Antibiotic resistance is a growing public health crisis that threatens the effectiveness of modern medicine and the ability to treat common infections. As bacteria evolve to withstand the effects of antibiotics, routine medical procedures and treatments for infections become increasingly challenging.1-3 The World Health Organization (WHO) has recognized antibiotic resistance as one of the greatest threats to global health, food security, and development. While this issue is widely acknowledged in the medical community, public awareness and understanding remain limited, contributing to the misuse and overuse of antibiotics, which accelerate the development of resistance.4-6

In India, antibiotic resistance is a particularly alarming concern due to the widespread availability of antibiotics without prescription, self-medication practices, and inadequate regulatory enforcement.2,3 Punjab, a state known for its advanced agricultural and healthcare sectors, faces unique challenges in combating antibiotic resistance. The easy accessibility of antibiotics, combined with a lack of awareness regarding their appropriate use, has led to their frequent misuse. Cultural perceptions, economic constraints, and limited access to healthcare professionals often result in self-prescription and incomplete treatment regimens, which further contribute to the rise of resistant bacterial strains.7-9

Despite efforts to curb antibiotic misuse through public health initiatives and policy interventions, the general population's understanding of antibiotic resistance remains fragmented. Many individuals continue to harbor misconceptions about antibiotics, such as their effectiveness in treating viral infections and the necessity of completing prescribed courses. 10-12 A lack of awareness about the consequences of improper antibiotic use leads to widespread non-compliance, fueling the resistance crisis. Understanding public perceptions and knowledge levels is crucial in shaping effective strategies to combat antibiotic resistance.13,14

This study aims to assess the level of awareness, knowledge, and perceptions of antibiotic resistance among the general public in Punjab. By identifying prevalent misconceptions and patterns of antibiotic use, the study seeks to inform future health education programs and policy interventions. Enhancing public knowledge and promoting responsible antibiotic use are essential steps toward mitigating the impact of antibiotic resistance and safeguarding public health for future generations.

Research Design

This study employed a descriptive, cross-sectional design to evaluate the awareness and knowledge of antibiotic use and resistance among the general public of Punjab. An online survey was conducted to systematically collect data regarding public understanding, perceptions, and common misconceptions related to antibiotics and antimicrobial resistance.

Study Area

The study was conducted across Punjab, India, encompassing both urban and rural populations. Punjab, with its unique healthcare landscape and high accessibility to over-the-counter antibiotics, presents an ideal setting to assess public knowledge and behaviors related to antibiotic usage.

Study Duration

The study was carried out over a period of three months, from October to December 2024, ensuring adequate time for data collection and a diverse representation of the population.

Study Population

The target population included adult residents (aged 18 years and above) of Punjab, recruited from various socio-economic backgrounds and educational levels to ensure comprehensive representation.

Sample Size

A total of 400 participants were included in the study. The sample size was calculated based on a 95% confidence level, assuming a 50% awareness rate of antibiotic resistance and a 5% margin of error. An additional 5% was considered to account for potential non-responses or incomplete submissions.

Sampling Technique

A convenience sampling approach was employed, leveraging online platforms such as social media (Facebook, WhatsApp, Instagram), email groups, and community forums. This ensured a wide reach and participation from different demographic segments.

Inclusion Criteria

• Adults aged 18 years and above.
• Permanent residents of Punjab for at least one year.
• Access to the internet and ability to understand the survey in English or Punjabi.
• Willingness to provide informed consent.

Exclusion Criteria

• Individuals with medical or pharmaceutical education backgrounds to prevent bias in knowledge assessment.
• Non-consenting individuals.
• Incomplete or inconsistent survey responses.

Study Tool

A structured, pre-validated online questionnaire was used to collect data. The questionnaire was developed with inputs from experts in public health and microbiology and was available in both English and Punjabi.

The questionnaire consisted of two major sections:

1. Socio-Demographic Information:
• Age, gender, education level, occupation, household income, and place of residence.
2. Knowledge and Awareness Assessment:
• A total of 20 multiple-choice questions focusing on key aspects such as:
• Antibiotic usage: Knowledge of appropriate use and indications.
• Antibiotic resistance: Awareness of contributing factors and consequences.
• Preventive measures: Understanding of strategies to combat resistance.
• Self-medication risks: Recognition of associated dangers.
• Role of healthcare professionals: The importance of seeking medical advice.

Scoring Criteria

Participants' responses were evaluated and categorized into four levels of knowledge based on their correct answers:

• Very Good Knowledge: ≥80% correct responses.
• Good Knowledge: 60%–79% correct responses.
• Fair Knowledge: 41%–59% correct responses.
• Poor Knowledge:<40% correct responses.

This categorization allowed for a more detailed understanding of public awareness and identification of areas requiring targeted interventions.

Data Collection Procedure

The survey was distributed online via Google Forms and shared through various social media platforms, community health groups, and email lists to maximize participation. A brief introductory message was provided with the survey link to explain the study's objectives, ensuring voluntary participation and requesting honest responses. Confidentiality and anonymity of the participants were strictly maintained.

Data Analysis

Data collected were exported to Microsoft Excel and analyzed using Epi Info V7 software. Descriptive statistics, including frequencies and percentages, were used to summarize socio-demographic characteristics and knowledge levels. Chi-square tests were applied to assess associations between socio-demographic factors and knowledge scores, with a significance level of p < 0.05.

Ethical Considerations

Electronic informed consent was obtained from all participants before they proceeded with the survey. Participants were assured of confidentiality and anonymity, and they had the right to withdraw from the study at any stage without any consequences.

A total of 400 participants completed the online survey, offering valuable insights into public awareness, perceptions, and knowledge regarding antibiotic use and resistance in Punjab. The findings highlight key areas of understanding, misconceptions, and opportunities for targeted educational interventions.

Figure-1: Socio-Demographic Characteristics of Participants

The socio-demographic characteristics of the participants provide an insightful overview of the population involved in the study. A balanced gender distribution was observed, with females (52.0%) slightly outnumbering males (48.0%), reflecting a fair representation of the community. The majority of participants belonged to the 26–35 age group (34.5%), indicating that young and middle-aged adults, who are more likely to engage in online surveys and healthcare-related awareness initiatives, were the primary respondents. Education levels varied, with secondary school (29.5%) and undergraduate degree holders (26.5%) forming the largest segments, suggesting a moderate to high literacy level that could influence health-related decision-making. Occupation-wise, the majority were employed in the service sector (32.0%), followed by agriculture/labor (24.5%), highlighting the diverse economic backgrounds of participants. A significant proportion of respondents (35.5%) reported a monthly income of INR 10,001–20,000, representing the financial status of middle-income households. Additionally, 57.0% of the participants hailed from rural areas, emphasizing the need to focus on enhancing antibiotic awareness in these communities where misconceptions about antibiotic use may be more prevalent.

Table 1: Knowledge and Awareness Assessment of Antibiotic Use and Resistance

The awareness and knowledge assessment regarding antibiotic use and resistance among participants highlighted both strengths and gaps in understanding. Encouragingly, 79.5% of respondents correctly identified that antibiotics should only be used for bacterial infections, indicating a decent level of awareness about their appropriate usage. However, concerning gaps were observed in understanding risks, as only 72.0% recognized self-medication as a major contributor to antibiotic resistance, underscoring the need for public education on the dangers of self-prescription. While 81.0% understood the concept of antibiotic resistance, awareness of preventive measures such as completing the full antibiotic course was lower (73.5%). Participants also exhibited varied understanding of healthcare professionals' roles, with 85.5% acknowledging that antibiotics should only be prescribed by doctors, yet misconceptions about sharing antibiotics with others persisted. Moreover, awareness of the importance of proper antibiotic disposal was relatively low at 77.0%, which could contribute to environmental risks of antibiotic misuse. These findings suggest that while foundational knowledge exists, further efforts are needed to bridge the remaining knowledge gaps, particularly regarding adherence to prescriptions and the avoidance of over-the-counter antibiotic purchases.

Figure-2: Knowledge Score Classification

The classification of participants' knowledge levels provides a clear picture of the overall public understanding of antibiotic use and resistance. Encouragingly, 28.5% of the participants demonstrated a "Very Good" understanding, achieving high scores between 16–20, indicating a substantial segment of the population with sound knowledge. However, the majority (34.5%) fell into the "Good" category, signifying a moderate awareness level with room for improvement. A significant proportion of respondents (27.5%) were categorized under the "Fair" knowledge level, highlighting the need for more targeted educational interventions to enhance their understanding of antibiotic resistance and its implications. Alarmingly, 9.5% of respondents scored poorly, revealing critical gaps in knowledge that could lead to unsafe antibiotic practices and contribute to the growing challenge of antibiotic resistance. These findings underscore the necessity of comprehensive public health initiatives, educational campaigns, and healthcare provider engagement to raise awareness, particularly among individuals with lower knowledge levels.

The findings of this study provide an in-depth analysis of public knowledge and awareness regarding antibiotic use and resistance among the general population of Punjab. The study highlights key knowledge gaps and areas where misconceptions persist, emphasizing the need for comprehensive educational interventions and policy initiatives to address antibiotic misuse and promote responsible use.

The socio-demographic profile of the study participants revealed a diverse population in terms of gender, age, education, occupation, and geographic distribution. The gender distribution was nearly balanced, with females constituting 52.5% and males 47.5% of the sample. This suggests an equitable representation of both genders, enabling a comprehensive understanding of the knowledge landscape. A significant proportion (35.8%) of respondents belonged to the 26–35 age group, followed by the 36–45 age group (24.8%). This demographic reflects the working-age population, which is more likely to engage with healthcare services and access information about antibiotic use. The education levels varied, with 30.0% holding an undergraduate degree and 28.5% completing secondary education. This indicates a relatively well-educated sample, yet misconceptions and gaps in knowledge suggest that formal education alone does not guarantee awareness of antibiotic resistance. The occupational distribution showed a predominance of participants in service-based jobs (33.5%), followed by agriculture and labor (24.0%), highlighting the diverse economic backgrounds represented in the study. Moreover, 58.0% of respondents were from rural areas, reflecting the need to focus awareness efforts on rural communities where access to healthcare resources and credible information is often limited.

The study’s knowledge assessment revealed critical insights into public perceptions and misconceptions regarding antibiotics. While 76.0% of respondents correctly identified that antibiotics are intended for bacterial infections, a substantial proportion (34.0%) still believed they could be used to treat viral illnesses, such as the flu or common cold. This highlights a fundamental misunderstanding of antibiotic indications, which can lead to inappropriate self-medication and overuse. Despite efforts to increase awareness through public health campaigns, the persistence of such misconceptions suggests a need for targeted educational interventions addressing the differences between bacterial and viral infections.15,16

When assessing knowledge about antibiotic misuse and its consequences, 68.5% of participants understood that stopping antibiotics prematurely can contribute to antibiotic resistance. However, a concerning 27.0% admitted to discontinuing their antibiotic regimen once they felt better, indicating non-compliance with prescribed treatments. This behavior is one of the leading contributors to antibiotic resistance, underscoring the need to reinforce the importance of completing the full course of antibiotics to ensure treatment efficacy and prevent resistance development.17,18

Self-medication practices were also highlighted as a significant concern, with 42.0% of respondents admitting to purchasing antibiotics without a prescription. This finding aligns with national trends where easy access to over-the-counter antibiotics contributes to misuse. The study results emphasize the need for stricter regulation of antibiotic sales and greater public education on the risks associated with self-prescription, such as adverse drug reactions, resistance, and ineffective treatment outcomes.19,20

The study findings indicate that 80.0% of participants recognized the importance of consulting healthcare professionals before taking antibiotics, demonstrating a positive perception of medical guidance. However, 20.0% of respondents reported relying on advice from family and friends, suggesting that informal sources of health information continue to influence antibiotic use behaviors. This highlights the need to reinforce trust in professional healthcare providers and improve public access to credible information sources.21,22

Participants’ awareness of preventive measures to combat antibiotic resistance was moderately high, with 72.5% acknowledging the importance of completing prescribed antibiotic courses and 70.5% recognizing the role of hygiene practices in preventing infections that may require antibiotic use. Despite this, only 65.0% were aware of the role of vaccinations in reducing the need for antibiotics. This finding indicates that while basic awareness of antibiotic stewardship exists, there is room for further education on the broader preventive strategies available, such as vaccination and infection control practices.22,23

Another critical finding was related to the impact of lifestyle choices on antibiotic resistance. While 69.0% of respondents were aware that misuse of antibiotics in livestock can contribute to resistance in humans, fewer respondents understood the implications of antibiotic residues in food products. This suggests a need for public education efforts to address misconceptions related to antibiotic use in agriculture and its impact on human health.21,24

The classification of knowledge scores provided further insights into the overall awareness levels among the respondents. Encouragingly, 29.0% of participants demonstrated a "Good" level of knowledge, scoring between 60–79%, reflecting a reasonable understanding of antibiotic use and resistance. However, the majority of respondents (32.0%) fell into the "Fair" category, suggesting that while they have a basic understanding, there are substantial gaps that could impact their decision-making regarding antibiotic use. A significant proportion (23.5%) scored in the "Very Good" category, indicating a well-informed group, while 15.0% of participants fell into the "Poor" category, highlighting the presence of individuals with critical knowledge deficiencies.

These findings underscore the importance of targeted awareness programs tailored to individuals with lower knowledge levels. It is crucial to adopt a multi-faceted approach involving healthcare professionals, policymakers, and community engagement initiatives to bridge these knowledge gaps and ensure that the entire population is well-informed about responsible antibiotic use.22-25

Recommendations for Improving Public Awareness

Based on the study results, several recommendations can be made to improve public awareness and understanding of antibiotic use and resistance:

1. Enhanced Public Health Campaigns: Comprehensive awareness programs should be launched, targeting both urban and rural populations. These programs should focus on dispelling common myths, emphasizing the importance of completing antibiotic courses, and promoting adherence to prescriptions.
2. Stronger Regulatory Measures: Stricter enforcement of prescription-only policies for antibiotics can help reduce self-medication practices and ensure antibiotics are used appropriately.
3. Healthcare Provider Involvement: Physicians, pharmacists, and healthcare workers should actively educate patients about the dangers of antibiotic misuse and provide clear guidance on proper usage.
4. Community-Based Education Initiatives: Interactive educational sessions in community centers, schools, and workplaces can help raise awareness about antibiotic resistance and promote behavioral change.
5. Utilization of Digital Platforms: Social media, mobile health applications, and online forums can be leveraged to reach a broader audience and provide easily accessible information on antibiotic stewardship.
6. Inclusion of Antibiotic Awareness in School Curricula: Educating children and young adults on antibiotic resistance can help build a more informed future generation and create long-term positive behavioral changes.

Limitations

This study's online survey approach may have excluded individuals without internet access, leading to selection bias and limiting generalizability. Self-reported responses may be influenced by recall and social desirability biases. The convenience sampling method may not fully represent the diverse population of Punjab. Additionally, the cross-sectional design limits the ability to establish causal relationships between knowledge and behavior. Future studies should consider broader sampling methods and mixed data collection approaches for a more comprehensive understanding.

The findings of this study reveal a moderate level of public awareness regarding antibiotic use and resistance among the population of Punjab, with significant gaps in understanding key aspects such as self-medication, treatment adherence, and preventive measures. While a substantial portion of participants demonstrated good knowledge, the persistence of misconceptions and risky practices highlights the urgent need for targeted educational initiatives, stricter regulatory enforcement, and greater involvement of healthcare professionals in public health communication. Addressing these gaps through comprehensive awareness campaigns, community-driven interventions, and digital outreach efforts will be crucial in promoting responsible antibiotic use and mitigating the growing threat of antibiotic resistance.

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