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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 5  |  Issue : 3  |  Page : 86-92

Knowledge of antibiotic resistance among healthcare workers in primary healthcare centers in Kaduna North local government area


1 Department of Paediatrics, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
2 Department of Microbiology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
3 Department of Community Medicine, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria

Date of Web Publication29-Jul-2019

Correspondence Address:
Dr. Maria A Garba
Department of Paediatrics, Ahmadu Bello University Teaching Hospital, Shika, Zaria
Nigeria
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DOI: 10.4103/ssajm.ssajm_23_18

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Keywords: Antibiotic resistance, antibiotics, healthcare workers, primary health care


How to cite this article:
Garba MA, Giwa F, Abubakar AA. Knowledge of antibiotic resistance among healthcare workers in primary healthcare centers in Kaduna North local government area. Sub-Saharan Afr J Med 2018;5:86-92

How to cite this URL:
Garba MA, Giwa F, Abubakar AA. Knowledge of antibiotic resistance among healthcare workers in primary healthcare centers in Kaduna North local government area. Sub-Saharan Afr J Med [serial online] 2018 [cited 2019 Aug 25];5:86-92. Available from: http://www.ssajm.org/text.asp?2018/5/3/86/263565




  Introduction Top


Antibiotics have undoubtedly played a significant role in saving lives and increasing longevity globally. Its advent, along with improvement in economic status, sanitation practices, education, nutrition, and the development of vaccines, is hugely responsible for the epidemiologic transitions observed in global health.[1] It has also played a significant role in the prevention of infections in high-risk patients.[1]

However, the emergence of resistance to these drugs, which was first observed barely a decade after their introduction, has, in recent times, become a global problem. Antibiotic resistance (AR) is a unique process inherent in all organisms.[2] Talaro[3] defines antimicrobial resistance (AMR) as an adaptive response to drugs that previously terminated the growth of bacteria such that they no longer have effect on them. This is driven by excessive and unnecessary prescriptions in healthcare settings, suboptimal infection control practices, and globalization.[4] Suboptimal infection control practice not only increases the need for antibiotic use and acts as a catalyst for development of AR, but also facilitates the spread of AR within healthcare settings.[4] Other factors responsible for the emergence of AR include poor regulation of antibiotics, stock-outs in government hospitals, difficulties in distribution, and infiltration of the drug market by substandard products.[5] Poverty and loss of confidence in the healthcare system also drives the purchase and sales of over-the-counter antibiotics.[5]

Methicillin-resistant Staphylococcus aureus (MRSA), extended-spectrum beta-lactamase, carbapenemase-producing organisms such as extreme drug-resistant Acinetobacter spp., Klebsiella pneumoniae carbapenemase, and Enterobacteriaceae-producing New-Delhi metallo-β-lactamase-1 have emerged over the past 3 decades both in hospital and community settings, from all regions of the world.[4],[6],[7],[8]

It is estimated that AR results in 2 million infections and over 23,000 deaths annually in the USA.[6] A report from India, one of the world’s highest consumers of antibiotics,[9] showed an increase in documented cases of resistant strains of Escherichia coli to cephalosporins from 70% in 2008 to 83% in 2013, and to carbapenems from 10% to 13% within the same period. An increase in MRSA from 29% in 2009 to 47% in 2014 is also noted.[10] High rates of AR in enteric pathogens such as E. coli, Shigella spp., nontyphoidal Salmonellae have similarly been reported in Nigeria.[5] A systematic review including 2203 S. aureus isolates from the south-south, south-west, north-east, and north-central zones of Nigeria showed a rise of MRSA from 18.3% in 2007 to 42.3% in 2013.[11] Similar trends have been reported from other African countries.[12]

The emergence of resistance can be delayed by rational use of antibiotics.[6] Antimicrobial stewardship has been lauded as one of the important measures to curb this emerging dangerous trend. Antimicrobial stewardship “is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.”[6]

Some strategies advocated in health facilities to improve the use of antibiotics and check the emergence of AR include the use of guidelines,[6],[7] surveillance for antibiotic use and AR, increasing the use of diagnostic tests, infection control interventions, use of checklists for surgical procedures, improving antibiotic supply chain, and regulating the use of antibiotics in the veterinary sector.[8] In addition, there is a need for development and support of education strategies of the general public, particularly antimicrobial prescribers to enable awareness of the magnitude of threat AR poses.[4]

Healthcare workers (HCWs) have been identified as being important in the emergence and spread of AR[4] as AR awareness is generally poor among these workers except for those working in academic institutions who are more abreast with current concepts.[5] This is because the curricula of many health professionals have limited or no mention of AMR.[5],[13] There have been several studies aimed at assessing the knowledge of AR among students, physicians, and nonphysician prescribers in developing countries but only a few included community health workers,[14],[15],[16],[17],[18],[19] who make up majority of health personnel in primary healthcare centers. It is thus important to discern their knowledge of AR as this will highlight necessary interventions required with regard to HCW education to promote antibiotic stewardship for public safety.

The objective of this research was to assess the knowledge of AR among HCWs in primary healthcare settings in Kaduna North local government area (LGA).


  Materials and methods Top


This was a cross-sectional study using quantitative methods.

The study was conducted in public primary healthcare centers (PHCs) in Kaduna North LGA, which has 12 political wards with a 2018-projected population of 509,986 (personal communication, Monitoring & Evaluation Officer, Kaduna North LGA).

There are 14 PHCs in Kaduna North LGA, including three health clinics. These are headed by the incharge who, due to shortage of staff, is usually a trained nurse or midwife. Where either of this is unavailable, it is headed by a community health officer.

The study population are HCWs working in PHCs across the local government. These include nurses, junior community health extension workers, community health extension workers, pharmacy and laboratory technicians, and voluntary community HCWs.

The sample frame was all health workers who prescribed antibiotics in the 14 primary health centers in Kaduna North LGA. Each of the 14 health facilities (sample unit) has an average of six HCWs (who prescribe antibiotics), thus giving a target population of 84.

All antibiotic prescribers were included in the study, whereas trainee HCWs and HCWs on posting from other LGA were excluded.

Sample size calculation was as follows:

Sample size (n) = Z2 × P(1−P)/e2

where P (population) = 84, e (margin of error) = 0.05, and z (z-score) = 1.96. Thus, sample size was calculated as 69.

A nonresponse rate of 10% was included to give the estimated sample size of 76.

A closed-ended questionnaire was adapted from the Centers for disease control and prevention (CDC).[20] Besides demographic information, all responses were in the form of “yes,” “no,” or “I don’t know.”

Eight copies were pretested in a PHC in a neighboring LGA (Igabi) to determine clarity and understanding of the questions. Based on demand during the pretest, the questionnaire was translated to Hausa language for ease of understanding of participants. To ensure that the information was not lost, it was translated back to English language and validated by a third party as recommended by Jacobsen.[21] Corrections were subsequently made before the main study.

The first section of the questionnaire sought background information of HCWs (sex, age, years of prescribing, and position in the health facility). The second part comprised 42 questions: knowledge of microbes (4), knowledge of antibiotic use (4), knowledge of AR (30), and perception of the scope of AR (4).

Due to the small number of HCWs in the PHCs, sampling was not performed. All antibiotic prescribers were included in the study. Prior to commencement of the study, informed written consent was obtained from all the participants. The questionnaire was considered valid for analysis if more than 80% of the questions were answered.

Each correct answer was allotted a score of 1 and each wrong answer 0. The total scores were computed, and the data were entered manually and analyzed using IBM SPSS V.21.0 (SPSS Inc., Chicago, Illinois, USA).

The data were cleaned and analyzed using descriptive statistics. Total scores of knowledge of microbes and antibiotics as well as AR were scaled up to percentages. A score of below 49 was regarded as “poor knowledge,” 50 to 74 as “good knowledge,” and above 75 as “very good knowledge.” Frequency of responses was computed as proportions, whereas the relationship between knowledge and categorical variables such as sex of the respondents, age, cadre, and site was analyzed using the χ2 test. A P < 0.05 was considered significant.


  Results Top


A total of 76 questionnaires were distributed and all were returned, giving a response rate of 100.0%. Of this number, two (2.6%) had responses below 80% of the questions and thus were dropped. Seventy-four questionnaires were subjected to analysis. Sixty-one (82.4%) of the respondents were females, whereas 13 (17.6%) were males, giving a F:M ratio of 4.8:1. Ten (13%) had been prescribing for more than 20 years, whereas 19 (25.7%) had been prescribing for between 1 and 5 years [[Table 1]].
Table 1 Sociodemographic characteristics of study participants

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On the questions on microbes and antibiotics, 21 (28.4%) had scores below 50%, whereas 19 (25.7%) scored 75% and above [[Figure 1]]. The mean score was 54.9%, whereas the median was 50%. The calculated standard deviation was 19. The maximum score was 100% and the minimum was 12.5%.
Figure 1 Scores for knowledge of germs and antibiotics by respondents

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The proportion of HCWs who had good knowledge of AR was 73% [[Figure 2]]. The minimum score was 20%, whereas the maximum was 93.3%. The mean score was 54.7%, whereas the median was 56.7% with a standard deviation of 12.2. The standard error of the mean was 1.42.
Figure 2 Grade of score of participants on knowledge of antibiotic resistance

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An analysis of the responses [[Table 2]] showed that almost all respondents (95.5%) agreed that use of antibiotics should only be based on a prescription of a health worker, but two-thirds (66.2%) agreed that it was acceptable to use antibiotics for cough and catarrhal symptoms, whereas a third (33.8%) believed that it was the drug of choice for all cases of diarrhea. Fifty-four percent of the respondents thought that the observation of hand hygiene to prevent infections was overrated. Only half of the respondents (50%) agreed that antibiotic use in animals contribute to AR. A quarter of the respondents (25.7%) believed that a change in antibiotics was enough when a patient on treatment was not improving and that it was unnecessary to consult with an infectious disease specialist.
Table 2 Participants responses to questions on antibiotic resistance

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Knowledge of AR was more among midwives/nurses, and this was statistically significant (Fisher’s exact, χ2 = 6.658, P = 0.034). The proportion of PHC workers who had never attended antibiotic prescription training was high as shown in [Table 3].
Table 3 Factors associated with knowledge of antibiotic resistance

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There was no statistical significance with regard to source of knowledge when HCWs with poor and good knowledge were compared (χ2 = 10.218, P = 0.123). A third of the participants (31.1%) had acquired knowledge of AR while at school, 21.6% at place of work, and 10.8% from compulsory continuous medical education (CME). About a quarter (24.3%) had acquired information on AR from multiple sources (preservice, CME, and places of work). One participant admitted having never heard of AR. Communication media served as at least one of the sources of information in six (8.2%) of the respondents.

About half of all respondents agreed that AR was a problem in their center, 34 (49.3%) in their state, and 32 (43%) in Nigeria. Only 39% agreed that it was a problem in other parts of the world.


  Discussion Top


The result of this study showed that 73% of the PHCs in Kaduna North LGA have good knowledge of AR. This is higher than previously obtained by Abera et al.[18] and Tafa et al.[19] who reported 63.5% and 62.8% among nurses and paramedical staff, respectively. It is worthy to note that AR is not taught in the curriculum of community health practitioners,[13] and that half of the respondents had learnt of AR either from CME, at work, or both.

The nurses’ better performance is in conformity with the findings by Asante et al.[15] and Ahmad et al.[22] who documented better knowledge among higher cadre health workers. No significant difference was found among sex, age, or years of prescribing and knowledge in the present study, which is in conformity with Chem et al.’s[16] report from Cameroon. Tafa et al.[19] had however showed that males were more knowledgeable than females. The lack of difference with regard to sex or age of the prescribers in this study may be due to gender bias (there were more female HCWs). The small sample size in this study could also be a contributing factor.

Almost all the participants were of the conviction that use of antibiotics should be based on prescription of the health worker, and a significant number of the respondents agreed that AR may follow antibiotic use; yet two-thirds prescribe antibiotics for catarrhal symptoms, which are mainly caused by viruses. Similarly, this has been reported by various authors also.[16],[18],[22] This disconnect may be largely due to a lack of understanding of the risk factors for AR or reluctance to translate theory to practice. It may also be conjectured that it is wrongly believed that AR may not result from the drugs prescribed by the health worker as was demonstrated by Dyar et al.[23] among medical students in the United Kingdom.The role of infectious disease specialists and that of the laboratory in diagnosis, the need for isolation of AR cases, and the consequential impact on mortality were not appreciated by majority of the respondents. This may be related to the lack of training on AR and attendance of antibiotic stewardship workshops as noted earlier. The lack of knowledge on the scope of the problem also supports this assumption. Only a small proportion of the participants had acquired knowledge of AR from CME and the media. This is rather alarming, giving the fact that global campaigns on awareness of AR are abound over the years.[24] It is plausible to speculate in this era of communication explosion that universal lack of internet access may also be a contributing factor. Although behavioral change interventions such as education of professionals have been shown to have significant impact on antibiotic prescribing,[25],[26] the suggestion by Lee et al.[25] for the investigation, review, and development of the content of the curricula of healthcare training institutions with regard to microbial virulence, mechanism of AR, and appropriate antibiotic prescribing is relevant and fundamental in the control of AR.


  Conclusion Top


A high percentage of HCWs in PHC in Kaduna North LGA have good knowledge of AR but a poor appreciation of the factors that contribute to it, as well as its impact on morbidity and mortality.

Recommendation

Findings from this research indicate that there is a crucial need for collaboration between the local government health and education departments to incorporate AR training in the curriculum of HCWs, as well as in-service training and retraining if the prevalence of AR is to be controlled. The adoption of antibiotic stewardship programs in PHC facilities, easy access to information, and behavioral change communication programs should be considered a priority for all HCWs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Federal Ministries of Agriculture, Rural Development and Health (FMoAEH). Antimicrobial use and resistance in Nigeria: Situation analysis and recommendation [Internet]. Abuja: FMoAEH; 2017. Available at https://ncdc.gov.ng/themes/common/docs/protocols/56_1510840387.pdf. [Last accessed on April 24, 2018].  Back to cited text no. 5
    
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Centre for Disease Control and Prevention (CDC). Core elements of hospital antibiotic stewardship programs [Internet]. Atlanta: CDC; 2015. Available at https://www.cdc.gov/antibiotic-use/healthcare/implementation/core-elements.html#_ENREF_13. [Last accessed on December 20, 2017].  Back to cited text no. 7
    
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Global Antibiotic Resistance Partnership − India Working Group (GARP). Rationalizing antibiotic use to limit antibiotic resistance in India. Indian J Med Res 2011;134:281-94.  Back to cited text no. 8
    
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Falagas ME, Karageorgopoulos DE, Leptidis J, Korbila IP. MRSA in Africa: Filling the global map of antimicrobial resistance. PLoS One 2013;8:e68024.  Back to cited text no. 12
    
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Abbo LM, Cosgrove SE, Pottinger PS, Pereyra M, Sinkowitz-Cochran R, Srinivasan A et al. Medical students’ perceptions and knowledge about antimicrobial stewardship: How are we educating our future prescribers? Clin Infect Dis 2013;57:631-8.  Back to cited text no. 14
    
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Asante KP, Boamah EA, Abdulai MA, Buabeng KO, Mahama E, Dzabeng F et al. Knowledge of antibiotic resistance and antibiotic prescription practices among prescribers in the Brong Ahafo Region of Ghana; a cross-sectional study. BMC Health Serv Res 2017; 17:422.  Back to cited text no. 15
    
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Chem ED, Anong DN, Akoacher JKT. Prescribing patterns and associated factors of antibiotic prescription in primary health care facilities of Kumbo East and Kumbo West Health Districts, North West Cameroon. PLoS One 2018;13:e0193353.  Back to cited text no. 16
    
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Zhang Z, Zhan X, Zhou H, Sun F, Zhang H, Zwarenstein M et al. Antibiotic prescribing of village doctors for children under 15 years with upper respiratory tract infections in rural China: A qualitative study. Medicine (Baltimore) 2016;95:e3803.  Back to cited text no. 17
    
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Abera B, Kibret M, Mulu W. Knowledge and beliefs on antimicrobial resistance among physicians and nurses in hospitals in Amhara Region, Ethiopia. BMC Pharmacol Toxicol 2014;15:26.  Back to cited text no. 18
    
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Tafa B, Endale A, Bekele D. Paramedical staffs knowledge and attitudes towards antimicrobial resistance in Dire Dawa, Ethiopia: A cross sectional study. Ann Clin Microbiol Antimicrob 2017;16:64.  Back to cited text no. 19
    
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22.
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23.
Dyar OJ, Hills H, Seitz L-T., Perry A, Ashiru-Oredope D. Assessing the knowledge, attitudes and behaviours of human and animal health students towards antibiotic use and resistance: A pilot cross-sectional study in the UK. Antibiotics 2018;7:10.  Back to cited text no. 23
    
24.
Saam M, Huttner B, Harbarth S. Evaluation of antibiotic campaigns. World Health Organization Expert Committee on the selection and use of essential medicines [Internet]. No date. Available at http://www.who.int/selection_medicines/committees/expert/21/applications/s6_antibiotic_awareness_campaigns.pdf. [Last accessed on April 20, 2018].  Back to cited text no. 24
    
25.
Lee C-R., Cho IH, Jeong BC, Lee SH. Strategies to minimize antibiotic resistance. Int J Environ Res Public Health 2013;10:4274-305.  Back to cited text no. 25
    
26.
Mölstad S, Löfmark S, Carlin K, Erntell M, Aspevall O, Blad L et al. Lessons learnt during 20 years of the Swedish strategic programme against antibiotic resistance. Bull World Health Org 2017;95:764-73.  Back to cited text no. 26
    


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    Tables

  [Table 1], [Table 2], [Table 3]



 

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