Awareness program for controlling the misuse of antibiotics and related resistance among mothers of children under 5 years

Abstract

Background

Antibiotics are pharmacological agents synthesized in laboratories or derived from microorganisms to inhibit the growth of other living microorganisms. Antibiotics resistance represents a serious problem described by WHO as “a global public health concern” especially in children.

Aim

To assess the impact of an antibiotic awareness program on the knowledge, attitude, and reported practices of mothers of children less than 5 years old Methods

A quasi-experimental pre-post-test design was conducted at immunization and primary health care centers on 375 mothers. The intervention included a structured awareness program employing lectures, group discussions, and audiovisual materials. Researchers used tools to assess socio-demographic characteristics, knowledge, attitudes, and reported practices, aiming to improve mothers’ understanding and behavior regarding antibiotic use.

Results

The mothers’ knowledge exhibited a substantial increase, as reflected in the total mean score rising from 6.25 ± 1.72 in the pre-test to 10.85 ± 2.49 in the post-test. Furthermore, the participants’ attitudes witnessed a noteworthy shift, with the pre-test total mean score of 28.19 ± 10.12 experiencing a considerable improvement post-program to reach 59.60 ± 12.40. Additionally, the reported practices of the mothers displayed positive changes, as evidenced by an improvement in the total mean score from 6.36 ± 1.97 in the post-test.

Conclusion

The well-designed awareness programs can play a crucial role in empowering mothers to make informed decisions and adopt responsible practices, contributing to the overall effort in controlling antibiotic misuse and combating resistance in the context of child healthcare.

Background

Antibiotics are pharmacological agents synthesized in laboratories or derived from microorganisms, primarily bacteria, to inhibit the growth or proliferation of other microorganisms [1]. These medications are crucial for saving lives and should be administered with meticulous care and efficiency [2], adhering to all necessary precautions and exclusively by trained healthcare professionals to mitigate potential unintended consequences [3]. Children under five years of age frequently experience viral infections, for which antibiotics are generally ineffective, yet antibiotics are often prescribed unnecessarily in this population [2]. The misuse of antimicrobial medications, including antibiotics (antibacterial), antifungals, antivirals, antimalarials, and anthelmintics, whether stemming from abuse, overuse, or suboptimal administration, leads to alterations in microbes such as bacteria, fungi, viruses, and parasites [4]. Consequently, these medications lose their effectiveness, a phenomenon known as antimicrobial resistance (AMR) as identified by the World Health Organization (WHO) [5]. AMR stands as a significant consequence of the inappropriate utilization of antibiotics by both the general public and healthcare providers [6].

Antibiotic misuse stands as a critical issue, recognized by the World Health Organization (WHO) as a “top 10 global public health concern” [3], especially concerning children, who are particularly vulnerable [2]. Given their susceptibility to infections of various origins, children frequently receive antibiotics more than any other medication [6]. This issue represents a significant global public health challenge, demanding prioritization by healthcare practitioners and organizations worldwide [7].

The behavior of antibiotic abuse is influenced by several factors, including age, socioeconomic status, and the accessibility of antibiotics. Improper and excessive use of antibiotics are major contributors to the emergence and dissemination of antimicrobial resistance [8]. Antibiotics are readily available as over-the-counter (OTC) medications or upon patient request, potentially fueling widespread antibiotic abuse [9]. Inadequate knowledge about microbial diseases and the pharmacokinetic and pharmacodynamic characteristics of different antibiotic classes lies at the heart of incorrect and inappropriate antibiotic utilization [10, 11]. Inaddition, the study by Szymczak et al. suggests that parents often do not seek antibiotics but rather reassurance that their child is healthy. Clinicians, however, may perceive a demand for antibiotics, contributing to their overprescription [12].

Antibiotic misuse has increased the occurrence of multidrug-resistant (MDR) bacteria in Egypt during the past few years. Lower healthcare professional to patient ratios is also involved for such kind of concern [6]. WHO estimated that every year in the world, infections caused by multidrug resistant (MDR) bacteria result in 700,000 deaths across all ages, of which around 200,000 are newborns [13]. 90% of neonates hospitalized with sepsis in the intensive care unit (ICU) in the Middle East had bacteria that were resistant to treatment [10]. AMR in low- and middle-income countries, including Egypt, is expected to worsen due to poverty and poor health systems [14, 15].

Mothers are frequently the primary caregivers for young children, wielding significant influence over healthcare decision-making processes [16]. Several studies suggest that mothers, as primary caregivers, play a pivotal role in deciding when and how antibiotics are administered to their children, often influenced by cultural beliefs, past experiences, and accessibility [1,2,3]. By imparting mothers with comprehensive knowledge concerning antibiotic employment and resistance, they are empowered to serve as advocates for their children’s health and engage in informed decision-making alongside healthcare professionals [9]. Notably, children under the age of 5 are notably susceptible to infections, underscoring the criticality of judicious antibiotic utilization for their overall well-being [17]. Through targeted educational initiatives directed at mothers, we endeavor to ensure the judicious administration of antibiotics, thereby facilitating appropriate treatment for children when warranted, while concurrently mitigating unnecessary exposure to antibiotics and attendant risks [13]. Therefore, this study was conducted to improve the level of mothers’ knowledge, attitude, and practice (KAP) related using of antibiotics among Egyptian children.

Research Hypothesis

H1: The implementation of the awareness program will lead to an improvement in mothers’ knowledge, attitudes, and reported practices regarding the control of antibiotic misuse and the associated resistance.

Materials and Methods

Study design and setting

A quasi-experimental pre-post design was conducted at both immunization and well-baby clinics affiliated with five primary health care centers in the Al Moquattam medical district, Cairo Health Directorate, Egypt. These centers include Al Sabeen Fadan, Al Mafareq, and Al Asmarat 1, 2, and 3. The Al Moquattam district is characterized as a semi-urban zone, and the affiliated primary health care centers primarily cater to children and mothers seeking maternal and child health services.

Study population

The study utilized a convenient sampling method to select participants. Mothers were approached during their visits to the primary health care centers for immunization, examination, or follow-up of their children. Participation was voluntary, and the specific inclusion criteria required that mothers be at least 18 years old, serve as the primary caregivers, and be able to read and write. Also, the focus was on mothers who were the primary caregivers of young children frequently attending these health centers.

The size of sample was statistically calculated by the following formula: The previous study by Çelebi & İskender [18] reported a mean pre-intervention knowledge score of 39.8 with a standard deviation of 5.3, and a post-intervention mean score of 47.6 with a standard deviation of 4.9. We used the standard formula for calculating sample size for a continuous outcome in a paired t-test design:

$${\text{n }} = \, \left[ {\left( {{\text{Z}}\alpha /{2 } + {\text{ Z}}\beta } \right) \, \times \, \sigma {\text{d}}} \right]{2 }/{\text{ d2}}$$

Therefore, with 95% power to detect a mean difference of 7.8, assuming a SD of difference of 4.98, we would need a sample size at least of 87 participants for a pre-post study design.

Initially, 470 mothers were approached to participate in the study. Out of the 470 approached, 412 mothers agreed to participate and were included in the study. After enrollment, there were 47 dropouts due to reasons such as relocation, health issues, and lack of further interest. Ultimately, 365 mothers were included in the final analysis.

Data collection tools:

Demographic information

The demographic questions in the study were about age, marital status, number of children, educational level, residence, working and income.

Pre-post knowledge assessment questionnaire

The questionnaire was developed by researchers after reviewing literature reviews Abd El-Kader & Mohammed, [19] and Alkhaldi et al. [20]. It aimed to assess mothers’ knowledge regarding antibiotic misuse and related resistance. The questionnaire consisted of 15 true/false statements, covering topics such as antibiotic indications, side effects, resistance, and complications. Each question was scored as correct = 1 and incorrect = 0, with the total score ranging from 0 to 15. [19, 20].

Pre-post attitude scale

The scale was adopted from Abdelsamea et al. [21]; for assessing the mothers’ attitude regarding misuse of antibiotics and related resistance. The attitude refers to the participants’ beliefs, perceptions, and feelings about antibiotic use, including their understanding of appropriate prescribing practices, antibiotic resistance, and the risks associated with misuse. The scale included dimensions such as the sources of antibiotics, awareness of antibiotic resistance, and recognition of misuse behaviors. It was a three points Likert scale in Arabic version, involving 24 statements. A 3-point Likert scale was used ranged from (Agree 3, not sure = 2, and disagree = 1), with lower scores indicating less favorable attitudes toward appropriate antibiotic use. Total score ranged from 24 to 72.

Pre-post reported practices questionnaire

The questionnaire was developed by the researchers dependent on Salama et al. [22] and Panagakou et al. [23]. It involved 11 statements asking about instructions before/during/after antibiotic administration, dose frequency & repetition, time to stop antibiotic, and its storage. Responses of all statements were (done = 1 and not done = 0). Total score ranged from 0 to 11.

Validity and reliability of the data collected

The measures were translated into the Arabic language by language expert for the purposes of this study. Face and content validity were assessed by experts in community health and pediatric nursing and pharmacology. The experts assessed the measures design, content, consistency, relevancy, and accuracy of the tools. In addition, measure reliability was assessed using the Cronbach alpha coefficient statistical test. The knowledge, attitude, and practice had adequate internal consistency reliability of 0.752, 0.940 and 0.709, respectively.

Data collection

Data was collected over four months, from the end of April 2023 to the beginning of September 2023. The pre-test data collection was conducted over one month. The awareness program on the misuse of antibiotics and related resistance was implemented during the second month. After the program concluded, there was a three-week interval, followed by post-test data collection, which lasted one month.

Researchers invited the mothers both in writing and verbally. Health care professionals at the immunization and primary health care centers approached the mothers. The relationship between the mothers and the investigators was primarily facilitated through the healthcare providers who introduced the study during routine visits.

Content Development Phase: The phase involved the development of program materials based on the pre-test results, aiming to address knowledge gaps, clarify misconceptions, and promote responsible antibiotic use. These materials were carefully designed by the research team, which included experts in community health, pediatric nursing, and pharmacology. To enhance the effectiveness of the intervention, a variety of resources were created, including posters and visual aids highlighting key messages about antibiotic misuse and resistance, as well as PowerPoint presentations covering topics such as indications for antibiotics, side effects, and proper storage practices. Additionally, simple and clear handouts were distributed as take-home guides to reinforce learning. Short video clips were used to demonstrate best practices for administering antibiotics, while discussion guides facilitated group discussions and brainstorming sessions. Including examples or detailed descriptions of these materials in the paper would help readers gain a better understanding of the intervention and its practical application.

Implementation phase: 365 mothers divided into ten groups, with each group attending four sessions. Continuous communication channels for questions and feedback. Sessions conducted at primary health care centers’ waiting areas. The program was developed by the researchers based on a thorough review of existing literature [19,20,21,22]. The sessions were conducted by the resercahers. The awareness program employed a structured approach to ensure its effectiveness. Each group of mothers participated in four sessions, with each session lasting one hour. Flexible scheduling accommodated participants’ availability, and sessions were conducted in the waiting areas of primary health care centers.

The training program included four sessions. Session 1: Understanding Antibiotics: indications for antibiotic use and side effects and potential complications. Session 2: Antibiotic Resistance: causes and consequences of antibiotic resistance and importance of responsible antibiotic use. Session 3: Practical Practices: proper storage of antibiotics, following instructions before, during, and after administration and recognizing when to stop antibiotic use. Session 4: Role of Health Professionals: insights from physicians, nurses, and pharmacists on antibiotic use and clearing misconceptions and addressing concerns.

Methodologies included brainstorming, lectures, group discussions, and audiovisual materials like posters, videos, PowerPoint presentations, and handouts. The program integrated auditory, visual, and interpersonal communication techniques to enhance understanding and retention. The use of audiovisual materials, such as videos and PowerPoint presentations, proved effective in engaging participants visually and auditorily. Group discussions and brainstorming sessions strengthened interpersonal communication, fostering a supportive learning environment.

Evaluation Phase: The post-test evaluation was conducted three weeks after the implementation of the awareness program to assess its impact on mothers’ knowledge, attitudes, and reported practices. The same tools used in the pre-test were employed for this assessment, ensuring consistency and reliability in measuring the changes brought about by the program. The evaluation revealed significant improvements in all areas, highlighting the program’s effectiveness in enhancing mothers’ understanding and practices regarding antibiotic misuse and resistance.

Statistical analysis

Data was entered and analyzed using SPSS version 24.0. Qualitative variables were presented as frequency and percentage, while quantitative variables were expressed as mean and standard deviation. To compare parametric variables, a paired sample t-test was performed. A multivariate regression analysis was conducted to examine the relationship between the dependent variable and multiple independent variables. The dependent variable was the total practice post-intervention score, while the independent variables included total knowledge post-intervention score, total attitude post-intervention score, age, education, residence, work status, marital status, and number of children. To assess normality, a Kolmogorov–Smirnov test was conducted. Since the p-value was greater than 0.05, the data was considered normally distributed.

Results

Characteristics of participants

The demographic details of the participants have been mentioned in the Table 1. The mean age of studied mothers was 36.03 ± 6.56. As for marital status, 74.0% of them were married and 57.3% had 3 children or more. In addition to 44.7% had a secondary educational level, 52.3% had a fixed work outside home and 66.0% were living in urban areas with inadequate monthly income by 78.6%.

Table 1 Distribution of mothers according to their socio-demographic data (n = 365)

Knowledge, attitude, and practice level among studied mothers

Concerning the mothers’ knowledge, total mean score of mothers’ knowledge was 6.25 ± 1.72 in pre-test while increased to 10.85 ± 2.49 in the post-test (p < 0.001). Also related to mothers’ attitude, total mean score of mothers’ attitude was 28.19 ± 1.12 in pre-test while increased to 59.60 ± 2.50 in the post-test (p < 0.001). In addition, mean score of mothers’ reported practice changed from 4.04 ± 1.71 to 8.36 ± 1.97 post intervention (p < 0.001)., see more details at Table 2 and Fig. 1.

Table 2 Pre-test and post-test mean comparison of mothers’ knowledge, attitude, and reported practices regarding the misuse of antibiotics

Fig. 1

Comparison between knowledge, attitude, and practice pre and post intervention

Factors affecting mothers’ practice

The multivariate regression analysis presented in Table 3 evaluates several factors influencing the total practice post-intervention scores. The intercept indicates a baseline score of −6.0342, significantly low when all predictors are zero (p = 0.000). Key predictors include total knowledge post-intervention (coefficient = 0.7049, p = 0.000) and total attitude post-intervention (coefficient = 0.5088, p = 0.000), both significantly enhancing the scores. Higher educational levels (coefficient = 1.8700, p = 0.000) also positively impact scores, while urban residence (coefficient = −1.2942, p = 0.000) and being a housewife (coefficient = −2.3333, p = 0.000) are associated with lower scores. Age and number of children show positive but not significant relationships, and marital status (divorced) has no significant effect. The model explains 98.6% of the variability in scores (adjusted R-squared = 0.986) with an overall significant model (F-statistic = 3041, p < 0.001).

Table 3 Multivariate regression analysis for mothers’ practice

Factors affecting mothers’ knowledge and attitude

The regression analysis in Fig. 2 reveals that “Work (outside home)” has the highest positive coefficient (5.3422, p < 0.001), indicating a substantial influence on total knowledge post-intervention. Similarly, “Education” (1.7742, p < 0.001) and “Children” (1.2311, p < 0.001) also demonstrate significant positive effects. “Total Practice Post” (0.9320, p < 0.001) and “Total Attitude Post” (0.1613, p < 0.001) are additional positive predictors, with practice having a stronger effect than attitude. In contrast, “Marital Status (single)” has a significant negative impact (−1.8693, p < 0.001), suggesting potential challenges for this group. Non-significant variables include “Age” (p = 0.0748) and “Residence (Urban)” (p = 0.9297), indicating minimal influence. These findings highlight the critical role of employment status, education, and family structure in shaping knowledge outcomes while identifying vulnerable groups needing targeted support.

Fig. 2

Regression coefficients and significance for total knowledge predictors

The regression analysis in Fig. 3. highlights several significant predictors of mothers’ attitudes post-intervention. Positive predictors include Total Practice Post (0.9373, p < 0.001), Total Knowledge Post (0.2248, p < 0.001), Education (3.7226, p < 0.001), Residence (Urban) (3.2233, p < 0.001), and Marital Status (single) (3.8154, p < 0.001), indicating that these factors strongly contribute to improved attitudes. Conversely, negative predictors such as Age (−0.7726, p < 0.001) and Children (-2.7729, p < 0.001) suggest that older mothers and those with more children face challenges in attitude improvement. The intercept (16.9090, p < 0.001) represents the baseline attitude score when all other variables are zero. These findings emphasize the importance of socio-demographic and behavioral factors in shaping attitudes, providing key insights for targeted interventions.

Fig. 3

Regression coefficients and significance for total attitude predictors

Discussions

Misusing of antibiotics is a crucial societal health problem. Children under five years have a possibility for receiving unnecessary antibiotics to treat infections. Parent’s misconceptions about use of antibiotics and resistance persist, considered as a vital community issue that could threaten the preschool children [24]. The core factors leading to incongruous antibiotic use are an inadequate time to assess ill child, financial status, parents’ different levels of knowledge, phobia of complications, and parents’ perception to give antibiotics for children [25].

Regarding mothers’ knowledge scores on the misuse of antibiotics and antibiotic resistance, the pre-test mean score was recorded as 6.25 ± 1.72. After implementing the awareness program, a significant improvement was observed, with the post-test mean score increasing to 10.85 ± 2.49. This knowledge result was agreed with the study of Abd El-Kader & Mohammed, [19] in UAE who illustrated that the majority of subjects had a satisfied knowledge level post intervention through the post-test and nearly three quarters through the follow up.

Additionally, the cross-sectional survey results of Agarwal et al. [26] in an Indian tertiary care hospital, along with the cross-sectional study of Alkhaldi et al. [20] conducted at two healthcare centers in Jordan, and the survey of Ekambi et al. [27] in Cameroon, all indicate a consistent finding. These studies have collectively identified a deficiency in the knowledge levels of both mothers and fathers concerning the optimal use of antibiotics for their children. Furthermore, all three studies recommend the implementation of training courses as a means to enhance the knowledge levels of parents.

Our study revealed inadequate attitude among the studied mothers regarding antibiotic use for their children in the pre-test. However, a significant positive shift in mothers’ attitudes was observed following an awareness program. These findings align with various studies, including those conducted by Karuniawati et al. [28] in Indonesia on antibiotic use, Shawq and Al-Musawi [29] in Baghdad-Iraq, Abd Elsamad et al. [30] in MCH centers in Beni-Suef governorate in Egypt, and Shtayyat & Abu-Baker [31] in both Jordan and Syria.

The study found a significant improvement in mothers’ reported practices related to appropriate antibiotic use post the educational program, indicating positive changes in self-reported behaviors. This comes on the same way of Abd El-Kader & Mohammed, [19] study in UAE that showed that only one quarter of mothers had satisfactory subjective practice level about appropriate antibiotic use among children during pre-test which increased to the majority after intervention program. A high effective program carried out by Abozed et al. [32] declared that most of mothers (98.6%) reached competent practices through the immediate post-test after their learning package application.

The pre-test result of reported practices of the current study was similar with the study findings of Islam et al. [33] at Dhaka city in Bangladesh for assessing the factors affecting the parents’ misuse of antibiotics towards their children. It showed that nearly two thirds of participated parents had unaccepted practices of antibiotics for their school children.

The multivariate regression analysis results provide several important insights into the factors influencing the total practice post-intervention scores. The coefficients for total knowledge and total attitude post-intervention are both positive and highly significant, indicating that increases in knowledge and positive attitudes significantly enhance mothers’ practices post-intervention. This aligns with existing literature, which emphasizes the importance of educational interventions in improving health-related behaviors.The study of Abdelsamea et al. [21] reported that there was a strong correlation between all of the KAP levels. Also Abozed et al. [32] reported a high significant correlation between total mothers’ knowledge and their practical knowledge Positive and uncertain attitudes of parents contribute to good antibiotic practices and help reduce antibiotic resistance [34, 35].Furthermore, There was positive impact of higher education on practice scores underscores the role of education in facilitating better health practices. In contrast, the negative coefficients for urban residence and being a housewife may reflect differences in healthcare access, health-seeking behaviors, or exposure to antibiotic-related awareness campaigns. While urban residents may have greater access to both over-the-counter medications and healthcare services, their practices could be influenced by increased self-medication tendencies or greater exposure to misinformation. Similarly, while housewives often have strong support systems, their antibiotic-related practices may be shaped by traditional beliefs, reliance on family advice, or differing levels of exposure to formal health education. The lack of significant impact from age and number of children suggests that these factors do not strongly influence the effectiveness of the intervention, possibly because the educational content was specifically designed to address misconceptions about antibiotic misuse across diverse demographic groups. While, other study found a significant correlation between good practices and several factors, including parents’ age, lower household income [33, 36].

According to the factors affecting mothers’ knowledge and attitude, the regression analysis revealed that employment status was the most influential predictor of mothers’ post-intervention knowledge, with “Work (outside home)” showing the highest positive coefficient (5.3422, p < 0.001). Similarly, education level (1.7742, p < 0.001) and the number of children (1.2311, p < 0.001) significantly contributed to improved knowledge scores. Positive predictors such as “Total Practice Post” (0.9320, p < 0.001) and “Total Attitude Post” (0.1613, p < 0.001) indicate that better practices and attitudes strongly correlate with increased knowledge, with practice having a greater impact than attitude. Conversely, marital status (“single”) had a negative coefficient (−1.8693, p < 0.001), highlighting challenges faced by single mothers. Non-significant variables, including age (p = 0.0748) and urban residence (p = 0.9297), demonstrated minimal influence. These findings underline the importance of employment, education, and family dynamics in shaping knowledge outcomes while identifying vulnerable groups in need of targeted support. Working mothers and educated mothers increase in knowledge can be explained by their greater exposure to health information, higher likelihood of accessing reliable healthcare resources, and more engagement in decision-making regarding their children’s healthcare.

According to mothers’ attitude, there are several significant predictors of mothers’ attitudes post-intervention. Positive predictors included Total Practice Post (0.9373, p < 0.001), Total Knowledge Post (0.2248, p < 0.001), education level (3.7226, p < 0.001), urban residence (3.2233, p < 0.001), and single marital status (3.8154, p < 0.001), demonstrating a strong contribution to improved attitudes. Conversely, age (−0.7726, p < 0.001) and the number of children (−2.7729, p < 0.001) negatively influenced attitudes, suggesting that older mothers and those with more children faced greater challenges in attitude improvement. These findings highlight the critical role of socio-demographic and behavioral factors in shaping attitudes and provide insights for designing targeted interventions.

These results align with previous studies in the literature. Islam et al. [37] identified significant influences of parental age, education level, employment status, income, child’s age, and family type on knowledge, attitude, and practice (KAP). Similarly, Das et al. [38] found that mothers’ education level was significantly associated with awareness of antibiotic resistance, while parental income influenced attitudes toward the use of expensive antibiotics (p < 0.05). Moreover, Paredes et al. [39] reported a positive correlation between knowledge and attitudes (Coefficient 0.53, 95% CI 0.38–0.68) after adjusting for parental age and education. Alkhaldi et al. [40] further demonstrated that mothers’ employment predicted positive attitudes toward antibiotics (OR = 3.1, p = 0.009), while positive antibiotic practices were associated with favorable attitudes (OR = 6.3, p < 0.001).

The current study builds upon these findings, reinforcing the strong interplay between education, employment, and practice in improving maternal knowledge and attitudes. These insights emphasize the necessity of tailoring interventions to specific socio-demographic characteristics to maximize their effectiveness.

Conclusions

In conclusion, the implementation of the awareness program has significantly improved mothers’ knowledge, attitudes, and reported practices regarding antibiotic misuse and resistance. The program’s success highlights the importance of integrating structured educational initiatives into routine maternal and child health services. Key factors influencing mothers’ practices related to antibiotic misuse include the level of knowledge and attitudes post-intervention. Higher educational levels positively impacted the outcomes, while urban residence and being a housewife were associated with lower scores. The study highlights the critical role of continuous education and awareness programs in empowering mothers to make informed decisions and adopt responsible antibiotic practices, thereby contributing to the broader efforts in combating antimicrobial resistance.

Limitations

• 1. While the study offers valuable insights, the sample size might limit the generalizability of the findings to other populations or regions.

• 2. The reliance on self-reported knowledge, attitudes, and practices may introduce response bias, where participants may overestimate their understanding or compliance.

• 3. The study measured outcomes immediately post-intervention, which limits the ability to assess long-term retention of knowledge and sustained behavior changes.

• 4. The study may not have adequately captured the full range of socioeconomic and cultural factors influencing antibiotic misuse and resistance.

• 5. The absence of a control group limits the ability to attribute improvements solely to the awareness program.

Strengths

• 1. The study demonstrated measurable improvements in knowledge, attitudes, and practices, highlighting the effectiveness of the intervention.

• 2. Conducting the sessions in primary health care centers ensured accessibility and relevance for the target population.

• 3. The study used a combination of teaching methods (e.g., brainstorming, audiovisual aids, group discussions), catering to various learning preferences.

• 4. Addressing antibiotic misuse and resistance, a global health priority, adds significant value to the research.

• 5. The study's inclusion of socio-demographic factors provided deeper insights into predictors of knowledge and attitudes, offering practical implications for targeted interventions.

Ethical considerations

Study proposal and tools were reviewed to be approved by Research Ethics Committee—Faculty of Nursing—Modern University for Technology and Information (MTI), Cairo, Egypt, with Formal Approval Number (FAN/73/2023). The informed written consents were obtained from mothers. Mothers agreed to participate in the current study were assured about all obtained data to be kept confidential with no personal identifiers in all questionnaires. They were informed their right in withdrawing from the study at phase or to complete.