The inappropriate use of antibiotics is a major contributor to the rise in antimicrobial resistance, worsening adverse drug reactions, and increased medical costs, which are becoming important global public health issues (1). Antibiotics are the most commonly used medications for children (2). Owing to the developmental stage of children, many organs and nervous system functions are not yet fully developed, and the risks associated with antibiotic use are greater than those in adults. Additionally, owing to their underdeveloped immune system, children are susceptible to illness and more likely to be exposed to unnecessary antibiotics, making the inappropriate use of antibiotics particularly prevalent in this population (3, 4). Therefore, it is necessary to determine whether antibiotics can be used in children.

Parents’ level of knowledge and attitude toward medication safety greatly impacts their children’s self-medication behavior. When children are sick, medication use depends primarily on their parents and guardians. Therefore, parents’ knowledge and behavior regarding antibiotic use greatly affect whether children can use antibiotics appropriately (5). If parents have misconceptions about antibiotics or engage in inappropriate behaviors in antibiotic use, the probability of children using antibiotics inappropriately will inevitably increase (6).

Self-medication with antibiotics (SMA), defined as the use of medicines based on personal experience without medical consultation (7), is one of the most common and inappropriate uses of antibiotics. A meta-analysis of 57 studies worldwide indicated that 24.0% of parents had administered antibiotics to their children without a doctor’s advice (4), and a cross-sectional study among 9,526 parents from three provinces of China indicated that the prevalence of SMA in children aged 0–13 years was 32.16% (8). Owing to differences in economic levels and antibiotic usage habits across different regions of China, there were significant variations in the prevalence of SMA among parents in different areas of China. A cross-sectional study conducted in two cities in China in 2020 showed that the incidence of SMA in children was 42.67% in Shaanxi Province and 18.78% in Zhejiang Province (9). Comparable trends have been observed internationally. For example, a recent study in central Iran reported a high prevalence of antibiotic use among children, underscoring the global scope of the issue (10).

In addition, self-storage with antibiotics (SSA), non-adherence to antibiotic treatment (NAAT), and the use of antibiotics for disease prevention by parents are important indicators of inappropriate use of antibiotics. Recently, there has been increasing research on the inappropriate use of antibiotics by Chinese parents; however, most studies have focused on SMA (11, 12). The inappropriate use behaviors of antibiotics among parents are diverse, but there have been no studies on the various inappropriate use behaviors and their influencing factors. Therefore, this study aimed to investigate parental knowledge about antibiotic use, assess the prevalence of inappropriate use behaviors, including SSA, SMA, NAAT, and the use of antibiotics for disease prevention, and identify related factors to provide targeted suggestions for promoting rational antibiotic use in children.

This study investigated knowledge about antibiotic use and inappropriate use behaviors of antibiotics and explored their related factors among parents in eastern China. We conducted a survey of parents from one kindergarten and one primary school in rural and urban areas of each region in Nantong City, which ensured that the sample was representative.

Among the parents, 29.24% scored <5, indicating a low awareness rate of antibiotic use knowledge among parents in Nantong City. Parents with low awareness of antibiotic use have insufficient understanding of the dangers of antibiotic abuse, lack the ability to use antibiotics reasonably, and are susceptible to inappropriate antibiotic use (14). This study suggests that children lived in rural areas, had brother or sister have lower levels of antibiotic awareness. Parents with lower education, without medical backgrounds, lower income, where older family members were involved in the children’s treatment with a lower AKS. Health education on the rational use of antibiotics should be emphasized to these parents to improve their understanding of the dangers associated with inappropriate antibiotic use in children. Engaging local health volunteers may also be a practical approach, as shown in Iran during the COVID-19 pandemic, where community volunteers significantly improved public health literacy and preventive behaviors (15).

Our study found that the prevalence of self-storage of antibiotics at home for children was 49.05% in the past year. Additionally, the research results showed that SSA was a risk factor for SMA by parents (aOR = 7.25, 95% CI = 5.69–9.24) and for administering antibiotics to children for disease prevention (aOR = 8.42, 95% CI = 5.61–12.63), which is consistent with previous research results (16, 17). A previous study showed that the antibiotics stored at home come from two main sources: leftover prescription drugs and purchases from pharmacies (18). Chinese parents can easily obtain over-the-counter antibiotics. Studies have shown that Chinese parents can still purchase antibiotics from retail pharmacies without a prescription (19, 20), which increases the opportunity for parents to store antibiotics. When children experienced similar symptoms as before or when they were sick, parents used antibiotics stored or remaining at home to treat the child based on past experience. This study suggests that parents with a medical background are more likely to keep antibiotics at home. Conversely, parents with a medical background were more likely to obtain antibiotics; however, parents with a medical background had a higher cognitive score for antibiotics. They believed that they had the medical knowledge and ability to provide reasonable medications to their children.

Our study found that the prevalence of SMA was 21.90%, which was lower than that of SMA in Mexican children (49.6%) (21), but higher than the prevalence of SMA in children in Europe (8%) (4), Zhejiang Province (18.78%), and China (9). SMA by parents promotes the excessive use of antibiotics in children, which might lead to a series of adverse consequences, such as misuse and abuse of antibiotics, concealment of true illness, and delayed treatment.

Our study suggests that 57.13% of parents discontinued with antibiotic treatment immediately after their children’s symptoms disappeared. Owing to inconsistent criteria for determining NAAT, it was not possible to compare the prevalence of NAAT in this study with that in previous studies. The reason why parents did not follow antibiotic treatment might be that Chinese parents are concerned about the side effects of antibiotics on their children when using them (22). Discontinuing antibiotics in advance could weaken the therapeutic effect and lead to incomplete sterilization; however, this could lead to residual antibiotics at home, thereby increasing the risk of SMA in children.

This study found that parents with lower antibiotic awareness scores had a greater risk of NAAT and took antibiotics for disease prevention, whereas parents with higher awareness scores were more likely to store antibiotics at home. Improving parents’ awareness of antibiotics could reduce the risk of NAAT and taking antibiotics for disease prevention; however, it might increase the risk of parents storing antibiotics at home, thereby increasing the inappropriate use of antibiotics. Other studies have shown that parents have higher antibiotic awareness scores and are more inclined to use antibiotics on their own (5). The research results suggest that the relationship between parental antibiotic awareness and the reasonable use of antibiotics was complex, and simply improving parental antibiotic awareness might have counterproductive effects (23). Similar complexity has been noted in other public health domains such as COVID-19, where population-level studies have demonstrated that knowledge alone does not always translate into safe practices without addressing underlying attitudes and contextual factors (24). Further research and exploration should simultaneously reduce parents’ inappropriate use of antibiotics while improving their awareness.

Our study also suggested that parents in poor physical condition were more likely to engage in inappropriate use behaviors, such as SSA, SMA, and NAAT, which is consistent with previous research findings (13). Children with poor health require frequent use of medication. Long-term medication habits make parents more dependent on antibiotics, increasing the likelihood of storing antibiotics at home and thus increasing the risk of inappropriate use of antibiotics.

This study has some limitations. First, this was a cross-sectional study, and it is difficult to clarify the causal relationship or the direction between the inappropriate use of antibiotics by parents and related influencing factors. For example, while it finds that lower knowledge is associated with non-adherence, we cannot be sure if poor knowledge leads to non-adherence or if experiencing antibiotic use (or misuse) influences how parents score on knowledge questions. Further prospective studies are required to validate the conclusions of this study. Second, using a self-administered questionnaire to investigate the antibiotic use behavior of parents of children within 1 year. Self-reported recall over 1 year is subject to social desirability and recall bias, which is particularly acute for sensitive health behaviors. The results were inevitably subject to recall and social desirability bias. Third, this study was only conducted in one prefecture-level city in eastern China, and the socioeconomic development level of Nantong City is relatively high in eastern China. Therefore, the results do not represent other regions in eastern China.

Parents in eastern China had lower antibiotic awareness scores. It is necessary to raise parental awareness of the dangers associated with inappropriate antibiotic use in children and strengthen their awareness of the rational use of antibiotics. Inappropriate use of antibiotics by parents is common, and it is necessary to develop rational medication strategies, limit the outflow of over-the-counter antibiotics, and reduce household antibiotic reserves and inappropriate use behaviors.