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Article

Adherence to Antibacterial Therapy and Associated Factors in Lower Respiratory Infections in War-Affected Areas: A Randomized Controlled Trial

by
Faiz Ullah Khan
1,2,3,
Farman Ullah Khan
1,4,
Haishaerjiang Wushouer
2,3,
Luwen Shi
2,3 and
Yu Fang
1,*
1
Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an 710061, China
2
Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China
3
International Research Centre for Medicinal Administration (IRCMA), Peking University, Beijing 100191, China
4
Department of Pharmacy Practice, Faculty of Pharmacy, Capital University of Science and Technology, Islamabad 46000, Pakistan
*
Author to whom correspondence should be addressed.
Antibiotics 2025, 14(10), 977; https://doi.org/10.3390/antibiotics14100977 (registering DOI)
Submission received: 27 June 2025 / Revised: 12 August 2025 / Accepted: 16 August 2025 / Published: 27 September 2025
(This article belongs to the Section Antibiotics Use and Antimicrobial Stewardship)
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Abstract

Background: Lower respiratory tract infections (LRTIs) are one of the leading causes of mortality. Pharmacist-led interventions can enhance adherence to antibiotics; the present study aims to determine adherence to the antibiotics prescribed for LRTIs and related factors. Methods: An individual randomized controlled trial was conducted with 1:1 (intervention = 205, control = 205) participants aged >18 years. The primary outcomes included adherence to therapy at weeks 1 and 2, awareness of antibiotic use, and appropriate discontinuation as prescribed. The secondary outcome measures were the overall clinical outcomes of the therapy and the effectiveness of educational interventions assessed at the final week 7 (overall assessment checked and treatment was not continued). The data were analyzed using different statistical methods, including descriptive statistics for data summarization, and inferential techniques were used. Results: Finally, 187 patients remained in the intervention group, and a total (n = 18) lost to follow-up. The awareness was significantly increased through pharmacist-led interventions (n = 106, 56.7%; p = 0.01), along with the factors leading to antibiotic resistance knowledge. Overall, adherence to antibacterial therapy for the LRTIs has improved (p ≤ 0.01), and a significant correlation exists between overall MMAS-8 mean scores and other demographic factors; interventions improved [0.441–2.151] with adherence (post-intervention). Higher adherence was found (p ≤ 0.05) among the participants in the intervention group compared to the control group and with (OR: 1.050; CI: 0.150–1.024) demographics (education, p = 0.05). Conclusions: Overall, the intervention group showed better awareness, understanding, and attitudes about antibiotics, and their adherence to antibiotic therapy improved significantly, along with the overall clinical outcomes.

1. Introduction

Lower respiratory tract infections (LRTIs) are still among the most prevalent diseases in the world, even though they are primarily preventable causes of death [1]. LRTI is the fifth-leading cause of death and the main contributor to disability-adjusted life years (DALYs) [1,2,3]. Age, poor socioeconomic situation, low birth weight, air pollution, congestion, malnutrition, and insufficient vaccination are all significant risk factors related to LRTI prevalence [4]. The epidemiology of LRTIs has changed significantly among individuals over the age of 70 in the past ten years [5]. Global research studies from diverse territories, including North America, Latin America, Europe, and the Asia-Pacific region, illustrate that the infections caused by CAP (community-acquired pneumonia) were discovered to primarily include resistance in S. pneumoniae [6,7]. Controlling the inappropriate use of antibiotics is one strategy to combat the decline in antibiotic effectiveness brought on by resistance [8]. An effort known as antimicrobial stewardship (AMS) seeks to encourage the responsible and safe use of antibiotics without compromising patient quality of life [9].
Educational interventions can improve the prescription, distribution, and/or use of antibiotics, which are frequently used as part of a combination of treatments. Community-based educational programmes increased knowledge and attitudes around the use of antibiotics and reduced the rates of antibiotic prescriptions [10]. Furthermore, the subject matter has not received much attention in Pakistan, particularly when it comes to thorough education initiatives for patients who visit pharmacies to increase adherence to antibiotic treatment and reduce needless medication storage in the home [11,12]. According to recent studies, pharmacy care services can help patients better adhere to their medicines [13,14].
Although wide-ranging experimental studies on antibiotic adherence in LRTI patients remain limited, current data indicate that targeted interventions can be more applicable. The tailored interventions can optimize antibiotic use along with adherence to antibiotics and have demonstrated significant benefits for patients with LRTIs in the experimental group [15]. Multidimensional approaches targeting general practitioners have been shown to improve adherence to first-line antibiotic prescribing suggestions for RTI patients, which led to positive treatment outcomes [16]. Correspondingly, interventions to increase adherence to clinical guidelines have reduced both the volume of antibiotic prescriptions and the inappropriate selection of antibiotics for RTI patients [17]. In geriatric populations, complete reviews have recognized the most promising antibiotic regimens for LRTI management in both hospital and outpatient settings [18]. Recently, specific interventions have determined significant improvements in key quality indicators for CAP management, supporting the effectiveness of multifaceted stewardship plans in improving clinical practice and decreasing resistance [19]. Moreover, pharmacists can assist patients with LRTIs and provide them with guidance on the appropriate use of their prescribed antibiotic treatment [20,21]. Research on pharmacist-led interventions to improve pharmacotherapy has revealed mixed findings, and there is a lack of large, comprehensive studies in community care settings to strengthen evidence-based practice [22]. Medication non-adherence is a common issue in clinical practice, whereas adherence greatly influences treatment clinical outcomes [23].
More than 50% of patients do not take their medicines as prescribed, which could result in the emergence of antibiotic resistance [24]. Based on a study of 63 studies conducted over 30 years, scientists found that adherent patients have a threefold higher likelihood of receiving a favourable result than non-adherent patients [25,26]. In the case of infectious disorders, non-adherence with antibiotics may result in the storage of medicines at home, which encourages self-medication, resulting in a vicious cycle that favours bacterial resistance [27]. Patients must strictly adhere to their prescribed medications for the effective and desired outcomes.
Therefore, the present study aimed to evaluate patients’ adherence to antibiotic therapy for LRTIs, as well as their awareness and the factors associated with adherence.

2. Results

A total of 590 participants were enrolled in this study. Of those, 410 were eligible for randomization post-screening (CP-I: n = 100, CP-II: n = 110, CP-III: n = 102, and CP-IV: n = 98), and 205 individuals were assigned to each group, while 180 were excluded. All patients consented to take part in the trial. Patients were assigned to one of the two groups (IG, n = 205; CG, n = 205) from the two UCs of Khwazakhela Swat. A total lost to follow-up were n = 18 and failed to achieve intervention in the IG, and, finally, 187 participants were included (Figure 1).
Overall, the majority of the participants were male in the IG (n = 176, 94.1%), with the mean age group of 18–23 (n = 59, 31.6%), as well as in the CG (n = 187, 91.2%), with the mean age group of 18–23 (n = 58, 28.3%). The demographic variables of patients (ARTIs n = 98, AECOPD n = 45, CAP n = 37, COPD n = 20) are reported (Table 1).
Most of the participants had a basic understanding of the term “antibiotics.” In both groups, respondents defined the antibiotics as the pills that cure infection, antibiotics in the CG (n = 134, 65.6%) vs. IG (n = 135, 72.2%; p = 0.00). Antibiotics used for the present illness, including penicillin (amoxiclav) in the CG (n = 40, 19.5%) vs. (n = 44, 21.4%) refill for the same class in the IG (n = 1, 0.5%) and polypharmacy, were observed for the penicillin class with other antibiotics in the CG (n = 20, 9.5%) vs. IG (n = 19, 10.1%) and macrolides (Azithromycin and Clarithromycin) in the CG (n = 30, 14.6%) vs. IG (n = 18, 9.7%) and commonly prescribed in the present illness of the CG (n = 89, 43.5%) vs. IG (n = 62, 30.2%) (Supplementary Material Table S1).

2.1. Primary Outcomes

The primary outcome was patient adherence to the prescribed antibiotic regimen, and general knowledge of the participants was assessed with different responses. Most of the respondents in the CG believe that coloured mucus can be treated with antibiotics, as CG (n = 134, 65.6%) vs. IG with no response (n = 43, 23.0%; p = 0.01). Not all cases of persistent cough need antibiotic therapy as CG (n = 0, 0.0%) vs. IG (n = 30, 16.0%). On the other hand, sore throat, persistent cough and cold, flu, along with fever, were mixed with chest infections or LRTIs in many of the participants in the CG (n = 140, 68.2%) vs. IG (n = 103, 55.1%). Overall, a significant increase in the knowledge was observed of the IG as given in Supplementary Material Table S2. The WHO (PAS-QA) responses were recorded for most of the participants who used antibiotics in the last month: CG (n = 40, 19.5%) vs. IG (n = 30, 16.0%). In the past 6 months, CG (n = 56, 27.3%) versus IG (n = 41, 21.9%), and more than 50% of the respondents used antibiotics in the past year: CG (n = 109, 53.2%) vs. IG (n = 116, 62.0%). On that occasion, participants tend to get antibiotics from a doctor or a nurse first aid clinic in the locality and get advice in the form of marking on the medicine packs: CG (n = 184, 89.8%) vs. IG (n = 157, 84.0%). The source of information responses is shown in Supplementary Material Figure S1.
Antibiotic resistance can be linked with overuse or regular consumption, with the correct and incorrect answers recorded (Supplementary Material Table S3). Bacterial resistance to a specific antibiotic can spread and transfer from one person to another: CG (n = 88, 42.9%) vs. IG (n = 113, 60.4%) (Supplementary Material Table S4). The presence of a duty pharmacist at CPs gave brief information on the antibiotics to the participants and dispensed them mainly on prescription. Additionally, Table 2 also presents the median and IQR of both groups in detail.
The BMQ-QA responses are in the LS from “SA to SD” format, and each question has its code. C1 worries about the medicine taken at present: CG with ‘A’ option (n = 59, 28.8%) vs. IG (n = 163, 79.5%). C3, participants found the present medicine CG with D option (n = 74, 36.1%) vs. IG (n = 65, 34.1%). The details about the BMQ-QA are given in Table 3. C4, the current medicine disruption with the participant’s life, found no significant association with CG with D option (n = 73, 35.6%) vs. the IG (n = 70, 37.4%). N5, medication protection against worsening has no significant association with CG, with ‘A’ option (n = 143, 69.8%) vs. IG (n = 120, 64.2%). C6, CG with ‘A’ option (n = 161, 69.8%) vs. IG (n = 152, 81.3%). Moreover, Table 3 provides a detailed comparison of the median and IQR for both groups.

2.2. Secondary Outcomes

The clinical improvement has been achieved, and overall MMAS-8 scores were improved in the IG than CG, as presented in Table 4, and overall percentages were taken for both groups. Participants miss their medication intentionally, and, in the last weeks, respondents have responded with yes: CG (n = 96, 54.4%) vs. IG (n = 81, 45.8%). During travels and when leaving home, participants always forget their medications.
The overall MMAS-8 was divided into lower (score 1–2), medium (score 2–3), and higher (>6) adherence. The participants had low adherence in the CG (n = 125, 61.0%) vs. IG (n = 32, 17.1%), medium adherence in the CG (n = 66, 32.0%) vs. IG (n = 60, 32.1%), and higher adherence was found in the CG (n = 14, 6.8%) vs. IG (n = 95, 50.8%). The overall results show that the adherence to antibacterial therapy for the LRTIs in the IG group has significantly improved (p ≤ 0.01) as compared to the CG (Figure 2).

2.3. Comparison of the Demographics

Different sociodemographic variables were checked against the MMAS-8 scores, as education has a significant (p < 0.05) association. The overall MMAS-8 mean scores have a significant (p ≤ 0.01) association with other demographic variables, CG (6.4 ± 2.1) vs. IG (7.8 ± 2.1). Overall, the demographic factors are linked with higher adherence compared to the medium group and the intermediate education group that followed (p = 0.089), with interventions [0.441–2.151]. Upon the final analysis, the multinomial regression model findings are presented in Table 5. The age group of 30–31 is more likely to show high adherence (p = 0.080) than other groups, with the odds ratio (OR: 2.040) and confidence interval [CI: 0.637–6.536]. The majority of educational interventional participants get healthier after the prescribed ABs are used correctly (Supplementary Material Table S5).
The financial situation is one of the main factors, and the monthly income is more than or equal to PKR 30000 (p = 0.006) to the ABs (OR:4.088) as per education received on prescribed ABs [1.488–11.229]. The analysis of the relationship between past medical history and adherence yielded a non-significant association (p > 0.05), indicating that a patient’s health background, whether distant or recent, does not significantly impact adherence to prescribed treatments. A noteworthy observation arises regarding intervention efficacy, suggesting that interventions administered at the onset of the present illness may play a crucial role in reducing non-adherence in the future. This strategic timing of interventions holds promise for enhancing patient adherence, potentially contributing to improved overall treatment outcomes.
The outcomes met the objectives of the RCT, and adherence was measured as higher in the IG as compared to the usual care and other categories. Gender is less likely to be a factor in adherence with the prescribed medications and is not influenced or changed (p > 0.05). The education secondary group (OR: 1.050) shows more adherence (p = 0.056) to the prescribed treatment with ABs as compared to other classifications [CI: 0.150–1.024]. The conclusive results of the randomized controlled trial (RCT) demonstrated the achievement of this study’s objectives. Notably, adherence rates within the IG surpassed those observed in the usual care group and other relevant categories. Remarkably, gender did not emerge as a significant factor influencing adherence to prescribed medications, as indicated by a non-significant p-value (p > 0.05). Upon closer examination of demographic variables, it was found that individuals in the secondary education group exhibited a slightly higher likelihood of adherence to the prescribed antibiotic treatment (OR: 1.050). While the p-value (0.056) suggests a trend toward significance, it falls just short of the conventional threshold. The confidence interval (CI: 0.150–1.024) further provides a range within which the true odds ratio is likely to exist. This implies that, although not statistically significant, there is a potential trend indicating greater adherence in the secondary education group compared to other classifications. The results based on the Mann–Whitney U test, comparing responses across demographic groups (Supplementary Material Tables S6.1 and S6.2) in detail.
In essence, this study’s outcomes underscore the efficacy of the intervention in promoting adherence, with noteworthy insights into demographic factors such as education level. While gender did not exert a discernible impact, the nuanced analysis of subgroups sheds light on potential variations in treatment adherence, particularly within the secondary education category. These findings contribute valuable information to the broader understanding of factors influencing adherence to prescribed medications.

3. Discussion

This is the first of its kind study examining antibiotic adherence in the LRTI patients from Pakistan post-conflict areas. The awareness and adherence have been improved, and the study group has become more compliant with the advised antibacterial therapy.
The overuse and non-adherence to antibiotic therapy have been highlighted by cross-sectional studies, point prevalence surveys, and significant work on these dimensions, which demonstrate the serious concern surrounding the irrational use of antibiotics in infectious diseases [28]. U. Taj and the authors raised awareness of the challenges that Pakistanis face when attempting to take prescription antibiotics, but our study has tried to reduce these challenges by increasing adherence [29]. The sharing of antibiotics among friends and family members is still common and comparable to that of other lower-income nations. According to research from the Philippines, there are misconceptions about antibiotic sharing with others and its relationship to demographics. A Saudi study by AAH Alenazi et al. reported that the term “resistant bacteria” is mostly known by coworkers and households through social media platforms [30]. Similar to results reported by Scott A. McEwen and his colleagues, our study has improved such factors, particularly the households with less familiarity with antibiotic resistance [31,32]. Participants’ health is dependent on their existing medications, and nearly the same finding was reported by Rachael J. Thorneloe and his colleagues [23].
The non-adherence includes not following prescriptions completely, skipping doses, using the wrong dosage intervals, and stopping medications too soon. There have been reports of non-adherence in 20–80% of cases, on average in the middle at 50–60% [33]. In Pakistan, inappropriate use of antibiotics is linked to several problems, including poor health literacy, low educational attainment, the expense of private practitioners, patient overcrowding, busy schedules, and an unmanaged medicine supply [34,35]. While Kuntz et al. highlighted various intentional and unintentional non-adherent behaviours requiring further treatment, our study found that most participants in the IG adhered to initial therapy and remembered to take their first dose [36]. Lornia and Maria reported that an educational intervention that contained information on antibiotic use and resistance significantly improved patient adherence, reduced antibiotic wastage, and highlighted that stronger general-overuse beliefs were associated with increased non-adherence [37]. The majority of patients in the current study continued to take their antibiotics as directed and did not stop taking them, differing from Khan and his colleagues’ earlier findings that most participants had stopped taking them after feeling better [37]. Participants also frequently forget their medications when travelling or leaving home, while, in the post IG, such factors are found to be controlled. All the efforts suggested that pharmacist-led intervention improved adherence with recommended antibiotics in the given population.
The present study has limitations too; first, the findings cannot be generalized to the entire country, as this study was conducted in post-conflict areas where adherence rates may be affected and a small proportion of female participation. Second, the study follow-up was ensured through reminder messages; however, contacting patients on time remained challenging. Due to the study protocols, the leak of information might be possible; patients may share intervention details with others, potentially affecting the CG participants nearby locality.
These findings have important implications for future scale-up in similar LMIC settings, where targeted educational interventions and strengthened healthcare infrastructure could significantly improve antibiotic adherence and reduce misuse.

4. Materials and Methods

4.1. Study Design

The present study is a single-blinded, two-arm, individual trial carried out to examine the effectiveness of pharmacist-led educational interventions for patients approaching community pharmacies (CPs) with prescriptions containing antibiotics for LRTIs.

4.2. Study Setting, Population, and Sample Size

This study was conducted in Swat, Khyber Pakhtunkhwa, Pakistan, which has over 2 million inhabitants, around 86% of whom live in rural areas. Infectious diseases, especially LRTIs, are still prevalent in Swat. The study area was influenced by military operations (2007–2009) and declared secure in 2009. The post-conflict challenges make it a key area for studying antibiotic adherence and awareness for the LRTI population. This study was conducted in two union councils (UCs) in the Swat district (Khwazakhela and Janu). In Pakistan’s new local government rules of administration, UC and neighbourhood councils (NHC) are the fundamental entities, with 2000–10,000 people per UC. A total of 200 participants were recruited in each group.
A sample size of the responses was achieved with a 95% confidence interval and a margin of error (5%), with the aim of a 1:1 allocation ratio in the intervention and control groups. A sample size of 400 (200 in each group) was assigned with a proposed 20% attrition rate for the dropout participants as per the published protocols. Sensitivity analysis was conducted for the potential impact of attrition on study and validity; we conducted both intention-to-treat (ITT) and per-protocol (PP) analyses. In the ITT analysis, all randomized participants were included, with missing data addressed using the last observation carried forward (LOCF) method. The PP analysis involved only those participants who completed this study according to protocol.

4.3. Data Teams’ Eligibility Criteria and Training

The DCT (data collection team) was most likely made up of healthcare staff (pharmacists, vaccinators, and female health workers). Pharmacists who received special training were assigned CPs (5 = CG: control group, 5 = IG: intervention group), where participants were recruited with complete permission. Before the trial began, effective communication skills training was provided, as well as pseudo-patient elements of training to measure counselling abilities at CPs.

4.4. Interventions

Based on available scientific evidence, criteria for antibiotic adherence were devised, including a short telephone-based educational intervention approach that was utilized. The EATSA (effectiveness of adherence to the specific antibiotics) pre-designed protocol was published earlier than the main study [38]. First, IG participants receive written information on the usage of ABs and adherence to LRTI antibiotic therapy, as well as advice about antibiotic storage at home, from a competent pharmacist and DCT. A brochure with information based on “Get Smart: Know; When Antibiotics Work” was produced. With the assistance of specialists, the pamphlets were adapted from WHO (World Health Organization)/CDC (Centers for Disease Control and Prevention) public awareness campaigns and translated into national (Urdu/Pushto) and local languages for better comprehension, as shown in Supplementary Material Figure S2. The bottom portions of the booklet included information on the necessity of antibiotic adherence and forgetting, proper disposal, storage counselling, and the importance of not sharing your antibiotics with others.
Secondly, trained pharmacists made visits to the consenting participant households and completed educational training on adherence and storage of antibiotics. A total of 3 sessions were conducted for the households. The WHO guidelines “How to Investigate the Use of Medicines by Consumers” were used for the consumption of medicines and aimed to enhance the rational use of antibiotics. The phone calls occurred early in the first week and then continued into the second week. The therapeutic success was determined by the ratio of those who followed through with their commitments to the recommended therapy. Then, on the third, fourth, fifth, and sixth calls, the participants followed up with a brief instructional technique to improve their understanding of how to utilize antibiotics properly.

4.5. Usual Care Improvement

Individually, both the IG and CG participants continued to receive pre-arranged regular phone calls, but the CG only obtained daily guidance for their antibiotics, with the treatment being classified as enhanced care. There were no placebos used in primary care for therapy, and the focus was on sticking to the recommended medication.

4.6. Inclusion Criteria

If patients with LRTIs obtained complete consent, they were examined for inclusion criteria at the CPs. For adult patients, regardless of gender, one of the study’s qualifying criteria is that participants must have resided in the study area for at least one year and be able to communicate in Urdu/Pushto or English (Supplementary Material Table S7). The participants in the IG arm had no other comorbidities and had not engaged in or been valuable members of any other study/trial-related RTIs or antibiotics in the past 4 months. Participants who were unable to properly answer the questions due to sight/vision, hearing, or cognitive difficulties, as well as those who did not meet the inclusion criteria, were disqualified and eliminated. A random digit number was generated through computer-based allocation. For each recruited participant, a 1:1 sample was utilized to assign them to the CG and IG. The status of allotment was conveyed to DCT administrators, who subsequently contacted individual pharmacists as soon as DCTs had obtained permission from the participants to participate in the trial. Before being randomly assigned to either the CG or IG arms, it was necessary to get informed consent as well as eligibility. The randomization point was kept a secret from research assistants, participants, and trial representatives (pharmacists).

4.7. Data Collection

Initially, qualified pharmacists at CPs collected information from patient medical records (medical notes checked for the diagnosis on prescription), and the results were kept secret from the pharmacist team. Each IG participant received a comprehensive packet of instructional written content. Oral counselling was offered in the region specific to the patients at CPs following textual counselling. The patient’s data was safely transferred to pre-determined data-collecting forms. The valid mobile phone numbers of patients were obtained and saved for future contact throughout the follow-up phase. In both UCs, trial DCTs communicated with participants using cell phones. Patients were requested to show their prescription, including antibiotics, after one week, and the initial therapeutic outcomes were assessed at the beginning of week 1 (initial effect of the antibiotics). After week 1, the second week involved discontinuation (as prescribed) and an enhancement in the knowledge, attitude, and practices initially assessed. Then, three follow-ups were completed: W3, W4, and W5 to assess the overall pharmacist-led interventions and their effectiveness, monitor sustained changes, and detect any relapse or inappropriate re-use of antibiotics. The antibiotics were not continued for long and stopped as prescribed (minimum 5 days to maximum 10 days), and information was given promptly to IG. Data gathering was updated and trustworthy to preserve data quality and dependability. All data were gathered once a week by the principal investigator (PI). We advised patients to read the SMS text messages delivered by our research team after a one-on-one appointment. Four sections of SMS text messages were included: awareness about LRTIs, understanding of antibiotics, modification of daily routine, and improvement of medication adherence. Week 7 marked the final assessment phase, during which trial participants were evaluated for overall outcomes (clinical and awareness-related). Moreover, patients in the intervention arm discontinued antibiotics as directed (in 5–10 days), and none continued antibiotics until week 7. The trial aligned with pre-defined protocols and SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) guidelines as detailed in the Supplementary Material Table S8.1.

4.8. Blinding

Due to its instructional character, blinding was difficult; however, some steps have been taken. Supplementary Material Table S8.2 provides comprehensive information about blinding. To minimize bias, both trial participants and outcome assessors were blinded to the intervention allocation. Blinding was maintained by identical packaging and labelling of both study arms. Specifically, the individuals responsible for collecting and analyzing data related to adherence were not included in delivering the intervention and remained unaware of participant allocation positions.

4.9. Outcomes Measures

The primary outcome was patient adherence to the prescribed antibiotic regimen, defined as taking ≥80% of the prescribed doses based on pill count and the enhancement of the knowledge, attitude, and practices of the patients. The secondary outcomes included clinical improvement and indicators like infection-related symptoms as per the adherence score with the outcomes of the therapy.

4.9.1. Primary Measures

The primary outcomes are more likely to be evaluated at time point two (week 1: initial course of antibiotics completion and week 2: initial adherence with awareness), whether the patient experienced any unpleasant effect or adherence to the prescribed therapy after the interventions was assessed, along with related factors. The BMQ (beliefs about medication questionnaire) was used to measure participant attitudes about antibiotics and was purely for the aim of evaluating participant attitudes regarding antibiotics. The primary outcome was to measure the level of the individual’s (LRTI) understanding of ABs with BMQ. The participants were allowed to try out the BMQ. Finally, an 18-item QA with a 4-factor structure that remained consistent across disease groups was developed. The BMQ-QA was validated in a variety of patient groups. The primary outcome of both PAS-QA (public awareness survey questionnaire) and BMQ would be to determine the level of antibiotic knowledge and understanding among LRTI patients. The internal consistency was checked through the Cronbach alpha test (>7 each), and the questionnaire’s cultural adaptability was ensured through the modified version of the BMQ and MMAS-8 (Morisky Medication Adherence Scale-8). Later, the questionnaires were translated into the local language (Urdu) as modified previously.

4.9.2. Secondary Measures

The effectiveness of the educational intervention on adherence to the recommended LRTI treatment was assessed based on overall clinical outcomes at week 7, even though the antibiotic treatment had already ended at week 1 or 2. Overall, adherence was taken as the outcome, with other factors to determine whether cured or not, and adhering or not to the recommended therapy. The first 07 questions on the MMAS-8 adherence scale need a yes or no (dichotomous) response, while the latter five are on a Likert scale. The “Pill Count” is a simple novel technique and method to assess patient medication adherence, particularly in antibiotics. The master assessments of the LRTI acceptance plan followed, as demonstrated by the terms “non-adherent” or “adherent” appearing on previously circulated tests. The current research group concluded that a patient who completes the first would be projected as one “disciple” with MMAS-8, 6, and an 80.0% rate of pill count.

4.10. Data Management

Data were managed per established procedures. Every day, the data was stored on a hardcopy evaluation study booklet with a participant’s name and codes assigned to each data file by the PI field office. The PI double-checked the data, addressed any issues accordingly, and a third person corrected any inconsistencies. The intervention’s confidentiality is known only to pharmacists, and all data forms are maintained in locked file cabinets. Daily, the trial team monitored this study’s progress.

4.11. Data Analysis

IBM-SPSS-Statistics (version 24.0) was used for the analysis of the data. Both descriptive (summarization) and inferential statistical (effect and associations) tests were used. The WHO-PAS and BMQ questionnaires were scored on a 5-point Likert Scale, with total and domain-specific scores computed and summarized as median with interquartile range (IQR); group comparisons were carried out by Mann–Whitney U statistics, while mean (SD) values were additionally calculated to descriptively summarize group-level differentiations (Supplementary Material Table S9). At each visit, the mean differences (MDs) between the two arms, with a 95% CI, for every visit from the IG were combined in a generalized mixed model. All analyses were established in full according to statistical plans assigned before the trial could be unmasked.

4.12. Ethical Approval, Consent, Registration, and Trial Status

The ethical approval was provided by the Xi’an Jiaotong University ethical committee with reference No: 2020–13541-XJTU and the project for further process and MMAS-8 questionnaire permission licence. The current study protocols were reviewed by a scientific expert in SGTHs (Saidu Group of Teaching Hospitals), Swat, and PIMS (Pakistan Institute of Medical Sciences). The trial protocol can be found on the website ChiCTR (http://www.chictr.org.cn/) with the reference number ChiCTR2000040453 and published version [38]. Informed consent was obtained before the data collection on an individual basis, and the challenges in the ethical consideration were discussed with the help of the DCT and pharmacists. CONSORT (Consolidated Standards of Reporting Trials) guidelines were used in this study, as detailed information was given in a separate checklist in Supplementary Material File S1.

5. Conclusions

Overall, the intervention group showed improved awareness, understanding, and attitudes toward antibiotics, with significantly better adherence to antibiotic therapy. The primary and secondary outcomes were achieved, with high adherence observed among LRTI patients to their prescribed treatment.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/antibiotics14100977/s1, Figure S1: Different sources of information; Figure S2: Brochure for the participants based on educational intervention; Table S1: Basic knowledge responses towards RTIs; Table S2: The general knowledge of the participants; Table S3: Response towards WHO-PAS-QA; Table S4: Trial participants responses on ABR; Table S5: Comparison of MMAS-8 scores with participant demographics; Table S6.1 & S6.2: The WHO-PAS Likert Scale and BMQ responses and Demographics association; Table S7: Details of a text message description of the contents; Table S8.1 & S8.2: SPIRIT and Blinding; Table S9: Mean differences and overall scores; File S1: CONSORT Checklis.

Author Contributions

Conceptualization, F.U.K. (Faiz Ullah Khan); methodology, Y.F.; software, F.U.K. (Farman Ullah Khan); validation, H.W. and L.S.; formal analysis, F.U.K. (Farman Ullah Khan) and H.W.; investigation, F.U.K. (Faiz Ullah Khan); resources, L.S.; data curation, F.U.K. (Faiz Ullah Khan); writing—original draft preparation, F.U.K. (Faiz Ullah Khan); writing—review and editing, F.U.K. (Faiz Ullah Khan) and Y.F.; visualization, H.W.; supervision, Y.F.; project administration, F.U.K. (Faiz Ullah Khan); funding acquisition, Y.F. All authors have read and agreed to the published version of the manuscript.

Funding

This study was supported by the National Natural Science Fund (71974156), the Young Talent Support Plan, and the High Achiever Plan.

Institutional Review Board Statement

The ethical approval was provided by the Xi’an Jiaotong University ethical committee with reference No: 2020–13541-XJTU (Dated: 28 January 2020) and the project for further process.

Informed Consent Statement

All participants provided written informed consent prior to their inclusion in this study.

Data Availability Statement

The data can be provided upon reasonable request to the corresponding author.

Acknowledgments

We (authors) acknowledge all the contributors to this research project.

Conflicts of Interest

The authors declare no conflict of interest.

References

  1. Collaborators, G.L. Estimates of the global, regional, and national morbidity, mortality, and aetiologies of lower respiratory tract infections in 195 countries: A systematic analysis for the Global Burden of Disease Study 2015. Lancet. Infect. Dis. 2017, 17, 1133–1161. [Google Scholar]
  2. Troeger, C.; Blacker, B.; Khalil, I.A.; Rao, P.C.; Cao, J.; Zimsen, S.R.; Albertson, S.B.; Deshpande, A.; Farag, T.; Abebe, Z. Estimates of the global, regional, and national morbidity, mortality, and aetiologies of lower respiratory infections in 195 countries, 1990–2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet Infect. Dis. 2018, 18, 1191–1210. [Google Scholar] [CrossRef] [PubMed]
  3. Le Roux, D.M.; Nicol, M.P.; Myer, L.; Vanker, A.; Stadler, J.A.; von Delft, E.; Zar, H.J. Lower respiratory tract infections in children in a well-vaccinated South African birth cohort: Spectrum of disease and risk factors. Clin. Infect. Dis. 2019, 69, 1588–1596. [Google Scholar] [CrossRef]
  4. United Nations International Children’s Emergency Fund (UNICEF). Levels and trends in child mortality: Report 2011. In Estimates Developed by the UN Inter-Agency Group for Child Mortality Estimation New York: United Nation’s Children Fund; United Nations Children’s Fund: New York City, NY, USA, 2011. [Google Scholar]
  5. Feldman, C.; Shaddock, E. Epidemiology of lower respiratory tract infections in adults. Expert Rev. Respir. Med. 2019, 13, 63–77. [Google Scholar] [CrossRef]
  6. File Jr, T.M.; Marrie, T.J. Burden of community-acquired pneumonia in North American adults. Postgrad. Med. 2010, 122, 130–141. [Google Scholar] [CrossRef] [PubMed]
  7. Song, J.-H.; Thamlikitkul, V.; Hsueh, P.-R. Clinical and economic burden of community-acquired pneumonia amongst adults in the Asia-Pacific region. Int. J. Antimicrob. Agents 2011, 38, 108–117. [Google Scholar] [CrossRef]
  8. Capuozzo, M.; Zovi, A.; Langella, R.; Ottaiano, A.; Cascella, M.; Scognamiglio, M.; Ferrara, F. Optimizing antibiotic use: Addressing resistance through effective strategies and health policies. Antibiotics 2024, 13, 1112. [Google Scholar] [CrossRef]
  9. Majumder, M.A.A.; Rahman, S.; Cohall, D.; Bharatha, A.; Singh, K.; Haque, M.; Gittens-St Hilaire, M. Antimicrobial stewardship: Fighting antimicrobial resistance and protecting global public health. Infect. Drug Resist. 2020, 13, 4713–4738. [Google Scholar] [CrossRef]
  10. Kandeel, A.; Palms, D.L.; Afifi, S.; Kandeel, Y.; Etman, A.; Hicks, L.A.; Talaat, M. An educational intervention to promote appropriate antibiotic use for acute respiratory infections in a district in Egypt- pilot study. BMC Public Health 2019, 19, 498. [Google Scholar] [CrossRef]
  11. Khan, F.U.; Khan, F.U.; Hayat, K.; Chang, J.; Saeed, A.; Khan, Z.; Ashraf, M.; Rasheed, U.M.; Atif, N.; Ji, W. Knowledge, attitude and practices among consumers toward antibiotics use and antibiotic resistance in Swat, Khyber-Pakhtunkhwa, Pakistan. Expert Rev. Anti-Infect. Ther. 2020, 18, 937–946. [Google Scholar] [CrossRef]
  12. Khan, F.U.; Khan, F.U.; Sajjad, A.; Ahmad, T.; Mallhi, T.H.; Ali, S.; Ullah, K.H.; Shah, S. Pattern of antibiotic dispensing at pharmacies according to access, watch, reserve (AWaRe) classification: Multicenter study after COVID-19 waves in different districts of Pakistan. BMC Res. Notes 2025, 18, 38. [Google Scholar] [CrossRef]
  13. Wei, L.; Yang, X.; Li, J.; Liu, L.; Luo, H.; Zheng, Z.; Wei, Y. Effect of pharmaceutical care on medication adherence and hospital admission in patients with chronic obstructive pulmonary disease (COPD): A randomized controlled study. J. Thorac. Dis. 2014, 6, 656. [Google Scholar]
  14. Fares, R.; Marjorie, B.; Chaballe, C.; Crunenberg, R. The outcomes of pharmacist-led pharmaceutical care within community pharmacies: An overview of systematic reviews. Res. Soc. Adm. Pharm. 2025, 21, 332–339. [Google Scholar] [CrossRef]
  15. Schouten, J.A.; Hulscher, M.E.J.L.; Trap-Liefers, J.; Akkermans, R.P.; Kullberg, B.-J.; Grol, R.P.T.M.; van der Meer, J.W.M. Tailored Interventions to Improve Antibiotic Use for Lower Respiratory Tract Infections in Hospitals: A Cluster-Randomized, Controlled Trial. Clin. Infect. Dis. 2007, 44, 931–941. [Google Scholar] [CrossRef] [PubMed]
  16. Kardas, P. Patient compliance with antibiotic treatment for respiratory tract infections. J. Antimicrob. Chemother. 2002, 49, 897–903. [Google Scholar] [CrossRef]
  17. Oliveira, I.; Rego, C.; Semedo, G.; Gomes, D.; Figueiras, A.; Roque, F.; Herdeiro, M.T. Systematic Review on the Impact of Guidelines Adherence on Antibiotic Prescription in Respiratory Infections. Antibiotics 2020, 9, 546. [Google Scholar] [CrossRef]
  18. Liu, Y.; Zhang, Y.; Zhao, W.; Liu, X.; Hu, F.; Dong, B. Pharmacotherapy of Lower Respiratory Tract Infections in Elderly-Focused on Antibiotics. Front. Pharmacol. 2019, 10, 1237. [Google Scholar] [CrossRef] [PubMed]
  19. Ablakimova, N.; Rachina, S.; Smagulova, G.; Vlasenko, A.; Mussina, A.; Zhylkybekova, A.; Yessenzhulova, A.; Koshmaganbetova, G.; Iztleuov, Y. Impact of complex interventions on antibacterial therapy and etiological diagnostics in community-acquired pneumonia: A 12-month pre-and post-intervention study. Front. Pharmacol. 2025, 16, 1627858. [Google Scholar] [CrossRef] [PubMed]
  20. Nguyen, T.-S.; Nguyen, T.L.H.; Van Pham, T.T.; Hua, S.; Ngo, Q.C.; Li, S.C. Impact of pharmaceutical care in the improvement of medication adherence and quality of life for COPD patients in Vietnam. Respir. Med. 2019, 153, 31–37. [Google Scholar] [CrossRef]
  21. van Boven, J.F.; Ryan, D.; Eakin, M.N.; Canonica, G.W.; Barot, A.; Foster, J.M.; Group, R.E. Enhancing respiratory medication adherence: The role of health care professionals and cost-effectiveness considerations. J. Allergy Clin. Immunol. Pract. 2016, 4, 835–846. [Google Scholar] [CrossRef]
  22. Craske, M.E.; Hardeman, W.; Steel, N.; Twigg, M.J. Components of pharmacist-led medication reviews and their relationship to outcomes: A systematic review and narrative synthesis. BMJ Qual. Saf. 2024, 33, 808–822. [Google Scholar] [CrossRef] [PubMed]
  23. Waaseth, M.; Adan, A.; Røen, I.L.; Eriksen, K.; Stanojevic, T.; Halvorsen, K.H.; Garcia, B.H.; Holst, L.; Ulshagen, K.M.; Blix, H.S. Knowledge of antibiotics and antibiotic resistance among Norwegian pharmacy customers–a cross-sectional study. BMC Public Health 2019, 19, 66. [Google Scholar] [CrossRef]
  24. Cooper, J.; Hall, L.; Penland, A.; Krueger, A.; May, J. Measuring medication adherence. Popul. Health Manag. 2009, 12, 25–30. [Google Scholar] [CrossRef] [PubMed]
  25. Osterberg, L.; Blaschke, T. Adherence to medication. N. Engl. J. Med. 2005, 353, 487–497. [Google Scholar] [CrossRef]
  26. DiMatteo, M.R.; Giordani, P.J.; Lepper, H.S.; Croghan, T.W. Patient adherence and medical treatment outcomes a meta-analysis. Med. Care 2002, 40, 794–811. [Google Scholar] [CrossRef]
  27. Vrijens, B.; Urquhart, J. Patient adherence to prescribed antimicrobial drug dosing regimens. J. Antimicrob. Chemother. 2005, 55, 616–627. [Google Scholar] [CrossRef]
  28. Saleem, Z.; Haseeb, A.; Godman, B.; Batool, N.; Altaf, U.; Ahsan, U.; Khan, F.U.; Mustafa, Z.U.; Nadeem, M.U.; Farrukh, M.J.; et al. Point Prevalence Survey of Antimicrobial Use during the COVID-19 Pandemic among Different Hospitals in Pakistan: Findings and Implications. Antibiotics 2023, 12, 70. [Google Scholar] [CrossRef]
  29. Taj, U.; Schmidtke, K.A.; Vlaev, I.; Read, D. Choice of methods can determine which behavioral determinates are identified for targeting in future behavior change interventions: Increasing antibiotic adherence in Pakistan. J. Health Psychol. 2022, 27, 1006–1013. [Google Scholar] [CrossRef]
  30. Alenazi, A.A.H.; Alotaibi, N.M.; Mujtaba, M.A. A survey of public knowledge and attitude related to antibiotic use and antibiotic resistance among Saudi people in northern region of Saudi Arabia. J. Young Pharm. 2020, 12, 237. [Google Scholar] [CrossRef]
  31. Khan, F.U.; Mallhi, T.H.; Khan, Q.; Khan, F.U.; Hayat, K.; Khan, Y.H.; Ahmad, T.; Fang, Y. Assessment of antibiotic storage practices, knowledge, and awareness related to antibiotic uses and antibiotic resistance among household members in post-conflict areas of Pakistan: Bi-central study. Front. Med. 2022, 9, 962657. [Google Scholar] [CrossRef] [PubMed]
  32. Pham-Duc, P.; Cook, M.A.; Cong-Hong, H.; Nguyen-Thuy, H.; Padungtod, P.; Nguyen-Thi, H.; Dang-Xuan, S. Knowledge, attitudes and practices of livestock and aquaculture producers regarding antimicrobial use and resistance in Vietnam. PLoS ONE 2019, 14, e0223115. [Google Scholar] [CrossRef]
  33. Pasina, L.; Brucato, A.; Falcone, C.; Cucchi, E.; Bresciani, A.; Sottocorno, M.; Taddei, G.; Casati, M.; Franchi, C.; Djade, C. Medication non-adherence among elderly patients newly discharged and receiving polypharmacy. Drugs Aging 2014, 31, 283–289. [Google Scholar] [CrossRef] [PubMed]
  34. Asghar, S.; Atif, M.; Mushtaq, I.; Malik, I.; Hayat, K. Factors associated with inappropriate dispensing of antibiotics among non-pharmacist pharmacy workers. Res. Soc. Adm. Pharm. 2020, 16, 805–811. [Google Scholar] [CrossRef] [PubMed]
  35. Atif, M.; Malik, I.; Asif, M.; Qamar-Uz-Zaman, M.; Ahmad, N.; Scahill, S. Drug safety in Pakistan. In Drug Safety in Developing Countries; Elsevier: Amsterdam, The Netherlands, 2020; pp. 287–325. [Google Scholar]
  36. Linn, A.J.; van Dijk, L.; Smit, E.G.; Jansen, J.; van Weert, J.C. May you never forget what is worth remembering: The relation between recall of medical information and medication adherence in patients with inflammatory bowel disease. J. Crohn’s Colitis 2013, 7, e543–e550. [Google Scholar] [CrossRef] [PubMed]
  37. West, L.M.; Cordina, M. Educational intervention to enhance adherence to short-term use of antibiotics. Res. Soc. Adm. Pharm. 2019, 15, 193–201. [Google Scholar] [CrossRef]
  38. Khan, F.U.; Fang, Y. Effectiveness of Pharmacist-Led Brief Educational Intervention for Adherence to the Antibiotics for Lower Respiratory Tract Infections (EATSA) in Post-Conflict Rural Areas of Pakistan: Study Protocol for a Randomized Controlled Trial. Antibiotics 2021, 10, 1147. [Google Scholar] [CrossRef]
Antibiotics 14 00977 g001
Figure 1. Overall process of this study.
Figure 1. Overall process of this study.
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Antibiotics 14 00977 g002
Figure 2. Overall, MMAS-8 measures in pre- and post-interventions.
Figure 2. Overall, MMAS-8 measures in pre- and post-interventions.
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Table 1. Demographic variables of the patients.
Table 1. Demographic variables of the patients.
Characteristics Control n (%)Intervention n (%)
Gender
Male187 (91.2)176 (94.1)
Female18 (8.8)11 (5.9)
Age (years)
18–2358 (28.4)59 (31.6)
24–2950 (24.4)47 (25.1)
30–3537 (18.0)41 (21.9)
36–4137 (18.0)29 (15.5)
>4123 (11.2)11 (5.9)
Education
Illiterate33 (16.1)26 (13.9)
Primary/Secondary84 (41.0)56 (29.9)
Intermediate70 (34.1)74 (39.6)
Bachelor’s or higher18 (8.8)31 (16.6)
Monthly income (PKR *)
>10,000–<20,00070 (34.1)61 (32.6)
>20,000–<300,00068 (33.2)69 (36.9)
>30,000–<40,00034 (16.6)39 (20.9)
>40,000–<50,0002 (1.0)4 (2.1)
>50,00031 (15.1)14 (7.5)
Past medical history
Yes60 (29.3)54 (28.9)
No145 (70.7)133 (71.1)
* PKR = Pakistani rupees.
Table 2. WHO questionnaire responses of the participants.
Table 2. WHO questionnaire responses of the participants.
WHO-QA ResponseControlMedian (IQR)InterventionMedian (IQR)
Animals raised for food should receive fewer antibiotics from farmers.Strongly agree40 (19.5)4 (1)113 (60.4)4 (0)
Agree92 (44.9)16 (8.6)
Neutral43 (21.0)21 (11.2)
Disagree13 (6.3)17 (9.1)
Strongly disagree17 (8.3)20 (10.7)
People shouldn’t store ABs and use them for different conditions in the future.Strongly agree10 (4.8)4 (3)120 (64.2)4 (1)
Agree110 (53.7)0 (0.0)
Neutral68 (33.2)45 (24.1)
Disagree15 (7.3)19 (10.2)
Strongly disagree2 (1.0)3 (1.5)
Caregivers must check the status of each of their children’s immunizations.Strongly agree16 (7.8)4 (1)132 (70.6)4 (2)
Agree121 (59.0)0 (0.0)
Neutral55 (26.8)43 (23.0)
Disagree3 (1.5)3 (1.6)
Strongly disagree10 (4.9)9 (4.8)
Strongly disagree0 (0.0)0 (0.0)
Doctors should only issue antibiotic prescriptions when necessary.Strongly agree7 (3.4)4 (0)121 (64.7)4 (1)
Agree109 (53.2)0 (0.0)
Neutral63 (30.7)31 (16.6)
Disagree18 (8.8)23 (12.3)
Strongly disagree8 (3.9)12 (6.4)
If I take my antibiotics as prescribed, I won’t be in danger of developing an antibiotic-resistant infection.Strongly agree0 (0.0)4 (0)152 (81.3)4 (0)
Agree0 (0.0)33 (17.6)
Neutral25 (12.2)2 (1.1)
Disagree155 (75.6)0 (0.0)
Strongly disagree25 (12.2)0 (0.0)
I’m concerned about how antibiotic resistance having will affect my family and my health.Strongly agree32 (15.6)4 (0)143 (76.5)4 (2)
Agree136 (66.3)12 (6.4)
Neutral37 (18.1)32 (17.1)
Disagree0 (0.0)0 (0.0)
Strongly disagree0 (0.0)0 (0.0)
One of the largest issues facing the globe is antibiotic resistance.Strongly agree21 (10.3)4 (0)118 (63.1)4 (1)
Agree120 (58.5)14 (7.5)
Neutral54 (26.3)44 (23.5)
Disagree10 (4.9)11 (5.9)
Strongly disagree0 (0.0)0 (0.0)
Antibiotic resistance will be resolved by medical professionals before it gets out of hand.Strongly agree15 (7.3)4 (1)95 (50.8)4 (3)
Agree93 (45.4)0 (0.0)
Neutral49 (23.9)39 (20.9)
Disagree1 (0.5)52 (27.8)
Strongly disagree47 (22.9)1 (0.5)
Table 3. Belief about medication (BMQ) responses of the participants.
Table 3. Belief about medication (BMQ) responses of the participants.
BMQ-QAResponseControlMedian (IQR)InterventionMedian (IQR)
N1My health, at present, depends on this medicine.Strongly agree38 (18.5)3 (2)43 (23.0)2 (1)
Agree59 (28.8)93 (49.7)
Neutral35 (17.1)20 (10.7)
Disagree73 (35.6)31 (16.6)
Strongly disagree0 (0.0)0 (0.0)
C1Having to take this medicine worries me.Strongly agree0 (0.0)2 (0)0 (0.0)2 (1)
Agree163 (79.5)127 (67.9)
Neutral35 (17.1)37 (19.8)
Disagree7 (3.4)23 (12.3)
Strongly disagree0 (0.0) 0 (0.0)
N2 My life would be impossible without this medicine.Strongly agree0 (0.0)3 (2)0 (0.0)4 (1)
Agree70 (79.5)62 (33.2)
Neutral5 (17.1)7 (3.7)
Disagree76 (3.4)68 (36.4)
Strongly disagree54 (0.0)50 (26.7)
C2I sometimes worry about the long-term effects of this medicine.Strongly agree0 (0.0)2 (1)0 (0.0)2 (1)
Agree139 (67.8)137 (73.3)
Neutral28 (13.7)20 (10.7)
Disagree24 (11.7)20 (10.7)
Strongly disagree14 (6.8)10 (5.3)
N3 Without this medicine, I would be very ill.Strongly agree24 (11.4)2 (2)0 (0.0)2 (0)
Agree133 (64.8)148 (79.1)
Neutral24 (11.7)19 (10.2)
Disagree17 (8.7)16 (8.6)
Strongly disagree7 (3.4)4 (2.1)
C3 This medicine is a mystery to me.Strongly agree9 (4.3)4 (3)0 (0.0)4 (2)
Agree69 (33.7)61 (32.5)
Neutral1 (0.5)13 (7.0)
Disagree74 (36.1)65 (34.8)
Strongly disagree52 (25.4)48 (25.7)
N4 My health in the future will depend on this medicine.Strongly agree14 (6.8)2 (0)0 (0.0)2 (1)
Agree157 (76.6)122 (65.2)
Neutral27 (13.2)29 (15.5)
Disagree7 (3.4)5 (2.7)
Strongly disagree0 (0.0)31 (16.6)
C4This medicine disrupts my life.Strongly agree10 (4.9)4 (2)0 (0.0)4 (1)
Agree67 (32.7)65 (34.8)
Neutral2 (1.0)0 (0.0)
Disagree73 (35.6)70 (37.4)
Strongly disagree53 (25.8)52 (27.8)
C5I sometimes worry about becoming too dependent on this medicine.Strongly agree14 (6.8)2 (0)19 (10.2)2 (1)
Agree160 (78.0)143 (76.5)
Neutral18 (8.8)15 (8.0)
Disagree12 (5.9)9 (4.8)
Strongly disagree1 (0.5)1 (0.5)
N5This medicine protects me from becoming worse.Strongly agree14 (6.8)2 (0)37 (19.8)2 (1)
Agree143 (69.8)120 (64.2)
Neutral24 (11.7)12 (6.4)
Disagree17 (8.3)12 (6.4)
Strongly disagree7 (3.4)6 (3.2)
C6This medicine gives me unpleasant side effects.Strongly agree8 (6.8)2 (2)0 (0.0)2 (0)
Agree161 (71.9)152 (81.3)
Neutral29 (12.7)29 (15.5)
Disagree7 (8.6)6 (3.2)
Strongly disagree0 (0.0)0 (0.0)
Table 4. Scores based on MMAS-8.
Table 4. Scores based on MMAS-8.
Questions ResponseControlIntervention
n (%)n (%)
Do you sometimes forget to take your medication?Yes0 (0.0)0 (0.0)
No205 (52.3)187 (47.7)
People sometimes miss taking their medicines for reasons other than forgetting. Thinking over the past 2 weeks, were there any days when you did not take your medicine?Yes96 (54.2)81 (45.8)
No109 (50.7)106 (49.3)
Have you ever cut back or stopped taking your medication without telling your doctor, because you felt worse when you took it?Yes10 (100.0)0 (0.0)
No195 (51.0)187 (49.0)
When you travel or leave home, do you sometimes forget to bring along your medication?Yes9 (100.0)0 (0.0)
No196 (51.2)187 (48.8)
Did you take your medicine yesterday?Yes17 (34.7)32 (65.3)
No173 (50.4)170 (49.6)
When you feel like your symptoms are under control, do you sometimes stop taking your medicine?Yes91 (52.9)81 (47.1)
No114 (51.8)106 (48.2)
Taking medication every day is a real inconvenience for some people. Do you ever feel hassled about sticking to your treatment plan?Yes90 (52.6)81 (47.4)
No115 (52.0)106 (48.0)
How often do you have difficulty remembering to take all your medications? (Please circle the correct number)Never/rarely125 (85.0)22 (15.0)
Once in a while10 (90.9)1 (9.1)
Sometimes36 (62.1)22 (37.9)
Usually30 (50.8)29 (49.2)
All the time104 (88.9)13 (11.1)
Table 5. Regression analysis for the relationship of adherence with demographic variables.
Table 5. Regression analysis for the relationship of adherence with demographic variables.
GroupsDeterminantsOdd Ratios95% CI [Lower–Upper]p-Value **
Adherence Group (higher adherence)
Gender
Male1.767[0.604–5.172]0.299
FemaleReference *Reference *
Age group (years)
18–231.640[0.531–5.066]0.049
24–291.157[0.369–3.630]0.390
30–352.040[0.637–6.536]0.080
36–411.641[0.500–5.388]0.230
>41Reference *Reference *Reference *
Education group
Illiterate1.579[0.301–2.634]0.833
Primary/Secondary1.050[0.150–1.024]0.056
Intermediate1.316[0.313–1.829]0.535
Bachelor’s or higherReference *Reference *Reference *
Monthly income (PKR)
>10,000–<20,0001.899[0.714–5.048]0.199
>20,000–<300,0004.088[1.488–11.229]0.006
>30,000–<40,0001.423[0.501–4.043]0.508
>40,000–<50,0003.402[0.367–31.496]0.281
>50,000Reference *Reference *Reference *
Medical history
Yes1.226[0.674–2.232]0.505
NoReference *Reference *Reference *
Adherence Group (medium adherence)Gender
Male2.340[0.681–8.043]0.177
FemaleReference *Reference *
Age group (years)
18–231.295[0.551–3.040]0.919
24–290.769[0.321–1.845]0.279
30–351.111[0.444–2.781]0.701
36–410.438[0.158–1.209]0.112
>41Reference *Reference *Reference *
Education group
Illiterate0.890[0.627–3.973]0.240
Primary/Secondary0.391[0.432–2.091]0.332
Intermediate0.756[0.441–2.151]0.089
Bachelor’s/higherReference *Reference *Reference *
Monthly income (PKR)
>10,000–<20,0001.482[0.560–3.924]0.429
>20,000–<300,0001.919[0.692–5.319]0.210
>30,000–<40,0001.391[0.507–3.818]0.521
>40,000–<50,0002.858[0.321–5.459]0.347
>50,000Reference *Reference *Reference *
Medical history
Yes1.003[0.553–1.821]0.992
NoReference *Reference *Reference *
* The reference category is as follows: Low adherence: ** Multinomial Regression Analysis: PKR = Pakistani rupees.
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Khan, F.U.; Khan, F.U.; Wushouer, H.; Shi, L.; Fang, Y. Adherence to Antibacterial Therapy and Associated Factors in Lower Respiratory Infections in War-Affected Areas: A Randomized Controlled Trial. Antibiotics 2025, 14, 977. https://doi.org/10.3390/antibiotics14100977

AMA Style

Khan FU, Khan FU, Wushouer H, Shi L, Fang Y. Adherence to Antibacterial Therapy and Associated Factors in Lower Respiratory Infections in War-Affected Areas: A Randomized Controlled Trial. Antibiotics. 2025; 14(10):977. https://doi.org/10.3390/antibiotics14100977

Chicago/Turabian Style

Khan, Faiz Ullah, Farman Ullah Khan, Haishaerjiang Wushouer, Luwen Shi, and Yu Fang. 2025. "Adherence to Antibacterial Therapy and Associated Factors in Lower Respiratory Infections in War-Affected Areas: A Randomized Controlled Trial" Antibiotics 14, no. 10: 977. https://doi.org/10.3390/antibiotics14100977

APA Style

Khan, F. U., Khan, F. U., Wushouer, H., Shi, L., & Fang, Y. (2025). Adherence to Antibacterial Therapy and Associated Factors in Lower Respiratory Infections in War-Affected Areas: A Randomized Controlled Trial. Antibiotics, 14(10), 977. https://doi.org/10.3390/antibiotics14100977

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