Knowledge and practice of mothers regarding use of Antibiotics and Antibiotic resistance
Christeena Paul, Sonu Ann Alex1, Shijit Treesa Varghese1, Angel Mariam Saji1, Arya Ashokan1,
Feba Daisy John1, Raseenamol A.K1, Rini Chacko1, Sr. Mary Jyothi2*, Anu Rose Andrew3
1B.Sc. Nursing Students, Pushpagiri College of Nursing, Tiruvalla, Kerala, India.
2Associate Professor, Child Health Nursing Dept., Pushpagiri College of Nursing, Tiruvalla, Kerala, India.
3Registered Nurse, Portsmouth University Hospital, NHS Trust, UK.
*Corresponding Author E-mail: mj07835@gmail.com
ABSTRACT:
Antibiotic resistance is the ability of a microorganism to withstand the effects of an antibiotic. When bacteria become resistant, the powerful antibiotics can no longer fight them, and the bacteria multiply causing the disease to flare up leading to deaths. A report ‘Review Antimicrobial Resistance’, stated that the deaths attributable to antimicrobial resistance [AMR] every year compared to other major causes of death in 2050 will be 10 million, as compared to death by RTA’s, cancer, cholera, DM, measles and tetanus.1 But, with the help of proper health education, 90% of the antibiotic resistance can be reduced2. Children are a vulnerable group more prone for infections, and thereby are higher consumers of antibiotics. Since, mothers are the prime decision makers of their child’s health, the investigators felt the need to assess the “Knowledge and practice regarding the use of antibiotics and antibiotic resistance among the mothers of children in the paediatric wards at a selected hospital in Pathanamthitta”. 100 mothers were selected for the current study using convenient sampling technique. Baseline variables, knowledge and practice among the mothers were assessed by using baseline performa, structured knowledge and practice questionnaire. The knowledge and practice scores were analyzed using frequency, percentage, mean and standard deviation. The association of the scores with selected baseline variables were assessed using Chi-square test and Kruskal-Wallis test. And the correlations of the knowledge and practice scores were assessed using the Pearson’s coefficient of correlation. In this study among 100 mothers, 65(65%) of mothers were found to have good knowledge, 26(26%) mothers had poor knowledge and 9 (9%) are having excellent knowledge regarding antibiotics and antibiotic resistance. About 47(47%) of them were having best practice, 45(45%) were found to have good practice and 8(8%) had poor practice with respect to use of antibiotics for their children. No correlation was found between mothers’ knowledge regarding the antibiotics and antibiotic resistance and their practice. In view of the study results, a pamphlet was developed and given to the ward for distribution to the parents of children getting admitted in the wards after content validity and expert advice.
KEYWORDS: Antibiotics, Resistance, Antibiotic resistance, Knowledge, Practice.
INTRODUCTION:
With the discovery of penicillin in 1928, by Alexander Fleming that marked a milestone in modern medicine, the “antibiotic revolution” began which saved millions of lives during Second World War2. Antibiotics are a group of powerful drugs capable of treating a wide range of bacterial illness and are now an indispensable part of modern medicine. These are substances produced by microorganisms which suppress the growth or destroy other microorganisms even at low concentrations.3 Antibiotics are substances which are used as a prophylactic agent against specific organisms to treat infections. These are also used as a preventive measure against infections in high risk situations after the procedures like dental extraction, tonsillectomy, endoscopies, catheterization or instrumentation of urinary tract.3 Thus, Antibiotics are used in two ways, which is as empiric therapy and as definitive therapy. In empiric therapy, the antibiotic must cover all the likely pathogens and a combination or a broad spectrum agent may be used. Whereas in a definitive therapy, specific antibacterial agents are prescribed based on the identified microorganism.3
But unfortunately, its irrational overuse, inappropriate prescription, over-the-counter self-medication, patient non-compliance, extensive use in agriculture/ animal husbandry and spread of resistant microbes is increasingly depleting this global resource, resulting in the development of increasingly hard to treat resistant microbes.4,5 Antibiotic resistance is the unresponsiveness of a microorganism to the antimicrobial agent. The resistance may be natural or acquired. In natural resistance, the organism does not respond to the antimicrobial agent, may be due to the absence of the particular enzyme or target site affected by the drug. Whereas in acquired resistance, the microbes which were previously sensitive to the antimicrobial agents become resistant to it. Drug resistance occurs when microbes survive and grow in the presence of a drug that normally kills or inhibits the microbe's growth. The history of drug resistance began with the development of antimicrobial drugs and the subsequent ability of microbes to adapt and develop ways to survive in the presence of antimicrobials3. In a study by Ahmed and Isra from Iraq, where five hundred and seventeen bacterial strains were isolated from different infections (urinary tract infections 171, burns infections 238, respiratory tract infection 55 and blood infection 53), Pseudomonas aeruginosa was found to be the most predominate bacteria (122 isolates) followed by K. Pneumoniae (96 isolates), E.coli (64 isolates), S. pyogenes (59 isolates), S. aureus (51 isolates), S. pneumoniae (48 isolates), Proteus. spp. (47 isolates) and Salmonella spp. (14 isolates). All bacterial strains were highly resistant to most antimicrobials with percentage between 90% to 100%. There were 459 bacterial strains (91.61%) that were multidrug resistant.6Antibiotic resistance is now one of the greatest threats to human health and drug tolerances, inactivation of the drug, drug impermeability are some of the consequences of antibiotic resistance.3
A recent study by “Times point” estimates that two lakh babies die each year as a result of antibiotic over use. Antibiotic resistant infections are spreading wings in India, killing over 58,000 children every year. Around 7,00,000 people around the world die annually due to drug-resistant infections. If no action is taken, it has been estimated that drug-resistant infections will kill 10 million people a year by 2050.7
Children are a vulnerable group that is more prone for infections, and therefore are higher consumers of antibiotics. A study to estimate the use of antibiotics in pediatric population conducted at “Sri Baby clinic” in Chennai on 100 children between 0 and 18yrs revealed that most of them got admitted with upper respiratory tract infections 46(46%), and gastroenteritis 23(23%) and 4 antibiotics were used for 2patients (2%), 3 antibiotics for 2 patients (2%), 2 antibiotics for 29 patients (29%), one antibiotic was used for 67 patients (67%) and most used antibiotics were Cephalosporins 65%, Quinolones 16%, Beta lactam antibiotics 11%.8 Mothers being the prime decision makers of their child’s health must be aware of the danger of antimicrobial resistance and their knowledge on the topic can definitely exert a control on the misuse of antibiotics. Nurses have an important role in regulating the use of antibiotics because they are aware about the growing menace of antimicrobial resistance and are in a best position to educate the patients regarding the proper use of antibiotics, course completion, causes of antibiotic resistance, its prevention etc. The investigators are a group of nursing students who realize this as the need of the hour; and aimed to assess the knowledge and practice regarding antibiotics, antibiotic use and antimicrobial resistanceamong mothers of children admitted in the paediatric clinical areas of a selected tertiary care hospital with a view to develop an informative pamphlet.
The objectives of the study were:
1. To assess the knowledge regarding use of antibiotics and antibiotic resistance among mothers of children in the paediatric clinical areas.
2. To assess the practice regarding use of antibiotics among mothers of children in the paediatric clinical areas.
3. To find the association between the level of knowledge of mothers and their selected baseline variables.
4. To find the association between the practice of mothers regarding use of antibiotics and their selected baseline variables.
5. To find the correlation between the knowledge and practice of mothers regarding use of antibiotics and antibiotic resistance
6. To prepare an informative pamphlet regarding use of antibiotics and antibiotic resistance.
The researchers assumed that the mothers of children in the paediatric clinical areas may have some knowledge regarding the use of antibiotics, need of course completion, causes of Antibiotic resistance and its prevention; and that an Informative Pamphlet may help in improving the mothers’ awareness on use of antibiotics and antibiotic resistance.
MATERIAL AND METHODS:
To achieve the objectives of the study a descriptive research design was used and the study setting included the Paediatric clinical areas of the selected hospital at Pathanamthitta district namely the paediatric outpatient department, paediatric casualty, immunization clinic, child development centre, paediatric medicine ward and paediatric surgery ward. 100 mothers of children seeking consultation or care at the hospital were selected using convenient sampling technique. Mothers of children obtaining services in the paediatric clinical areas of the selected hospital in Pathanamthitta district who were available at the time of data collection and those who were able to read and write Malayalam or English were included in the study. Mothers who were not willing to participate in the study were excluded from the study.
The variables studied are ‘Knowledge’ and ‘Practice’ of mothers. In this study, knowledge referred to the awareness of mothers about use of antibiotics and antibiotic resistance as assessed by modified WHO questionnaire on antibiotic resistance for multi-country public awareness survey. ‘Practice’ herereferred to the use of antibiotics by the mothers for their children as assessed by a practice questionnaire prepared by the investigators to be filled by the mothers which covered details on the intake of antibiotics, course completion or compliance, time of administration, side effects etc.
Development and Description of Tools:
The data collection instruments or tools included a baseline proforma, the modified WHO questionnaire on antibiotic resistance for multi-country public awareness survey to assess mother’s knowledge regarding use of antibiotics and antibiotic resistance; and practice questionnaire on use of antibiotics by mothers. These were developedfollowing adequate review of the available literature. Initially the blueprint of the tools and content for pamphlet were prepared. Initially, a draft tool was formulated and the tools were then modified as per suggestions from the guides and experts. Since, mothers have to read, understand and fill in it, the tools were then translated to Malayalam and verified by language experts. The corrected tools were then given to subject experts for content validation. The tools were then finalized incorporating the suggestions of the experts and guides.
The baseline proforma included the items like mother’s age, education, average family income/month, occupation, and previous knowledge of mothers. The modified WHO questionnaire on antibiotic resistance consisted of 12 multiple choice questions to assess the knowledge of mothers of children regarding the use of antibiotics and its resistance. Each correct response was given a score of one and incorrect response was given zero. The maximum possible score was 12 and minimum score was zero. Based on the score obtained the knowledge of mothers was categorized as- excellent (>75%; scores >9), good (50-75%; scores between 6 and 9) and poor (<50%; scores less than 6). The Practice Likert scale questionnaire on use of antibiotics was prepared by the investigators. It consisted of 10 items to assess the practice of mothers of children regarding the use of antibiotics and each item was scored as 2, 1 and 0 for the options many times/Always, Once or twice and Never respectively. The maximum possible score was 20 and zero was the minimum score. Based on the total scores obtained, the practices of mothers were categorized as- Best (>75%), Good (50-75%) and Poor (<50%).
Following content validation, the tools were administered to 20 mothers for reliability assessment & pretesting. The combined Chronbach’s alpha (a) of 0.77 revealed that the tools were reliable. Further, the pilot study conducted among 10(10%) mothers showed that the study was feasible.
After obtaining the ethical clearance from the Institutional Ethical Committee (Pcon/136/964/19) and permission from hospital authorities, the study participants were identified by the investigators as per the inclusion criteria using convenient sampling technique at the paediatric clinical areas of the selected hospital, Thiruvalla. The main study was conducted among 100 participants in February 2019. The purpose of the study was explained to the participants and confidentiality of the information was ensured. The investigators administered the research tools to the eligible participants who gave a written consent expressing their willingness to participate in the study. It took 15-20 minutes for a mother to fill the baseline proforma, structured knowledge questionnaire and structured practice questionnaire. In a day, the investigators collected data from around 20 participants. Measures were taken to exclude the pilot study samples from the main study as the setting was the same. After receiving the filled-up the questionnaires, the investigators ensured all the questions are attempted and clarified doubts of the participants regarding the use of antibiotics and antibiotic resistance. The collected data were coded and entered on to the master sheet on the same day of data collection.
The analysis was done using descriptive statistics like frequency and percentage; and inferential statistics like chi-square and Kruskal Wallis tests to find the association and Pearson’s correlation to compare the knowledge and practice scores.
RESULTS:
Mothers’ knowledge regarding antibiotic use and antibiotic resistance:
The mean± standard deviation of the mothers’ knowledge scores was 8.46 ± 1.69. Thedistribution of themothers based on their level of knowledge regarding antibiotics and antibiotic resistance is displayed in Fig.1
Fig 1: Pie diagram on distribution of mothers based on their knowledge regarding Antibiotics and antibiotic resistance
Mothers’ practice regarding antibiotic use for their children:
The minimum mothers’ practice score was 10 and the maximum score was 20 with mean ± standard deviation of 16.9±2.57. The frequency and percentage distribution of mothers based on their item wise practice regarding antibiotic use is discussed in table 1 and thedistribution of themothers based on their level of practice of antibiotic use for their children is depicted in Fig 2.
Table 1: Table depicting the item wise practice of mothers regarding antibiotic use for their children N=100
|
S. No. |
Practice regarding antibiotic use |
Always f (%) |
Sometimes f (%) |
Never f (%) |
|
1. |
Buys antibiotics with a doctor’s prescription. |
89(89%) |
7 (7%) |
4(4%) |
|
2. |
Gives it to the child as he/she falls ill, before even consulting a doctor. |
1 (%) |
4 (4%) |
95 (95%) |
|
3. |
Stops giving as soon as he/she feels better. |
3 (3%) |
18 (18%) |
79 (79%) |
|
4. |
Gives the same antibiotics as used for previous illness. |
7 (7%) |
11 (11%) |
82(82%) |
|
5. |
Checks the expiry date before giving. |
81 (81%) |
2 (2%) |
17 (17%) |
|
6. |
Adds other substances to it to facilitate easy intake. |
14 (14%) |
7 (7%) |
79 (79%) |
|
7. |
Follows exact time in administering. |
86 (86%) |
2 (2%) |
12 (12%) |
|
8. |
Asks doctor to prescribe an antibiotic for speedy recovery |
5 (5%) |
9 (9%) |
86 (86%) |
|
9. |
Asks doctor to describe the side effects of the prescribed antibiotics. |
48 (48%) |
17 (17%) |
35 (35%) |
|
10. |
Ensures to give the exact amount as prescribed |
81(81%) |
3(3%) |
16 (16%) |
Fig 1: Bar diagram on distribution of mothers based on their practice of antibiotic use for their children
DISCUSSION:
The present study was conducted to assess the knowledge and practice regarding use of antibiotics and antibiotic resistance among the mothers. In this study among 100 mothers, only 5(5%) of mothers are having poor knowledge, 67 (67%) of mothers are having good knowledge, and 28(28%) are having excellent knowledge regarding antibiotics and antibiotic resistance. The knowledge scores appear to be reasonably good probably as the group was highly educated with 79% of the mothers having an educational qualification of graduation and above. In a study by Patil PJ, 55% of the surveyed population used antibiotics and 76.66% peoples were aware about safe use of antibiotics.9 In contrast to this, a similar study done in Saudi Arabia on the knowledge, attitude and practice on antibiotic use and resistance showed that 72.3% of the respondents were not having adequate knowledge about antibiotic resistance.10A yet another study conducted among Jordanian mothers demonstrated that only 21.7% of 401 participants had adequate knowledge about use of antibiotics and antibiotic resistance.11
In the current study, among 100 mothers 75(75%) of mothers are having best practice, 25(25%) of mothers are having good practice and none of the mothers were having poor practice. Here, the practice scores appear to be far better than the knowledge scores with 89% of mothers using only doctor prescribed antibiotics, 79% of the mothers continuing the medications till the prescribed course is administered. In contrast to this, a similar study done in Saudi Arabia showed that most participants use antibiotics rarely i.e. 48.3% of 1960 participants.9 51.4% of respondents use self-prescribed antibiotics and 42% of participants discontinue the course on alleviation of symptoms. Whereas similar findings were noted in another study conducted in Kosovo, which showed that 70.4% of total participants relied only on medical prescription of antibiotics.12
CONCLUSION:
Rapid spread of antimicrobial resistance locally, regionally or globally is a great epidemiological concern today and the emergence of ‘superbugs’ (bacteria highly resistant to antimicrobial agents) has severely threatened therapeutic options in the last few decades.2 Awareness and behaviour modification in this regard is the need of the hour.This study revealed that the mothers had good knowledge and practice with regard to the topic which can still be improved. The findings may not be generalizable as 79% of them were having an educational qualification of graduation and above. The study was limited to 100 participants from a single setting and depended on the self-report of mothers. It is recommended that it can be taken up as a multi-centric study on a large scale with more participants to get an exact picture of the situation. Nurses play an important role to prevent antibiotic resistance and such research would contribute to plan out nursing interventions at various levels to curb the menace.
CONFLICT OF INTEREST:
The authors have no conflict of interest regarding the study.
ACKNOWLEDGEMENT:
The investigators acknowledge gratefulness to the study participants and to all who directly or indirectly contributed to the success of the study.
REFERENCES:
1. Harbarth S, Samore MH. Antimicrobial resistance determinants and future control. Emerging Infectious Diseases. [Internet]. [Cited on 18 february2019]. Available from: https://doi.org/10.3201/eid1106.050167 PMID: 15963271
2. Aishwarya J. Ramalingam. History of Antibiotics and Evolution of Resistance. Research J. Pharm. and Tech. 8(12): Dec., 2015; Page 1719-1724. doi: 10.5958/0974-360X.2015.00309.1
3. Science daily. Definition of antibiotic resistance [internet] 2016 [cited on 26 February 2019]. Available from: https://www.sciencedaily.com/terms/antibiotic_resistance.html
4. Sreeja. M.K, Gowrishankar N.L, Adisha. S, Divya. K.C. Antibiotic Resistance-Reasons and the Most Common Resistant Pathogens – A Review. Research J. Pharm. and Tech. 2017; 10(6): 1886-1890. doi: 10.5958/0974-360X.2017.00331.6
5. J. Divya Maria, VijeyAanandhi. M. An Overview on Antibiotic use and resistance. Research J. Pharm. and Tech. 2017; 10(8): 2793-2796. doi: 10.5958/0974-360X.2017.00494.2
6. Ahmed AbduljabbarJaloobAljanaby, IsraaAbduljabbarJaloobAljanaby. Profile of Antimicrobial Resistance of Aerobic Pathogenic Bacteria isolated from Different Clinical Infections in Al-Kufa Central Hospital –Iraq During period from 2015 to 2017. Research J. Pharm. and Tech 2017; 10(10):3264-3270. doi: 10.5958/0974-360X.2017.00579.0 Available on: https://rjptonline.org/AbstractView .aspx?PID= 2017-10-10-3
7. PadmajaUdayakumar. Medical pharmacology.4th edition: CBS publications; New Delhi. 2005: page no: 197-99, 122-24.
8. Maheshwari. P, Manimekalai. P, Anuja. P, AbukBiar. Antibiotic Drug Utilization and Evaluation in Pediatric Patients. Research J. Pharm. and Tech. 2017; 10(8): 2704-2706. doi: 10.5958/0974-360X.2017.00480.2
9. Patil PJ, Patil VS, Chavan RH. Awareness, Knowledge and Attitude about Antibiotics use among Society. Research J. Pharm. and Tech. 2020; 13(11):5202-5206. doi: 10.5958/0974-360X.2020.00909.9
10. Department of Periodontics and Community Dentistry, College of Dentistry, King Saudi University, Riyadh. Knowledge, attitude and practice of antibiotic use and misuse among adults in Riyadh, Saudi Arabia. [Internet]. [Cited on 2019 February 26]. Available form:https://www.ncbi.nlm.nih.gov/pubmed/28917069.
11. Department of Pharmaceutical Sciences, Faculty of Pharmacy, The University of Jordan, Amman, Jordan. Knowledge, attitudes and behavior regarding antibiotics use and misuse among adults in the community of Jordan. [Internet]. [Cited on 2019 February26].Availableform:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3744980.
12. Department of Community, Environmental and Occupational Medicine, Faculty of Medicine, Ain Shams University. Mother's knowledge about antibiotic and role of self- prescription. [Internet]. [Cited on 2019 February 26]. Available form: https: //www.ncbi.nlm.nih.gov/pubmed.in
Received on 14.01.2022 Modified on 17.05.2022
Accepted on 31.08.2022 © A&V Publications all right reserved
Int. J. Nur. Edu. and Research. 2022; 10(4):294-298.
DOI: 10.52711/2454-2660.2022.00068