Project – Assessment of Community Awareness and Preventive Practices Regarding Antimicrobial Resistance among Households in Selected Communities in Bekwarra

CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

Antimicrobial resistance (AMR) has emerged as one of the most significant public health challenges confronting populations across the world. Antimicrobial medicines, including antibiotics, antifungals, antivirals and antiparasitic medicines, have transformed the management of infectious diseases and have made many previously life-threatening conditions treatable. However, microorganisms can develop resistance to medicines designed to eliminate or control them. The World Health Organization (WHO) defines antimicrobial resistance as a situation in which microorganisms such as bacteria, viruses, fungi and parasites no longer respond adequately to antimicrobial medicines, making infections more difficult or sometimes impossible to treat (World Health Organization [WHO], 2024).

AMR is not merely a problem within hospitals or laboratories; it is also a community and household health problem. The use and misuse of antimicrobial medicines by individuals and households contribute to the selection and spread of resistant microorganisms. Behaviours such as taking antibiotics without professional advice, using antibiotics for illnesses that do not require them, purchasing incomplete courses of medication, sharing medicines with relatives, keeping leftover antibiotics for future illnesses and failing to use medicines according to professional instructions can contribute to antimicrobial resistance. WHO emphasises that controlling AMR requires behavioural change because inappropriate antimicrobial use occurs both within healthcare settings and in the wider community (WHO, 2024).

The magnitude of AMR demonstrates why community-level prevention is essential. The Global Burden of Disease analysis estimated that bacterial AMR was associated with approximately 4.95 million deaths globally in 2019, including about 1.27 million deaths directly attributable to bacterial AMR (Antimicrobial Resistance Collaborators, 2022). The analysis covered 204 countries and territories and 23 bacterial pathogens and demonstrated that AMR represents a substantial burden across different regions of the world. Lower respiratory infections accounted for more than 1.5 million deaths associated with resistance, while Escherichia coli, Staphylococcus aureus, Klebsiella pneumoniae, Streptococcus pneumoniae, Acinetobacter baumannii and Pseudomonas aeruginosa were among the major pathogens contributing to the burden (Antimicrobial Resistance Collaborators, 2022).

The significance of AMR extends beyond mortality. Resistant infections can result in prolonged illness, treatment failure, increased healthcare expenditure, longer hospital stays and increased pressure on health systems. They may also complicate routine medical procedures such as surgery, caesarean delivery, cancer treatment and management of chronic diseases because these procedures often depend on effective antimicrobial medicines. The global AMR burden is therefore a threat not only to infectious-disease management but also to the broader functioning of modern healthcare.

The problem is particularly important in low- and middle-income countries, where infectious diseases remain common and access to diagnostic services, qualified healthcare professionals and effective antimicrobial stewardship may be limited. Communities may experience barriers such as cost of healthcare, distance to health facilities, long waiting times, inadequate health information and limited access to laboratory testing. Under such circumstances, households may resort to informal sources of healthcare, including patent medicine vendors, community pharmacies, previous prescriptions, friends and relatives, or medicines kept at home. These practices can increase the possibility of inappropriate antimicrobial use.

Community awareness is therefore an important component of AMR prevention. Awareness involves more than simply having heard the expression “antimicrobial resistance.” It includes understanding what antimicrobial resistance means, recognising that microorganisms—not human bodies—develop resistance, knowing that antibiotics are ineffective against viral infections such as most common colds, understanding the dangers of unnecessary antimicrobial use, recognising the importance of appropriate dosing and duration, and knowing that infection prevention measures can reduce the need for antimicrobial treatment. WHO has repeatedly identified awareness, education and behaviour change as essential components of AMR control.

The distinction between knowledge and actual preventive practice is especially important. A person may know that misuse of antibiotics can produce resistance but may nevertheless purchase antibiotics without a prescription when a family member develops symptoms. Similarly, a household may understand the importance of completing a prescribed course but may stop treatment when symptoms improve or save remaining medication for another occasion. Consequently, assessing awareness without examining actual practices may provide an incomplete picture of the community’s vulnerability to AMR.

Preventive practices against AMR include several behaviours at the household and community levels. These include using antimicrobials only when appropriately prescribed or recommended by qualified healthcare professionals, taking medicines at the recommended dose and duration, avoiding sharing antimicrobial medicines, not using leftover medicines, obtaining appropriate diagnosis where required, practising hand hygiene, maintaining safe food and water practices, receiving recommended vaccinations, and seeking appropriate medical care when illness occurs. Such practices reduce unnecessary antimicrobial exposure and can also reduce the incidence and transmission of infections.

The One Health concept has further expanded understanding of AMR. Antimicrobial resistance does not arise exclusively from human medicine. Resistant microorganisms and resistance genes can move among humans, animals, food systems and the environment. Antimicrobials are used in human healthcare, veterinary medicine, animal production and other sectors, meaning that effective AMR control requires coordinated action across these sectors. WHO and other international health agencies therefore promote a One Health approach that recognises the interconnectedness of human, animal and environmental health. Nigeria’s current National Action Plan 2.0 for AMR similarly adopts a One Health approach and identifies improved AMR awareness, education, understanding and behaviour change as one of its strategic objectives.

Households occupy a critical position within this One Health response. Household members make everyday decisions concerning illness, medicine purchasing, storage and administration. Parents and caregivers may decide which medicines to give children; adults may determine whether to seek professional care or self-medicate; and household members may share medications or recommendations based on previous experiences. These decisions can affect antimicrobial consumption and consequently influence the development and spread of resistance.

In Nigeria, the challenge of inappropriate antibiotic use is well documented. A large cross-sectional study involving 8,370 respondents across several Nigerian states found substantial gaps in community knowledge and practices concerning antibiotic use and antimicrobial resistance. The study reported misconceptions concerning the conditions for which antibiotics should be used and identified premature discontinuation of antibiotic treatment among some participants (Adda et al., 2023). These findings demonstrate that community knowledge and behaviour remain important areas for intervention.

Evidence from Lagos State also indicates that antibiotic use among community residents requires attention. Abiola et al. assessed knowledge, attitudes and practices concerning antibiotic use among residents of Ikeja Local Government Area and highlighted the public-health importance of inappropriate antibiotic use in the community. Their study was based on the recognition that many antibiotic-resistant pathogens are community-acquired and that public education has an important role in reducing behaviours that contribute to resistance (Abiola et al., n.d.).

The Nigerian government has responded to the growing AMR threat through national policy. Nigeria’s One Health Antimicrobial Resistance National Action Plan 2.0 (2024–2028) identifies six strategic objectives, including strengthening AMR governance, improving AMR awareness and behaviour change, strengthening surveillance and research, improving infection prevention and control and vaccination, optimising access to and use of quality antimicrobials, and building capacity for innovation and research. The plan explicitly recognises community engagement and behaviour change as necessary elements of Nigeria’s AMR response.

This policy direction demonstrates that AMR prevention cannot be left entirely to hospitals, physicians, pharmacists or government agencies. The behaviour of community members and households is an essential part of the response. The WHO similarly states that awareness-raising campaigns, education and training are intended to replace behaviours that contribute to AMR with behaviours that help prevent its emergence and spread.

The issue is particularly relevant in Cross River State. A recent study by Otu et al. (2025) assessed knowledge and perceptions of community members concerning antimicrobial use and resistance in Cross River State, Nigeria. The study noted that Nigeria has a substantial AMR burden and that public awareness and responsible antimicrobial practices remain suboptimal. The authors specifically identified the need for interventions that improve community knowledge and support responsible antimicrobial practices.

The relevance of the Cross River evidence to the present study is substantial because Bekwarra is a Local Government Area in Cross River State. However, evidence obtained from the state as a whole cannot automatically be assumed to describe the situation in Bekwarra. Communities differ in socioeconomic characteristics, educational attainment, healthcare accessibility, cultural practices, medicine-use patterns and exposure to health information. Consequently, there is a need for local-level assessment of awareness and preventive practices.

Bekwarra communities include households with different levels of formal education, economic circumstances and access to healthcare services. In such settings, decisions about medicines may be influenced by previous illness experiences, recommendations from relatives and friends, availability of medicines, perceived severity of illness, cost of professional consultation and accessibility of healthcare facilities. These factors can shape antimicrobial practices independently of formal health education.

The household is particularly important because health decisions frequently begin at home. When an individual develops fever, cough, diarrhoea, skin infections or other symptoms, family members may decide whether the person should visit a health facility, purchase medicine directly, use medicine previously prescribed for a similar condition or try a traditional remedy. If antibiotics are readily available without appropriate diagnosis, households may mistakenly use them for conditions that do not require antimicrobial therapy. Such behaviour can increase unnecessary antimicrobial exposure and contribute to resistance.

Another concern is the persistence of misconceptions about antibiotics. Some community members may perceive antibiotics as general-purpose medicines capable of treating almost any illness. Others may believe that stronger or more expensive antibiotics are automatically better, or that treatment should stop as soon as symptoms disappear. Some may believe that a medicine previously effective for one person should automatically be used for another person with similar symptoms. Such beliefs may encourage inappropriate antimicrobial use.

At the same time, households may not always have adequate opportunities to receive reliable information about AMR. Health information may be provided during healthcare visits, through community health workers, schools, churches, radio, television, social media, pharmacies and public-health campaigns. However, the extent to which households in selected Bekwarra communities have received AMR information and understand its implications remains an empirical question.

The problem is also dynamic because antimicrobial resistance continues to evolve. The 2024 United Nations high-level political declaration on AMR recognised the scale of the threat and committed countries to stronger action, including efforts to reduce deaths associated with bacterial AMR by 10% by 2030 from the estimated 2019 baseline. The declaration also emphasised preventive measures, access to appropriate treatment and stronger awareness initiatives. This international commitment reinforces the importance of community-level interventions.

World AMR Awareness Week also demonstrates the importance attached to public education. WHO’s 2024 campaign used the theme “Educate. Advocate. Act now.”, emphasising that awareness and appropriate practices are necessary for reducing the emergence and spread of drug-resistant infections. The message is particularly relevant to households because community members are not passive recipients of AMR interventions; their everyday behaviours can either increase or reduce antimicrobial pressure.

It is therefore important to distinguish between awareness and preventive practices. A household may report awareness of AMR without practising responsible antimicrobial use. Conversely, some households may demonstrate appropriate practices without being familiar with the technical term “antimicrobial resistance.” An assessment that examines both dimensions can provide a more useful understanding of community vulnerability and identify specific areas requiring health education.

Furthermore, household-level preventive practices may extend beyond antimicrobial consumption. Infection prevention through handwashing, safe food handling, adequate sanitation, safe water, vaccination and appropriate management of infectious illnesses can reduce the occurrence and transmission of infections and therefore reduce the demand for antimicrobial treatment. AMR prevention is consequently connected to broader community-health practices.

Against this background, assessing awareness and preventive practices among households in selected communities in Bekwarra is important for generating local evidence. Such evidence can assist community-health practitioners, local health authorities, healthcare workers and policymakers in identifying knowledge gaps, misconceptions and risky practices. It can also support the development of targeted health-education interventions that are appropriate to the local context.

The present study therefore focuses on the assessment of community awareness and preventive practices regarding antimicrobial resistance among households in selected communities in Bekwarra. By examining what households know about AMR and how they respond to antimicrobial-related health risks, the study seeks to provide evidence that can contribute to improved community participation in Nigeria’s broader AMR-control efforts.

1.2 Statement of the Problem

Antimicrobial resistance is increasingly recognised as a major threat to effective healthcare because infections that were previously treatable with commonly available medicines may become difficult or impossible to treat. The estimated 4.95 million deaths associated with bacterial AMR globally in 2019, including 1.27 million deaths attributable directly to resistance, demonstrate the seriousness of the problem (Antimicrobial Resistance Collaborators, 2022).

Although AMR has often been discussed in relation to hospitals, laboratories and healthcare professionals, a substantial part of the problem occurs within communities. Households influence antimicrobial consumption through decisions about whether to seek professional care, whether to purchase medicines without prescriptions, whether to share medicines, whether to retain leftover medicines and whether to follow recommended treatment instructions. WHO identifies inappropriate antimicrobial use by patients and other community behaviours as important drivers of resistance and emphasises behavioural change as part of AMR control.

The problem is that community members may not possess sufficient knowledge to distinguish appropriate from inappropriate antimicrobial use. Some individuals may not understand the meaning of AMR or may believe that resistance means that a person’s body has become resistant to antibiotics. Others may not know that antibiotics are ineffective against viral infections. There may also be misconceptions that taking antibiotics whenever one develops fever, cough or other common symptoms is a good preventive measure.

Evidence from Nigeria supports concern about these knowledge gaps. Adda et al. (2023), in a large community-based study across Nigerian states, reported significant gaps in understanding antibiotic use and AMR, including misconceptions about the conditions for which antibiotics should be used and premature discontinuation of antibiotic treatment. These behaviours can increase inappropriate antimicrobial exposure and create conditions that favour resistance.

The problem is compounded by self-medication and informal access to medicines. In communities where healthcare services may be perceived as costly, inconvenient or inaccessible, households may rely on medicines previously prescribed for similar illnesses or seek recommendations from non-professional sources. A systematic-review protocol on antibiotic misuse and self-medication in Nigeria noted a consistent concern about antibiotic misuse and self-medication among Nigerian adults (Misau et al., 2022). Although self-medication may sometimes be motivated by practical considerations, inappropriate use of antibiotics can create individual and community-level risks.

Another problem is that knowledge does not necessarily translate into practice. Individuals who have heard of AMR may still engage in behaviours that increase antimicrobial resistance. They may stop treatment once symptoms improve, use antibiotics prescribed for another person, fail to complete a recommended course, or use antibiotics without adequate diagnosis. Therefore, simply measuring whether households have heard about AMR may overestimate their actual preparedness to prevent it.

The situation is particularly important in Cross River State. Otu et al. (2025) found that awareness and responsible antimicrobial practices among community members in Cross River State were suboptimal and emphasised the need for interventions to improve community knowledge and practices. More recent research has also assessed antimicrobial-use knowledge, perceptions and practices among health workers in Cross River State, demonstrating that AMR remains an important state-level health issue requiring attention across different sectors.

However, state-level findings do not necessarily reveal the specific situation among households in Bekwarra. Communities within Cross River State differ considerably in their social, cultural, economic and healthcare environments. Consequently, there is a problem of insufficient local evidence concerning what households in selected Bekwarra communities know about AMR and whether their daily practices are consistent with AMR prevention principles.

There is also concern that limited awareness may weaken the implementation of Nigeria’s AMR policies at the community level. Nigeria’s National Action Plan 2.0 (2024–2028) specifically identifies improved AMR awareness, education, understanding and behaviour change as a strategic objective and calls for community engagement as part of a One Health response. If households remain inadequately informed or continue practices that promote inappropriate antimicrobial use, national and state-level AMR-control efforts may have limited impact.

The consequences of inadequate awareness and poor preventive practices can extend beyond individual households. Inappropriate antimicrobial use can contribute to the selection of resistant microorganisms, which can spread among family members and within communities. Resistant infections can subsequently increase treatment costs, prolong illness and place additional demands on health facilities. This means that antimicrobial practices within one household can have implications for the wider community.

The problem is therefore not simply the presence of antimicrobial resistance but the possibility that community members may unknowingly contribute to its development and spread. Without reliable information about household awareness and preventive practices, it is difficult to determine the most important gaps that should be addressed through health education and community-health interventions.

It is against this background that the present study seeks to assess community awareness and preventive practices regarding antimicrobial resistance among households in selected communities in Bekwarra. The study will determine the level of awareness, identify common misconceptions and risky practices, assess preventive behaviours and examine whether awareness is significantly associated with preventive practices. The findings are expected to provide evidence for targeted community-health education and contribute to broader efforts to reduce antimicrobial misuse and AMR in Cross River State and Nigeria.

1.3 Purpose of the Study

The general purpose of this study is to assess community awareness and preventive practices regarding antimicrobial resistance among households in selected communities in Bekwarra, Cross River State.

Specifically, the study seeks to:

1. assess the level of awareness of antimicrobial resistance among households in selected communities in Bekwarra;
2. determine the sources of information about antimicrobial resistance among household members;
3. assess household knowledge of the causes, consequences and prevention of antimicrobial resistance;
4. identify common antimicrobial-use practices among households in the selected communities;

1.4 Research Questions

The following research questions will guide the study:

1. What is the level of awareness of antimicrobial resistance among households in selected communities in Bekwarra?
2. What are the major sources of information about antimicrobial resistance among households in the selected communities?
3. What do household members know about the causes, consequences and prevention of antimicrobial resistance?
4. What antimicrobial-use practices are commonly adopted by households in the selected communities?

1.5 Research Hypothesis

The following null hypothesis will be tested at the 0.05 level of significance:

H₀: There is no significant relationship between community awareness of antimicrobial resistance and preventive practices among households in selected communities in Bekwarra, Cross River State.

1.6 Significance of the Study

The study will be significant to the following groups:

Households and community members: The findings will help household members understand the importance of responsible antimicrobial use and the role of everyday preventive behaviours in reducing AMR. The study may increase awareness of the dangers of self-medication, sharing antibiotics, retaining leftover medicines and using antimicrobials without appropriate professional guidance.

Community health workers: Community health workers may use the findings to identify misconceptions and risky antimicrobial practices within the communities. This can help them design health-education messages that address actual community needs rather than relying on general assumptions.

Healthcare professionals: Nurses, doctors, pharmacists and other healthcare professionals may benefit from information about household antimicrobial-use patterns. The findings can support improved patient counselling, antimicrobial stewardship and community outreach.

Primary healthcare facilities: Healthcare facilities serving communities in Bekwarra may use the findings to strengthen health education on antimicrobial use, infection prevention, appropriate healthcare seeking and adherence to prescribed treatment.

Government and policymakers: The findings may provide local evidence for implementing Nigeria’s One Health AMR National Action Plan 2.0, particularly its objective of improving awareness, education, understanding and behaviour change.

Public-health educators: The study may assist public-health educators in developing targeted campaigns on AMR. Such campaigns can address specific misconceptions identified among households and promote practical behaviours that reduce unnecessary antimicrobial exposure.

Pharmacists and medicine vendors: The findings may highlight community practices involving the purchase and use of antimicrobials and reinforce the importance of appropriate counselling and responsible medicine dispensing.

Researchers and students: The study will contribute to the growing literature on AMR awareness and preventive practices in Nigeria. It may also serve as a reference for future studies examining antimicrobial use, community health behaviour and One Health interventions in Cross River State.

The wider community: Improved household practices can reduce unnecessary antimicrobial use and contribute to slowing the emergence and spread of resistant microorganisms. Consequently, the benefits of the study may extend beyond individual participants to the broader community.

1.7 Scope of the Study

The study is focused on the assessment of community awareness and preventive practices regarding antimicrobial resistance among households in selected communities in Bekwarra, Cross River State, Nigeria.

The study will focus on adult household members who are eligible to provide information about health and medicine-use practices within their households. It will examine awareness of the meaning of antimicrobial resistance, causes and drivers of AMR, consequences of resistance, appropriate antimicrobial use and measures for preventing AMR.

The study will also examine household practices relating to antimicrobial medicines, including obtaining medicines, self-medication, use of prescriptions, sharing medicines, use of leftover antimicrobials, adherence to prescribed instructions and seeking professional healthcare. In addition, preventive practices such as hand hygiene, safe food and water practices, vaccination and appropriate management of infections will be considered.

Geographically, the study will be restricted to selected communities within Bekwarra Local Government Area of Cross River State. The study will not cover all communities in Cross River State, and findings will therefore be interpreted within the context of the selected study communities.

1.8 Operational Definition of Terms

Antimicrobial: A medicine or agent used to prevent or treat infections caused by microorganisms, including bacteria, viruses, fungi and parasites.

Antimicrobial Resistance (AMR): The condition in which microorganisms develop the ability to survive or continue multiplying despite exposure to antimicrobial medicines that would ordinarily control or eliminate them.

Awareness: The extent to which household members have heard about, understand and can correctly identify important information concerning antimicrobial resistance, its causes, consequences and prevention.

Community Awareness: The collective level of knowledge and understanding of antimicrobial resistance among members of the communities included in the study.

Preventive Practices: Actions undertaken by household members to reduce inappropriate antimicrobial use and the development or spread of antimicrobial resistance.

Household: Persons living together in the same dwelling and sharing arrangements for daily living, with the study focusing on households within the selected Bekwarra communities.

Antimicrobial Use: The consumption, administration or application of antimicrobial medicines for the prevention or treatment of infections.

Antimicrobial Misuse: The inappropriate use of antimicrobial medicines, including unnecessary use, incorrect dosing, inappropriate duration, self-medication or use for conditions for which the medicine is not indicated.

Self-Medication: The use of medicines by an individual without appropriate consultation or prescription from a qualified healthcare professional.

Antibiotics: Antimicrobial medicines specifically used against bacterial infections. Antibiotics do not treat viral infections such as the common cold or influenza.

Health Education: The provision of relevant information and skills intended to improve individuals’ and communities’ knowledge, attitudes and practices regarding health.

Community: A group of people living within a defined geographical area and sharing social, environmental or institutional characteristics.

1.9 Organisation of the Study

The study will be organised into five chapters. Chapter One presents the introduction, background to the study, statement of the problem, purpose of the study, research questions, research hypothesis, significance of the study, scope of the study and operational definitions of terms.

Chapter Two will review relevant literature on antimicrobial resistance, community awareness, antimicrobial use, preventive practices, factors influencing antimicrobial use and empirical studies related to AMR awareness and prevention. Relevant theoretical perspectives guiding the study will also be examined.

Chapter Three will present the methodology adopted for the study. It will discuss the research design, study area, population of the study, sample size, sampling technique, instrument for data collection, validity and reliability of the instrument, procedure for data collection and methods of data analysis.

Chapter Four will present, analyse and interpret the data collected from respondents. The findings will be organised according to the research questions and hypothesis.

Chapter Five will present the summary of findings, conclusion and recommendations. Suggestions for further studies will also be provided.

Project – Assessment of Community Awareness and Preventive Practices Regarding Antimicrobial Resistance among Households in Selected Communities in Bekwarra