Project – Assessment of Knowledge, Attitudes and Preventive Practices Regarding Antimicrobial Resistance among Households in Selected Communities in Bekwarra Local Government Area, Cross River State

CHAPTER ONE

INTRODUCTION

1.1 Background of the Study

Antimicrobial resistance (AMR) has emerged as one of the most important public health challenges of the twenty-first century. Antimicrobial medicines, including antibiotics, antivirals, antifungals and antiparasitic medicines, have transformed the management of infectious diseases and have contributed substantially to improvements in life expectancy and modern medical practice. However, the effectiveness of these medicines is increasingly threatened by the ability of microorganisms to survive exposure to medicines that would previously have killed them or inhibited their growth. The World Health Organization (WHO) describes antimicrobial resistance as a condition in which microorganisms change over time and no longer respond to medicines, making infections more difficult to treat and increasing the risk of disease spread, severe illness and death (World Health Organization [WHO], 2015).

The seriousness of AMR is demonstrated by its substantial global health burden. The Global Research on Antimicrobial Resistance study estimated that bacterial AMR was directly responsible for approximately 1.27 million deaths globally in 2019 and was associated with approximately 4.95 million deaths. The burden was particularly high in sub-Saharan Africa, where the estimated death rate attributable to resistance was among the highest globally (Antimicrobial Resistance Collaborators, 2022). These figures demonstrate that AMR is not merely a future threat but an existing public health problem capable of undermining the effective treatment of common infections.

Antimicrobial resistance also has implications beyond the treatment of individual infections. Effective antimicrobial medicines are essential for many aspects of contemporary healthcare, including surgery, treatment of severe infections, cancer care, transplantation and management of immunocompromised patients. When microorganisms become resistant to available medicines, treatment becomes more complicated, expensive and potentially unsuccessful. Resistant infections can result in longer periods of illness, prolonged hospitalisation, increased healthcare expenditure and greater risks of complications and death. Thus, the control of AMR is essential not only for infectious disease management but also for maintaining the safety and effectiveness of the broader health system.

The development and spread of AMR are influenced by several interconnected factors. Inappropriate use and overuse of antimicrobial medicines are among the major drivers. Other contributing factors include poor infection prevention and control, inadequate water, sanitation and hygiene, inappropriate antimicrobial use in animals and food production, environmental contamination, inadequate surveillance and limited public awareness (WHO, 2015). The WHO therefore emphasizes a multisectoral and One Health approach because antimicrobial resistance can emerge and spread across humans, animals, food systems and the environment.

The problem of AMR is particularly important in low- and middle-income countries, including Nigeria. Many communities experience challenges relating to access to qualified healthcare providers, diagnostic facilities, affordable medicines and reliable health information. In such circumstances, individuals may resort to practices such as self-medication, purchasing medicines without prescriptions, sharing medicines with relatives or friends, using leftover medicines and discontinuing treatment when symptoms improve. These behaviours may contribute to inappropriate antimicrobial exposure and consequently facilitate the development and spread of resistance.

Self-medication with antibiotics is an important behavioural dimension of the AMR problem. In a Nigerian study involving community residents and undergraduate students, Ajibola et al. (2018) examined self-medication with antibiotics alongside attitudes and knowledge regarding antibiotic resistance, demonstrating the relevance of community behaviour to antimicrobial use and resistance. Similarly, Isah et al. (2023), in a Nigerian community pharmacy-based survey, assessed public knowledge and attitudes concerning antibiotic use and resistance, highlighting the importance of understanding what members of the public know and believe about antibiotics.

Knowledge is an important component of antimicrobial-resistance prevention. Members of a community who understand that antibiotics are intended for bacterial infections, recognize that antibiotics do not treat viral illnesses, know the importance of completing prescribed treatment and understand the consequences of inappropriate antibiotic use may be more likely to engage in responsible antimicrobial practices. Conversely, misconceptions can encourage inappropriate behaviour. For example, individuals may believe that antibiotics can treat every type of fever, cough or cold, or that stronger or more expensive antibiotics are necessarily better. Such misconceptions may increase inappropriate antimicrobial consumption.

However, knowledge alone may not always translate into appropriate behaviour. Attitudes toward antimicrobial medicines can influence whether individuals seek professional medical advice, follow prescriptions, purchase antibiotics without prescriptions or stop treatment when they feel better. Consequently, examining knowledge without assessing attitudes and practices may provide an incomplete understanding of community-level antimicrobial use. A Knowledge, Attitudes and Practices (KAP) approach is therefore useful because it allows researchers to examine what people know about AMR, how they perceive the problem and how their beliefs are reflected in their everyday preventive behaviours.

At the global level, the WHO Global Action Plan on Antimicrobial Resistance established five major objectives: improving awareness and understanding of AMR through effective communication, education and training; strengthening knowledge through surveillance and research; reducing the incidence of infection; optimizing the use of antimicrobial medicines; and developing the economic case for sustainable investment in the response to AMR (WHO, 2015). These objectives recognize that public education and behavioural change are important components of AMR control.

The importance of public participation has become even more prominent in recent years. The WHO’s people-centred approach to AMR emphasizes that effective action must address the barriers individuals and communities encounter when trying to prevent, diagnose and treat infections. The approach places people and their needs at the centre of AMR interventions rather than focusing exclusively on healthcare institutions and professionals (WHO, 2023). This perspective is particularly relevant to household-level studies because many decisions concerning health-seeking, medicine purchasing, medicine storage and treatment adherence occur within households.

Nigeria has also recognized AMR as an important national health concern. The country’s response is situated within the broader global AMR framework and involves surveillance, antimicrobial stewardship, infection prevention and control, public awareness and multisectoral collaboration. Nevertheless, national strategies can only achieve their intended outcomes when they are translated into appropriate practices at community and household levels. This makes local assessment important because national averages may conceal substantial differences between states, local government areas and communities.

Recent evidence from Cross River State further demonstrates the relevance of AMR research in the state. Otu et al. (2026), in a cross-sectional study of healthcare workers in Cross River State, found that although a majority of respondents demonstrated good knowledge and positive perceptions of AMR, important gaps remained in antimicrobial-use practices. Notably, 54.3% of the healthcare workers who reported prescribing antibiotics acknowledged prescribing them in ways that did not conform to guidelines, while patient pressure and medicine availability were among the reported influences on prescribing behaviour. Although healthcare workers constitute a different population from households, this evidence demonstrates that AMR-related knowledge, perceptions and practices remain relevant issues within the Cross River State health environment.

The household is a particularly important unit for investigating antimicrobial resistance because household members are often the first decision-makers when illness occurs. Parents, caregivers and other adults may determine whether an ill person should visit a health facility, purchase medicine from a patent medicine vendor or pharmacy, use previously prescribed medicine, use a home remedy or wait for symptoms to resolve. In rural and semi-rural communities, these decisions may be influenced by household income, distance to health facilities, previous experiences with healthcare providers, availability of medicines, advice from relatives and friends, and perceptions of illness severity.

Furthermore, households may contribute to the transmission and prevention of resistant organisms through hygiene and infection-prevention practices. Hand hygiene, safe food preparation, appropriate sanitation, proper disposal of medicines and responsible use of antibiotics are all relevant to the wider AMR response. The WHO emphasizes that reducing infections through measures such as improved infection prevention and control, water, sanitation and hygiene and immunization can help reduce the need for antimicrobial medicines and thereby contribute to AMR prevention.

The challenge is particularly significant where reliable information about antimicrobial medicines is limited. People may recognize the term “antibiotic resistance” without understanding what it means or how their personal behaviours contribute to it. Others may have heard about “drug resistance” but may not recognize practices such as unnecessary antibiotic use, sharing medicines, buying antibiotics without prescriptions or failing to follow prescribed instructions as potential contributors. A community-level assessment is therefore necessary to establish whether awareness is superficial or whether it is accompanied by accurate knowledge and appropriate attitudes and practices.

Evidence from other Nigerian populations indicates that knowledge, attitudes and practices regarding antibiotics are not uniform. For example, Abubakar and Sárváry (2023) reported varying levels of knowledge, attitudes and practices among healthcare workers in Niger State, demonstrating that even among health professionals, appropriate knowledge does not necessarily guarantee optimal practices. Similarly, Davwar et al. (2023) found that Nigerian doctors demonstrated predominantly fair-to-good knowledge but that attitudes and practices were not uniformly strong, with only a small proportion classified as having good practice scores. These findings reinforce the need to examine knowledge, attitudes and actual practices as related but distinct dimensions.

The need for local evidence is especially important in Bekwarra Local Government Area of Cross River State. Communities within the Local Government Area have their own socioeconomic, cultural, healthcare-access and health-information characteristics. Findings from urban centres or other parts of Nigeria cannot automatically be assumed to represent households in Bekwarra. Without empirical evidence from the area, it may be difficult for public health practitioners and other stakeholders to determine the extent to which households understand AMR, whether they hold appropriate attitudes toward antimicrobial use and whether they engage in preventive practices.

The study therefore focuses on selected communities in Bekwarra Local Government Area, Cross River State, with the aim of assessing household knowledge, attitudes and preventive practices regarding antimicrobial resistance. By examining these three dimensions together, the study seeks to generate evidence that can support context-specific health education, antimicrobial-stewardship interventions and community-based AMR prevention strategies.

The importance of this investigation is further reinforced by the evolving global AMR agenda. The 2024 United Nations High-Level Meeting on AMR and subsequent global initiatives have emphasized the need for stronger action against antimicrobial resistance, while the WHO’s 2026 biennial report highlights continuing gaps in the implementation of national AMR action plans and the need for stronger coordinated One Health action. Thus, community-level research such as this study can contribute to the evidence base required for translating global and national AMR priorities into practical interventions at the household level.

Ultimately, antimicrobial resistance cannot be controlled solely through policies directed at hospitals, doctors, pharmacists or laboratories. Individuals and households are important participants in antimicrobial stewardship. Their knowledge, attitudes and practices can either support or undermine efforts to preserve the effectiveness of antimicrobial medicines. It is against this background that this study assesses knowledge, attitudes and preventive practices regarding antimicrobial resistance among households in selected communities in Bekwarra Local Government Area, Cross River State.

1.2 Statement of the Problem

Antimicrobial resistance is an increasingly serious public health problem because microorganisms that cause infections are becoming resistant to medicines that were previously effective. The consequences include treatment failure, prolonged illness, increased healthcare costs, longer hospital stays and avoidable deaths. Globally, bacterial AMR was estimated to have directly caused 1.27 million deaths and to have been associated with 4.95 million deaths in 2019, with particularly high mortality rates reported in sub-Saharan Africa (Antimicrobial Resistance Collaborators, 2022).

Despite the growing burden of AMR, antimicrobial medicines remain widely used in communities. Inappropriate use may occur when antibiotics are taken without professional advice, used for conditions for which they are not indicated, shared among family members, obtained without prescriptions, taken in incorrect doses or discontinued before the prescribed course is completed. These practices can create conditions that favour antimicrobial resistance and may contribute to the circulation of resistant microorganisms within communities.

A major concern is that members of the public may not fully understand the relationship between their everyday medicine-use behaviours and antimicrobial resistance. Some households may regard antibiotics as ordinary medicines for treating almost any illness, including conditions that may not require antimicrobial therapy. Misconceptions concerning the causes and treatment of common illnesses may therefore encourage unnecessary antimicrobial consumption. Where knowledge is inadequate, health messages about AMR may not result in meaningful behavioural change.

Attitudes constitute another important dimension of the problem. Some individuals may perceive antibiotics as harmless medicines that can be used whenever symptoms occur. Others may believe that stopping treatment once symptoms disappear is acceptable or that keeping unused antibiotics for future illnesses is practical. Such attitudes may influence actual behaviour and make antimicrobial stewardship difficult at community level. Evidence from Nigerian studies shows that knowledge and attitudes concerning antibiotics vary across populations, suggesting the need for population-specific assessment rather than assuming that general awareness automatically translates into appropriate use (Ajibola et al., 2018; Isah et al., 2023).

Preventive practices also remain important because AMR is not caused solely by inappropriate medicine use. Poor hand hygiene, inadequate sanitation, unsafe food handling, poor infection prevention and improper disposal of antimicrobial medicines may facilitate the spread of resistant microorganisms. The WHO therefore recommends a comprehensive response involving infection prevention, responsible antimicrobial use, surveillance, public awareness and multisectoral action (WHO, 2015, 2023).

Although AMR has received increasing global and national attention, there is insufficient community-specific evidence concerning what households in Bekwarra Local Government Area know about antimicrobial resistance, how they perceive the problem and what they actually do to prevent its occurrence and spread. Much of the available Nigerian literature has focused on healthcare professionals, students, hospital patients or residents in other geographical locations. For instance, existing Nigerian studies have examined healthcare workers and medical doctors, but their findings cannot adequately describe household behaviours in Bekwarra communities (Abubakar & Sárváry, 2023; Davwar et al., 2023).

The issue is also relevant to Cross River State, where recent research among healthcare workers has identified continuing gaps in antimicrobial-use practices despite relatively good knowledge and perceptions of AMR (Otu et al., 2026). This suggests that the presence of AMR knowledge does not automatically guarantee appropriate antimicrobial practices and highlights the importance of assessing the population beyond healthcare workers.

If households in Bekwarra have inadequate knowledge, negative attitudes or inappropriate preventive practices, the situation could undermine efforts to control AMR and increase the potential for inappropriate antimicrobial use and transmission of resistant organisms. On the other hand, if knowledge and attitudes are generally adequate but preventive practices remain poor, interventions would need to focus more strongly on behavioural change, access to appropriate healthcare and community-based antimicrobial stewardship.

The absence of reliable local evidence creates a practical problem for public health planning. Without knowing the existing level of household knowledge, attitudes and practices, health educators and other stakeholders may find it difficult to design interventions that respond to the actual needs of communities. Generic awareness campaigns may fail to address specific misconceptions or behavioural barriers experienced by households in the Local Government Area.

It is therefore necessary to empirically assess the knowledge, attitudes and preventive practices regarding antimicrobial resistance among households in selected communities in Bekwarra Local Government Area, Cross River State. The findings of this study are expected to provide evidence for strengthening community health education, promoting responsible antimicrobial use, improving preventive behaviours and supporting broader efforts to reduce the emergence and spread of antimicrobial resistance.

1.3 Purpose of the Study

The main purpose of this study is to assess the knowledge, attitudes and preventive practices regarding antimicrobial resistance among households in selected communities in Bekwarra Local Government Area, Cross River State.

Specifically, the study seeks to:

1. assess the level of knowledge of antimicrobial resistance among households in selected communities in Bekwarra Local Government Area;
2. determine the attitudes of households toward antimicrobial resistance and responsible antimicrobial use;
3. assess the preventive practices adopted by households to reduce antimicrobial resistance and the spread of resistant infections;
4. determine the relationship between household knowledge of antimicrobial resistance and their preventive practices; and

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 communities in Bekwarra Local Government Area?
2. What are the attitudes of households toward antimicrobial resistance and responsible antimicrobial use?
3. What preventive practices do households adopt to reduce antimicrobial resistance and the spread of resistant infections?
4. What relationship exists between household knowledge of antimicrobial resistance and their preventive practices?

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 knowledge of antimicrobial resistance and preventive practices regarding antimicrobial resistance among households in selected communities in Bekwarra Local Government Area, Cross River State.

1.6 Significance of the Study

This study will be significant to several groups.

Households and community members: The study will provide information on the importance of appropriate antimicrobial use and preventive behaviours. It may help community members recognize the risks associated with self-medication, inappropriate antibiotic use, sharing medicines and failure to follow professional advice.

Public health practitioners: Findings from the study may assist public health professionals in designing targeted community-based interventions. Rather than relying solely on general AMR messages, health educators may use the findings to address specific knowledge gaps, misconceptions and behavioural practices identified among households.

Healthcare providers: The findings may provide healthcare workers with information about community perceptions and practices relating to antimicrobial medicines. Such information can strengthen patient counselling and antimicrobial-stewardship activities.

Government and health authorities: Evidence generated from the study may assist relevant authorities in developing or strengthening community-level AMR awareness programmes, particularly within Cross River State. The findings may also contribute to broader implementation of Nigeria’s AMR-control efforts.

Community leaders and organisations: Traditional leaders, religious organisations, community-based organisations and other local stakeholders may use the findings to support health education and behavioural-change activities within their communities.

Researchers and students: The study will contribute to the body of literature on antimicrobial resistance in Nigeria, particularly at community and household level. It may also provide a basis for future research on antimicrobial use, self-medication, health-seeking behaviour and AMR in rural and semi-rural communities.

Public health policy: The study may contribute evidence supporting the people-centred approach to AMR advocated by WHO, which recognizes that effective AMR control must address the barriers experienced by individuals and communities when preventing and treating infections (WHO, 2023).

1.7 Scope of the Study

The study will focus on the assessment of knowledge, attitudes and preventive practices regarding antimicrobial resistance among households in selected communities in Bekwarra Local Government Area, Cross River State.

In terms of content, the study will examine household understanding of antimicrobial resistance, causes and consequences of AMR, appropriate and inappropriate antimicrobial use, attitudes toward antibiotics and other antimicrobial medicines, self-medication, adherence to prescriptions, sharing and storage of medicines, healthcare-seeking behaviour, hygiene, infection prevention, safe food practices and other preventive measures relevant to AMR.

In terms of population, the study will focus on adult household members who are sufficiently knowledgeable about health and medicine-use practices within their households.

Geographically, the study will be restricted to selected communities within Bekwarra Local Government Area of Cross River State. The findings will therefore primarily reflect the circumstances of the selected communities and should not automatically be generalized to all communities in Cross River State or Nigeria.

1.8 Operational Definition of Terms

Antimicrobial: A medicine or substance 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 growing in the presence of medicines that would ordinarily inhibit or kill them, making infections more difficult to treat.

Attitude: The beliefs, perceptions, feelings and dispositions held by household members toward antimicrobial medicines, antimicrobial resistance and preventive measures.

Community: A geographically defined group of people living within a particular locality and sharing social and environmental characteristics.

Household: A group of persons who live together and share living arrangements and may jointly make decisions concerning health and medicine use.

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

Preventive Practices: Actions undertaken by individuals or households to prevent infections and reduce the inappropriate use and spread of antimicrobial-resistant microorganisms, including appropriate hygiene, healthcare-seeking, responsible medicine use and adherence to prescribed treatment.

Self-medication: The use of medicines by an individual to treat a perceived illness without appropriate consultation or prescription from a qualified healthcare professional.

Antibiotic: An antimicrobial medicine used specifically against bacterial infections.

Antimicrobial Stewardship: Coordinated efforts to ensure that antimicrobial medicines are used appropriately, safely and effectively in order to improve treatment outcomes while reducing the development and spread of resistance.

1.9 Organization of the Study

The study will be organized into five chapters. Chapter One presents the introduction, including the background of the study, statement of the problem, purpose of the study, research questions, hypothesis, significance, scope and operational definitions. Chapter Two will review relevant literature and theoretical perspectives related to antimicrobial resistance, knowledge, attitudes and preventive practices. Chapter Three will present the research methodology, including the research design, study area, population, sample and sampling procedure, instrument for data collection, validity and reliability of the instrument, data-collection procedure and method of data analysis. Chapter Four will present and analyze the data obtained from respondents. Chapter Five will provide the summary, conclusion and recommendations based on the findings of the study.

Project – Assessment of Knowledge, Attitudes and Preventive Practices Regarding Antimicrobial Resistance among Households in Selected Communities in Bekwarra Local Government Area, Cross River State