Karbala survey finds uneven antimicrobial stewardship knowledge and AWaRe awareness

A cross-sectional survey of 360 physicians, pharmacists, and dentists in Karbala, Iraq, found generally favorable attitudes toward antimicrobial stewardship but uneven knowledge, self-reported practices, and awareness of the World Health Organization’s Access, Watch, and Reserve antibiotic classification. Across the three professions, mean scores were 3.416 out of 5 for knowledge, 3.799 for attitudes, and 3.568 for practices, producing a total knowledge-attitude-practice score of 3.594. Only 95 participants, or 26.4%, reported prior awareness of AWaRe.

Awareness was highest among pharmacists at 50.8%, compared with 15.0% of physicians and 13.3% of dentists, revealing substantial differences among professionals involved in prescribing, dispensing, and counseling on antibiotic use. The study was conducted from 1 September to 13 October 2025 in public hospitals and specialized dental centers across Karbala Governorate. Researchers used a nonprobability convenience sample with fixed quotas of 120 participants per profession to facilitate comparisons rather than reproduce the local workforce distribution.

Of the final sample, 254 participants completed a self-administered questionnaire face to face and 106 completed an English-language online version distributed through official professional groups with verified identities. The instrument combined 15 five-point knowledge-attitude-practice items—five for each domain—with a binary AWaRe awareness question, a multiple-response item about information sources, and nine perception statements that were completed only by respondents already familiar with the classification. Four subject experts reviewed the questionnaire, and a pilot involving 15 professionals, five from each group, assessed clarity and feasibility.

Physicians achieved the highest average total KAP score, at 3.713, followed by pharmacists at 3.581 and dentists at 3.489. Physicians also scored higher than pharmacists for knowledge, with means of 3.520 and 3.357, respectively, and higher than both pharmacists and dentists for practice, at 3.707 compared with 3.532 and 3.467. Dentists had the lowest attitude score, 3.632, while physicians and pharmacists scored 3.912 and 3.855.

Bonferroni-adjusted pairwise comparisons confirmed that physicians had higher total scores than both other professions, while pharmacists and dentists did not differ significantly from one another. In a general linear model adjusted for profession, education, gender, age, experience, hospital type, and AWaRe awareness, physicians retained higher total KAP scores than dentists, with an unstandardized coefficient of 0.148 (95% confidence interval 0.039 to 0.256; p = 0.008). Pharmacists did not differ significantly from dentists after adjustment.

Profession was also the main independent predictor of AWaRe awareness. In binary logistic regression, pharmacists had 5.284 times the adjusted odds of awareness compared with physicians (95% confidence interval 2.443 to 11.432; p < 0.001), whereas dentists did not differ significantly from physicians, with an adjusted odds ratio of 0.825 (95% confidence interval 0.338 to 2.014). No other included characteristic—education, experience, age, gender, or hospital type—was independently associated with awareness.

Participants with post-bachelor education had higher unadjusted scores in every KAP domain and in total KAP, but the association disappeared after accounting for profession and other covariates. This pattern is important because 75.0% of physicians held post-bachelor qualifications, compared with 14.2% of pharmacists and 10.8% of dentists, making education and professional group closely intertwined in the sample. Item-level responses showed that some principles were widely endorsed, while several misconceptions and reservations remained.

Agreement was strongest for the statement that correct antibiotic use can help reduce antimicrobial resistance, reported by 92.5%, and for taking culture and sensitivity samples before starting antibiotics, reported by 87.8%. Yet 66.9% agreed that newer and more costly antibiotics are more efficacious, and 60.8% agreed that development of new antibiotics can keep pace with current resistance patterns. The study measured agreement with questionnaire statements rather than directly observed clinical decisions, so these findings describe the respondents’ reported knowledge and attitudes rather than verified prescribing behavior.

Self-reported practice responses were mixed. Most respondents, 74.7%, supported changing an intravenous antibiotic to an oral form after three days when medically appropriate. However, only 51.1% disagreed with the claim that limiting antibiotic use impairs good patient care, and 47.8% disagreed with using broad-spectrum antibiotics when narrower alternatives are effective.

Regarding over-the-counter antibiotic dispensing for minor infections, 43.9% agreed that pharmacists may hand out antibiotics without a prescription. These responses indicate incomplete endorsement of several stewardship principles, but the questionnaire did not record prescriptions, dispensing encounters, patient outcomes, or clinical indications. They therefore cannot establish how often respondents actually selected, dispensed, or administered antibiotics in practice.

Among the 95 participants who reported prior AWaRe awareness, perceptions were generally favorable. Their mean AWaRe perception score was 4.009 out of 5. Pharmacists had the highest score at 4.126, followed by physicians at 3.864 and dentists at 3.729; after Bonferroni adjustment, only the pharmacist–dentist difference was statistically significant.

Among aware respondents, 88.4% agreed that training was needed on antimicrobial resistance, stewardship, and AWaRe, 86.3% believed AWaRe could suggest safe antibiotic choices, and 85.2% believed following the classification could help reduce resistance. By comparison, only 46.3% agreed that hospital regulations and guidelines encourage consideration of AWaRe in practice. Pharmacy or pharmacists were the most frequently reported source of AWaRe information, cited by 64.2% of aware respondents, followed by scientific sources and media, each at 16.8%, the WHO at 14.7%, and physicians at 13.7%; respondents could select more than one source.

Within the aware subgroup, total KAP scores were positively correlated with AWaRe perception scores, with a Spearman’s rho of 0.344 and p = 0.001. This statistical association does not demonstrate that greater stewardship competence causes more favorable views, or vice versa. The cross-sectional design cannot establish causality, and the correlation was calculated in a restricted group of 95 respondents whose prior awareness may itself be related to their perceptions.

The result nevertheless identifies a measurable relationship between general stewardship KAP and engagement with the classification in this sample. It also supports examining broader stewardship education and AWaRe-specific learning together rather than treating awareness of a classification as an isolated subject, while avoiding assumptions about causal effects or changes in clinical behavior. Several limitations constrain the interpretation and generalizability of the results.

Recruitment relied on accessible public hospitals, dental centers, and voluntary professional groups, so the sample may overrepresent respondents who were available, reachable, or especially interested in stewardship. Equal professional quotas supported balanced comparisons but meant that prevalence estimates, including the overall 26.4% AWaRe awareness figure, should not be treated as representative of Karbala’s entire health workforce. Mixing face-to-face and online recruitment may also have introduced selection effects, while voluntary and anonymous participation allowed respondents to present socially desirable answers.

The cross-sectional design could not track practices over time or determine causation. Furthermore, the study was confined to Karbala, the education variable combined different post-bachelor qualifications into one category, and AWaRe perception results were available only for participants who already knew the classification. The favorable perception scores should therefore not be generalized to the 73.6% who reported no awareness.

Within those limits, the survey provides baseline evidence that antimicrobial stewardship education in this setting varied substantially by profession. Physicians reported the strongest overall KAP performance, dentists had the lowest attitude scores, and pharmacists were substantially more likely to know AWaRe despite not having the highest overall KAP mean. The results support profession-tailored education: the study’s authors identified a need for stronger resistance and stewardship content in dental training, while highlighting pharmacists’ potential contribution to AWaRe teaching, dispensing guidance, and prescribing advisory support.

At the institutional level, the low agreement that hospital guidelines encourage AWaRe use indicates that individual awareness alone has not necessarily translated into routine implementation. The survey does not demonstrate that any educational or policy intervention will improve prescribing outcomes, but it identifies specific gaps that future studies and locally tailored stewardship programs can evaluate.

Subject of Research: Antimicrobial stewardship knowledge, attitudes, practices, and WHO AWaRe awareness among physicians, pharmacists, and dentists in Karbala, Iraq

Article Title: Antimicrobial resistance and stewardship knowledge, attitudes, practices, and WHO AWaRe awareness among physicians, pharmacists, and dentists in Karbala, Iraq

Article References: Almubarak, A., & Abdulridha, M. K. (2026). Antimicrobial resistance and stewardship knowledge, attitudes, practices, and WHO AWaRe awareness among physicians, pharmacists, and dentists in Karbala, Iraq. Pharmacia, 73, Article e194858. https://doi.org/10.3897/pharmacia.73.e194858

Image Credits: AI Generated

DOI: 10.3897/pharmacia.73.e194858

Keywords: antimicrobial resistance, antimicrobial stewardship, WHO AWaRe, physicians, pharmacists, dentists, Iraq, survey, antibiotic use, healthcare education, Antimicrobial, resistance