Project – Assessment of Knowledge, Attitudes and Preventive Practices Regarding Antimicrobial Resistance among Households in Urban Communities.

CHAPTER ONE

INTRODUCTION

1.1 Background of the Study

Antimicrobial resistance (AMR) has emerged as one of the most important public health challenges confronting the world. Antimicrobial medicines, including antibiotics, antifungals, antivirals and antiparasitic medicines, are essential for the prevention and treatment of infectious diseases. However, microorganisms can develop mechanisms that enable them to survive exposure to medicines that would previously have been effective against them. When this occurs, infections become more difficult to treat and may result in prolonged illness, increased healthcare expenditure, treatment failure, disability and death. The World Health Organization (WHO) identifies AMR as a major global health threat and emphasises that misuse and overuse of antimicrobials are among the major factors driving the emergence and spread of resistance (World Health Organization [WHO], 2026).

AMR is not a problem restricted to hospitals or healthcare professionals. It is increasingly recognised as a community-wide public health problem involving households, patients, healthcare providers, pharmacies, food systems, animals and the environment. The way individuals and households obtain, use, store and dispose of antimicrobial medicines can influence the development and spread of resistant organisms. Consequently, public knowledge, attitudes and everyday preventive practices are important components of efforts to contain AMR.

The seriousness of AMR is reflected in its global health burden. The WHO reports that bacterial AMR was associated with more than 4.7 million deaths globally in 2021. It also reports that approximately one in six laboratory-confirmed bacterial infections worldwide was resistant to antibiotics in 2023 (WHO, 2026). These figures demonstrate that antimicrobial resistance is no longer a distant or theoretical threat. It affects the ability of health systems to treat common infections and threatens the effectiveness of important medical interventions, including surgery, cancer treatment and other procedures that depend on effective antimicrobial therapy.

The consequences of AMR extend beyond individual patients. Resistant infections can require more expensive medicines, longer hospital stays, additional laboratory investigations and more intensive care. At the household level, this may translate into increased expenditure on healthcare, loss of income due to prolonged illness, disruption of family responsibilities and increased risk of complications. At the health-system level, AMR increases pressure on already constrained healthcare resources. The WHO therefore considers AMR both a health and socioeconomic challenge requiring coordinated action across sectors (WHO, 2023, 2026).

One of the major drivers of antimicrobial resistance is inappropriate antimicrobial use. Antimicrobials may be misused when people take them without professional advice, use the wrong medicine, use antibiotics to treat viral illnesses, take incorrect doses, discontinue treatment when symptoms improve, share medicines with relatives or friends, or retain unused medicines for future illnesses. Such behaviours may expose microorganisms to inadequate antimicrobial concentrations and contribute to the selection and transmission of resistant organisms. The problem is therefore closely connected with human behaviour and health-seeking practices.

Households are particularly important in this regard because many decisions concerning illness management take place at the household level. Family members may decide whether to seek professional healthcare, purchase medicines directly from pharmacies or patent medicine shops, use medicines previously prescribed for another illness, or rely on recommendations from relatives, friends or other informal sources. These decisions are influenced by knowledge, perceived severity of illness, financial circumstances, accessibility of healthcare services, previous treatment experiences and cultural beliefs.

Knowledge is an important component of responsible antimicrobial use. Individuals need to understand what antimicrobials are, what conditions they treat, why resistance develops and what behaviours contribute to resistance. However, knowledge alone does not necessarily produce appropriate behaviour. A person may have heard about antibiotic resistance but may still purchase antibiotics without a prescription or stop taking the medicine when symptoms disappear. Therefore, assessment of knowledge should be complemented by examination of attitudes and preventive practices.

Attitudes refer to individuals’ beliefs, perceptions and dispositions toward antimicrobial use and resistance. A positive attitude toward antimicrobial stewardship may include recognising that antibiotics should be used only when necessary, accepting professional advice, understanding that antibiotics are not effective against viral infections, and recognising the importance of completing prescribed treatment as directed. Conversely, attitudes that regard antibiotics as harmless or universally effective may encourage inappropriate use.

Preventive practices are equally important. Preventing infections reduces the need for antimicrobial medicines and consequently reduces opportunities for antimicrobial resistance to emerge. Such practices include regular hand hygiene, safe food and water practices, appropriate sanitation, vaccination, respiratory hygiene, infection prevention, seeking appropriate healthcare when necessary and using prescribed medicines responsibly. WHO’s approach to AMR increasingly emphasises prevention, appropriate antimicrobial use and a One Health perspective because resistance can emerge and circulate among humans, animals and the environment (WHO, 2024).

The relationship between public awareness and antimicrobial use has received considerable attention in recent research. Chukwu et al. (2020), in a national survey of public awareness of AMR in Nigeria, found substantial gaps in public understanding. Among 482 respondents from six Nigerian states, 56.5% reported familiarity with the term “antibiotic resistance”, but only 8.3% demonstrated good knowledge of AMR. Furthermore, 31.3% of respondents who had used antibiotics in the preceding six months had obtained them without a prescription, while 26.1% believed that antibiotics did not need to be completed once the individual felt better. The researchers concluded that poor understanding of AMR and inappropriate antibiotic use remained important concerns among the Nigerian public.

The findings of Chukwu et al. (2020) are particularly important because they demonstrate a gap between awareness and actual knowledge. Merely hearing the term “antibiotic resistance” does not mean that individuals understand the causes, consequences and preventive measures associated with resistance. The study also found that respondents living in urban areas had higher knowledge scores than rural respondents, although the difference was not statistically significant. This suggests that urban residence alone does not guarantee adequate knowledge or appropriate antimicrobial practices.

More recent Nigerian evidence reinforces concerns about inappropriate antibiotic use within communities. Isah et al. (2023) assessed public knowledge and attitudes toward antibiotic use and resistance among 964 clients attending selected community pharmacies in Lagos and Abuja. Their findings revealed important misconceptions about antibiotics; for example, some respondents incorrectly identified non-antibiotic medicines as antibiotics, while many expressed beliefs inconsistent with appropriate antibiotic use. The study also found that urban residence was associated with knowledge and attitudes toward antibiotics. The researchers recommended stronger public education and antimicrobial stewardship programmes within community pharmacy settings.

Similarly, Akande-Sholabi and Oyesiji (2023) examined antimicrobial stewardship knowledge, perceptions and factors associated with antibiotic misuse among consumers visiting community pharmacies in southwestern Nigeria. Their work demonstrates that antibiotic misuse among members of the public is influenced by several factors and that community-level antimicrobial stewardship requires interventions that address consumer knowledge and perceptions as well as medicine-use behaviours.

The importance of public attitudes is also supported by research beyond Nigeria. Ancillotti et al. (2018) found that simply informing members of the public about antibiotic resistance may not be sufficient to produce responsible antibiotic-use behaviour. Public beliefs, perceptions of personal responsibility and social expectations can influence whether people use antibiotics appropriately. This reinforces the need for interventions that address not only what people know but also how they perceive antimicrobial medicines and their own responsibility in preventing resistance.

Public awareness interventions can nevertheless play an important role. Gilham et al. (2024), in a rapid systematic review of global AMR awareness campaigns, examined interventions intended to improve public awareness and antimicrobial-use behaviours. Their review highlights the importance of public communication and awareness interventions as components of wider antimicrobial stewardship efforts.

The Nigerian situation is especially significant because of the country’s large population, infectious disease burden, medicine-use patterns and challenges relating to access to healthcare. Nigeria has therefore developed national policy responses to AMR. The country’s first National Action Plan for Antimicrobial Resistance covered 2017–2022 and provided a framework for coordinated action against AMR. Following this initial plan, Nigeria launched the Second One Health National Action Plan for Antimicrobial Resistance (2024–2028). The plan reflects a One Health approach, recognising the interconnectedness of human, animal and environmental health in the prevention and control of antimicrobial resistance (Federal Government of Nigeria, 2024).

The launch of the second national action plan demonstrates that AMR has become a national policy priority. Nigeria’s strategy recognises that effective control requires not only surveillance and antimicrobial stewardship within healthcare facilities but also public engagement and behavioural change. This is particularly important because households are active participants in the antimicrobial-use chain. A national policy may provide appropriate guidelines, but its effectiveness can be weakened if individuals continue to obtain antibiotics without appropriate advice, use medicines incorrectly or fail to practise basic infection prevention.

The need for community-focused AMR research is further demonstrated by Nigeria’s recent efforts to strengthen national AMR surveillance. In December 2025, Nigeria launched its first nationally representative AMR survey, with technical support from WHO and other partners. The initiative was designed to generate evidence to guide policy, improve patient outcomes and strengthen the health system’s response to AMR. The development of national surveillance is important, but surveillance of resistant organisms must be complemented by research into the knowledge, attitudes and practices that contribute to antimicrobial use at community level.

Cross River State provides an important setting for such investigation. The state contains urban communities where people have access to different sources of medicines and healthcare services. Urban residents may obtain health information through healthcare workers, pharmacies, social media, family networks and other sources. At the same time, urban communities may experience challenges such as overcrowding, informal medicine use, self-medication, inadequate health information and varying levels of access to qualified healthcare professionals.

Evidence from Cross River State shows that AMR is a relevant local health concern. A 2026 cross-sectional study among healthcare workers in Cross River State assessed knowledge, perceptions and practices relating to antimicrobial use and resistance. Although many healthcare workers demonstrated good knowledge and perceptions, the study identified gaps in antimicrobial prescribing and guideline adherence. Notably, 54.3% of respondents acknowledged prescribing antibiotics outside recommended guidelines, with patient pressure and medicine availability identified among the factors influencing practice (Otu et al., 2026).

The relevance of this finding to household research is that antimicrobial resistance involves interactions between healthcare providers and medicine users. Patients may request antibiotics, pressure providers for particular medicines or seek antibiotics from alternative sources. Conversely, healthcare providers influence prescribing and counselling. Therefore, understanding AMR among healthcare workers without examining the households that consume antimicrobial medicines would provide only part of the picture.

Calabar Municipality is particularly relevant because it represents an urban environment where households interact with multiple healthcare and medicine-distribution channels. The municipality includes diverse communities with differences in socioeconomic conditions, educational backgrounds, health information exposure and access to healthcare. These differences may influence knowledge of AMR, attitudes toward antimicrobial medicines and preventive practices.

Households in urban communities may face a paradox. On one hand, urban residents may have greater access to hospitals, pharmacies, health information, educational institutions and digital communication. On the other hand, greater access to medicines may also facilitate self-medication and inappropriate antimicrobial use when medicines are obtained without adequate professional guidance. Isah et al. (2023) found that urban residence was associated with antibiotic knowledge and attitudes among community pharmacy clients, illustrating that urban context can influence antimicrobial-related behaviour but does not automatically ensure appropriate practices.

The concept of preventive practice is particularly important in the context of AMR. Prevention is generally more sustainable than relying solely on antimicrobial treatment after infection has occurred. Handwashing, environmental sanitation, food hygiene, safe water, vaccination and appropriate infection prevention can reduce the incidence and spread of infections. When fewer infections occur, there is less need for antimicrobial treatment and therefore fewer opportunities for inappropriate antimicrobial exposure.

Household practices concerning medicines are also important. Unused antibiotics should not be casually stored and later used for another illness because the medicine may be inappropriate for the new condition, may have been stored incorrectly or may be insufficient to complete an appropriate course. Similarly, sharing antibiotics among household members may expose individuals to unsuitable medicines and dosages. Appropriate disposal of unused medicines is also relevant because pharmaceutical residues can enter the environment and contribute to antimicrobial resistance.

The One Health perspective provides a useful framework for understanding these relationships. AMR is not generated exclusively within hospitals. Resistant microorganisms and antimicrobial residues can move among humans, animals, food systems and the environment. Household behaviours may therefore interact with broader environmental and community processes. For example, poor sanitation, inappropriate disposal of medicines and inadequate infection-control practices can create conditions that facilitate the persistence and transmission of resistant organisms.

The WHO has emphasised that AMR research should address the epidemiology, drivers and prevention of resistance, particularly in low- and middle-income countries where health systems may have fewer resources to respond to resistant infections (WHO, 2023, 2024). This makes community-level research in Nigeria particularly valuable because local evidence can help health authorities design interventions that are appropriate for specific populations.

Despite the growing recognition of AMR, there remains an important evidence gap concerning household-level knowledge, attitudes and preventive practices in specific urban communities of Cross River State. Existing Nigerian studies have provided useful national and regional evidence, but much of the available research has focused on healthcare professionals, pharmacy clients or general populations across multiple states. For example, Chukwu et al. (2020) provided valuable national evidence but sampled respondents from only six states and did not specifically focus on households in Calabar Municipality. Similarly, recent research in Cross River State has focused on healthcare workers rather than household members.

This creates a need for a context-specific assessment among households in selected urban communities of Calabar Municipality. Such an assessment can establish what household members know about AMR, how they perceive the problem, the extent to which they engage in preventive practices, and the relationship among these dimensions. The findings may help identify misconceptions, risky behaviours and areas requiring targeted health education.

Therefore, this study is designed to assess the knowledge, attitudes and preventive practices regarding antimicrobial resistance among households in selected urban communities in Calabar Municipality, Cross River State. By generating local evidence, the study is expected to contribute to the development of more targeted community health education, antimicrobial stewardship and infection-prevention interventions.

1.2 Statement of the Problem

Antimicrobial resistance represents a serious and growing threat to public health because it reduces the effectiveness of medicines used to treat infectious diseases. When microorganisms become resistant, infections that were previously manageable may become more difficult and expensive to treat. Resistant infections may lead to prolonged illness, hospitalisation, treatment failure and death. Globally, bacterial AMR was associated with more than 4.7 million deaths in 2021, while approximately one in six laboratory-confirmed bacterial infections was resistant to antibiotics in 2023 (WHO, 2026).

Although antimicrobial resistance has traditionally been regarded as primarily a clinical or hospital problem, evidence increasingly shows that households and communities play a critical role in its emergence and spread. Individuals make decisions about when to seek healthcare, where to obtain medicines, whether to use antibiotics, whether to follow prescribed instructions and whether to practise infection-prevention measures. Consequently, inappropriate household practices can undermine professional antimicrobial stewardship efforts.

The problem is particularly concerning where antibiotics can be obtained or used without adequate professional guidance. In Nigeria, evidence from a national public-awareness survey showed that 31.3% of respondents who had taken antibiotics within the previous six months had done so without a prescription. The same study found that only 8.3% of respondents demonstrated good knowledge of AMR, despite more than half reporting familiarity with the term “antibiotic resistance” (Chukwu et al., 2020). These findings suggest that public awareness does not necessarily translate into sufficient understanding or responsible antimicrobial use.

There are also concerns about misconceptions surrounding antibiotics. A community pharmacy-based study involving 964 respondents in Lagos and Abuja identified substantial misunderstandings concerning which medicines are antibiotics and found attitudes inconsistent with responsible antibiotic use (Isah et al., 2023). Such misconceptions can contribute to inappropriate medicine use and may increase the risk of antimicrobial resistance.

The problem extends beyond knowledge. Individuals may know that AMR is dangerous but still engage in risky behaviours. People may stop taking antibiotics when symptoms improve, use medicines left over from previous illnesses, share medicines with family members, purchase antibiotics without prescriptions or use antibiotics for illnesses that do not require them. Attitudes concerning the perceived effectiveness, safety and accessibility of antibiotics may influence these practices. Therefore, examining knowledge alone cannot provide a complete understanding of household behaviour regarding AMR.

Preventive practices also require attention. If households consistently practise good hygiene, sanitation, vaccination and appropriate infection-prevention behaviours, the frequency of infections may be reduced and the need for antimicrobial treatment may decline. However, poor preventive practices can increase infection transmission and subsequently increase antimicrobial consumption. Thus, a comprehensive community response to AMR should examine both antimicrobial-use behaviours and broader infection-prevention practices.

The Nigerian government has responded to the AMR challenge through national policy. Nigeria launched its Second One Health National Action Plan for Antimicrobial Resistance covering 2024–2028, demonstrating national commitment to addressing AMR through coordinated human, animal and environmental health interventions. However, national policies and action plans require community-level awareness and behavioural change to achieve sustainable impact.

There is also a local evidence problem. In Cross River State, recent research among healthcare workers found relatively good knowledge and perceptions of AMR but identified important gaps in antimicrobial practices, including non-adherence to prescribing guidelines and the influence of patient pressure (Otu et al., 2026). This demonstrates that AMR-related behavioural challenges exist within the state. However, evidence concerning the knowledge, attitudes and preventive practices of household members in urban communities of Calabar Municipality remains limited.

The absence of sufficient household-level evidence presents a practical problem for public health planning. Without knowing what households understand about AMR, how they perceive their responsibility for preventing resistance and what preventive behaviours they actually practise, health educators and public health authorities may find it difficult to design interventions that address the specific needs of the population. General AMR campaigns may fail to correct locally prevalent misconceptions or address the specific barriers that influence household practices.

Furthermore, urban communities may possess distinctive characteristics that justify specific investigation. Urban households may have relatively greater access to healthcare facilities, pharmacies, medicine vendors, educational institutions and digital information platforms. However, such access may have both positive and negative consequences. Greater access to health information can improve awareness, while easy access to medicines may facilitate self-medication and inappropriate antibiotic use. The findings of Isah et al. (2023), which identified urban residence as a predictor of knowledge and attitudes among community pharmacy clients, reinforce the importance of examining the urban context.

Another concern is the possible gap between knowledge, attitude and practice. A household may possess adequate knowledge of AMR but have poor preventive practices because of cost, convenience, cultural beliefs, previous experiences or limited access to healthcare. Conversely, some households may practise appropriate preventive behaviours without fully understanding the scientific basis of AMR. Identifying these relationships is important because interventions based exclusively on information provision may be insufficient if behavioural and structural barriers remain unaddressed.

Therefore, the central problem of this study is the limited context-specific empirical evidence on the knowledge, attitudes and preventive practices regarding antimicrobial resistance among households in selected urban communities of Calabar Municipality, Cross River State. It is not sufficiently established whether household members possess adequate knowledge of AMR, whether their attitudes support responsible antimicrobial use and resistance prevention, or whether they consistently practise behaviours capable of reducing the emergence and spread of resistant organisms.

The study consequently seeks to provide empirical evidence on the knowledge, attitudes and preventive practices of households regarding antimicrobial resistance in selected urban communities of Calabar Municipality. The findings are expected to provide a basis for targeted community health education, antimicrobial stewardship initiatives and preventive interventions within the municipality.

1.3 Purpose of the Study

The general purpose of this study is to assess the knowledge, attitudes and preventive practices regarding antimicrobial resistance among households in selected urban communities in Calabar Municipality, Cross River State.

Specifically, the study seeks to:

1. assess the level of knowledge of antimicrobial resistance among household members in selected urban communities of Calabar Municipality;
2. determine the attitudes of household members toward antimicrobial resistance and responsible antimicrobial use;
3. assess the preventive practices adopted by households to reduce the emergence and spread of antimicrobial resistance;
4. determine the relationship between knowledge of antimicrobial resistance and preventive practices among households;

1.4 Research Questions

The following research questions will guide the study:

1. What is the level of knowledge of antimicrobial resistance among households in selected urban communities of Calabar Municipality?
2. What are the attitudes of household members toward antimicrobial resistance and responsible antimicrobial use?
3. What preventive practices do households adopt to reduce antimicrobial resistance?
4. Is there a relationship between knowledge of antimicrobial resistance and preventive practices among households?

1.5 Research Hypothesis

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

H₀: There is no statistically significant relationship between knowledge of antimicrobial resistance and preventive practices among households in selected urban communities of Calabar Municipality, Cross River State.

1.6 Significance of the Study

The study will be significant to households, community health practitioners, public health authorities, healthcare providers, policymakers, researchers and the wider community.

Households: The findings may increase awareness of the causes, consequences and prevention of AMR. The study may help households understand the risks associated with self-medication, inappropriate antibiotic use, incomplete treatment and sharing of antimicrobial medicines.

Community Health Practitioners: Community health workers and other public health professionals may use the findings to develop targeted health education programmes addressing specific misconceptions and risky practices identified among households.

Public Health Authorities: The findings may provide useful local evidence for designing community-level antimicrobial resistance interventions in Calabar Municipality. Such evidence may support awareness campaigns, community mobilisation, health promotion and infection-prevention activities.

Healthcare Providers: Doctors, nurses, pharmacists and other healthcare workers may gain a better understanding of community perceptions and behaviours concerning antimicrobial use. This may improve patient counselling and communication concerning responsible antimicrobial use.

Government and Policymakers: The study may provide evidence relevant to implementation of Nigeria’s Second One Health National Action Plan for AMR (2024–2028), particularly with respect to public awareness, community engagement and behavioural change.

Community Leaders: Religious leaders, traditional leaders, youth organisations, women’s groups and other community stakeholders may use the findings to support community education and mobilisation activities.

Researchers: The study will contribute to the growing literature on AMR knowledge, attitudes and practices in Nigeria. It may also serve as a reference for future studies examining AMR in other communities of Cross River State and other Nigerian urban settings.

Healthcare System: Improved household knowledge and preventive practices could contribute indirectly to reduced inappropriate antimicrobial use, fewer preventable infections and reduced pressure on healthcare facilities.

1.7 Scope of the Study

The study focuses on the assessment of knowledge, attitudes and preventive practices regarding antimicrobial resistance among households in selected urban communities in Calabar Municipality, Cross River State.

Geographically, the study is restricted to selected urban communities within Calabar Municipality, Cross River State.

The study focuses on three major dimensions:

1. Knowledge of AMR, including understanding of antimicrobial resistance, causes, consequences, appropriate antimicrobial use and factors that promote resistance;
2. Attitudes toward AMR, including perceptions concerning antibiotic effectiveness, self-medication, prescription requirements, treatment completion, responsibility for preventing AMR and willingness to adopt responsible antimicrobial-use behaviours; and
3. Preventive practices, including appropriate healthcare-seeking behaviour, responsible use of prescribed antimicrobials, avoidance of unnecessary antibiotic use, hand hygiene, sanitation, vaccination, infection prevention, safe medicine storage and disposal practices.

The study will focus on adult household members who are able to provide information about health and medicine-use practices within their households. It will not attempt to conduct laboratory testing of antimicrobial-resistant organisms. Rather, the study is concerned with self-reported knowledge, attitudes and preventive practices.

1.8 Operational Definition of Terms

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

Antimicrobial Resistance (AMR): The ability of microorganisms to survive or continue multiplying despite exposure to antimicrobial medicines that would ordinarily be effective against them.

Antimicrobial Stewardship: Coordinated actions designed to promote appropriate use of antimicrobial medicines, improve patient outcomes and reduce the emergence and spread of antimicrobial resistance.

Attitude: The beliefs, perceptions, feelings and dispositions of household members toward antimicrobial resistance, antimicrobial use and preventive behaviours.

Community: A defined geographical area in which people live and interact and share certain social, environmental and institutional characteristics.

Household: A person or group of persons living together and sharing arrangements for food, residence or other household responsibilities, whether or not they are related by blood.

Knowledge: The information and understanding possessed by household members concerning antimicrobial resistance, its causes, consequences, prevention and responsible antimicrobial use.

Preventive Practices: Actions undertaken by individuals or households to prevent infections and reduce inappropriate antimicrobial use and the emergence or spread of antimicrobial resistance.

Self-Medication: The use of medicines by an individual without appropriate consultation with a qualified healthcare professional for the condition being treated.

Urban Community: A geographically defined settlement within Calabar Municipality characterised by relatively high population concentration and access to urban infrastructure, services and institutions.

1.9 Organisation of the Study

The study will be organised into five chapters.

Chapter One presents the introduction, background of 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 conceptual, theoretical and empirical literature relating to antimicrobial resistance, knowledge, attitudes, antimicrobial-use behaviours, preventive practices and community-level AMR prevention. The chapter will also present the theoretical and conceptual frameworks guiding the study.

Chapter Three will describe the methodology of the study, including the research design, study area, population of the study, sample size, sampling technique, instrument for data collection, validity and reliability of the instrument, method of data collection and methods of data analysis.

Chapter Four will present, analyse and interpret the data collected from respondents. The research questions will be answered and the hypothesis will be tested at the 0.05 level of significance.

Chapter Five will present the summary of findings, conclusion, recommendations and suggestions for further studies.

Project – Assessment of Knowledge, Attitudes and Preventive Practices Regarding Antimicrobial Resistance among Households in Urban Communities.