Antibiotics are drugs used in the treatment and prevention of infections. Antibiotics resistance (ABR) is the result of bacteria, viruses, fungi, and parasites evolving over time and no longer responding to these medicines. Antibiotics become ineffective, and infections become difficult or impossible to treat.[1] According to the World Health Organization (WHO), ABR is one of the top public health threats facing humanity, [2] and it is ever-increasing. [3,4]

Misuse of antibiotics poses enormous challenges including prolonged hospital stays, high mortality rates, and a greater economic burden. [5] Although there are several factors that contribute to the development of ABR, improper antibiotic use has been found to be the primary cause. Overuse of antibiotics, inadequate course of therapy, sharing prescribed medication with others, saving part of a prescribed treatment course and using it later to treat the same symptoms, and obtaining antibiotics without prescriptions are all factors that lead to ABR. [6,7] Insufficient knowledge about antibiotics among health-care workers and patients plays a significant role.[8,9] Antibiotics may be dispensed without a prescription for several reasons, including profit-seeking, failure of patients to obtain prescriptions, and a lack of strict inspection by regulatory authorities.[10]  To solve the problem of ABR, proper use of drugs must be ensured.[11] The effectiveness of antibiotics against disease can be preserved only when they are used with a valid prescription and when the full course is completed.[12] 

Prescribing doctors and governmental bodies are responsible for increasing the awareness of antibiotic use and misuse among the general public and formulating laws on drug availability.[13] Knowledge, attitude, and practices regarding antibiotic use and its resistance can be substantially improved through communication and education.[14] The development of better communication strategies between health-care workers and patients should be a focal point for researchers and health-care officials. Conclusive evidence about baseline knowledge, attitude, and practices of any target group is required before planning or strengthening any teaching or training program for that group.[15,16]  Many studies have shown that people with higher levels of education have more knowledge of antibiotic resistance compared to people with low levels of education.[17,18]

A study by Effah et al. found that people of higher and lower education levels may have a similar level of knowledge about ABR, but it was also shown that working in the health-care sector is a major contributor to the level of knowledge on antibiotic resistance.[19] Medical students generally have high knowledge[17] and positive attitudes[20,21] regarding antibiotics resistance, but there is supportive evidence that self-medication is more prevalent among medical students compared to peer groups from non-medical fields.[22] Studies have been conducted around the world looking into physicians’ knowledge, attitude, and practices on antibiotic use and resistance, the commonly used information sources for prescribing, and recommendations to improve antibiotic prescribing.[23,24] These studies all enable researchers and policy-makers to assess the ground situation and implement feasible remedial measures. Health-care workers need innovative and effective methods to instruct patients on the usage of antibiotics. Possible steps that can be taken include instituting regular CME programs and developing institutional antibiotic policies. Infectious disease consultants, hospital infection control nurses, and pharmacists can be recruited to implement anti-septic precautions. Antibiotic prescribing guidelines must be implemented at the institutional level. Allied measures like formulary restriction could reduce knowledge-attitude dissonance.[25] Future interventions could consider social media among other communication strategies to promote appropriate use for antibiotic-related information-seeking in the general population.[26]

Aims and Objectives

Primary objective

The primary objective of the study is to assess the knowledge, attitudes, and practices regarding antibiotics use and resistance among the residents;. This provides a baseline to assess possible remedial methods to resolve the issue and to decide upon suitable communication techniques to increase awareness among different target groups.

Secondary objective

This study also aims to analyze factors associated with a higher degree of knowledge about antibiotics resistance, such as level of education and health-care workers in family/ friends circle.

Study Site

Venkateshwara Institute of Medical Sciences, Gajraula

Study Design

Descriptive cross-sectional study.

Study Population

Residents visiting OPDs of VIMS, Gajraula.

Sample Size

488 voluntary participants were recruited for the study after calculating a minimum sample size of 385 for a representative population.

Sample size calculation for the study:

N=Zα2pq/d2

Where N is the sample size,

Z value for α at 0.05 is 1.96–P)=0.5

d is absolute precision, which is 5% or 0.05

N=(1.96*1.96) [(0.5) (1–0.5)]/(0.05*0.05) N=384.16

The minimum sample size is taken as 385.

Inclusion Criteria

Participants above 18 years of age.

Exclusion Criteria

Individuals are unwilling to participate in the study.

Study Procedure

Study was conducted after obtaining approval from the Institutional Ethics Committee.  Informed consent was received from the participants after explaining the nature of the study in the local language and their freedom to refuse. Participants were asked to fill up a questionnaire that contained questions assessing their knowledge, attitude and practices toward antibiotics use and antibiotics resistance.

Study Tools

Questionnaire, in English and translated into the local language (Hindi).

Analysis of Data

Data were collected and analyzed using IBM SPSS Statistics version 29.0.0.0. All variables were checked for normality. Simple descriptive analyses were computed for demographic details and scores for knowledge, attitude, and practices.

A total of 488 responses were received from patients visiting the various OPDs of Venkateshwara Institute of Medical Sciences, Gajraula. Among the respondents, 257 (52.7%) were females while 231 (47.3%) were females [Table 1]. The participants were from all different age groups, 18–25 years (172, 35.2%), 25–40 years (158, 32.4%), 40–60 years (137, 28.1%), and above 60 years (21, 4.3%) [Table 2]. The respondents were also grouped based on their level of education [Table 3]. 55 (11.3%) participants had the education of Class 10 or below, 218 (44.7%) had completed class 12, out of which 137 (28.1%) are currently pursuing a UG course, 140 (28.7%) had completed a UG course, and 75 (15.4%) had completed a PG course. Grouping was done based on occupation [Table 4].

Table 1: Gender distribution

Table 2: Age-wise distribution

Table 3: Highest level of education

Table 4: Occupation

Table 5: Antibiotic use in the past 12 months

Table 6: When do you decide to stop taking prescribed antibiotics?

Table 7: Assessing practices for acquiring antibiotics

Table 8: Assessing knowledge about antibiotics

Assessing previous history of antibiotic use:

As seen in Table 5, 417 (85.5%) of the participants had taken antibiotics within the past 12 months before the study. Most of them (194) had consumed them only once in the past year, but 8.2% of the total participants (40) had consumed antibiotics more than 5 times over the past year for various symptoms including fever, cough, cold, diarrhea, sore throat, urinary tract infection (UTI), headache, and body pain. Participants were asked when they thought that they should stop taking antibiotics once they had begun treatment. The majority of respondents (280, 57.4%) knew that the full course of antibiotics should be taken as directed [Table 6]. However, 220 participants (45.1%) did admit that in the past, they had stopped taking prescribed antibiotics before completing the course when they felt better, without consulting their doctor.

Assessing practices of acquiring antibiotics:

Our study revealed that 301 respondents (61.7%) said that they have never purchased antibiotics without consulting a doctor first, only 28 (5.7%) admitted to asking their doctors for antibiotics even when told they were not required, in the past, 22.7% of respondents (111) have refused antibiotics when prescribed by a doctor, and 30.9% of participants admit to having used leftover antibiotics from a previous prescription to treat similar symptoms at a later date. 39.3% have shared antibiotics prescribed to them with friends and family to treat the same symptoms. When asked if anyone has ever explained the correct way to use antibiotics to them, 288 (59%) participants said that health-care workers had explained it to them and 235 (48.2%) participants felt confident enough in their knowledge of the proper use of antibiotics to share it with others [Table 7].

Assessing knowledge about antibiotic use:

Participants were given a list of medical conditions and asked which of them could be treated with antibiotics. The majority of participants (368, 75.4%) correctly identify UTI as a disease that can be cured by antibiotics. The majority also know that they are ineffective against viral diseases. 387 participants (79.3%) know that antibiotics are ineffective against 440 (90.2%) know that they are ineffective against AIDS. However, 339 out of 488 (69.5%) respondents believe that antibiotics are effective against colds. 220 (45.1%) believe that antibiotics help you recover faster from colds. Participants were asked if they knew the name and use of several common drugs and if those drugs were antibiotics or not. It is seen that a fairly average number of the respondents have a general idea about the common over-the-counter (OTC) drugs and prevalent types of antibiotics available [Table 8].

Assessing awareness of key terms related to antibiotic resistance and sources of information:

Respondents were given a list of terms related to the issue of antibiotic resistance and asked whether they had heard any of them before. These included drug resistance, antibiotic resistance, antibiotics resistance, antibiotic-resistant bacteria and superbugs.

The term with the highest awareness was “Antibiotic Resistance”, with 317 (64.9%) participants who had heard of it. This was closely followed by 287 (58.8%) having heard of “Drug Resistance”. 204 (41.8%) participants knew about “antibiotics Resistance”, 209 (42.8%) were aware of “Antibiotic-Resistant Bacteria”, and 119 (24.4%) had come across the word “Superbug”. The percentage of respondents who have never heard any of the terms is 121 (24.8%). When asked about the sources from which they had come to know these terms, 107 (21.9%) said that they had heard about them from doctors and friends, 168 (34.4%) had read about them in articles online, and 165 (33.8%) had learned about it from the news and other media sources. 99 (20.3%) participants had studied the concept of ABR in school and college textbooks.

Misconceptions of respondents on the use and misuse of antibiotics:

To explore levels of understanding of the issue of antibiotic resistance and the application of their knowledge in practice, respondents were presented with a list of statements and asked whether they agreed or disagreed. A large majority (83.6%) of participants agree that requiring a prescription to purchase antibiotics is a good practice. 55.7% disagree that antibiotics will cure you faster than other medications your doctor might prescribe. 66.8% know that a doctor is not a bad doctor if they do not prescribe antibiotics on the patient’s demand. This shows a high degree of awareness of appropriate antibiotic use among the public [Figure 1].

81.4% of participants know that the body can fend off infections with its own immune system and does not always require antibiotics. 44.7% know that antibiotics do not kill all microorganisms in the body. 45.1% of people agree that antibiotic resistance is a serious health issue [Figure 2].

51.2% of participants are under the impression that regular use of antibiotics is the primary risk factor for resistant infection. 31.6% feel that antibiotic resistance might affect them personally, and their families. 42.3% believe that if they practice judicious antibiotic use as an individual, they will be safe from resistant infection [Figure 3].

The purpose of this study was to gauge the level of awareness of the residents about the proper usage of antibiotics and their understanding of the issue of antibiotics resistance. An attempt was made to receive responses from all representative demographics of the general population. Out of 488 voluntary participants, there was found to be an adequate and equal or appropriately proportional representation of the relevant demographic criteria, including gender, age groups, occupation, highest education level, and income. The ratio of health-care workers to non-health-care workers was 0.21, which eliminates the bias due to a general increased knowledge awareness in the case of individuals in the medical field.[19] Medical students were seen to display a generally positive outlook toward the judicious use of antibiotics and curbing the issue of ABR.[20,21] A study by Hu et al. highlights the urgent need for effective training programs about antibiotics among medical students.[23] On assessing participants’ practices regarding antibiotic use, the majority of participants knew to finish the prescribed course of medication as recommended by the WHO.[2] However, 45.1% of participants admitted that they had stopped their courses without completing them at some point in the past. Although the majority has not done so, there exists a minor dissonance between knowledge and practice in a small portion of individuals, possibly due to insufficient knowledge. This could be rectified by measures like formulary restriction.[25] 

The majority of respondents have knowledgeable practices in acquiring antibiotics. The majority (61.7%) have not purchased antibiotics without consulting a doctor and procuring a prescription. A study by Poyongo and Sangeda conducted in pharmacists, it is concluded that more than 90.0% of pharmacists agreed that dispensing without a prescription contributes to the inappropriate use of antibiotics and the development of ABR. [10] In this study, majority (77.3%) consume them when prescribed and do not refuse a prescription when told it is required. Only 5.7% of participants have asked doctors for antibiotics without them being required. 69.1% of participants have never used leftover antibiotics from a previous prescription to treat symptoms later on. 61.7% have never shared antibiotics with friends or family. This shows a general trend of responsible antibiotic use among the population. Even if knowledge and attitude are present, some practices need to be emphasized.[27] It is possibly a direct reflection of awareness about ABR and the realization that inappropriate antibiotic use is the main cause of its exacerbation.[6-9] Similarly in a study carried out by Roque et al. and Davey et al. concluded that several factors play a contributing role in antibiotic resistance. These include people sharing their prescribed medication with others, using leftover medication from previously prescribed treatments to treat similar symptoms later on, and acquiring antibiotics without an appropriate prescription. The main cause, however, is identified to be the inappropriate use of antibiotics.[6,7]

On assessing participants’ knowledge about antibiotics and their uses, it was found that a majority of them knew of the existence of OTC drugs and commonly prescribed antibiotics but were unsure of the specific uses of both of them. The majority of participants were familiar with drug names but some were unsure of whether they were antibiotics or not. Amoxicillin and azithromycin were correctly identified by the majority to be an antibiotic. Many participants did not know the drug azithromycin, but a comfortable majority knew the other 11 drugs on the list. Perception of the drug name and use combined with the awareness that it is or is not an antibiotic shows an appreciable level of knowledge among the residents which will surely contribute to judiciousness in drug use.[2]  On assessing participants’ awareness of terms related to ABR, a majority of them had been exposed to one or more of them at some point. Majority of participants acquired this knowledge through online sources implying that social media could be an effective means of spreading awareness about ABR and its effects.[26] 

On assessing and addressing participants’ misconceptions about antibiotic use, it was found that a majority of them had good attitudes about the judicious use of drugs. They agreed that needing a prescription to obtain antibiotics was good. Acknowledgement of healthy antibiotic usage practices is further substantiated by participants’ understanding that our body’s immune system can fight mild infections on its own and that antibiotics are needed only for targeted attacks against pathogens. The majority agree that ABR is a serious health issue, which shows an appreciable level of understanding of the situation. A majority do think that taking antibiotics regularly makes you more susceptible to resistant infection. This assumption comes at the risk of assuming that consuming antibiotics judiciously means that you are safe from resistant infection. This is not always the case – inappropriate antibiotic use causes the problem, but it can affect anyone. A majority of participants do accept that ABR might affect them and their families. This study has been useful to gauge the baseline knowledge, attitude, and practices of the general population visiting VIMS which is required before planning or strengthening any teaching or training program for the public.[15,16].

The knowledge, attitude, and practices of the residents visiting the OPDs of VIMS are found to be quite satisfactory, considering that an adequate and diverse sample of the population was taken. There was no blatant dissonance observed between knowledge and practices. Health-care workers were found to have a higher degree of knowledge and awareness, as observed in other studies as well. The majority of the residents  has a good attitude and awareness about the severity of ABR and the importance of appropriate antibiotic use. There were minor misconceptions in the case of several people believing antibiotics are effective against the common cold. The knowledge level of both health-care and non-health-care workers in the studied sample is found to be adequate. There is more scope for study in this area with altered demographic focus and multicentric methods to better gauge the baseline situation of the general population. A linked effort involving doctors, representatives of pharmaceutical companies, informal health providers, and the residents  shows promise for an interesting study.

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