Knowledge,attitude,and practice on antibiotics use among healthcare workers: A cross-sectional study in Niger state,Nigeria

Abstract

Introduction

Antibiotic resistance is a public health concern in Nigeria and the world, and healthcare workers contributed to the upsurge of antibiotic resistance in hospital settings. This study focused on the knowledge, attitude, and practice (KAP) of antibiotic use and the frequency of prescriptions of antibiotics from the list of WHO Model Essentials Antibiotics (AWaRe) (in the last 6 months) among healthcare workers and established the determining factors in six hospitals in Niger state, Nigeria.

Methodology

A KAP survey was conducted in Niger State, Nigeria, from March to June 2022. A structured self-administered, pretested questionnaire was distributed to six hospitals in the state following a stratified random sampling considering the staff capacity, the population of the city, and patients’ patronage.

Results

A total of 350 questionnaires distributed, and 313 (89.4%) completed and returned from the six hospitals. The median scores were knowledge (75%), attitude (69%), practice (62%), and self-reported prescription (70%), and respondents with good scores were knowledge [195 (62.3%)], attitude [185 (59.1%)], practice [201 (64.2%)], and prescription [117 (37.4%)]. In multivariate analysis, older respondents are more likely to have a good prescription (p = 0.006), and prior antimicrobial training improved their knowledge (p < 0.001), attitude (p = 0.007), and prescription pattern (p = 0.009). All the study participants had prescribed one or more of the most prescribed antibiotics; Amoxicillin clavulanate (Access group, 96.5%), Amoxicillin (Access group, 95.9%), and Metronidazole (Access group, 95.7%).

Conclusions

The study suggests that antibiotic education for healthcare workers and antimicrobial stewardship programs are significant interventions to mitigate antibiotic overuse in the state.

Keywords

Antibiotic resistance WHO AWaRe antibiotics classifications knowledge attitudes practices knowledge,attitude,and practice

Background`

The ongoing widespread antimicrobial resistance (AMR) has hindered the prevention and treatment of infections caused by bacteria, parasites, viruses, and fungi (Dhingra et al., 2020). As a result, antimicrobial resistance has become a more severe threat to global public health over the last two decades, and it is now regarded as the most significant health threat in the twenty-first century (Parveen et al., 2022). If nothing is done to halt the growing trend of AMR, 10 million people will die globally by 2050, with 4 million deaths each in Asia and Africa (O'Neill, 2014).

Tertiary hospitals are prime locations for the emergence and spread of antimicrobial-resistant organisms since tertiary facilities provide the highest degree of healthcare services, including medical student training (Chukwu et al., 2021; Ogoina et al., 2021).

Inadequate regulations of the distribution and sale of prescription medications are a significant factor contributing to the widespread availability of misused antibiotics (Akinyandenu and Akinyandenu, 2014). The significant determinants of the irrational use of antibiotics among healthcare workers are inadequate education, knowledge, attitude, and practice of prescribers, patient–doctor interaction, and pharmaceutical promotions (Domche Ngongang et al., 2021). There have been reports of higher antibiotic usage rates in several developing nations, including Pakistan, Nepal, Eritrea, Uzbekistan, Oman, Sudan, Jordan, Zimbabwe, Lebanon, Yemen, and Nigeria (Akinyandenu and Akinyandenu, 2014; Khalifeh et al., 2017). In addition, the extensive use and misuse of antibiotics in animals result in antibiotic-resistant bacteria of animal origin, which can be transmitted to people through environmental exposure, food items, agricultural workers, and pet owners (Ihedioha et al., 2020). As a matter of concern, the World Health Organization (WHO) established the Access, Watch, and Reserve (AWaRe) classification of antibiotics to aid in the establishment of tools for antibiotic stewardship at the local, national, and global levels and to lessen the spread of antibiotic-resistant microorganisms and also to help countries improve their antibiotic monitoring and stewardship efforts (WHO, 2017).

According to the 2013 registered health workforce profile, Nigeria had 71,396 Community Health Extension Workers, 16,979 pharmacists, 65,759 Medical doctors, and 249 566 nurses and midwives (Chukwu et al., 2021). Only medical professionals and dentists are permitted by law to administer medications to patients, except for primary health cares (PHC) (Auta et al., 2016). Since most PHCs lack physicians, nurses, or community health workers administer most prescriptions using standing orders or procedures. Despite this, nurses and other community health professionals have less expertise in medications and are less likely to follow treatment recommendations, making them a potential safety risk for their patients (Auta et al., 2016).

AMR has been identified as a potential challenge to public health in Nigeria, necessitating the collection of comprehensive, high-quality, and locally relevant data to guide the development of evidence-based interventions (FMAEH, 2017). The main focuses of the Nigeria Action Plan on Antimicrobial Resistance (2017–2022) NAPAR are to raise awareness and knowledge of AMR and associated themes; strengthen One Health AMR surveillance and research; improve infection prevention and control (IPC) in the tripartite sector; encourage rational access to antibiotics and antimicrobial stewardship; and invest in AMR-related research and development (FMAEHa, 2017). Despite multiple initiatives by the government, policymakers, and global non-governmental organisations, there are still gaps that require more attention and urgent solutions to curb antibiotic resistance in Niger State and Nigeria at large. The study focuses on the knowledge, attitude, and practice (KAP) of antibiotics and the frequency of prescriptions of eighteen antibiotics from the list of WHO Model Essentials Antibiotics (AWaRe) (in the last 6 months) among healthcare workers and established the determining factors of antibiotic usage in six hospitals in Niger state, Nigeria.

Materials and methods

Study site and sampling

This study was carried out in Niger State, located in North Central and one of the federating geopolitical states in Nigeria. A state with a population of 6,220,617 people and a 76,363 km² total area. The capital city is Minna, and the state is located at latitude 3.20 East and longitude 11.300 North. The Federal Capital City of Nigeria is 150 kilometres away. The state is divided into three (3) geopolitical zones (Zones A, B, and C).

The study was carried out in six hospitals in the three zonal regions in the state. A multistage sampling technique was employed for the study participants. The first stage involved the division of all the hospitals in the state according to the zones. The final stage involved the selection of two hospitals from each zone by stratified random sampling, considering the staff capacity, population of the city, and patients’ patronage.

Study sample size

The population of health workers was 1696 in the state, according to the Niger State Healthcare Development Agency Data (Niger State Healthcare development agency, 2022). For this study, out of a 1696 population of health workers in Niger State, a minimum of 303 sample size of healthcare respondents was drawn using the Epi Info™ App designed by the Centers for Disease Control and Prevention (CDC) with an expected frequency of 40% and was increased to 350 to account for a 16% attrition rate.

Study design and data collection

A hospital-based cross-sectional study was conducted from March to June 2022 among healthcare workers in Niger State, Nigeria. A structured self-administered, pretested questionnaire was designed using previous studies (Kabba et al., 2020; Chukwu et al., 2021; Ogoina et al., 2021). The questionnaire was categorised into eight sections in which Section A contained the sociodemographic parameters of respondents; Section B included 20 positive and negative questions covering their knowledge of antibiotics and antibiotic resistance; Section C had 15 positive and negative questions evaluating the attitude towards the prescription of antibiotics; Section D comprised 17 positive and negative questions assessing the practice of prescribing antibiotics, Section E evaluated the frequency of self-reported antibiotic prescriptions in the past 6 months using six-point Likert scale. Finally, sections F, G, and H assessed the participants’ opinions on interventions, the sector to target to slow down antibiotic resistance, and sources of antibiotic resistance, respectively.

A five-point Likert scale was used for Sections B–D. The scoring system used was: strongly agree = 5, agree = 4, neutral = 3, disagree = 2 and strongly disagree = 1, and the scores were reversed for negative questions. The scores range for Section B was 20–100, Section C was 15–75, and Section D was 17–85. The scoring system for section E was: always = 6, most of the time = 5, sometimes = 4, rarely = 3, ever prescribed = 2, and never = 1.

Statistical analysis

Study variables were summarised using descriptive statistics, including frequencies, percentages, medians, and interquartile range (IQR). All scores were assessed for normality using the Shapiro-Wilk test (quantitative variables were not normally distributed). Spearman rho’s correlation coefficient was used with the following scores range: 0–0.25 = weak, 0.25–0.5 = fair, and 0.5–0.75 = good to describe the strength and direction of the knowledge, attitude, practice, and prescription scores. A chi-square test was used for bivariate analysis. In multivariate analysis, knowledge, attitudes, practice, and prescription were grouped into good scores (≥ 75%), average scores (≥25–74%) poor scores (<25%). Binary logistic regression was used to model the odds of knowledge, attitude, practice, and prescription with a 95% confidence interval and a p-value <0.05 across the study population. All the statistical data analysis was performed using SPSS window version 28 (version 28, IBM, Chicago, IL).

Inclusion and exclusion criteria

All permanent and visiting healthcare workers involved in patient management were eligible to participate in this research. However, healthcare workers holding administrative positions and non-healthcare workers in the hospital were excluded from this study. In addition, all healthcare workers in private health facilities were excluded from this study.

Results

Demographic characteristics of respondents

Out of the 350 questionnaires distributed, 313 (89.4%) were completed and returned from the six hospitals in Niger state. There were 169 (54.0%) males and 143 (46.0%) females among the respondents, who were mainly between the ages of 36 and 49 years and were spread across the six hospitals (Table 1). The majority of the respondents were nurses (N = 154 [49.2%]), with years of experience between 5–14 years (60.7%) and the age of 36 years below (47.9%). In addition, most respondents continued their education (N = 234, [74.8%]), and most had training on antimicrobials (N = 193 [61.7%]). The Zone B (N = 126 [39.8%]) and Zone A (N = 118 [37.6%]) regions had the highest proportion of respondents (Table 2)

Table 1.

Demographic characteristics of respondents.

Variables	N (%)
Age
<36 years	150 (47.9)
36–49 years	124 (39.6)
>49 years	39 (12.5)
Gender
Male	169 (54.0)
Female	144 (46.0)
Years of experience
5–14 years	190 (60.7)
25-25 years	85 (27.2)
>25 years	38 (12.1)
Profession
Physician	56 (17.9)
Nurse	154 (49.2)
CHEM	41 (13.1)
Dentist	8 (2.6)
Pharmacists	18 (5.8)
Others	36 (11.5)
Training
Continuous education	234 (74.8)
At least one conference/year	55 (17.6)
None	24 (7.7)
Prior training on AMR
Yes	193 (61.7)
No	120 (38.3)

CHEM: Community health extension worker; AMR: antimicrobial resistance.

Table 2.

Knowledge, attitude, and practice of antibiotics and antibiotics resistance.

Knowledge	Strongly agree, %	Agree, %	Neutral, %	Disagree, %	Strongly disagree, %
Amoxicillin is a safe antibiotic in the first 3 weeks of pregnancy	70.6	16.0	4.8	4.5	4.2
Methicillin-resistant Staphylococcus aureus is also resistant to cephalosporin	45.7	32.9	11.8	5.1	4.5
Gentamicin requires dose reduction in patients with renal failure	47.3	34.5	12.1	2.9	3.2
Non-febrile diarrhoea should not be treated with antibiotics	47.6	23.3	10.5	9.6	8.9
Branded antibiotics are better than their generics counterpart	49.2	24.3	10.5	6.4	9.6
Antibiotics can cure viral infections	46.6	17.9	7.7	8.9	18.8
The use of antibiotics will speed up the recovery from a cold and cough	51.4	16.9	10.5	6.7	14.4
Frequent use of antibiotics will decrease the efficacy of treatment when using the antibiotic again	37.7	23.6	12.1	14.4	12.1
Antibiotics can cause an imbalance in the body’s bacterial flora	32.6	28.4	20.4	8.6	9.9
The use of antibiotics among animals can reduce the effect of antibiotics on humans	28.1	25.2	10.5	16.9	19.2
Antibiotics are effective in protozoal infection management	40.3	23.0	14.7	5.1	16.9
Antibiotics help patients to recover faster when added to malaria treatment	44.4	20.1	10.9	7.7	16.9
Antibiotics use might lead to dangerous allergies, which could cause death	31	21	18.5	14.7	14.7
Inappropriate empiric choices of antibiotics promote antibiotic resistance	43.1	26.5	14.7	8.9	6.7
Dispensing antibiotics without prescription should be more closely controlled to prevent irrational use	46.6	25.6	10.9	7.7	9.3
Inappropriate duration of antibiotics course promotes antimicrobial resistance	49.2	22.0	10.5	6.7	11.5
Poor infection control in hospitals spreads antibiotic resistance	40.3	25.2	12.1	8.3	14.1
Patient poor adherence to antibiotic therapy promotes antibiotic resistance	43.5	24.9	12.5	7.0	12.1
Sub-standard quality of antibiotics promotes antibiotic resistance	43.5	19.8	12.8	8.6	15.3
New antibiotics will be developed in the future that will keep up with the problem of ‘resistance’.	49.5	24.9	10.9	6.4	8.3
Attitude
Antibiotic resistance is a severe public health issue worldwide	67.1	21.1	4.2	2.2	5.4
Antibiotics resistance is a severe health issue in Nigeria	54.6	27.2	4.8	7.3	6.1
Antibiotics are a problem in other hospitals but not in our hospital	33.9	18.2	17.3	9.6	21.1
Antibiotics could be used to prevent bacterial infection in patients with viral URTI	44.4	24.9	15.3	7.3	8.0
Any patient with a fever would benefit from antibiotic therapy	46.6	21.4	17.3	6.7	8.0
Prolonged use of broad-spectrum antibiotics is a risk factor for antibiotic resistance	45.0	17.6	18.5	8.0	10.9
Patients may feel better if you prescribe antibiotics to satisfy their demands and expectations	40.9	22.7	10.5	8.6	17.3
There is nothing I can do as a person to lower the risk of antibiotics in our hospital	39.3	16.3	15.3	16.3	16.0
There is no risk of resistance if antibiotics are taken as prescribed	48.6	21.4	10.9	8.0	11.2
Persons who have never taken antibiotics have no risk of resistance	37.7	28.1	15.3	6.4	12.5
It is better to stop antibiotics as soon as the patient feels better	41.2	24.3	10.2	8.3	16.0
Regular hand washing can prevent antibiotics resistance	33.9	25.2	16.9	10.5	13.4
A long course of antibiotics is less likely to cause resistance than a short course	37.1	20.1	23.6	9.6	9.6
Pharmaceutical companies sometimes influence my choice of antibiotics	35.1	23.0	20.4	9.3	12.1
Antibiotic resistance could be transmitted from healthcare workers to patients in a hospital setting.	39.0	17.6	10.2	8.3	24.9
Practice
I often prescribe antibiotics, even when it’s not indicated, because I do not have the time to explain to the patient why they are inappropriate.	24.0	18.2	17.9	6.7	33.2
Sometimes prescribe antibiotics so that patients continue to trust me	20.8	22.7	14.7	9.6	32.3
Prescribe antibiotics because patients insist on it	19.2	15.3	16.9	16.9	31.6
Prescribe antibiotics in situations where I can’t conduct a systematic follow-up of the patient	20.1	18.8	15.3	20.8	24.9
In case of doubt, it is preferable to use a wide-spectrum antibiotic to ensure that the patient is cured of an infection	31.3	23.3	16.3	15.3	13.7
Prescribe antibiotics following antibiotic prescribing guidelines	44.4	17.6	16.3	7.7	14.1
Prescribe antibiotics following patient demands and expectations	24.9	17.3	17.6	15.3	24.9
Prescribe antibiotics based on standard treatment guidelines	46.6	16.3	17.9	8.6	10.5
Prescribe antibiotics for the common cold	34.5	17.3	21.1	13.4	13.7
Prescribe antibiotics for pneumonia	39.3	21.4	17.9	13.1	8.3
Prescribe antibiotics for malaria	39.0	16.6	17.9	13.1	8.3
Stop antibiotics immediately patient’s symptoms resolve	31.0	19.8	17.3	16.6	15.3
Prescribe antibiotics if you do not trust the available laboratory results	26.5	22.4	19.2	12.5	19.5
Wait for culture result before prescribing antibiotics	35.8	22.7	15.7	13.1	12.8
Prescribe antibiotics based on the recommendation of pharmaceutical companies	32.9	18.2	20.8	12.1	16.0
Prescribe antibiotics inappropriately because the appropriate antibiotics are not available	28.1	13.4	14.4	10.5	33.5
De-escalate from broad-spectrum to narrow-spectrum antibiotics as soon as a culture are available	37.1	20.8	20.1	9.6	12.5

Knowledge, attitude, and practice of antibiotics and antibiotic resistance among healthcare workers

In the knowledge section, most study participants deemed amoxicillin safe in the first 3 weeks of pregnancy (86.6%). The respondents correctly agreed on the importance of gentamycin dosage adjustment in treating patients with renal pathology (81.8%) and that branded antibiotics are better than their generic counterparts (73.5%). Most of the respondents correctly believed that methicillin-resistant staphylococcus aureus is resistant to cephalosporin (78.6%), frequent use of antibiotics will mitigate its treatment efficacy (61.3%), antibiotics should not be administered for non-febrile diarrhoea (70.9%). In addition, a smaller number of respondents correctly believed that antibiotics could cause an imbalance in the body’s bacterial flora (32.6%), life-threatening allergies (31%), and antibiotic resistance arising from the use of antibiotics in animal husbandry (28.1%). However, greater than two-fifths of participants incorrectly believed antibiotics can cure protozoan infections (40.3%), speed up recovery from colds and coughs (51.4%), cure viral infections (46.6%), and speed up recovery when combined with antimalarials (44.4%).

In the attitude section, participants were aware of the global (82.2%) and national (81.8%) public health issues of antibiotic resistance, which could be a problem for their hospital (52.1%), and 55.6% believed that they could not lower antibiotic resistance in their various hospitals. However, half of the participants believed that patients’ adherence to prescriptions (70%) and people who had never taken antibiotics (65.6%) had no risk of antibiotic resistance. Furthermore, half of the participants believed that antibiotic resistance could be transmitted from healthcare workers to patients (56.6%) and that regular hand washing prevents antibiotic resistance (59.1%).

In the self-reported prescribing practice section, patients’ demands and expectations (24.9%), seeking patients’ trust (20.8%), insisting on it (19.2%), and prescribing inappropriate antibiotics due to unavailability of appropriate antibiotics (28.1%) had little negative influence on respondents’ practices. Respondents had prescribed antibiotics for common colds (51.8%), pneumonia (60.7%), and malaria (55.6%). In addition, about half of the respondents prescribed antibiotics because they did not trust the laboratory result (48.9%) and stopped antibiotics immediately after the patient’s symptoms resolved (50.8%). 54.6% of respondents prescribed wide-spectrum in the case of doubt, 58.5% waited for the culture, and 57.9% de-escalate from wide-spectrum to narrow-spectrum antibiotics as soon as culture results were available.

Descriptive statistics of knowledge, attitude, practice, and prescription scores

Out of 313 respondents, 195 (62.3%), 185 (59.1%), 201 (64.2%), and 117 (37.4%) had good knowledge, attitude, practice, and self-reported prescription, respectively.

Multivariate analysis of the predictors of good knowledge, attitude, practice, and prescription

The factors associated with good knowledge, attitude, practice, and prescriptions are shown in Table 3. Respondents between 36 and 49 years were 3.2 times more likely to have good knowledge, whereas respondents over 49 years were 4.6 times more likely to have a good prescription. Regardless of their year of experience, all respondents were significantly associated with good knowledge. Those who had previously participated in antimicrobial training were more likely to have more knowledge (3.4 [CI 1.8, 6.2]), attitude (2.3 [CI 1.3, 4.2]), and prescription (0.4 [CI 0.2, 0.8]) than those without any prior training, but not significantly associated with the practice. Physicians, nurses, and community health extension workers were associated with a better understanding than the other professions. Other training and gender of the respondents had no significant association with good knowledge, attitude, practice, and prescription.

Table 3.

Multivariate analysis of the predictors of good knowledge, attitude, practice, and prescription.

Variables	Good knowledge	Good attitude	Good practice	Good prescription
Variables	AOR (95% CI)	AOR (95% CI)	AOR (95% CI)	AOR (95% CI)
Age
<36 years	1*	1	1	1
36–49 years	3.2 (1.6,6.4) *	0.9 (0.5,1.8)	1 (0.5,1.8)	2.0 (1.0,4.0)
>49 years	2.2 (0.8,6.2)	0.8 (0.3,2.1)	0.9 (0.3.2.3)	4.6 (1.5,13.7) *
Gender
Male	1	1	1	1
Female	1.1 (0.6,1.9)	1.0 (0.6,1.8)	1.0 (0.6,1.7)	2.5 (1.4,4.4)
Years of experience
5–14 years	1*	1	1	1
25-25 years	0.3 (0.2,0.6) *	1.2 (0.6,2.3)	1.4 (0.8,2.7)	0.5 (0.3,1.1)
>25 years	0.3 (0.1,0.9) *	1.0 (0.4,2.6)	2.0 (0.8,5.0)	0.6 (0.2,1.6)
Profession
Physician	1*	1	1	1
Nurse	2.7 (1.3,5.9) *	1.1 (0.5,2.2)	1.2 (0.6,2.3)	0.7 (0.3,1.5)
CHEM	3.4 (1.2,9.3) *	0.9 (0.3,2.4)	1.1 (0.5,2.8)	0.4 (0.2,1.1)
Dentist	0.8 (0.1,5.5)	0 (0,0)	3.3 (0.7,16.9)	0.3 (0.1,1.8)
Pharmacists	0.8 (0.1,3.3)	0.1 (0.0,0.7) *	1.1 (0.3,3.5)	0.5 (0.2,1.6)
Others	2.2 (0.8,6.5)	0.6 (0.2,1.6)	0.9 (0.3,2.2)	1.3 (0.4,3.8)
Training
Continuous education	1	1	1	1
At least one conference/year	1.2 (0.6,2.4)	1.3 (0.7,2.8)	1.6 (0.8,3.0)	1.2 (0.6,2.4)
None	0.9 (0.3,2.5)	0.9 (0.3,2.5)	1.2 (0.5,3.3)	2.8 (0.8,9.7)
Prior training on AMR
No	1	1	1	1
Yes	3.4 (1.8,6.2) *	2.3 (1.3,4.2) *	0.6 (0.3,1.0)	0.4 (0.2,0.8)*

CHEM: Community health extension worker; AMR: antimicrobial resistance; 1: ref.; AOR: adjusted odds ratio, CI: 95% confidence interval *p < 0.05.

Spearman rho’s correlation between knowledge, attitude, practice, and prescription scores

The spearman rho analysis shows that knowledge, attitude, practice and prescription scores were significantly positively correlated, with the association being fairer between knowledge and attitude and weaker between attitude and prescription.

Frequency of prescription of antibiotics belonging to WHO AWaRe groups

Brief on AWaRe groups, Access groups are effective against a wide variety of susceptible pathogens that are frequently diagnosed while also exhibiting a lower potential for resistance than antibiotics belonging to other categories. The Watch group includes antibiotic classes with a higher resistance potential, including the majority of the Critically Important Antimicrobials for Human Medicine and/or antibiotics at a relatively high risk of bacterial resistance selection and antibiotics in the Reserve group should be used only for confirmed or suspected infections caused by multidrug-resistant organisms and should be considered ‘last resort’ options. The scores range of prescription was 18–108 with an interquartile range median of 76 (67, 80). 37.4% of respondents had a good score range for the prescription. In Figure 1, all the study participants had prescribed one or more of the most prescribed antibiotics; Amoxicillin clavulanate (Access group, 96.5%), Amoxicillin (Access group, 95.9%), Metronidazole (Access group, 95.7%), Ceftriaxone (Watch group, 95.6%), Ciprofloxacin/ofloxacin (Watch group, 95.3%), and Cefuroxime (Watch group, 94.9%). Fluoroquinolones, third-generation cephalosporins, beta-lactamase inhibitors, imidazoles, and penicillins were the classes of antibiotics that were mainly prescribed by most of the respondents.

Intervention to reduce antibiotic resistance

86% of respondents agreed with an educational intervention on antibiotics therapy for prescribers, 84% suggested an adequate and effective committee to monitor infections within health facilities, and 82% and 80% wanted the health policymakers in the state to establish antibiotics resistance surveillance that would monitor and collect data on antibiotic resistance and implement antimicrobial usage policy in the state, respectively.

Sectors targeted to slow down the development of antibiotics resistance

The majority of respondents chose patients’ adherence to antibiotics (78.0%), antibiotic prescription by a doctor (77.9%), antibiotic use in hospitals (73.8%) and hospital hygiene (72.8%) as the significant sectors where intervention should be targeted to curtail the insurgence of antibiotic resistance.

Sources of current information on antibiotic resistance

The most recent sources of antibiotic resistance mentioned by the respondents were direct communication with an expert (70.6%), continuing education (66.10%), scientific journals (65.5%), and internet forums (64.50). However, the least-mentioned information source was a digital platform (TV, radio, and social media) (55.60%).

Discussion

It has been stated that a better understanding of physicians’ knowledge and beliefs on antimicrobial use and resistance can increase the efficacy of interventions aimed at enhancing antimicrobial use in hospitals and preventing antibiotic resistance (Labi et al., 2018). Therefore, this study analysed the knowledge, attitude, and practice of antibiotic use among healthcare workers in both tertiary and secondary hospitals in Niger State, Nigeria.

Several studies have shown that the degree of antibiotic awareness among healthcare workers has increased over the past few years (Chukwu et al., 2021). Most respondents agreed that antibiotic resistance is a problem in Nigeria and around the world, which is in line with national studies conducted in Nigeria (Ogoina et al., 2021), Sierra Leone (Kabba et al., 2020), Ethiopia (Abera et al., 2014), Ghana (Labi et al., 2018) and Gabon (Adegbite et al., 2022). However, only one-third of respondents agreed that AMR is a serious issue in their hospitals, in contrast to the same national surveys (Kabba et al., 2020; Ogoina et al., 2021). This calls for an antibiotic resistance awareness campaign within the health facilities in the state.

From our findings, physicians had better knowledge of antibiotics and antibiotic resistance and a more positive attitude towards prescriptions than nurses, similar to other studies conducted in the Gambia (Chaw et al., 2017) and Ethiopia (Abera et al., 2014). These differences could be explained by the differences in the level of training on antibiotic prescribing, which is more comprehensive in the medical curriculum (Chaw et al., 2017). In addition, a moderate level of comprehension was demonstrated concerning safety when prescribing antibiotics, including amoxicillin during the first 3 weeks of pregnancy, the potential for a life-threatening allergic reaction to antibiotics, and adjusting gentamicin dosage in patients with renal issues. In contrast, a previous study reported a high level of understanding about safety and concerns while prescribing antibiotics (Asante et al., 2017; Chaw et al., 2017; Kabba et al., 2020). However, three-quarters of the respondents incorrectly believed that antibiotics are effective against protozoan infections and that they expedite recovery when combined with antimalarial or cold and cough treatments, in line with another report (Garba et al., 2018). Therefore, it could be attributed to insufficient knowledge about the risk factors for antibiotic resistance, or antibiotics prescribed by healthcare workers may not result in antibiotic resistance (Garba et al., 2018). Interestingly, a study conducted in the USA (Schroeder et al., 2021) showed a progressive reduction in the utilisation of antibiotics for acute respiratory tract infections. So, actions like educating doctors and patients about antibiotics and antimicrobial stewardship programs could help stop the overuse of antibiotics.

Subsequently, our findings indicated that two-fifth of our respondents exhibited a positive attitude towards inappropriate prescriptions, including patients’ demands and expectations, gaining patients’ trust, prescribing inappropriate antibiotics, and mistrusting laboratory results. Research in the Caribbean (Nicholson et al., 2018) reported a lower rate of doctors’ adherence to patients’ demands, which could result from education interventions via workshops and conferences. In addition to mistrusting laboratory results, the cause could be that, even when laboratory services are available in the facilities, laboratory maintenance and regular reagent supply are insufficient, compromising their services and reliability (Risk et al., 2013; Chaw et al., 2017).

Our results reported that they practised effective infection prevention and control (IPC) and understood that AMR could be spread from health care to patients. A study from Gabon (Adegbite et al., 2022) and Nigeria (Babatola et al., 2021) reported that 30% of healthcare workers and 83% of physicians agreed that poor hand hygiene and infection control could contribute to AMR transmission in hospital settings. Hand hygiene is an effective infection control method for preventing AMR transmission in hospital settings and is a critical intervention recommended by WHO (Darzi et al., 2017). In addition, an appropriate and competent committee educate the health care professionals and monitor infections in healthcare institutions.

This study indicated that over half of the healthcare workers would de-escalate therapy, an improvement over the Caribbean study (Nicholson et al., 2018) and the Jamaican study (Chin et al., 2010), which reported 6% and 7.7%, respectively. Encouragement to de-escalate should be a focus in future programs since progress has been made through educating physicians on the value of the practice and drawing attention to the outcomes of the 2010 study in conferences, workshops, and small group sessions by local microbiologists.

In this study, 18 antibiotics were prescribed by an average of 90.2% of respondents. It further demonstrated that 62.6% of healthcare workers were prescribing antibiotics inappropriately. In addition, β-lactamase inhibitors, Fluoroquinolones, third-generation cephalosporins, imidazoles, and penicillins are the classes of antibiotics most respondents mainly prescribed, which is in line with other studies (Asante et al., 2017; Abubakar, 2020; Kabba et al., 2020; Ogoina et al., 2021). As a result, implementing antimicrobial stewardship is vital in the hospital setting to promote the judicious use of broad-spectrum antibiotics.

It has been estimated that the overall consumption of antibiotics in pigs, chickens, and cattle is 172 mg/kg, 148 mg/kg, and 45 mg/kg, respectively, globally (Mann et al., 2021). In our study, over half of the respondents knew that antibiotic resistance could arise from livestock and animal husbandry. Evidently, compared to a national survey (Ogoina et al., 2021), this demonstrates an increasing awareness of combating and reducing antibiotic resistance in the country. Our study further reinforces the national survey’s recommendations to promote awareness about the association between antimicrobial use in animals and the onset of AMR in people and entrench a national antimicrobial use and resistance surveillance system in livestock and animal husbandry in Nigeria.

This study demonstrated the significance of antibiotics and antibiotic resistance training. We observed that knowledge, attitude, and prescription are associated with training on antibiotics and antibiotic resistance. Furthermore, other reports showed that educational programs could ameliorate healthcare workers’ awareness, improve AMR knowledge, and support appropriate prescribing behaviour (Hu et al., 2016).

Study limitations and strengths

Since the survey was questionnaire-based, there was a chance that participants might prefer to express opinions that they felt were socially acceptable rather than their genuine opinions. Additionally, registered practitioners working in private health facilities known to be critical players in the administration of antibiotics across many LMIC settings were not included in this study’s analysis of AMR knowledge and antibiotic usage. Furthermore, a qualitative Likert scale was used to assess the frequency of antibiotic prescriptions among respondents, which may or may not represent the quantitative equivalent of antibiotic prescriptions among respondents. Finally, the strength of this study is the inclusion of nurses and community health workers to broaden the research on the critical facilitator in antibiotic prescription in primary health care. All healthcare workers, including physicians, are transferred between tertiary, secondary, and primary health care and vice versa.

Conclusion

In conclusion, our study indicated moderate knowledge, attitudes and practices of healthcare workers on antibiotics and antibiotic resistance. However, there was a poor practice of prescribing antibiotics following WHO standard guidelines on antibiotic prescriptions. Therefore, it calls for concern and immediate action, such as increasing awareness and educating healthcare workers on antibiotics and antibiotic resistance would be helpful. Furthermore, implementing antimicrobial stewardship programs to improve their prescribing patterns of antibiotics will mitigate the irrational use of antibiotics. In addition, establishing an influential committee to monitor infections within health facilities and inform the health policymakers in the state to develop antibiotic resistance surveillance that will monitor and collect data on antibiotic resistance in line with Nigeria’s National action plan on antimicrobial resistance (NAPAR) would be helpful.

Supplemental Material

Supplemental Material - Knowledge, attitude, and practice on antibiotics use among healthcare workers: A cross-sectional study in Niger state, Nigeria

Supplemental Material for Knowledge, attitude, and practice on antibiotics use among healthcare workers: A cross-sectional study in Niger state, Nigeria by Bala Abubakar1 and Attila Sárváry Journal of Infection Prevention

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Attila Sárváry

Supplemental Material

Supplemental material for this article is available online.

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