Knowledge, Attitude and Practice Analysis of Antibiotics Use and Misuse in Tertiary Care Rural Hospital Patients

Introduction: In recent decades, the increase in bacterial resistance against all major antibiotics is a growing worldwide problem and is a significant threat to global public health in the 21century. Objective: Assess the knowledge, attitude, and practice of antibiotics use and misuse among the tertiary care rural hospital patients. Methods: This is a cross-sectional analytical study conducted at tertiary care teaching rural hospital in India between December2020 to April 2021. A self-administered questionnaire was distributed to the patients of outpatient departments in hospital. The questionnaire consisted of 3 parts, first part consist of demographic variables, second and third part regarding knowledge, attitude and practice of patients towards use of antibiotics. SPSS 21 was used for data analysis. Results: Out of the 110 participants, 56(50.91%) were males and 54(49.09%) were females. 55(50%) patients received antibiotics from friends, relative and pharmacist without medical doctor checkup. 38(34.55%) patients had started antibiotics as preventive medication for any infection, 73 (66.36%) patients got better earlier and have stopped. 52(47%) patient expect antibiotics from doctor for common cold. 42% patient obtained antibiotics without valid prescription from relatives, Original Research Article Katole et al.; JPRI, 33(60B): 2807-2814, 2021; Article no.JPRI.80077 2808 pharmacist or self-prescription without producing valid prescription obtained from the doctor. In the knowledge domain while majority of respondent were well aware that antibiotics are hazardous during pregnancy and lactation and can lead to severe allergic reactions. But very few respondent knew about resistance can transfer from animal to human and human to human, also very few respondent knew about antibiotics can alter human body bacterial flora. Conclusion: There is lack of knowledge regarding antibiotics use and resistance among general population. Strict strategies need to employ like antibiotics prescription audit, antibiotics dispensing monitoring, effective public health education, and promoting health worker and patient communication.


INTRODUCTION
The increasing evolution among the bacteria / microbes to become resistant against the antimicrobials has been noticed as a significant public health threat during the last decades [1]. This spread of resistance directly affects not only the therapeutic effectiveness of drugs but also the increase in treatment failure episodes and costs and mortality rates among patients [2]. Improper and indiscriminate use of antibiotics are important reasons for antibiotic resistance in our country [3][4][5]. Misuse of antibiotics occurs due to many reasons like physicians knowledge and experience, diagnostic uncertainty, while general public knowledge, practice, beliefs and attitudes towards antibiotic use, self-administration of antibiotics, patient's expectations from doctors, and patients experience with antibiotics, insufficient patient education by physicians, poor healthcare worker and patients communication are important key factors which directly influence antibiotics use and misuses [6][7][8]. There is a common preoccupation among the common public that antibiotics can help in early recovery and sometimes prevent further development of illness. There is a major gap in understanding about antibiotics use among general population, also very few studies in Indian rural population regarding antibiotics utilization [9,10] are available, hence current study was planned to assess knowledge, attitudes and practice regarding antibiotics misuse in rural population.

Study Design and Population:
This crosssectional analysis study was conducted at a tertiary care rural hospital in India between December 2020 and April 2021. The participant patients have been suffering from various illness and regularly attending the department of Medicine, ENT, Ophthalmology and General surgery. Patients aged 18 years or above were included in study. Well-structured questionnaires were prepared in English and official regional language Marathi.The questionnaires mostly based on the questions taken from various previous studies, which were edited in context with the objectives of the study [11,12,13]. A literature review of past similar studies of antibiotics misuse was done to identify potential domains for the study instrument and changes made to suit the local population. A pilot study was also conducted to test the validity of the questionnaire for content, readability, design and comprehension on 20 local peoples and necessary modifications were made so that the questionnaire was simple for understanding and answering, still gave accurate data.
The final version of the questionnaire, consists of 24 questions, divided into four parts. The first part was about demographic variables of local populations. The second part consists of questions regarding participants' knowledge and belief regarding antibiotic use and antibiotic resistance with Yes, No and don't know options. Third part is regarding the respondent's attitude towards antibiotics use consist of 5 statements with yesno options. The fourth part is comprised of 4 multiple choice questions with suitable options.
Data analysis was done using SPSS 21. The prevalence of antibiotics use, misuse and its awareness were determined by comparing outcome measures. Numerical variables were reported as percentage.
[if possible, please provide the details of antibiotics (along with Brand names), which are in the reach of the general population. This would help authors to authenticate their research validity in terms of having the information of most utilized antibiotics without prescription.]
Respondents were compared according to their demographic parameters: age, gender, marital status, educational level, antibiotics usage. Among the respondents, 21(19%) were in the age group of 18-35, 46(42% were in 35-50 years age group and 26(24%) were in 50 to 65 year age group, while 17(15%) are in more than 65 year age group. 83(75%) were married, 75(68%) were having education more than high school.  From the assessment of knowledge domain it was found that only 44 % of respondents were aware about of antibiotic resistance, while 68% were not known the reasons for antibiotic resistance, and 22% respondents thing about antibiotic resistance due to improper use and 14% knew that prior stopping antibiotic could leads to antibiotic resistance. 88% women respondents were found to be aware of the risky course of antibiotics during pregnancy and even not safer during breast feeding, 74% respondents were agreed that antibiotics could cause allergic reactions. 57% respondents were unaware about antibiotics use in animals can cause human antibiotic resistance, in fact 30% denied that animal antibiotic use leads to human antibiotic resistance. Only 36% agreed that one should not stopped taking antibiotics once patients start feeling better, while 28% respondents disagreed to it, while 46% respondents were not know relation between full course of antibiotics and antibiotics resistance. 11% respondents were aware that resistance can spread from human to human, and only 5% respondents aware that resistance can spread from animal to humans. However, 15% respondents aware about the fact that antibiotics can cause negative effects on the body's own bacterial flora.
While analyzing attitude domain of questionnaire it was found that, 44% peoples are keeping antibiotics at home for any emergency use. While 35% respondents takes antibiotics as preventive treatment before any start of any symptoms, 50% respondent procured antibiotics from friends and relatives without prior consultation with medical doctor. While 66% patient stopped taking antibiotics before completing the course of treatment, 47% respondents expect antibiotics should be prescribed by doctor for common cold symptoms and for every fever illness and 14% peoples force doctor to prescribe antibiotics if not prescribed.
68% respondent use antibiotics only after doctors prescription while 18% respondents use antibiotics on pharmacist advise, 11% on relatives advise and 13% on self -prescription. 40% people use antibiotics for fever, while 28% uses antibiotics for pain in any part of body and 11% use if they feel tired, 34% use for toothache like reason. 38% respondents stopped using antibiotics if they feel better, while 68% patient completed full course, 50% respondents trust doctor if he doesn't prescribe antibiotics.

DISCUSSION
According to WHO, Antibiotic resistance is one of the top 10 global public health problem humanity is facing [1]. Antibiotic resistance can cause multiple problems including prolonged hospitalization of serious patients, results in rising the demand for more expensive antibiotics, hence increasing the financial burden [14,15]. Antibiotic resistance has become a major health problem across the world especially in the developing countries like India [16]. It is not difficult in India to obtain any antibiotic without prescription over the counter; hence problems of antibiotic resistance increasing day by day. Therefore, it results in indiscriminate and inadequate use of antibiotics in humans and animals as well [17,18]. Undoubtedly, it is directly related to the consumption described by other authors too [19,20,21]. There are limited number of publications are available in the literature, therefore, we aimed to highlight the effects of knowledge, beliefs, attitude and practice of antibiotics use in rural areas of our region.
On positive note, we found that majority of population are agree that antibiotics are hazardous for pregnancy and breastfeeding, also majority of population knows antibiotics can cause severe allergic reactions, which is comparable with other similar studies [22]. While as much as about 40 % population aware of term antibiotic resistance considering rural area which is interesting for us. Also majority of population are (58%) are still using antibiotic only after medical Doctors advice. This finding may be attributed to increase in educational level among population.
But still some major misbelief about antibiotic use and resistance is present among the general population, leading to misuse of antibiotics. Around 47% population expect to take antibiotics for common cold, this is because there is lack of understanding that common cold is caused by viruses and not by bacteria and antibiotic are used against only for bacterial diseases. From this study nearly 40% population still believe that keeping antibiotics for emergency use is a good habit, while 50% population think that it is good to procured antibiotics from friends, relatives and friends and pharmacist without any proper medical consultation and doctor's prescription. Various past studies have confirmed that using leftover mediations results in poor patient compliance with antibiotics therapy [23], which may increase antibiotic resistance [23].
About 25% of respondents have disagreed to complete a full course of antibiotics, and 66% of respondents have stopped taking antibiotics if they feel better. It's very important to complete full course on antibiotics to restrict antibiotics resistance, according to the WHO, when a patient stops antibiotics course prematurely it results in promotes growth of natural resistant strains and therefore it is advisable for patients to always complete full course of antibiotics prescribed to them by a certified health professional [23,24].Furthermore, patients need to educate regarding antibiotics resistance as 72% and 82% unaware about fact that antibiotics resistance can spread from person to person and animal to person, respectively. Also, about 75% respondents are not aware that antibiotics can negatively alter our own natural bacterial flora. This finding are correlates with various past studies studies [22,11,12,13].
Subsequently, the general public needs to be educated that antibiotics efficacy will be preserved only when used only as per doctor's advise guidelines and when the full course is completed [23,24]. Patients and healthcare workers communication can play important role to minimize antibiotics resistance. Healthcare worker can convey appropriate usage of antibiotics to general public through effective communication. This has proved in various studies also [25,26,11,12,27]. But in same study it is noted that healthcare workers and doctors not give enough time to communicate how to use antibiotics, this should be changed [13,28,29]. A number of related studies were reported [30][31][32][33][34]. Some of the key studies on antibiotics resistance and related issues were reviewed [35][36][37][38][39].
Contrary to other studies [13,28,29], in our study, the level of education and misuse of antibiotics do not relate to each other significantly, as even respondents with higher education have a deficit of basic antibiotics usage knowledge.

CONCLUSION
Considering the rapid growth of antibiotic resistance in India and the related gross effects of antibiotics resistance, the current study demonstrated important lacunae regarding antibiotic use in the general public. There is lack knowledge and understanding regarding the safe use and consumption of antibiotics. There is a need to establish effective multifaceted intervention to improve appropriate use of antibiotics, which should include the following: 1) need To audit antibiotic prescription from healthcare facility. 2) Effective public health education program using all media 3) Strategies need to be employed to promote effective communication between healthcare workers, specifically pharmacists, doctors, and the general public regarding safe and appropriate antibiotics usage.4) Need to enforce the strict regulations on the sales and supply of antibiotics and to monitor all the sources from which these are obtained.

ETHICAL APPROVAL AND CONSENT
Study was approved by the institutional review committee. A written consent was taken from all respondent before participation in study, Participant confidentiality was assured by assigning each respondent a unique a code number for the purpose of analysis only.