|Year : 2022 | Volume
| Issue : 3 | Page : 186-192
Knowledge, Attitude, Practice (KAP) study regarding antimicrobial use guidelines of ICMR among doctors working in primary, secondary, tertiary healthcare facilities in a tribal area of North Odisha
Kumar Haraprasad Misra, Kali Prasad Pattanaik, Anjali Tarai, Bhakti Sagar Pradhan
Department of Pharmacology, PRM Medical College and Hospital; Maharaja Sriram Chandra Bhanja Deo University, Baripada, Odisha, India
|Date of Submission||25-Nov-2021|
|Date of Decision||28-Dec-2021|
|Date of Acceptance||08-Jan-2022|
|Date of Web Publication||26-Dec-2022|
Dr. Anjali Tarai
Department of Pharmacology, PRM Medical College and Hospital, Baripada, Odisha
Source of Support: None, Conflict of Interest: None
Background: Antimicrobial resistance occurs with irrational use of antimicrobials, self-medication, and misuse of drug. Using data from ICMR's AMR surveillance, ICMR has developed evidence-based treatment guidelines for the treatment of 10 syndrome and infection.
Aims and Objective:
- To assess the knowledge, attitude, and practice regarding the use of antimicrobials according to ICMR guidelines among doctors working in a tribal area of North Odisha.
Methods: A self-administered 18-question KAP survey tool was provided to total 53 doctors working in primary, secondary, tertiary healthcare facilities.
The study systematically was done at the primary health center (in Rangamatia) and then upgraded primary health center (in Kisantandi), then community health center (in Bangiriposi) and finally medical college (PRM Medical College, Baripada) from June to August.
Data were collected regarding how they are practicing use of antimicrobials in
- Prophylaxis and treatment of surgical site infections.
- Use of antimicrobials for upper respiratory tract infection
- For management of antibiotic-associated diarrhea.
Results: We discovered that most of the doctor's, i.e., 77% are unaware about the ICMR guideline while 13% know very well. In case of attitude of doctors toward ICMR guideline of antimicrobial use, it is found that majority of them, i.e., 90%, have very good attitude. So while 5% of doctors have no attitude toward the guideline. But when it comes to practice according to ICMR guidelines, a majority of doctors i.e., 58% fared well.
Conclusions: Our findings indicate dissonance between knowledge and practices among doctors. So there needs to be much more widened awareness program so that the treatment guideline can be reached near the doctors working in tribal areas.
Keywords: Antimicrobial guideline, attitude, ICMR, knowledge, practice
|How to cite this article:|
Misra KH, Pattanaik KP, Tarai A, Pradhan BS. Knowledge, Attitude, Practice (KAP) study regarding antimicrobial use guidelines of ICMR among doctors working in primary, secondary, tertiary healthcare facilities in a tribal area of North Odisha. J NTR Univ Health Sci 2022;11:186-92
|How to cite this URL:|
Misra KH, Pattanaik KP, Tarai A, Pradhan BS. Knowledge, Attitude, Practice (KAP) study regarding antimicrobial use guidelines of ICMR among doctors working in primary, secondary, tertiary healthcare facilities in a tribal area of North Odisha. J NTR Univ Health Sci [serial online] 2022 [cited 2023 Jan 29];11:186-92. Available from: https://www.jdrntruhs.org/text.asp?2022/11/3/186/365013
| Background|| |
The recognized effects of Inappropriate use of antibiotics are multiple rapid emergence of resistance, adverse drug reaction, and treatment failure. There have been data regarding irrational use of antimicrobials among doctors and paramedics in primary, secondary, tertiary healthcare facilities. They are having limitation of knowledge about ICMR guidelines and how to follow the guidelines.
Antimicrobial stewardship program guidelines and training have lagged behind among health professionals and lack of awareness and knowledge about appropriate use of antimicrobials among population in tribal area of India. Antimicrobial resistance occurs with such as lack of awareness and support from physicians, lack of trained manpower and sometimes limited focus by administration., Using data from ICMR's AMR surveillance, ICMR has developed evidence-based treatment guidelines for the treatment of ten syndrome and infection.
The purpose of this study is to improve Knowledge,Attitude,Practice regarding antimicrobial use guidelines among doctors and paramedics in different healthcare facilities in tribal area in country at the same time to improve the health quality among population in India.
Antibiotics have been a crucial development in the evolution of medical treatment, effectively reducing the morbidity and mortality from bacterial diseases that were previously left untreated.
However, irrational use of antibiotics (including veterinary antimicrobial misuse/overuse, environmental contamination, nosocomial transmission, suboptimal point of care diagnostics, and suboptimal dosing) has contributed to the emergence and selection of resistant bacteria.
Consequently, World Health Organization (WHO) has warned that the world is entering a “post antibiotic” era where even minor infection and injury, previously manageable with antimicrobials, will cost lives.
It is well known that knowledge of antibiotics is quite poor among patients and the general public in multiple countries.,,,,,,
Aims and objective
To assess the knowledge, attitude and practice regarding the use of antimicrobials according to ICMR guidelines among doctors working in a tribal area of North Odisha.
| Methods|| |
- Type of study—Cross sectional study. IEC No_2, Dated 19/6/2019 of IEC PRM MCH, Baripada.
- Study area—Tribal district of North Odisha (Mayurbhanj district of Odisha)
- Study subject—Doctors of Primary Health Care (PHC) upgraded primary health center (UGPHC) and community health center (CHC) and tertiary healthcare level like medical college in Mayurbhanj district of Odisha.
- INCLUSION CRITERIA—All doctors working in PHC, UGPHC, CHC & medical college of who give consent to participate in study
- EXCLUSION CRITERIA—A) Private practitioners
B) Nurses, pharmacists, and other healthcare providers
- Collecting feedback on knowledge about 2018 ICMR guidelines of use of antimicrobials from doctors of Primary Health Care (PHC) upgraded primary health center (UGPHC) and community health center (CHC) and tertiary healthcare level like medical college and tribal district by asking questionnaires.
- Collecting data regarding how they are practicing use of antimicrobials
- Prophylaxis and treatment of surgical site infections.
- Use of antimicrobials for upper respiratory tract infection and
- For management of antibiotic-associated diarrhea.
A self-administered 18-question KAP survey tool was provided to doctors working in primary, secondary, tertiary healthcare facilities in order to establish the knowledge, attitudes, and practices regarding antibiotic use in tribal district Mayurbhanj of Odisha.
The questionnaire was taken from a validated, self-administered, cross-sectional questionnaire and based on a literature review. The final questionnaire was pre-tested before data collection, and covered a broad range of domains assessing the KAP of doctors. The study adopted a convenience sampling methodology to recruit participants for the KAP survey due to resource limitations.
Based on a study about antibiotic prescription practices for prophylaxis and treatment of surgical site infections, use of antimicrobials for upper respiratory tract infection and for management of antibiotic-associated diarrhea was observed. The doctors participated were 53 in number. It must be noted that intent was to assess the KAP of Doctors.
The primary health system in India is divided into primary, secondary, and tertiary levels, with subcenters (SCs) and primary health centers (PHCs) constituting the first point of entry, community health centers, and smaller sub-district hospitals constituting secondary care, and medical colleges, and district hospitals constituting tertiary care within the government system. The study started at the primary health center (in Rangamatia) and then upgraded primary health center (in Kisantandi), then community health center (in Bangiriposi) and finally medical college (PRM Medical College, Baripada).
The study was approved by Institutional Ethical Committee (IEC), PRM MCH Baripada Reference No 2 on 19/06/2019. Data collection took place over approximately two months from June to August. We continuously approached participants to attain our target sample size of 53 respondents. All study participants were assured for confidentiality.
Analysis done by reviewing the feedbacks of participants regarding good, fair, and poor knowledge and also positive and negative attitude and good fair and poor practice according to their response.
Data for all 53 participants were collected in Microsoft Excel and data were analyzed. Analysis of the data regarding awareness among healthcare professionals about ICMR guidelines, implementation of ICMR guidelines of antimicrobial use in their practice and their suggestion and implementation was done by mean, percentage.
| Results|| |
Of the total 53 doctors, a majority of doctors, i.e., 47%, were in between age 36 and 45 years followed by age group between 45 and 60, 26–35 >60 years, respectively, and none were in between the age group of 18 and 25 years [Table 1].
In the total 53 doctor's pool, majority (71%) were males and 15% were females. A majority of doctors, i.e., 88%, are working in medical college Health setting. Knowledge of doctors about antimicrobial guidelines of ICMR was divided into three groups like the doctors who knew nothing about the guidelines, who knew somewhat, and who knew all the syndrome treatment guidelines. So we discovered that most of the doctors, i.e., 77%, were unaware about the ICMR guidelines while 13% knew very well [Table 2].
In case of attitude of doctors toward ICMR guideline of antimicrobial use, it is found that a majority of them, i.e., 90%, had positive attitude [Table 3].
But when it comes to practice according to ICMR guidelines, a majority of doctors, i.e., 58%, fared well [Table 4].
Now coming to individual syndromes, in case of treatment of surgical site infection, 13% doctors have both knowledge and practice regarding ICMR treatment guidelines while 28% still follow other antimicrobials differing from ICMR. Surprisingly, 58% doctors have no knowledge of the guideline but prescribe the antibiotics at par as mentioned in ICMR guidelines [Table 5].
Similarly in case of prophylaxis of surgical site infection, a majority of doctors, i.e., 56%, prescribed same antimicrobial as ICMR without knowing guideline, whereas 28% gave antibiotics other than ICMR guideline [Table 6].
In antibiotic-associated diarrhea, 56% doctors prescribe antibiotic to cure the diarrhea while still 30% doctors prescribe ORS for milder form of antibiotic-associated diarrhea [Table 7].
In upper respiratory tract infection, though ICMR guideline suggests no antibiotic is required for acute bronchitis, still 35% of doctors prefer to give antibiotics [Table 8].
| Discussion|| |
A majority of doctors were found to have poor knowledge about the guidelines. This may be due to the fact that many doctors across India prescribe antibiotics in PHC settings as a precautionary measure to compensate for diagnostic uncertainty due to lack of availability of point-of-care diagnostic tests, poor infection control, and inadequate sanitation practices.
Other studies,,,,,,,, have focused predominantly on the KAP of clinicians in tertiary care hospitals, which address a limited part of the antibiotic dispensing pathway. These studies generally report poor practice in allopathic practitioners
While the presence of informal providers is particularly salient in India, such providers can be found in every health system, according to the WHO., A systematic review conducted by Sudhinaraset et al. finds that people across developing countries use informal providers due to convenience, affordability, and social and cultural preferences; many providers across countries such as Vietnam and Bangladesh reported poor adherence to national guidelines with respect to antibiotic use.
In developed economies such as the USA, antibiotics are only prescribed by graduate physicians, but similar problems persist with respect to inappropriate overuse of antibiotics: recent studies estimated that at least 30% of all antibiotic prescriptions in outpatient settings in the USA are considered inappropriate, and 50% of all antibiotic prescriptions for respiratory tract infections are inappropriate.,
The authors found that inappropriate prescription practices were linked to a multitude of factors, including clinical factors, demographic characteristics of patients, severity of illness, previous infection history, compromised immune response, geographic region, among others.
Multicenter studies conducted across the USA, Scotland, Switzerland, Sweden, Slovenia, Spain, France, and England examined knowledge, attitudes, and practices related to antibiotic use among medical students and found that the vast majority wished to acquire more knowledge about choosing appropriate antibiotic treatment.,,
Moreover, many relied on Wikipedia more than formal peer-reviewed sources or textbooks for guidance on antimicrobial use.
Our findings further indicate that there is poor knowledge and awareness of antibiotic uses among doctors and a strong lack of correlation between knowledge and practices among doctors.
This is supported by other studies as well: Das et al. have demonstrated significant quality gaps between private and public providers of Primary Health Care in other Indian states, noting incorrect medical diagnoses, incorrect treatments, and inconsistent adherence to clinical checklists.
Similarly, Scaioli et al. used the original questionnaire adapted in our study on a convenience sample of students from medical, dental, nursing, and other health professions in Italy and found that health professionals do not practice what they know: in other words, high levels of knowledge do not translate into appropriate attitudes and practices with respect to antibiotic use.
We found that doctors treated common illnesses such as cold, cough, fever, and watery loose stools with antibiotics without clinical indication, largely due to diagnostic uncertainty and lack of robust follow-up.
In order to better tackle the growing threat of resistance, India also adopted the National Action Plan on Antimicrobial Resistance (2017–2021) in April.
The efforts to involve informal health providers can form a critical community-level component of antibiotic stewardship programs moving forward, in addition to emphasizing antibiotic resistance in the curriculum, increasing access to aid doctors in decision making, and increasing the use of prescription audits in primary care settings.
Any effort to tackle antibiotic resistance must also include patient education and counseling, because patient demands are a major cause for overuse of antibiotics among formal and informal health providers alike.
Several recent studies demonstrate that the Internet and social media, in particular, can be an effective resource for disseminating high-quality health information to improve antibiotic stewardship in the community.,
Future interventions must be taken by social media within their communication strategy to promote appropriate use for antibiotic-related information in the general population.
| Conclusions|| |
Our findings indicate dissonance between knowledge and practices among allopathic doctors.
Some doctors are aware about the guideline and prescribe antibiotics according to it, while others are not aware and so do not follow the guideline. Still there are a majority of doctors having no knowledge of guidelines but prescribe at par with ICMR guidelines.
So there needs to be much more widened awareness program so that the treatment guideline can be reached near the doctors working in tribal areas.
But overall, doctors scored more in attitude followed by practice then knowledge.
So this was a KAP study of antimicrobial guideline of ICMR regarding four syndromes and their treatment guidelines.
The study took place in a subject category of 53 doctors in a tribal area of Odisha.
Overall result of the study was poor in terms of knowledge as most of the doctors are not aware of the ICMR guidelines, but in practice performance was very satisfactory.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kshirsagar NA. History of clinical pharmacology in India: A brief account. In: Patil PN, Gulati OD, Balaraman R, editors. Topics in the History of Pharmacology. Ahmadabad: RK Goyal Publisher; 2005. p. 148–69.
Indian Council of Medical Research. Thrust Areas of Research for Basic Medical Sciences. Available from: www.icmr.nic.in/thrust/thrustbms.htm. [Last accessed on 2013 Mar 20].
World Health Organization. The World Health Report 2008-Primary Health Care (Now More Than Ever), The challenges of a changing world. Figure 8. The shift towards non-communicable diseases and accidents as causes of death. Available from: http://www.who.int/whr/2008/08_chap1_fig08_en.pdf
. [Last accessed on 2012 Jan 03].
Gales AC, Jones RN, Turnidge J, Rennie R, Ramphal R. Characterization of Pseudomonas aeruginosa
isolates: Occurrence rates, antimicrobial susceptibility patterns, and molecular typing in the global SENTRY Antimicrobial Surveillance Program, 1997–1999. Clin Infect Dis 2001;32(Suppl 2):S146–5.
Hoa NQ, Trung NV, Larsson M, Eriksson B, Phuc HD, Chuc NT, et al
. Decreased Streptococcus pneumoniae
susceptibility to oral antibiotics among children in rural Vietnam: A community study. BMC Infect Dis 2010;10:85.
Mathai E, Chandy S, Thomas K, Antoniswamy B, Joseph I, Mathai M, et al
. Antimicrobial resistance surveillance among commensal Escherichia coli
in rural and urban areas in Southern India. Trop Med Int Health 2008;13:41–5.
Jain D, Sinha S, Prasad KN, Pandey CM. Campylobacter
species and drug resistance in a north Indian rural community. Trans R Soc Trop Med Hyg 2005;99:207–14.
Bashir A, Abbas Z, Farhat S, TandonV, Singh Z. Rationalizing antibiotic use to limit antibiotic resistance and novel antimicrobials. JK Pract 2012;17:1–6.
Napolitano F, Izzo MT, Di Giuseppe G, Angelillo IF. Public knowledge, attitudes, and experience regarding the use of antibiotics in Italy. PLoS One 2013;8:e84177.
Davis M, Liu TL, Taylor Y, Davidson L, Schmid M, Yates T, et al
. Exploring patient awareness and perceptions of the appropriate use of antibiotics: A mixed-methods study. Antibiotics 2017;6:23.
Barker AK, Brown K, Ahsan M, Sengupta S, Safdar N. Social determinants of antibiotic misuse: A qualitative study of community members in Haryana, India. BMC Public Health 2017;17:333.
Hawkings NJ, Wood F, Butler CC. Public attitudes towards bacterial resistance: A qualitative study. J Antimicrob Chemother 2007;59:1155–60.
Norris P, Chamberlain K, Dew K, Gabe J, Hodgetts D, Madden H. Public beliefs about antibiotics, infection and resistance: A qualitative study. Antibiotics 2013;2:465–76.
Kotwani A, Wattal C, Joshi P, Holloway K. Knowledge and perceptions on antibiotic use and resistance among high school students and teachers in New Delhi, India: A qualitative study. Indian J Pharmacol 2016;48:365–71.
] [Full text]
Kotwani A, Wattal C, Katewa S, Joshi PC, Holloway K. Factors influencing primary care physicians to prescribe antibiotics in Delhi India. Fam Pract 2010;27:684–90.
Akkerman AE, van der Wouden JC, Kuyvenhoven MM, Dieleman JP, Verheij TJ. Antibiotic prescribing for respiratory tract infections in Dutch primary care in relation to patient age and clinical entities. J Antimicrob Chemother 2004;54:1116–21.
Bianco A, Papadopoli R, Mascaro V, Pileggi C, Pavia M. Antibiotic prescriptions to adults with acute respiratory tract infections by Italian general practitioners. Infect Drug Resist 2018;11:2199–205.
Lindberg BH, Gjelstad S, Foshaug M, Høye S. Antibiotic prescribing for acute respiratory tract infections in Norwegian primary care out-of-hours service. Scand J Prim Health Care 2017;35:178–85.
George S, Stetz L, Patel M. Antibiotic resistance: Toward better stewardship of a precious medical resource. Aetna White Papers 2018:1–22.
Sampath S, Venoukichenane V. Knowledge, Attitude and Practice of antibiotics usage among health care personnel in a tertiary care hospital. Sch J Appl Med Sci 2016;4:3294–8.
Krishna BY, Sasi Sekhar TVD, Palaparthi L. A KAP study regarding anti-microbial resistance among medical students in South India. IOSR J Dent Med Sci 2015;14:2279–861.
Sahoo KC, Tamhankar AJ, Johansson E, Lundborg CS. Antibiotic use, resistance development and environmental factors: A qualitative study among healthcare professionals in Orissa, India. BMC Public Health 2010;10:21–39.
Khan AKA, Banu G, Reshma KK. Antibiotic resistance and usage—A survey on the knowledge, attitude, perceptions and practices among the medical students of a Southern Indian teaching hospital. J Cln Diagn Res 2013;7:1613–6.
Padmanabha TS, Nandini T, Manu G, Savka MK. Knowledge, attitude and practices of antibiotic usage among the medical undergraduates of a tertiary care teaching hospital: An observational cross-sectional study. Int J Basic Clin Pharmacol 2016;5:2432–7.
Omaswa F. Informal health workers- to be encouraged or condemned? Bull World Health Organ 2006;84:83.
Sudhinaraset M, Ingram M, Lofthouse HK, Montagu D. What is the role of informal healthcare providers in developing countries? A systematic review. PLoS One 2013;8:e54978.
Hersh AL, Kronman MP. Inappropriate antibiotic prescribing: Wind at our backs or flapping in the breeze? Pediatrics 2017;139:e20170027.
Chua KP, Fischer MA, Linder JA. Appropriateness of outpatient antibiotic prescribing among privately insured US patients: ICD-10-CM based cross sectional study. BMJ 2019;364:k5092.
Dyar OJ, Pulcini C, Howard P, Nathwani D, on behalf of ESGAP, (the ESCMID Study Group for Antibiotic Policies). European medical students: A first multicentre study of knowledge, attitudes and perceptions of antibiotic prescribing and antibiotic resistance. J Antimicrob Chemother 2013;69:842–6.
Abbo LM, Cosgrove SE, Pottinger PS, Pereyra M, Sinkowitz-Cochran R, Srinivasan A. Medical students' perceptions and knowledge about antimicrobial stewardship: How are we educating our future prescribers? Clin Infect Dis 2013;57:631–8.
Minen MT, Duquaine D, Marx MA, Weiss D. A survey of knowledge, attitudes, and beliefs of medical students concerning antimicrobial use and resistance. Microb Drug Resist 2010;16:285–9.
Das J, Holla A, Das V, Mohanan M, Tabak D, Chan B. In urban and rural India, a standardized patient study showed low levels of provider training and huge quality gaps. Health Aff (Millwood) 2012;31:2774–84.
Scaioli G, Gualano MR, Gili R, Masucci S, Bert F, Siliquini R. Antibiotic use: A cross-sectional survey assessing the knowledge, attitudes and practices amongst students of a school of medicine in Italy. PLoS One 2015;10:e0122476.
Zucco R, Lavano F, Anfosso R, Bianco A, Pileggi C, Pavia M. Internet and social media use for antibiotic-related information seeking: Findings from a survey among adult population in Italy. Int J Med Inform 2018;111:131–9.
Anderson A. Online health information and public knowledge, attitudes, and behaviours regarding antibiotics in the UK: Multiple regression analysis of Wellcome Monitor and Eurobarometer Data. PLoS One 2018;13:e0204878.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]