LEBANESE UNIVERSITY

Faculty of Science

Master’s in Healthcare Management, Quality & Technology

RESEARCH PROPOSAL

Prepared by: Hawraa Ibrahim

Layal Mroweh

Title:
AWARENESS AND UNDERSTANDING OF ANTIMICROBIAL RESISTANCE

HMQT 401 – Research Methodologies

Fall 2021-2022

Advisor : Dr. Jamal Charara

Contents
ACKNOWLEDGEMENT................................................................................................................................III
ABSTRACT...................................................................................................................................................IV
LIST OF SYMBOLS.......................................................................................................................................VI
LIST OF ABBREVIATIONS............................................................................................................................VII
CHAPTER ONE: INTRODUCTION...............................................................................................................VIII
1.1. Background.......................................................................................................................................VIII
1.2. Problem Statement.............................................................................................................................IX
1.4. THESIS OUTLINE...................................................................................................................................XI
CHAPTER TWO: LITERATURE REVIEW........................................................................................................XII
CHAPTER THREE: METHODOLOGY AND DESIGN......................................................................................XIV
CHAPTER FOUR: RESULTS AND DISCUSSION............................................................................................XVI
CHAPTER FIVE: CONCLUSION.................................................................................................................XVIII
CHAPTER SIX: REFERENCES.......................................................................................................................XIX
 ACKNOWLEDGEMENT

My colleagues and I would like to thank our advisor (J. Charara, Ph.D., Department of
Physics and Electronics) of the faculty of (Sciences 1) at Lebanese university for giving us this
chance to elaborate this topic within well-developed research and emphasize various aspects of
our issue which is of significant impact on our population.

I am thankful of all those whom I have had great delight to work with through this project and
through others. Such project reveals a present issue that is facing our population and to create
fresh evidence on the impacts of antibiotic-related awareness.

I would be grateful if content of research matched your wanders and questions related to the
issue and if we were able to comprehend the extent of consequences over our targeted
population.
 ABSTRACT
Global health policy's major instruments for changing public behavior and combating antibiotic
resistance are education and awareness raising. Our goal was to create fresh empirical evidence
on the implications of antibiotic-related awareness raising in a low-income country
environment, given the constraints of an awareness agenda and the paucity of social research
to support alternative approaches. We conducted an educational activity to disseminate broad
antibiotic-related messages as well as learn about people's perceptions and health behaviors.
The sampling was used to pick private and public hospitals using a systematic selection
procedure. Physicians and nurses were providing services certain hospitals at the time of the
survey. In a difference approach, we were able to analyze the activity's outputs, knowledge
results, and immediate behavioral implications using survey data. Participants' awareness and
understanding of "drug resistance" were influenced by the educational exercise, although the
effects on attitudes were small. The evidence on behavioral effects was limited and
contradictory, but one likely outcome was a disproportionate adoption of antibiotics by
professional healthcare practitioners. Our findings call into question the sustained dominance
of antibiotic resistance awareness raising as a behavioral intervention. There is a lack of
comprehensive data on the amount of AMR awareness among participants. As a result, the
purpose of this study was to determine the present level of AMR awareness and understanding.
 LIST OF SYMBOLS

%=Percent
 LIST OF ABBREVIATIONS

AMR=Antimicrobial Resistance

WHO=World Health organization

FAO=Food and Agriculture Organization

OIE=World Organization for Animal Health

AST=Antimicrobial Susceptibility Test

 CHAPTER ONE: INTRODUCTION

1.1. Background
Antimicrobial resistance (AMR) is a growing serios problem worldwide public health in
community showing up the active treatment of infectious diseases.[1] The World Health
Organization (WHO) is inducing and supporting awareness creation among health workers as
one of the plans to minimize the percentages of contingency and the carriage of AMR. [4,5] This
article was prepared to extend an up-to-date estimate of the knowledge, methods and
antibiotic prescribing behaviors. Antimicrobials have saved hundreds of millions of human and
animal lives and their discovery made crucial medical improvement.[3]However, increasing
AMR may widely decrease future antimicrobial successful effects.[7]The World Health
Organization (WHO), the Food and Agriculture Organization of the United Nations (FAO), and
the World Organization for Animal Health (OIE) admit that AMR is a serious warning to human
and animal health and influences the environment negatively, especially on treatment
outcomes such as prolonged morbidity, hospital stay and increased risk of mortality.[8,9]
Furthermore, patients suffer from drug resistant bacteria request more expensive therapy.
[12]Therefore, AMR affects financial burden and increase healthcare costs. Antimicrobial
resistance problem is competition in low-income countries because of high wide spread
presence of infection, irrational uses of antimicrobials, over-the-counter availability of
antibiotics and lack of clinical microbiology laboratories for antimicrobial susceptibility testing
and loads of antimicrobial prescriptions.[10] More than 50% of antibiotics worldwide are taken
without returning to doctors or physicians, without medical guidance and improper regulations
of antibiotics. Nurses in hospitals play an effective role in decreasing transmissions of resistant
bacteria and promoting awareness on AMR for patients and communities. [13,14] Thus,
information on physicians’ and nurses’ knowledge and belief on AMR will permit the
development of more effective interventions on containment of AMR. While the World Bank
set out bacterial susceptibility to antimicrobials as a “public good” that needs global protection.
Due to a limited variety of efficacious antimicrobials, the same products or those within the
same class are used in humans, animals, agricultural crops, and aquaculture.[5,6]This leads to
bacterial resistance by increasing setting of microbes to the same or similar antimicrobials,
complicating AMR containment.[8]Few drugs belonging to new antimicrobial classes have
recently been released and efforts to reduce antimicrobial use and limit use of new
antimicrobials reduce economic incentives for product development.[15]

Key Words: WHO, FAO, OIE, AMR

1.2. Problem Statement

The wrong use of antibiotics causes serious problems in our society and has become a global
concern for public health. For this reason, it is necessary to study and investigate the awareness
of the use of antibiotics, and also health care professionals, pharmacists, doctors and the media
should play an important role in educating people how to use drugs properly. [5,6] enhanced

The emergence and spread of AMR are further by lack of access to effective drugs, access to
antibiotics “over the counter” in some countries, the availability of substandard and falsified
products, misuse of antibiotics in food production, increased global travel, medical tourism and
trade, and the poor application of infection control measures. [1,8]

Another major cause of AMR is the release of antibiotics into the environment. This can occur
as either as a result of poor manufacturing practices, the improper disposal of unused
medication, human and animal excretion, and the inadequate disposal of human and animal
corpses.[1]In many countries, particularly in low-and middle-income countries, access to
effective antimicrobials as well as complementary technologies including vaccines and
diagnostics continues to remain a significant challenge, furthering AMR.[18]A growing list of
infections – such as pneumonia, tuberculosis, blood poisoning, gonorrhea, and foodborne
diseases – are becoming harder, and sometimes impossible, to treat as antibiotics become less
effective.[17]Where antibiotics can be bought for human or animal use without a prescription,
the emergence and spread of resistance is made worse.[19] Similarly, in countries without
standard treatment guidelines, antibiotics are often over-prescribed by health. We are heading
for a post-antibiotic era, in which common infections and minor injuries.
1.3. Objectives

Global health policy's major instruments for changing public behavior and combating antibiotic
resistance are education and awareness raising.[30] Our goal in this study was to create fresh
evidence on the impacts of antibiotic-related awareness raising in a low-income country
environment, given the constraints of an awareness agenda and the absence of social research
to support alternative approaches. [27,28] In a difference approach, survey data allowed us to
analyze the activity's outputs, knowledge outcomes, and immediate behavioral implications.
[28] Participants' awareness and understanding of "drug resistance" were influenced by the
educational exercise, although the effects on attitudes were small. [30,31] The evidence on
behavioral effects was limited and contradictory, but one likely outcome was a
disproportionate adoption of antibiotics by professionals.[32] Antibiotics have been successfully
used to treat infections for many years, making infectious disease treatment easier and
reducing morbidity and mortality [33]. Antibiotic benefits, however, may be jeopardized by the
emergence of antimicrobial resistance (AMR) in both hospital and community settings,
according to new findings [32,34]. Standard treatment has become ineffective as a result of this
new trend, complicating patient management and increasing patient morbidity and death.
[38]Antibiotic resistance is exacerbated by antibiotic abuse and overuse, as well as inadequate
infection prevention and control [37]. To combat the threat of AMR, a holistic approach will
include actions conducted at all levels of society (the general public, policymakers, health and
agriculture professionals) to prevent the impact and spread of resistance. [36] The aim of the
study to increase the awareness and knowledge, antibiotics should only be used when
prescribed by a licensed health expert. [35] The general public can play an important role by
taking steps to prevent infections and only using antibiotics when prescribed by a competent
health professional.[40] Other preventative measures include following the prescription to the
letter, never using leftover antibiotics, and never sharing medications with others. In several
low-income countries, antibiotic resistance has been documented, [39] observing the rapid
evolution of flouroquinolone-resistant Escherichia coli in such community, documenting the
emergence of a community-associated methicillin-resistant Staphylococcus aureus, and
substantial antibiotic resistance rates among common Gram-positive and Gram-negative
isolates from various clinical specimens. Antibiotic misuse by the general public has been
identified as a significant risk factor for antibiotic resistance [39].

At the moment, there is a scarcity of comprehensive data on the general public's understanding
of antimicrobial resistance at a national level, which might be used to guide the implementation
of strategic interventions to combat the spread of AMR.[40] As a result, this poll summarizes
current public understanding and prevalent behaviors in this area.[33] Therefore, this survey
provides at a glance, the current public awareness and common behaviors related to antibiotics
use within population.[35]

1.4. THESIS OUTLINE

Current limitations in the understanding and control of antimicrobial resistance (AMR) in
different countries of low income are described through a comprehensive review focusing on

 Educational Awareness
 Effective communication and Comprehensive information on the level of awareness of
AMR among participants
 Prevention of transmission of AMR

1- Research Design and methodology

 Samples and methods used to deduct the objective of this study.[16]

 A study using case reports, dose calculations, and surveys for discussion among eligible
physicians and nurses working in hospitals.[18]
 Random Cross-sectional study done in different streets of cities in low-income country
by selecting three different streets ang villages in this country.

2-Result and Discussion

 Reveal overall deficiency in the knowledge of proper antibiotic use and AMR in the
wider cities in Nigeria.
 People are inclined to purchase and use same antibiotics from previous illnesses.
 Antibiotics should only be used when prescribed by a licensed health expert.
 CHAPTER TWO: LITERATURE REVIEW
Antibiotic resistance occurs when a medication loses its capacity to effectively inhibit bacterial
growth. In the presence of therapeutic amounts of antibiotics, bacteria become ‘resistant' and
continue to grow [9]. Bacteria that proliferate even when antibiotics are present are known as
resistant bacteria.

Antibiotics are normally effective against them, but when they grow less sensitive or resistant, a
larger dosage of the same antibiotic is required to have an impact.

Antibiotic resistance can develop as a result of natural selection, in which all bacteria are given
some level of low-level resistance [3]. In fact, resistance was recorded long before antibiotics
were used to treat infections [13]. Antibiotic resistance is caused by indiscriminate use of
antibiotics.

Superbugs are microbes that are resistant to antibiotics. These are no longer only a laboratory
problem; they have evolved into a global menace that has resulted in significant death tolls and
life-threatening illnesses [28]. In volatile settings such as civil upheaval, violence, starvation, and
natural disasters, the consequences of these illnesses are further exacerbated [29]. If we do not
act against antibiotic resistance, a post-antibiotic period would result in frequent infections and
tiny injuries may result in death, according to the World Health Organization (WHO) [29].
Multidrug-resistant germs are killing more people around the world. In low-income countries,
more than 63,000 individuals die each year from hospital-acquired bacterial infections [30].
Multiple drug resistance (MDR) bacterial infections kill an estimated 25,000 patients each year
[31]. Data collection were piloted at local hospital about AMR knowledge, a total of 34-item-
questions were self-administered to survey professional profiles, knowledge and beliefs on
antimicrobial resistance. [18,24]

The questions were used to address professional profiles such as qualifications, specialty,
working hospital departments, service years, sources of information on antimicrobial
resistance, training on AMR, exposure of using antimicrobial susceptibility test (AST) results and
working in public and private hospitals.[24]

The two-way educational engagement allowed us to learn about the medicine use of the
villagers in different countries, as well as to communicate antibiotic-related concepts and
messages, but with limited results on attitudes and immediate behavioral implications. Our
method would confront challenges as a large-scale antibiotic-related awareness-raising effort.
On the one hand, our educational activity's small-group format does not lend itself to
deployment among the full village population. The incomplete dissemination of the signals
beyond the participants, on the other hand, suggested that the activity's beneficiaries would be
more privileged groups. Other methods of promoting awareness, such as hospital or media-led
information campaigns, may be able to reach out further, but they, too, may suffer from
inequitable uptake and unforeseen interpretations of messages across socio-economic strata.
Still, no matter how encouraging the awareness-raising outcomes were, the weak and/or
ambiguous link between awareness, attitudes, and behavior should lower our expectations
about antibiotic-related awareness raising to change treatment-seeking behavior. Existing
behavior may rather be driven by such factors as personal experience, advice, help from family
members and friends, despair, and/or uncertainty in an obscure and fragmented health system
[38–42]. The continued high level of antibiotic use among participants and villagers with already
“desirable” attitudes, together with widespread poverty and the generally low access to public
healthcare, even in our peri-urban setting, suggest that solutions to problematic forms of
antibiotic use do not necessarily reside in the domain of awareness raising, but rather in more
fundamental areas like access to healthcare and medicine. Our case does not render
awareness-raising activities obsolete, but it does suggest that they can, at best, be only a small
facet of AMR-related behavioral policies.
 CHAPTER THREE: METHODOLOGY AND DESIGN
Research Design and Methodology

 Method:

1-This part reveals the methods that have been utilized in this research to emphasize samples
and methods used to deduct our conclusion for this issue.[16]A study that applies case reports,
dose calculations, and surveys to emphasize what is discussed regarding this issue was
conducted among eligible physicians and nurses working in hospitals.[18]

2- Random Cross-sectional study done in different streets of cities in low-income country. This
was a cross-sectional study done using a pre-tested and validated questionnaire adapted from
the data collection tool consisted of 15 main articles, divided into three sections, targeting
information on the use of antibiotics, knowledge of antibiotics and knowledge of antibiotic
resistance.

 Samples addressed:

1-The sampling interval was used to pick five private and eight public hospitals using a
systematic selection procedure.[23] 235 physicians and 4,902 nurses were providing services in
a total of 26 hospitals (19 public and 7 private) at the time of the survey. A sample size of 411
was estimated based on a total population of 5,137 physicians and nurses. [21,22]

2- Administration to head of the household as well as to every member of the household of

different ages (17 and above) and gave consent. One household per house was recruited into
the study.

 Sample method:

Sample method used was a quantitative and qualitative one where data collection the
questions were piloted at local hospital about AMR knowledge and participants in different
cities (students, households, different aged people….). Stratified random sampling method was
used to select five streets in different low outcome countries (Nigeria. Syria and Lebanon), a
total of 34-item-questions were self-administered to survey professional profiles, knowledge
and beliefs on antimicrobial resistance. [18,24]

The questions were used to address professional profiles such as qualifications, specialty,
working hospital departments, service years, sources of information on antimicrobial
resistance, training on AMR, exposure of using antimicrobial susceptibility test (AST) results and
working in public and private hospitals.[24] Another questionnaires were administered to head
of the household as well as to every member of the household of different ages(17 and above )
and gave consent. One household per house was recruited into the study. In the event that a
household head declined consent to participate in the study, another household in the same
house was approached and in places where there is only one household per a house, the next
house was enlisted. The study was conducted within a period of six months

 Ethical considerations

Even though this research was implemented by previous researchers and our job was limited to
reviewing all the previously published articles, we are of great concern that such data was
collected following ethical. [19,24] Informing participants about aim of such studies and their
progression, and the importance of awareness about the usage of wrong antibiotics that causes
serious problems in our society and has become a global concern for public health. For this
reason, it is necessary to study and investigate this topic.

CHAPTER FOUR: RESULTS AND DISCUSSION

The systematic review observed several important features in design and methodology of
included studies that would be useful for developing a tool to determine levels of knowledge
and awareness of antibiotic use and AMR.
Setting objectives is vital to guide study design and all included studies had clear objectives
focusing on assessing levels of knowledge, awareness or attitudes and behavior related to
antibiotic use and awareness of AMR and associated factors. A qualitative and quantitative
methods were appropriate for the assessment of population knowledge about and awareness
of proper use of antibiotics under the resource constraints. It measures exposure and outcomes
at the same time and can find possible associations between exposure and outcomes [30].
A recent systematic review on public knowledge and beliefs about AMR has shown that
synthesis of qualitative and quantitative studies provided more in-depth understanding of
people’s knowledge and beliefs about AMR than using quantitative data alone [8]. In this
review, the number of quantitative studies was three times higher than qualitative studies and
mixed methods. Due to the strengths and limitations of each method, quantitative studies,
especially cross-sectional surveys, are more appropriate for population-based surveys while
qualitative methods are useful for in-depth explanation in small-scale research-based
assessments.
Although various methods can be used for sampling and recruitment, the key strengths of
household-based cross-sectional surveys is the representativeness of the population. Although
the sizes of samples are usually limited by the budget available for very large surveys, a
representative sampling frame is essential for generalization of the survey findings to the
population [32]. Inappropriate sampling frames were seen in the studies conducted in some
low-income countries (Syria and Nigeria)
Assess knowledge, attitudes and practice of antibiotic use in the population, the sampling frame
was the population in the capital city which did not therefore represent the whole population.
In the Syrian study, which aimed to provide an insight of the current knowledge and practices
regarding antibiotic use among individuals living in the Syria. We acknowledge that while
random sampling is ideal as it properly represents the population, it is time- and resource-
consuming. Stratified random sampling and cluster random sampling can be applied to
household-surveys as these methods can also achieve representativeness and reduce selection
bias. Cluster random sampling is also less costly and feasible; it is a common method used by
many studies [33].
Recruiting samples such as adult members or those who have clear understanding of the
language used in surveys is critical for ensuring high-quality responses in many surveys.
However, specific sampling methods may introduce selection biases, which should be
considered before setting inclusion and exclusion criteria.
In Nigeria, prescription monitoring is poorly conducted and prescription drugs, including,
antimicrobials are routinely sold over the counter in pharmacies and by patent proprietary
medicines vendors [14]. Consequently, there is risk of increase in antimicrobial resistance in the
country. This has been worsened by the lack of confidence in the public health sector due to
drug shortages and poor medicine accessibility. The present study adapted and utilized a
modified version of the WHO questionnaire on antimicrobial resistance. About two thirds of the
respondents (66.8%) have taken antibiotics in the last 6 months with 41.5% taking antibiotics
within a month to the survey. This result is slightly lower than 56.5% monthly consumption rate
reported among consumers patronizing pharmacies.
The findings of this study reveal overall deficiency in the knowledge of proper antibiotic use and
AMR in the wider cities in Nigeria. The very busy lifestyle and heavy commercial activities in
wide cities may have significantly contributed as barrier to awareness dissemination. Wider
cities hindered access to educational and health facilities. This goes to show that the overall
poor level of knowledge is irrespective of gender and place of abode. The result of our findings
reveals that people are inclined to purchase and use same antibiotics from previous illnesses.
Although majority of the respondents correctly identified skin/wound infection (77.2%) and
bladder infection (68.9%) as conditions treatable with antibiotics, quite a number of them also
selected headaches, body aches, pain including viral infections (cold and flu, Catarrh, Measles
and HIV), as indications for antibiotics use. This has exposed a high level of misconceptions
amongst the Nigerian public on the indications for the use of antibiotics and the need for health
workers to explain the difference between viral and bacterial infections when communicating
with patients.

CHAPTER FIVE: CONCLUSION

We developed an educational activity and deployed it, between two rounds of complete adult
population censuses. Difference-in-difference analysis of the survey data provided a detailed
picture of the activity’s outputs, outcomes, and impacts to inform awareness-centric global
AMR agendas. The two-directional educational activity enabled us to learn about the medicine
use of the participating villagers in different low -income countries, and it permitted us to share
antibiotic-related ideas and messages, albeit their outcomes on attitudes and their immediate
behavioral impacts were limited. As an antibiotic-related awareness-raising intervention at
scale, our approach would face obstacles. On the one hand, the small-group format of our
educational activity does not lend itself to deployment among an entire village population. On
the other hand, the incomplete diffusion of the messages beyond the participants suggested
that the beneficiaries of the activity would be more privileged groups. Other forms of
awareness raising, such as hospital- or mass-media-led information campaigns, may be able to
reach out further, but they, too, may suffer from inequitable uptake and unforeseen
interpretations of messages across socio-economic strata. Still, no matter how encouraging the
awareness-raising outcomes were, the weak and/or ambiguous link between awareness,
attitudes, and behavior should lower our expectations about antibiotic-related awareness
raising to change treatment-seeking behavior. Existing behavior may rather be driven by such
factors as personal experience, advice, help from family members and friends, despair, and/or
uncertainty in an obscure and fragmented health system [38–42]. The continued high level of
antibiotic use among participants and villagers with already “desirable” attitudes, together with
widespread poverty and the generally low access to public healthcare, the suggested solutions
to problematic forms of antibiotic use do not necessarily reside in the domain of awareness
raising, but rather in more fundamental areas like access to healthcare and medicine. Our case
does not render awareness-raising activities obsolete, but it does suggest that they can, at best,
be only a small facet of AMR-related behavioral policies.
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