription, frequency, reasons, conditions treated, sources, and perceptions of accessibility.
The survey was available in Arabic and English.
Three experts in public health and pharmacy practice reviewed the questionnaire for clarity and content A pilot test with 25 adults was conducted to assess comprehension and Minor adjustments were made based on feedback, and pilot responses were excluded from the final analysis.
Ethical Approval and Consent The study received formal approval from the Ministry of Health Institutional Review Board.
Ethical Approval Number:
H-2025-1735 (Central IRB Ae Ministry of Health.
Saudi Arabi.
Electronic informed consent was obtained from each participant before accessing the Participation was voluntary, anonymous, and no identifying data were Data Collection Procedures The survey was distributed through widely used social media platforms, including WhatsApp.
Twitter, and Telegram, to reach adults across different age groups and regions.
Participants were encouraged to answer independently and honestly.
The data collection system prevented multiple submissions from the same device to reduce duplication.
Several steps were taken to minimize potential bias throughout the study.
Anonymity and neutral question wording helped reduce information and social desirability Recall bias was minimized by limiting antibiotic-use questions to the previous 12 months.
Measurement bias was reduced through expert review, translation validation, and pilot testing.
During analysis, multicollinearity between predictors was assessed using variance inflation factors.
Statistical Analysis Data were exported from Google Forms into Microsoft Excel and then analyzed using IBM SPSS Statistics version 29.
Descriptive percentages, means, and standard
ORIGINAL ARTICLE
deviations were calculated for all relevant Bivariate associations were examined using NA tests for categorical variables.
Independent-samples t-tests for continuous variables, and pointbiserial correlation where appropriate.
multivariable binary logistic regression model was then constructed to identify independent predictors of antibiotic selfmedication.
Only complete cases were included in the model.
Knowledge scores and perception variables were entered as predictors along with relevant demographic Model diagnostics included the HosmerAeLemeshow goodness-of-fit test, variance inflation factors to assess collinearity, and Nagelkerke RA to evaluate explanatory power.
Internal consistency for knowledge and perception items was assessed using CronbachAos alpha.
Table 1.
RESULTS
Monthly household income (SAR) A total of 523 respondents completed the survey.
As shown in Table 1, most participants were aged 25Ae34 years .
6%), followed by those aged 18Ae24 years .
5%).
Females represented 59.
of the sample.
Slightly more than half of the participants were single .
1%), while 2% were married.
Regarding education, 62.
0% held a bachelorAos degree, and 21.
4% had postgraduate qualifications.
Over half of respondents were employed .
6%).
Monthly household income was fairly distributed across income categories, 0% earning 10000Ae14999 SAR 3% earning Ou 15 000 SAR.
Chronic disease was reported by 23.
3% of participants, and two-thirds .
5%) had medical insurance coverage.
As shown in Table 2, the majority of respondents .
4%) visited a physician at least once in the previous 12 months, 8% reported no medical visits.
Knowledge of antibiotic use and resistance varied considerably.
Only 36.
7% correctly recognized that antibiotics are not effective against viral infections such as colds or Most participants .
understood that incomplete antibiotic courses can contribute to antimicrobial Similarly, 59.
8% correctly disagreed that using leftover antibiotics is safe if symptoms are similar.
Overall, while awareness of antibiotic resistance Sociodemographic and health characteristics of respondents (N = .
Variables Category Age .
18Ae24 25Ae34 35Ae44 Ou 45 Male Female Single Married Other High school or below BachelorAos degree Postgraduate degree Employed Unemployed/Student/ Homemaker < 5000 5000Ae9999 10000Ae14999 Ou 15000 Yes Yes Gender Marital status Education level Employment status Chronic disease Medical insurance coverage Note: Percentages are rounded to one decimal.
Table 2.
Healthcare access and antibiotic knowledge (N = .
Item Response Q9.
Frequency of physician visits in the past 12 months Once or twice 3Ae5 times > 5 times None True False .
True .
False True False .
Q10.
AuAntibiotics are effective against viral Ay Q11.
AuIncomplete antibiotic course can lead to resistance.
Ay Q12.
AuUsing leftover antibiotics is safe if symptoms are similar.
Ay was relatively high, misconceptions about antibiotic indications remained common.
Of the total respondents, 42.
reported that they had used antibiotics without a medical prescription, while 9 % indicated that they had never done so (Figure .
This finding suggests that nearly two out of every five adults in the sample engaged in non-prescribed antibiotic use, highlighting the continued challenge of antibiotic misuse in the Bali Medical Journal 2025.
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Among those who reported selfmedication, the frequency of antibiotic use varied during the previous 12 months.
As shown in Figure 2, 18.
4 % reported self-medicating once, 14.
0 % used antibiotics two to three times, and 9.
% used them more than three times.
contrast, 57.
9 % of respondents reported no use of antibiotics without prescription during the same period.
Together, these findings indicate that while antibiotic selfmedication remains prevalent, repeated or habitual use is comparatively less common.
Detailed patterns of SMA are summarized in Table 3.
The most common self-treated conditions were upperrespiratory complaints such as colds, sore throats, and flu .
4%), followed by gastrointestinal problems .
8%), urinary tract infections .
5%), and dental or gum infections .
9%).
Community pharmacies were the principal source of antibiotics .
3%), followed by family or friends .
7%) and leftover medicines .
4%).
The leading motivations for selfmedication included avoiding consultation costs .
2%) and saving time .
7%).
Previous successful experiences .
and advice from relatives or friends .
1%) also contributed substantially.
These findings emphasize that SMA in Saudi Arabia is largely convenience-driven and reinforced by easy antibiotic access through pharmacies and social networks.
ParticipantsAo perceptions regarding antibiotic regulation and awareness are presented in Table 4.
More than half of respondents .
3%) either strongly agreed or agreed that antibiotics can be obtained too easily in Saudi Arabia, reflecting a broad public perception of weak control over antibiotic sales.
About one-quarter .
7%) remained neutral, while only a small proportion .
0%) disagreed or strongly disagreed with this statement.
A strong majority .
3%) supported stricter enforcement of prescription-only antibiotic sales, whereas one-third .
did not perceive additional regulation as This indicates general public approval for tighter control and monitoring of antibiotic dispensing practices.
Regarding willingness to participate in educational interventions, approximately half of the respondents .
7%) expressed readiness to attend awareness sessions about appropriate antibiotic use.
However.
Figure 1.
Figure 2.
Distribution of self-medication with antibiotics among participants (N = .
Frequency of self-medication with antibiotics in the past 12 months among participants (N = .
nearly the same proportion .
3%) were unwilling, suggesting mixed levels of motivation for engaging in educational or behavioral change programs.
The relationship between antibiotic knowledge and self-medication behavior is summarized in Table 5.
Participants who reported self-medicating with antibiotics had a significantly lower mean Bali Medical Journal 2025.
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knowledge score .
74 A 0.
compared with those who did not self-medicate .
A 0.
The mean difference of Ae0.
54 was statistically significant .
< 0.
Bivariate NA tests were conducted to explore the unadjusted relationships between self-medication with antibiotics and key demographic and attitudinal variables (Table .
Among the examined ORIGINAL ARTICLE factors, perceived ease of antibiotic access and support for stricter enforcement of prescription-only sales were the only variables showing statistically significant self-medication Participants who agreed that antibiotics are easily obtainable without a prescription were significantly more likely to self-medicate (NA = 12.
53, p = 0.
Conversely, those who supported stricter regulatory enforcement were less likely to engage in self-medication (NA = 9.
87, p = The multivariable binary logistic regression model (Table .
examined independent predictors of self-medication with antibiotics among 423 respondents who provided complete data.
The overall model was statistically significant (NA = 31.
07, p < 0.
and demonstrated acceptable fit (Nagelkerke RA = 0.
indicating that the included variables explained approximately 5.
5 % of the variance in self-medication behavior.
After adjusting for all covariates, three factors were significantly associated with antibiotic self-medication.
Participants with higher antibiotic knowledge scores were significantly less likely to self-medicate .
OR = 0.
95%CI 0.
58Ae0.
91, p = 0.
, showing that better understanding of appropriate antibiotic use reduced the odds of misuse by approximately 27%.
Conversely, those who perceived antibiotics as easy to obtain were almost twice as likely to self-medicate compared with those who disagreed with this statement .
OR = 1.
89, 95%CI 1.
20Ae 97, p = 0.
In contrast, respondents who supported stricter enforcement of prescription-only sales had significantly lower odds of self-medication .
OR = 58, 95%CI 0.
36Ae0.
92, p = 0.
Employment status, chronic disease, and medical insurance coverage were not statistically significant predictors .
> The direction of their associations, however, suggested that employed and insured participants were slightly less likely to self-medicate, whereas those with chronic diseases had higher but nonsignificant odds of doing so.
Model diagnostics were performed to evaluate the validity and reliability of the logistic regression model (Table .
Variance Inflation Factor (VIF) values for Table 3.
Patterns of self-medication: conditions, sources, and reasons (N = .
Item Option Conditions treated without prescription (Q.
Sources of antibiotics (Q.
Reasons for self-medication (Q.
Table 4.
Cold / flu / sore throat Diarrhea/stomach upset Urinary tract infection Dental or gum infection Community pharmacy Family or friends Leftovers from the previous Avoiding doctor consultation Convenience/saving time Previous successful experience Influence from family or Perceptions and willingness toward antibiotic regulation and awareness (N = .
Item Response Strongly agree Agree Neutral Disagree Strongly disagree Q19.
Stricter enforcement of prescriptiononly sales is necessary Yes Q20.
Willing to attend awareness sessions on appropriate antibiotic use Yes Q18.
Antibiotics can be obtained too easily in Saudi Arabia Table 5.
Association between knowledge score and self-medication with antibiotics (N = .
Statistic Value Mean knowledge score (Self-medicated = Ye.
74 A 0.
Mean knowledge score (Self-medicated = N.
28 A 0.
Mean difference Oe0.
p-value < 0.
Point-biserial correlation .
Oe0.
all predictors were below 2.
0, indicating the absence of multicollinearity and confirming that independent variables were statistically distinct.
The HosmerAeLemeshow goodnessof-fit test showed a non-significant result (NA = 7.
63, df = 8, p = 0.
, suggesting that the model fit the data well and that the predicted probabilities corresponded closely to observed outcomes.
The Nagelkerke RA value of 0.
055 indicated that the model explained approximately 5% of the variance in self-medication behavior, an expected range for behavioral and knowledge-based public health Overall, the model was statistically Bali Medical Journal 2025.
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ORIGINAL ARTICLE
significant (Likelihood Ratio NA = 31.
07, p < 0.
An exploratory mediation analysis was conducted to examine whether perceived ease of antibiotic access mediated the relationship between antibiotic knowledge and self-medication behavior (Table The analysis revealed a statistically significant indirect effect of knowledge on self-medication through perceived accessibility .
stimate = Ae0.
065, boot SE = 0.
021, 95%CI = Ae0.
109 to Ae0.
The direct effect of knowledge on selfmedication remained significant after accounting for the mediator .
stimate = Ae0.
312, boot SE = 0.
086, 95%CI = Ae0.
to Ae0.
Among males, higher antibiotic knowledge was significantly associated with lower odds of self-medication .
OR = 0.
71, 95%CI 0.
52Ae0.
96, p = 0.
, while perceiving antibiotics as easy to obtain nearly doubled the odds of self-medication .
OR = 2.
01, 95%CI 1.
11Ae3.
63, p = Supporting stricter enforcement of prescription-only regulations showed a protective but borderline-significant association .
OR = 0.
61, 95%CI 0.
35Ae1.
p = 0.
Similarly, among females, knowledge remained a significant protective factor .
OR = 0.
76, 95%CI 0.
59Ae0.
98, p = 0.
and perceived ease of antibiotic access remained a strong positive predictor .
OR = 1.
82, 95%CI 1.
10Ae3.
01, p = 0.
Support for stricter enforcement also demonstrated a significant protective effect .
OR = 0.
58, 95%CI 0.
33Ae1.
00, p = Among participants with higher education .
achelorAos degree or abov.
, greater antibiotic knowledge was significantly associated with reduced odds of self-medication .
OR = 0.
95%CI 0.
56Ae0.
93, p = 0.
Similarly, perceiving antibiotics as easily obtainable significantly increased the likelihood of self-medication .
OR = 1.
88, 95%CI
14Ae3.
09, p = 0.
Support for stricter enforcement of prescription-only policies showed a protective effect, reaching the threshold of statistical significance .
OR = 60, 95%CI 0.
36Ae1.
00, p = 0.
Among participants with lower education .
igh school or belo.
, the same directional relationships were observed Table 6.
Bivariate NA tests for associations with self-medication (N = .
Variable NA p-value Gender (Male/Femal.
Education (High vs.
Lo.
Employment status Chronic disease (Yes/N.
Medical insurance (Yes/N.
Perceived ease of antibiotic access (Agree/Disagre.
Supports stricter enforcement (Yes/N.
*p<0.
05 is significant Table 7.
Binary logistic regression analysis of factors associated with self-medication using antibiotics (N = .
Predictor
95% CI
p-value Employment status (Employed = .
52 Ae 1.
Chronic disease (Yes = .
91 Ae 2.
Medical insurance (Yes = .
48 Ae 1.
Knowledge score .
Ae.
58 Ae 0.
Perceives antibiotics as easy to obtain (Agree = .
20 Ae 2.
Supports stricter enforcement (Yes = .
36 Ae 0.
Table 8.
Model diagnostics: Multicollinearity and model fit Diagnostic Result Interpretation All predictors < 2.
No multicollinearity detected HosmerAeLemeshow NA 8 df, p = 0.
Nagelkerke RA 5% variance explained Likelihood Ratio NA = 31.
p < 0.
Model significant overall Variance Inflation Factors (VIF) Model significance Table 9.
Exploratory mediation analysis Effect Estimate .
og-odd.
Boot SE 95% CI Interpretation Indirect effect .
Oe0.
Oe0.
109 Ae (Oe0.
Significant mediation Direct effect .
A) Oe0.
Oe0.
481 Ae (Oe0.
Remains significant Table 10.
Stratified logistic regression analyses based on gender Male .
= .
aOR .
% CI] Female .
= .
aOR .
% CI] Knowledge score .
Ae.
52Ae0.
59Ae0.
Easy access (Agree = .
11Ae3.
10Ae3.
Enforcement need (Yes = .
35Ae1.
33Ae1.
Predictor Bali Medical Journal 2025.
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but did not reach conventional significance Knowledge remained protective .
OR = 0.
75, 95%CI 0.
49Ae1.
14, p = 0.
while perceived ease of access remained a risk factor approaching significance .
OR = 1.
95, 95%CI 1.
00Ae3.
80, p = 0.
Support for stricter enforcement also trended toward a protective association .
OR = 0.
62, 95%CI 0.
33Ae1.
15, p = 0.
Figure 3 presents adjusted odds ratios .
OR) with 95% confidence intervals for three key predictors, knowledge score, perceived ease of antibiotic access, and support for enforcement policies, separately for male and female participants.
Table 11.
Stratified logistic regression analyses based on education level Predictor High education .
= .
aOR .
% CI] Low education .
= .
aOR .
% CI] Knowledge score .
Ae.
56Ae0.
49Ae1.
Easy access (Agree = .
14Ae3.
00Ae3.
Enforcement need (Yes = .
36Ae1.
33Ae1.
DISCUSSION
This study examined the prevalence and determinants of self-medication with antibiotics (SMA) among adults in Saudi Arabia.
The findings indicate that SMA remains highly prevalent .
1%),
confirming that antibiotic misuse continues to represent a major public health challenge in the Kingdom despite ongoing regulatory and educational The patterns observed align with national and international literature, highlighting that antibiotic misuse is sustained by inadequate knowledge, easy access, and social normalization of selftreatment.
1Ae5 The current prevalence aligns closely with several reports in Riyadh1,3,5.
Dammam2.
Medina10, and Al-Baha13 regions, where SMA rates have ranged from 35% to 60%.
Similar proportions were documented in systematic reviews of Saudi and global populations17.
Alghamdi et al.
13 and Alrasheed et al.
3 both noted that SMA continues to occur across all age groups and educational levels, suggesting that misuse is deeply ingrained in community health behavior.
Recent evidence by Morsy18 and Malli et al.
further confirms that this behavior persists even among health-educated individuals, including university and healthcare students, underscoring the limited impact of existing awareness campaigns.
Low antibiotic knowledge emerged as a key predictor of SMA in this study, antibioticsAo role in viral infections and incomplete treatment courses.
These findings are consistent with earlier work by Figure 3.
Stratified logistic regression by gender showing adjusted odds ratios .
OR) and 95% confidence intervals for predictors of self-medication with antibiotics.
Al-Shibani et al.
Albusalih et al2, and AlMehmadi et al.
4, who demonstrated that knowledge gaps and inappropriate storage of leftover antibiotics were common across the Saudi population.
Similarly, a recent cross-sectional study by Al-Mehmadi et al.
4 and an updated national review7 reaffirmed that poor understanding of antibiotic resistance remains widespread.
Internationally, comparable associations have been observed in meta-analyses from university settings in the Middle East and North Africa, highlighting the universality of this behavioral determinant.
The observed negative correlation between knowledge score and selfmedication supports behavioral models suggesting that cognitive awareness is central to rational antibiotic use.
BuKhamsin et al.
11 reported that higher antibiotic literacy was protective against misuse among university students.
Knowledge shapes attitudes and perceived control, thereby influencing intention and The mediation effect identified in this study strengthens this framework by demonstrating that knowledge indirectly reduces SMA through perceptions of Despite the 2018 Saudi Ministry of Health directive banning non-prescription antibiotic sales, the persistence of SMA reflects ongoing access through community pharmacies.
This is consistent with reports by Alghamdi et al.
13 and Hafez et al.
21, which documented that antibiotics remain easily obtainable without prescription in Saudi Arabia and other Arab countries.
Alrasheed et al.
22 recently emphasized the role of pharmacists as key stakeholders in controlling antibiotic misuse, showing that targeted pharmacist interventions can significantly reduce inappropriate sales.
Likewise.
Alghamdi et al.
13 found that individuals obtaining antibiotics directly from pharmacies were less likely to receive appropriate guidance on dosage or duration.
The perception of antibiotics as Autoo easy to obtainAy was strongly associated Bali Medical Journal 2025.
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ORIGINAL ARTICLE
with SMA in this study.
Similar findings were reported by Allam et al.
10 in Medina and by Nazari et al.
15 in broader Middle Eastern populations.
Participants who favored stricter enforcement were less likely to self-medicate, reinforcing that regulatory trust and compliance attitudes influence antibiotic behavior.
Globally.
Xu et al.
20 and Gebregziabher et al.
16 observed that even in regions with restrictive laws, weak enforcement mechanisms, and cultural acceptance of self-care perpetuate Consistent with prior Saudi and regional studies1Ae5, demographic factors such as gender, age, and income were not significant predictors once knowledge and attitudes were controlled for.
However, stratified analysis revealed slightly stronger protective effects of knowledge among women and those with higher education, echoing findings from Behzadifar et 6 These results suggest that antibiotic literacy, rather than sociodemographic status alone, drives behavioral change.
The persistence of SMA despite national interventions highlights the need for integrated and sustainable Public awareness campaigns must extend beyond information dissemination to include behavioral insights and culturally tailored messaging.
As recommended by the WHOAos Global Action Plan on Antimicrobial Resistance, education should target both the public and healthcare professionals.
Engaging pharmacists as community educators, as proposed by Alrasheed et al.
22, and leveraging digital health tools to monitor and regulate dispensing, in alignment with Vision 2030 priorities, could provide sustainable solutions.
Moreover, lessons from international systematic reviews20 and regional collaborations3 indicate that successful antimicrobial stewardship depends on multi-sectoral governance, linking public health education, pharmacy regulation, and digital reporting systems.
This study contributes to the growing Saudi literature by applying multivariable, mediation, and stratified analyses to identify both direct and indirect pathways influencing SMA.
Nonetheless, its cross-sectional nature precludes causal inference, and reliance on selfreported data may introduce bias.
Future longitudinal studies should explore causal pathways and assess the impact of digital awareness interventions and pharmacybased regulatory audits.
This study provides updated national evidence on SMA in Saudi Arabia and applies multivariable, mediation, and stratified analyses to understand behavioral drivers.
The questionnaire underwent expert review and pilot testing, enhancing its validity.
However, the cross-sectional design limits causal interpretation, and the convenience sampling limits generalizability.
Selfreported data may also introduce recall or desirability bias.
Future studies using probability sampling and longitudinal designs are recommended.
CONCLUSION
Self-medication with antibiotics remains a persistent problem in Saudi Arabia, underpinned by low public knowledge, easy access to antibiotics, and limited enforcement of prescription policies.
Interventions should integrate educational, regulatory, and behavioral components, supported by pharmacists, clinicians, and digital health initiatives.
A sustained national strategy, anchored in evidence from both Saudi and global contexts, is essential to curb antibiotic misuse and preserve antimicrobial efficacy.
AUTHOR CONTRIBUTIONS
A Conceptualization: Anas Ali Alhur.
Jomanah Alghuwainem A Methodology: Anas Ali Alhur.
Hala Algahtni A Validation: Sara Shabana.
Nermeen Alqadi A Formal Analysis: Anas Ali Alhur A Investigation: Seham Mufarreh.
Lama Musa A Data Curation: Shahad Alshahrani.
Rawan Fayhan A Writing Ae Original Draft: Anas Ali Alhur.
Taif Almutairi A Writing Ae Review & Editing:
Mohammed Althomali.
Raghad Almathkouri.
Seham Alsuhaymi A Visualization: Abdullah Alqahtani A Supervision: Mohammed Alharbi A Project Administration: Mohammed Alharbi Bali Medical Journal 2025.
: 732-740 | doi: 10.
15562/bmj.
FUNDING
This research received no external funding.
ETHICAL APPROVAL AND
INFORMED CONSENT
This study received ethical approval from the Ministry of Health Institutional Review Board.
Saudi Arabia (IRB Approval No: H-2025-1.
All participants provided electronic informed consent prior to completing the questionnaire.
Participation was voluntary, anonymous, and no identifying information was CONFLICT OF INTEREST The authors declare no conflicts of interest related to this study.
REFERENCE