Antibiotic Resistance in Trinidad: A population-based survey of adults.

Nyeil Ali ¹, Subrina Alli ¹, Ashley Ali ¹, Aleema Ali ¹, Chelsi Ali ¹, Jada Abraham ¹, Imtiaz Abdool, Azalia Antoine ¹, Isaac Dialsingh ², Roshan Parasram ³, Shalini Pooransingh ¹

¹ Faculty of Medical Sciences, The University of the West Indies, St. Augustine Campus, Champs Fleurs, Trinidad and Tobago.
² Faculty of Science and Technology, The University of the West Indies, St. Augustine Campus, St. Augustine, Trinidad and Tobago.
³ Ministry of Health, Trinidad and Tobago

Corresponding Author:
Nyeil Ali
The University of the West Indies, St. Augustine Campus,
Champs Fleurs, Trinidad and Tobago.
E-mail: [email protected]

DOI: 10.48107/CMJ.2020.05.005

Copyright: This is an open-access article under the terms of the Creative Commons Attribution License which permits use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Objectives: Antibiotic resistance (ABR) is a growing public health issue globally. This study aimed to ascertain the public’s knowledge of antibiotic resistance and to determine any associated demographic factors.

Method:  A cross-sectional survey was undertaken in Trinidad using a modified version of a World Health Organization questionnaire. Five hundred and fifty participants aged 16 years and older were interviewed.  Data were analysed using SPSS Version-22.

Results: The response rate was 91% (502/550). Most responders (53%) reported having taken antibiotics during the 6-month period prior to the survey. Almost 60% of responders believed that sore throat and colds/flu can be treated with antibiotics. Sixty-seven percent of responders believed that they had no individual role in combating the issue. Responders with a primary level education or older respondents were more likely than responders with a higher level of education or younger to agree that antibiotic resistance only affects those who use antibiotics frequently (p= 0.002 and p=0.017 respectively). Income level was also significantly associated with knowledge levels, the higher the income the more knowledgeable the responder.

Conclusion: Our study found that public knowledge of antibiotic resistance is low. Age, income and educational levels were significantly associated with certain knowledge parameters. Much work needs to be done to change the attitudes of responders who believe they have no role to play in the fight against this national and global threat. These findings may be useful to health education professionals and government antimicrobial resistance programmes.

Introduction

Antibiotic resistance (ABR) is an important and increasing public health problem. Antibiotic resistance is the phenomenon whereby bacteria attain the ability to resist the effects of antibiotics.¹ While antibiotic resistance can occur as a natural process, high antibiotic consumption accelerates its development.² Instances of antibiotics misuse combined with the lack of development of new antibiotics exacerbate the phenomenon of antibiotic resistance. This can lead to ineffectiveness of medical interventions utilising antibiotics.³

Bacterial strains that are resistant to antibiotics are rapidly emerging and pose a major health risk, for example, the emergence of drug resistance in Neisseria gonorrhoeae, which is a common sexually transmitted infection globally.⁴ The World Health Organization (WHO) classifies antibiotic resistance as “a major threat to the world’s health, development and security of food,” and hence advocates for an urgent change to the current use and style of prescribing antibiotics.⁵ Additionally, antibiotic-resistant infections place a strain on health care systems as they can lead to extended treatment periods and a rise in the global mortality rate.^6,7

In 2015, the WHO conducted a global study involving 12 countries from the six WHO regions.⁸ In that WHO study, Barbados and Mexico represented the Region of the Americas. This current study sought to undertake the study in Trinidad and Tobago (TT) as TT was not included in the global survey. The authors believed that the information derived would be useful for the Ministry of Health’s Antimicrobial resistance (AMR) prevention and control efforts.

This study therefore aimed to determine the knowledge and awareness of antibiotic resistance among the Trinidadian public and to ascertain if there are factors associated with levels of awareness and knowledge.

Methods

Study Design: A cross-sectional study was undertaken using convenience sampling. The methodology for the study was based on that of the 2015 WHO ABR survey with minor modification to the design and data collection tool in order to allow for an adequate comparison.⁸

Study Population: This study population included persons residing in Trinidad.

This study sample included participants who satisfied the inclusion criteria. The inclusion criteria were as follows: 1.) Subjects who were 16 years and older. 2.) Subjects who were able to communicate in English and without any obvious mental health conditions that would prevent satisfactory participation.

The WHO survey included participants aged 16 years and older. Since this study aimed to replicate the WHO study, participants aged 16 years and older were also included, despite the age of consent in Trinidad and Tobago being 18 years of age.

Sample Size: A sample size of 550 participants was determined by the authors based on the methodology of the WHO study wherein 500 participants were included from countries that conducted face to face surveys; whereas in countries undertaking online surveys, the sample size was 1000 participants. In their study, the WHO stated that the sample size was recommended as the study aimed to ascertain views from the general public and not specific groups in society. They further clarified that a sample of 500 was thought to allow for a robust study which at the same time allowing for effective resource management and that a similar study on antimicrobial resistance conducted by the European Commission in 2009, used as a similar sample size.^8,9

Data Collection: Data collection took place at public spaces throughout Trinidad mainly shopping areas where persons from all socio-economic strata may be sampled. Data were collected for a one week period (which included all days of the week) in January 2018.

At the various locations, using convenience sampling, the researchers approached potential participants, introduced themselves, explained the nature of the study and asked the potential participants their willingness to participate. Participants (18 years or older) who agreed, completed and signed a consent form. Participants who were 16 and 17 years old  were selected only if i.) a parent of legal guardian was present at the time of survey and ii.) both the participant and guardian consented to taking part in the survey.

The data collection tool in the WHO report was designed for adaptation on a country by country basis. The questionnaire used in the study was a modified version of this tool adapted to the local context, for example using local counties, income ranges that are more representative of local figures or removal of terms like “hawker” which are not commonly used in Trinidad.

This modified tool was piloted over a two week period in December 2017 among a group of second year university students (n=20). They were interviewed by the authors to ensure the questions being asked were clear and unambiguous. After completing this exercise, the authors were satisfied that no further modifications were needed.

The questionnaire consisted of 8 questions related to demography and 14 questions on ABR. Questions included frequency of antibiotic use, conditions that antibiotics should be used in and opinions on antibiotic use and antibiotic resistance.

Data were obtained using face-to-face surveys conducted by the researchers.

Data Analysis: Responses were analysed using Statistical Package for the Social Sciences (SPSS) Version-22. Chi Square testing was performed as part of data analysis.

Ethical approval: This study was approved by the Campus Ethics Committee of the University of the West Indies, St. Augustine Campus on the 8^th of December 2017. Reference number: CEC378/11/17.

Results

The response rate of this study was 91% (502/550). Table 1 shows the demographic characteristics of the responders. Of the 502 responders, the majority 60% (n=301) were female. In terms of educational attainment, 39% (n=196) of responders self-reported higher/university level education, 46% (n=230) further/secondary level, 11% (n=55) basic/primary level and 4% (n=20) reported no formal education. In terms of monthly household income (all figures in Trinidad and Tobago dollars (1 USD = 6.79 TTD)), 23% (n=110) of responders belonged to households with a monthly household income of less than TTD 5 000, 39% (n=189) belonged to households earning between TTD 5 000 – 9 999, 24% (n=117) belonged to households earning between TTD 10 000 – 19 999 and 14% (n=68) belonged to households earning more than TTD 20 000 monthly.

Table 1: Demographic characteristics of respondents

Antibiotic Usage

When responders were asked when they last used antibiotics, 53% (n=266) reported using antibiotics within the past six months, with 20% (n=100) of persons reporting usage within the last month.

Responders were presented with names of common diseases and asked if antibiotics were used in the treatment of these diseases. Table 2 outlines the findings which included 85% (n=420) of responders stating that Urinary Tract Infections (UTIs) can be treated using antibiotics; 61% (n=303) said cold/flu was treatable with antibiotics and 59% (n=292) said sore throats were treatable with antibiotics. More than half (51%, n=247) of the respondents believed that gonorrhoea was not treated with antibiotics.

Table 2: Percentage of ‘Yes’ responses from all responders to “Can these conditions be treated with antibiotics?”

Awareness of antibiotic resistance

Responders were asked if they knew terms specific to Antibiotic and Antimicrobial resistance. The findings revealed that the most commonly known term was Antibiotic resistance (53%, n=266) followed by Drug resistance (43%, n=216), Antibiotic resistant bacteria (32%, n=161), Superbugs (25%, n=126), Antimicrobial resistance (20%, n=100) and AMR (12%, n=60).

Knowledge of antibiotic resistance

Figure 1 shows the level of agreement of responders to statements about antibiotic resistance. Eighty-four percent (n=413) of responders said that antibiotic resistance happens when the body becomes resistant to antibiotics, causing them to not work well. Additionally, 56% (n=274) of respondents said that antibiotic resistance is only a problem for people who take antibiotics regularly.

Figure 1: Percentage of ‘true’ responses from all responders to statements designed to determine knowledge of antibiotic resistance.

Age vs the statement – antibiotic resistance is only a problem for people who take antibiotics regularly

Figure 2 demonstrates that older responders were more likely to claim the statement was true. Forty-seven per cent (n=67) of responders aged 16-24 years said the statement was true compared to 71% (n=43) of responders over the age of 55 years (p = 0.017).

Figure 2: Age based responses to whether antibiotic resistance is only a problem for people who regularly take antibiotics.

Attitudes surrounding Antibiotic resistance

Figure 3 shows statements about ABR and the agreement of responders to each. The majority of responders (56%, n=265) agreed that Antibiotic resistance was a major global threat.

Additionally, 88% (n=417) of responders stated it was everyone’s responsibility to tackle the issue but 67% (n=318) felt they could not do anything about it and 67% (n=318) were worried for themselves and their families. Furthermore 57% (n=271) of responders thought that they would be fine if they took their medications as prescribed.

Figure 3: Percentages of all responders who agreed to statements surrounding attitudes towards antibiotic resistance.

Income vs the statement – there is not much people like me can do to stop Antibiotic resistance

Table 3 demonstrates that the higher a responder’s monthly household income, the lower their chances of agreeing with the above statement. Seventy-seven percent (n=79) of responders with a household income of less than TTD 5 000 per month agreed with the statement versus 54% (n=36) of responders with a household income of more than TTD 20 000 per month (p = 0.027).

Table 3: Percentage of responses from all responders to “There is not much people like me can do to stop antibiotic resistance” by household income (p = 0.027)

Education vs the statement “I am not at risk of getting an antibiotic-resistant infection, as long as I take my antibiotics as directed”

The data outlined in Table 4 shows that the higher the responder’s education levels are, the chances of them agreeing with the statement decreases. Sixty-seven percent (n=12) of persons with no education agreed with the statement versus 51% (n= 93) of those with higher education (p = 0.023).

Table 4: Percentage of responses from all responders to “I am not at risk of getting an antibiotic-resistant infection, as long as I take my antibiotics correctly” by level of education. (p = 0.023)

Actions that can be taken to address Antibiotic resistance

Participants were asked to state which statements to address ABR they agreed with. Ninety-one percent (n=436) of responders thought antibiotics should be used only when prescribed; and 90% (n=429) of responders thought doctors should prescribe antibiotics only when required.  Actions for maintaining personal hygiene by regular handwashing and vaccinating children were supported by 96% (n = 459) and 97% (n=464) of responders, respectively.

Education vs the statement “People should use antibiotics only when they are prescribed by a doctor or nurse”

The higher the responder’s educational attainment, the increased likelihood of agreement with the statement. Sixty-seven percent (n=12) of persons with no education agreed with the statement versus 94% (n= 175) of those with higher education (p = <0.001).

Income vs the statement – “Doctors should only prescribe antibiotics when they are needed”

The higher a responder’s monthly household income, the higher their chances of agreeing with the above statement. Eighty-two percent (n=84) of responders with a household income of less than TTD 5 000 per month agreed with the statement versus 100% (n=67) of responders with a household income of more than TTD 20 000 per month (p = 0.006).

Discussion

This study presents useful findings that may be used by the Ministry of Health in their national efforts against antibiotic resistance.

It has been well established that high antibiotic consumption accelerates the development of antibiotic resistance.² Our study found that the majority of responders (53%, n=267) reported using antibiotics in the past 6 months with approximately 20% (n=102) of these reporting use in the previous month. The global average for use within the past 6 months was 65%.⁸ Mexico reported a higher antibiotic consumption (75%) in the past 6 months.⁸ Barbados, along with Serbia were the two countries in the global survey with the lowest reported antibiotic usage (35% and 48% respectively) within the past 6 months.⁸ Nevertheless, the data generally suggests antibiotic use is common across the globe.

The misuse of antibiotics for viral infections has been well studied with physicians, pharmacists and patients contributing to this phenomenon.^10-14 Lee et al. found that those in lower socio-economic groups and those with diabetes had higher expectations of being prescribed antibiotics, while men and those with lower educational attainment but higher psychological distress and feelings of control over their health displayed a greater attitude of antibiotic entitlement.¹⁰ The majority of responders (61%, n=303) in our study stated that antibiotics may be used for colds/flu which was in keeping with the data from Mexico (61%) and the global average (64%), while less than half (47%) of Barbadian responders agreed.⁸

In order for the public to take appropriate action in combating antibiotic resistance, they should possess a certain level of awareness. Our study showed that just over half (53%, n=266) of responders knew of the term “antibiotic resistance” compared to 43% of Barbadian responders, 89% in Mexico with a global average of 70%.⁸

Rapidly emerging antibiotic resistant infections pose a danger to health, development, food security and the healthcare system.^4-7 The majority of study responders (56%, n=256) agreed that antibiotic resistance was a major global threat, and this was comparable to Mexico where 55% of responders agreed with the statement; the global average was 63%.⁸ In contrast, in Barbados, less than 3 in 10 responders (27%) stated that antibiotic resistance was a major global threat.⁸ There is therefore a clear need for raising knowledge and awareness about the seriousness of this issue in Latin America and the Caribbean.

Despite 20% (n=102) of responders reporting antibiotic usage in the past month and 53% reporting usage in the previous six months, more than half of responders stated that antibiotic resistance was a problem solely for persons who regularly utilise antibiotics. Fifty-seven percent (n=271) of responders believed that they were not at risk of acquiring an antibiotic resistant infection if medicines were taken as prescribed. The majority did not believe there was anything they could do to address the issue. In addition, most (52%, n = 247) responders were of the view that medical experts will solve the problem before it becomes too serious. These findings indicate that responders lack insight into the issue. They do not see a role for themselves in the battle against antibiotic resistance. In comparison, 59% of Mexican responders and globally, 64% agreed that medical experts will solve the problem.⁸ However, 56% of Barbadian responders neither agreed nor disagreed with the statement.⁸

Certain knowledge parameters were found to be significantly associated with age, income and education levels in our study. Similar findings were reported in other studies. Alqarni et al. found higher mean knowledge scores among responders working in the health sector, higher educational groups and high monthly income groups.¹⁵ A study by Andre et al. also found a positive association between education level and knowledge about the effectiveness of antibiotics.¹⁶ A Trinidad study in 1992 found that tertiary level education was significantly associated with knowledge about safety and usage of antibiotics while possessing private health insurance was associated with knowledge of safety and side effects.¹⁷

In terms of actions responders could take to address the issue, overwhelmingly 91%  (n=436) of responders agreed that only using antibiotics when prescribed will help combat antibiotic resistance and that doctors should prescribe antibiotics only when required (90%, n=431). These findings were mirrored globally (87% and 89% respectively).⁸ It appears that some responders were of the view that if they practice appropriate antibiotic use, they will be safe from antibiotic resistant infections. However, the majority of respondents (61%) stated that antibiotics can be used for colds/flu. This shows that most individuals were unaware of the appropriate use of antibiotics. They also do not seem to appreciate that tackling antibiotic resistance depends on many factors and that everyone is at risk of contracting an antibiotic resistant organism.

Limitations of the study

The study sampling method was convenience sampling. This sampling method may have introduced selection bias.  However, the shopping areas sampled allowed for a cross-section of the population of Trinidad which was seen in the demographic data of responders. Self-reporting can also lead to incorrect information particularly concerning education and income levels. The study findings do not support information bias since the findings on education and income levels were mirrored in other studies.^{8,11,15,17,18}

Conclusion

Antibiotic resistance is a major Public Health problem. This Trinidad study found that antibiotic use is common. It appears public knowledge of antibiotic resistance requires enhancement. There were misperceptions among the study population about the indications for antibiotic use with the majority of responders stating it can be used for sore throats and the cold/flu. Additionally, it seems the study population is unaware of its role in addressing the threat of antibiotic resistance and the multifactorial aetiology of antibiotic resistance which requires a whole of society approach. Age, income and educational levels were significantly associated with reported knowledge with younger, the economically better off and more educated responders possessing better knowledge. Importantly responders did not see a role for themselves in addressing antibiotic resistance. Our study findings and available data for Barbados and Mexico reveal gaps in knowledge and a lack of awareness of the potential seriousness of antibiotic resistance.⁸

The information obtained from this study may be used to direct the efforts of health education professionals.  Further research in the form of focus groups may be conducted with subgroups including prescribers to understand expectations and behaviours surrounding antibiotic use. The One Health approach is key to tackling antibiotic resistance across sectors and the Government of Trinidad and Tobago, in collaboration with partners, has implemented the One Health approach which is a positive step.^5,21 This study findings can assist the programme managers who are responsible for implementing the national Antimicrobial Resistance Action Plan, in particular, at the community level.

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