Understanding on antibiotics and antibiotic resistance among a group of internet users in Sri Lanka and development of a simple online educational tool

Background: Cooperation of the general public is required to successfully combat the imminent threat of antibiotic resistance (ABR). This study was conducted in two parts; 1) to assess the understanding of internet users on antibiotics and ABR and 2) to develop a simple educational tool to improve the understanding on ABR among internet users. Methods: Part 1: A web-based self-administered questionnaire was used to gather data. Open ended questions were analyzed thematically. A knowledge score was calculated from the close-ended questions. 204 responses were analyzed. Part 2: A The developed tool received favourable feedback from those who engaged with it but has room for improvement.


Introduction
Antibiotic resistance (ABR) is a global public health threat. However, its effects on developing countries are more pronounced. 1 While ABR is a natural phenomenon, inappropriate prescription of antibiotics, antibiotic misuse by patients, weak infection control in health care settings and poor hygiene and sanitation of people lead to increasing rates in emergence and spread of ABR. 2,3 Multidrug resistance and pan-drug resistance where bacteria become resistant to multiple classes of antibiotics or all available antibiotics are also increasingly recognized. 4 The general public plays a key role in preventing and minimizing the impact of ABR. 2,3,5 The general public contributes to antibiotic misuse by demanding antibiotics, over the counter purchase of antibiotics and not following prescription advice. 2,3 Antibiotics are considered a quick-fix for diseases by many who use them and this behavior is driven by lack of knowledge. 6 While knowledge does not translate 100% to behavioral changes, knowledge on antibiotics and antibiotic resistance do promote appropriate use of antibiotics. 3 It is therefore worthwhile to evaluate knowledge and practices of the public towards antibiotics, their use and ABR and to have simple tools to educate them. Social media has become very popular among the public. While used most often as a tool for social interactions, social media can be used to gather information from the public and to disseminate knowledge. 7,8 We therefore developed simple online tools for this study and disseminated them through social media.
This study was conducted in two parts.
Part 1survey of existing knowledge, attitudes and practices on antibiotics and ABR among internet savvy general public. Part 2developing of a simple educational tool addressing the common misconceptions identified through Part 1.

Part 1
A self-administered questionnaire was developed in English, pretested among a group of internet users known to the researchers with similar demographics to the expected participants, and translated into Sinhala and Tamil. Content validity was established by two experts. The tool was administered through Google Forms and disseminated via social media platforms Facebook, Twitter and WhatsApp groups. Two hundred and twenty four (224) internet users answered the questionnaire and 20 of them were excluded as they were medical officers. Answers of the remaining 204 were analyzed.
The questionnaire consisted of 29 questions in three sections, 5 for socio-demographic data, 15 questions for knowledge on antibiotics and antibiotic resistance including 5 open ended questions and another 9 questions for use of antibiotics. Of the 15 questions on knowledge, 10 were used to calculate the knowledge score.

Part 2
Part 2 of the study was designed based on the findings of part 1. A Google Form based educational tool was developed where the participants are able to answer a few questions and get feedback. This was developed in English and translated to Sinhala.
This was disseminated through the same social media platforms as part 1 for anyone interested in updating themselves on antibiotics and antibiotic resistance, from November 2019.
This tool has a few sections. The first section titled "Who are they and what do they do?" is on what micro-organisms are and what infectious diseases are. The second section titled "Bugs that we meet and do us harm" is on what a pathogen is, what an antibiotic is and on the use of antibiotics for the common cold, and the last section titled "When bugs start fighting back" is on antibiotic resistance. All questions were multiple choice in nature. At the end of each section, answers were provided for the participants to reflect upon.

Part 1
Analysis was carried out on 204 responses.
Fourteen of 204 (6.9%) participants stated that they did not know what an antibiotic was. The definitions given by the 190 (93.1%) participants who stated they knew what an antibiotic is were thematically analyzed ( Table  2.1).
Of the 169 participants who had given the names of antibiotics, 12 included drugs or substances other than antibiotics as examples. These included antiseptics with antibacterial properties such as povidone iodine and triclosan, a vaccine (anti-rabies vaccine), paracetamol, chlorpheniramine and cetirizine, domperidone, aspirin, insulin, saline, and plants (cannabis and "weniwelgeta"). 157 had stated names of antibiotics. The most frequently identified antibiotics were amoxicillin (n=106), and penicillin (n=70). Of those 32 had named both amoxicillin and penicillin. 89 participants had named additional antibiotics which included erythromycin (named by 24) co-amoxiclav (named by 20) and ciprofloxacin (named by 16). The spellings used by many were incorrect.
When asked if they had heard the term antibiotic resistance, 147 (72.1%) stated yes and 56 (27.5 %) stated no, while one person refrained from answering the question. Answers given to the open-ended question "What do you understand by the term antibiotic resistance?" were categorized into common themes and are given in Table 2.2 Ten questions were given to evaluate knowledge on antibiotics, antibiotic resistance, and antimicrobials. Each correct answer was given one mark and zero for a wrong answer. Neutral and not responded answers were taken as wrong answers.
Seven (3.4%) participants gave correct answers for all questions while 5 (2.5%) got zero total marks. The mean knowledge score out of 10 was 4.9 (SD2.4) while the median was 5 and 114 (55.9%) obtained ≥5 marks. Knowledge scores, categorized into gender, age and education levels are given in Table 3.
On individual questions, it was worth noting that over 50% thought that antibiotics can cure a cold or speed up recovery from a cold, and diarrhoea (Table 4).
Antibiotics had been taken by 86 (42.1%) participants in the 3 months preceding the questionnaire. Antibiotics were taken for respiratory tract infections by 55 participants. Prescriptions from a doctor were used by 67 participants, 18 (8.8% of total respondents) had taken on their own and one person did not give an answer. Of the 18 participants who had taken antibiotics on their own, 14 stated they chose the antibiotics, 2 stated the antibiotics were chosen by pharmacists, one stated it was chosen by a nursing officer and one person did not answer the question.
Considering good practices on antibiotic use, 85 (41.7%) participants stated they always completed the full course of antibiotics, 125 (61.3%) never used leftover antibiotics and 108 (52.9%) never volunteered to give antibiotics that were prescribed to someone else. Ninety nine (48.5%) participants had not requested for antibiotics over the counter (Table 5). However, 166 (81.8%) of the participants had done at least one wrong practice sometimes or always.

Part 2
A hundred and two participants engaged with the educational tool from November 2019 to May 2021, fifty one participants with the English version and 51 participants with the Sinhala version. Summary of the answers is given in Table 6, along with the qualitative feedback given by the participants. Of the 101 participants, 72 (70.6%) identified antibiotics as drugs that are used to treat any infection while 78 (76.8%) identified antibiotic resistance to occur when bacteria become resistant to antibiotics. At the end of the activity, 81 (79.4%) stated they found the activity helpful and 66 (64.7%) stated that the tool will help them to change their practices.

Discussion
This study was designed to evaluate knowledge and practices regarding antibiotics and antibiotic resistance among internet users in Sri Lanka and to develop a simple educational tool based on the findings of the study.
In the first part of this study, we identified that many who believed they knew what an antibiotic was, in fact did not understand the term correctly. They were asked in two instances what is meant by an antibiotic, first through an open-ended question and second in a question with a Likert scale answer. One hundred and ninety (93.1%) stated that they knew what an antibiotic was. In the open-ended question, with thematic analysis, 93 (48.9%) defined antibiotics as drugs that act against bacteria while 51 (26.8%) stated they act against micro-organisms. In the second question, 185 (90.7%) participants stated that they agreed or strongly agreed with the statement that antibiotics are active against bacteria. However, 74 (36.3%) agreed, strongly agreed or were neutral to the statement that antibiotics are active against viruses. These results indicate that the understanding about the term antibiotic was not comprehensive among the participants. While the term antibiotic is technically used to denote antibacterial agents, for a lay-person, it is not specific like the terms antivirals or antifungals. This linguistic issue may create a misunderstanding among the general public about the term, which can lead to a false belief that antibiotics are active against all micro-organisms. Tracing the origin of the term 'antibiotic', it is evident that the same confusion has been prevalent for a long time. 9 Similar to many previous studies done in Sri Lanka and elsewhere, among the general public as well as health care workers, the current study identified that many believed antibiotics are active against viruses and that they can cure or speed up recovery from a cold, or other predominantly viral infections. 10,11,12,13 Reflections on these findings led us to develop an educational tool commencing at the level of a microorganism, infectious disease and an antibiotic rather than starting at the level of antibiotic resistance. Many previous studies and tools which have been developed are aiming at the level of antibiotic resistance than at a more basic level (https://www.e-bug.eu/, http://www.imperial.ac.uk/medicine/hpru-amr/applications-and-tools/antibiotic-prescribinggame/ ).
The overall knowledge score obtained by the study participants as shown in part 1 was also poor. The proportion of participants with ≥5 marks was significantly higher among those who had or were undergoing tertiary education compared to those with only secondary education. However, the distribution of marks as compared through the Mann-Whitney U test was not significantly different between the two groups. This is an expected finding and the differences in the statistics could be due to the relatively low sample sizes. Marks were higher among those aged ≥30 years than the group who were <30 years in age. The proportion obtaining ≥5 marks, while not statistically significantly different, was higher among the older age group too. Overall knowledge on antibiotics and resistance has been almost universally found to be not satisfactory. 10,12,13,14 Given that the majority of our study participants were undergoing or had been through university education, this situation is of concern. The older group who were self-motivated to take this questionnaire are likely to be ones who are keener about the issue, as reflected in the higher knowledge score.
Thematic analysis of the open-ended question stems on antibiotic resistance (Table 2.2), of questions used for the knowledge score (Table 4) and the findings of part 2 highlights that understanding of antibiotic resistance also has room for improvement. The misconceptions on ABR ranged from antibiotics becoming ineffective, body resisting antibiotics to antibiotics resisting bacteria. This shows that overall understanding on antibiotic resistance also needs to be improved among the study participants.
Despite the low overall knowledge, 190 (93.1%) participants stated they knew what an antibiotic was and 147 (72.1%) had heard about antibiotic resistance. However, a number of them named un-related drugs as antibiotics, in addition to giving incorrect definitions of the terms 'antibiotic' and 'antibiotic resistance'. Over confidence about their knowledge of antibiotics motivates frequent use of antibiotics even for self-limiting disease. 15,16 Inappropriate antibiotic prescription for acute respiratory tract infections is a major problem 17 aggravated by self-administration of antibiotics even for mild respiratory symptom. 18 Consequently, antibiotic resistance has become a challenging issue in the Sri Lankan health sector. Self-medication of antibiotics is known to be a prevalent practice in Sri Lanka. 18 One of the commonest antibiotics listed by the study participants is amoxicillin, which is commonly used for respiratory tract infections in Sri Lanka. 17 Of our study group, most believed that antibiotic use in cold-like illnesses either cures the disease or speeds up recovery, reflecting this trend (Table 4).
In the current study, the majority (166, 81.8%) misused antibiotics at least sometimes or always. While knowledge is not always reflected in practice, lack of knowledge on antibiotics or antibiotic resistance is a probable contributory cause of such misuse. 19 However, our study also identified that prescribers need to improve their communication with patients when antibiotics are prescribed as more than half the participants (n=115:56.4%) stated they are not told of the drugs being prescribed.
While there are some existing tools aimed at improving understanding on antibiotics, it is important to tailor-make educational tools to target gaps in knowledge and understanding of the target population. 20 We therefore developed a tool aimed at the key deficits identified by part 1 of the study. Among those who used the tool, 81 (79.4%) found it helpful while a lesser percentage thought the tool will help them to change their behavior towards antibiotic use. As this was meant to be an educational tool, we did not capture the demographic details of the participants and are unable to comment if the population reached through the tool is similar to the participants of part 1 of the study. The authors hope to develop the tool to be more attractive and to incorporate cultural aspects to make it more interesting to the local community. We aim to translate it to Tamil in the near future.

Conclusion
The results of this preliminary study show that there is room for improvement in knowledge and awareness on antibiotics and antibiotic resistance among internet users in Sri Lanka. Knowledge scores indicate a significant difference in education level and age groups. Lack of awareness of antibiotic usage was highlighted in the study, showing the need for taking appropriate measures to discourage misuse of antibiotics and minimize antibiotic resistance among the Sri Lankan population. The tool developed garnered favourable feedback from those who used it so far and could be developed further as a tool to provide basic education on antibiotics and infections.