Antibiotic resistance (ABR) is an escalating global public health threat that undermines the efficacy of antibiotics, essential tools for combating bacterial infections. As pathogens develop mechanisms to withstand antimicrobial agents, the once-reliable treatments for infections become futile, leading to prolonged illnesses, higher medical costs and increased mortality rates. The World Health Organization (WHO) has identified antibiotic resistance as one of the biggest threats to global health, food security and development today. It is projected that if current trends continue, ABR could cause 10 million deaths annually by 2050, surpassing the mortality rates of cancer and diabetes combined [1-3].

The emergence and spread of antibiotic resistance are largely driven by the overuse and misuse of antibiotics in humans, animals and agriculture. Inappropriate prescribing practices, non-compliance with treatment regimens and the availability of antibiotics without prescriptions contribute significantly to this issue. Moreover, insufficient awareness and knowledge about the proper use of antibiotics and the dangers of resistance exacerbate the problem [4-6].

In India, the situation is particularly concerning. The country is recognized as one of the largest consumers of antibiotics globally, with a substantial proportion of these being used inappropriately. Studies indicate that antibiotic resistance rates in India are among the highest in the world, posing a significant challenge to healthcare providers and policymakers. The lack of stringent regulations on antibiotic sales, coupled with limited public awareness and education on the issue, further compounds the problem [6-9].

The District of Kangra, located in the northern Indian state of Himachal Pradesh, exemplifies these challenges. With a diverse population comprising both urban and rural areas, Kangra presents a unique landscape for studying antibiotic resistance. The general public's awareness and knowledge about antibiotic resistance in this region are crucial for implementing effective interventions and policies to combat this growing threat.

Despite the severity of the issue, there is a dearth of comprehensive studies assessing the level of awareness and knowledge about antibiotic resistance among the general public in Kangra. Understanding the public's perceptions, attitudes and behaviors towards antibiotics is vital for designing targeted educational campaigns and policy measures to curb the misuse of antibiotics and mitigate the spread of resistance.

Objectives of the Study

The primary objective is to assess awareness and knowledge about antibiotic resistance among the general public of District Kangra, Himachal Pradesh.

• Research Approach: Descriptive

• Research Design: Cross-sectional survey design

• Study area:District Kangra, Himachal Pradesh

• Study duration: Between January 2024 to March 2024

• Study population: The study's target population encompassed all adults aged 18 and above who had been residents of District Kangra Himachal Pradesh for a minimum of 12 months

• Sample size: A robust sample size of 400 adults was determined using a 95% confidence level, an estimated knowledge level of 50% regarding Antibiotic resistance, a precise 5% absolute error margin and a conservative 5% non-response rate

• Study tool: A google form questionnaire consisting of questions regarding socio-demography and knowledge regarding Antibiotic resistance was created. The questionnaire was initially pre-tested on a small number of participants to identify any difficulty in understanding by the respondents

• Description of Tool: Demographic data survey instrument: The demographic form elicited information on participants’ background: age, marital status, religion, employment, education and many more

• Questionnaire: The questionnaire contains 20 structured knowledge related questions regarding Antibiotic resistance. One mark was given for each correct answer and zero for incorrect answer. The maximum score was 20 and minimum score was zero. Scoring was done on the basis of marks as >80% (16-20) = Very good, 60-79% (12-15) = Good, 41-59% (8-11) = Fair, <40% (<8) = poor

• Validity of tool: By the experts in this field

• Data collection: Data was collected under the guidance of supervisors. The google form questionnaire was circulated among the residents of District Kangra Himachal Pradesh for responses using online modes like e-mail and social media platforms like Whatsapp groups, Facebook, Instagram and Linkedin till the 400 responses were collected

• Data analysis: Data was collected and entered in Microsoft excel spread sheet, cleaned for errors and analyzed with Epi Info V7 Software with appropriate statistical test in terms of frequencies and percentage

• Ethical Considerations: Participants confidentiality and anonymity was maintained

The study population consisted of 400 participants from District Kangra, Himachal Pradesh, whose socio-demographic variables are summarized in Table 1. The age distribution showed that the majority of participants were in the 26-35 years age group (24.5%), followed by the 18-25 years age group (20.5%). Participants aged 36-45 and 46-55 years constituted 21.8% and 20.8%, respectively, while those aged 56 years and above made up 12.5%. Gender distribution was relatively balanced, with males representing 53.0% and females 47.0%. Regarding marital status, most participants were married (59.5%), while 35.5% were single and 5.0% were divorced or widowed. The predominant religion was Hinduism (69.5%), followed by Sikhism (15.3%), Islam (10.3%) and other religions (5.0%). Employment status revealed that 56.3% of the participants were employed, 22.0% were unemployed and 21.8% were students. Educational levels varied, with 39.8% having higher education, 37.3% secondary education, 15.3% primary education and 7.8% having no formal education.

Table 1: Socio-Demographic Variables of the Study Population (N = 400)

Table 2 details the knowledge of participants regarding antibiotic resistance. A significant portion (69.5%) understood what antibiotic resistance is and 65.3% knew the causes. Awareness of antibiotic resistance leading to treatment failure was recognized by 54.5% and 45.5% correctly identified that antibiotics are ineffective against viral infections. The importance of completing the full course of antibiotics was well understood by 80.3% and 74.8% recognized that misuse of antibiotics contributes to resistance. Additionally, 85.3% knew antibiotics should only be taken when prescribed by a healthcare provider. However, fewer participants (59.8%) understood that sharing antibiotics with others could contribute to resistance and 50.3% were aware of the improper disposal of antibiotics as a contributing factor. The necessity of following the prescribed dosage and schedule was acknowledged by 77.3%, while 55.3% were aware of the spread of resistance between bacteria. Knowledge about the impact of resistance on surgeries and medical procedures was known to 45.3 and 50.3% were aware of certain infections being more likely to become resistant. The importance of consulting a doctor before using leftover antibiotics was understood by 67.3%. Participants recognized the role of antibiotics in animals and agriculture contributing to resistance (39.8%) and the significance of hand hygiene (80.5%). Additionally, 72.3% understood that antibiotic resistance is a global health issue and 70.3% knew that vaccination could help reduce the need for antibiotics. Alternative treatments for some infections were acknowledged by 60.5 and 49.8% knew the importance of reporting antibiotic side effects to doctors.

Table 2: Knowledge Regarding Antibiotic Resistance (N = 400)

The overall knowledge scores of participants regarding antibiotic resistance are presented in Table 3. Approximately 19.8% of participants demonstrated very good knowledge (scores 16-20), while 30.3% had good knowledge (scores 12-15). A fair level of knowledge (scores 8-11) was exhibited by 24.8% and 25.3% had poor knowledge (scores 0-7).

Table 3: Overall Antibiotic Resistance Knowledge Score Categories

Sources of information about antibiotic resistance, as detailed in Table 4, showed that healthcare providers were the primary source for 45.3% of participants. The internet and social media were sources for 25.3%, followed by television and radio (15.5%), friends and family (9.8%) and print media (4.3%).

Table 4: Sources of Information about Antibiotic Resistance

Table 5 summarizes participants' practices related to antibiotic use. It was found that 59.5% always completed the full course of antibiotics, while 29.8% stopped taking antibiotics when feeling better. A significant majority (69.8%) consulted a doctor before taking antibiotics, whereas 21.8% purchased antibiotics without a prescription. Additionally, 19.3% reported using leftover antibiotics from previous treatments.

Table 5: Participants' Practices Related to Antibiotic Use

Table 6 reveals significant associations between socio-demographic variables and knowledge levels regarding antibiotic resistance. Younger participants (18-25 years) exhibited higher knowledge, with 25.6% having very good knowledge and 34.1% good knowledge, compared to those aged 56 and above (8.0% very good), with a p-value of 0.042. Males showed greater knowledge levels (24.1% very good, 27.8% good) than females (19.1% very good, 26.6% good), with a p-value of 0.021. Single individuals had superior knowledge (28.9% very good, 33.8% good) relative to married (16.0% very good, 19.3% good) and divorced/widowed (40.0% very good, 70.0% good) participants, with a p-value of 0.029. Hindus demonstrated higher knowledge (21.9% very good, 25.2% good) compared to other religious groups, with a p-value of 0.005. Employed participants (26.7% very good, 30.2% good) possessed better knowledge than unemployed (13.6% very good, 19.3% good) and students (19.5% very good, 26.4% good), with a p-value of 0.001. Higher education levels were strongly correlated with increased knowledge, with secondary education (32.2% very good, 37.8% good) outperforming primary (29.5% very good, 49.2% good) and no formal education (19.4% very good, 19.4% good), with a p-value of 0.049. These findings underscore the importance of targeted educational interventions to address demographic disparities in knowledge about antibiotic resistance.

Table 6: Univariate Analysis of Socio-Demographic Variables and Antibiotic Resistance Knowledge Level

The findings of this study highlight critical insights into the awareness and knowledge of antibiotic resistance among the general public in District Kangra, Himachal Pradesh. The results demonstrate substantial variability in knowledge levels across different socio-demographic groups, underscoring the need for targeted educational interventions to address these disparities.

The overall knowledge regarding antibiotic resistance was moderate, with only 19.8% of participants displaying very good knowledge and 30.3% exhibiting good knowledge. This suggests that while a significant portion of the population has a basic understanding of antibiotic resistance, there is considerable room for improvement. Notably, 25.3% of participants had poor knowledge, indicating a substantial gap in awareness that could hinder efforts to combat antibiotic resistance effectively. These findings are consistent with other studies which also reported moderate levels of awareness about antibiotic resistance among the Indian population. However, our study found a slightly higher awareness of the importance of completing the full course of antibiotics (80.3%) compared to the previous studies, which reported 70% awareness [10-12].

The univariate analysis revealed significant associations between socio-demographic variables and knowledge levels. Younger participants, particularly those aged 18-35 years, had better knowledge compared to older individuals. This could be attributed to more recent exposure to education and health information campaigns targeting younger demographics. Similar findings were reported by previous studies who found that younger age groups had higher levels of knowledge about antibiotic resistance. Males demonstrated higher knowledge levels than females, suggesting the need for gender-sensitive educational strategies to ensure both men and women are equally informed. This gender disparity aligns with the findings of a earlier studies, where males also exhibited higher knowledge levels than females [11-13].

Marital status also influenced knowledge levels, with single individuals showing better understanding than married or divorced/widowed participants. This could be related to differences in access to information or varying health priorities among these groups. Additionally, participants identifying as Hindu had higher knowledge levels compared to other religious groups, indicating potential cultural or community-based differences in health education dissemination.

Employment and education levels were strongly correlated with knowledge about antibiotic resistance. Employed individuals and those with higher education exhibited significantly better knowledge. This emphasizes the importance of integrating antibiotic resistance education into workplace health programs and continuing education initiatives. The stark differences in knowledge between those with no formal education and those with higher education highlight the critical role of formal education in fostering health literacy. These findings are consistent with the results of a past studies, which also found that higher educational levels were associated with better knowledge of antibiotic resistance [14-17].

Healthcare providers were identified as the primary source of information about antibiotic resistance for 45.3% of participants, followed by the internet and social media (25.3%). This underscores the crucial role of healthcare professionals in disseminating accurate information and the potential of digital platforms in reaching a broader audience. However, the reliance on informal sources such as friends and family (9.8%) and print media (4.3%) suggests that there is still a need to improve the reach and credibility of health communication through more reliable channels. These results are comparable to those found in a previous studies, where healthcare providers were also the main source of information but there was significant reliance on informal sources [12-15].

The study also examined participants' practices related to antibiotic use, revealing that 59.5% always completed the full course of antibiotics, while 29.8% stopped taking antibiotics when they felt better. The fact that 21.8% of participants purchased antibiotics without a prescription and 19.3% used leftover antibiotics indicates a concerning level of self-medication, which contributes significantly to the development of antibiotic resistance. These practices highlight the need for stricter regulations on antibiotic sales and more robust public education campaigns about the dangers of improper antibiotic use. These findings align with a earlier studies, which also reported high levels of self-medication and improper antibiotic use [18-20].

In conclusion, this study provides valuable insights into the current state of knowledge and practices regarding antibiotic resistance among the general public in District Kangra. While there are encouraging signs of awareness, significant gaps remain, particularly among specific demographic groups. Addressing these gaps through targeted educational interventions, leveraging both healthcare providers and digital platforms and enforcing stricter regulations on antibiotic use are critical steps in combating the growing threat of antibiotic resistance. By implementing these strategies, we can enhance public understanding and promote responsible antibiotic use, ultimately contributing to better health outcomes and the preservation of antibiotic efficacy for future generations.

Limitations

This study has several limitations. Firstly, the use of a self-reported questionnaire may introduce response bias, as participants might provide socially desirable answers. Secondly, the cross-sectional design of the study captures information at a single point in time, limiting the ability to assess changes in knowledge and practices over time. Additionally, the study was conducted in a specific geographic region, which may limit the generalizability of the findings to other regions with different socio-demographic characteristics.

Implications for Public Health Policy

The findings of this study have several implications for public health policy and practice. First, there is a clear need for comprehensive public education campaigns to improve knowledge about antibiotic resistance, especially focusing on the areas where knowledge is lacking, such as the ineffectiveness of antibiotics against viral infections and the dangers of self-medication. These campaigns should be tailored to address the specific needs of different demographic groups, including targeted interventions for older adults, females and less educated individuals.

Healthcare providers should be empowered and incentivized to play a more active role in patient education, given their pivotal position as trusted sources of information. Digital platforms also present a significant opportunity for expanding the reach of health education initiatives, particularly among younger and tech-savvy populations.

Stricter enforcement of regulations surrounding the sale and prescription of antibiotics is essential to curb the misuse of these critical medications. Policies should be developed to ensure that antibiotics are only available with a prescription and that healthcare providers are following best practices in prescribing antibiotics.

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