Antimicrobial resistance (AMR) poses a growing global threat to public health, rendering once-effective antibiotics and antimicrobial treatments ineffective against bacterial infections. This phenomenon not only endangers the lives of individuals but also poses severe challenges to healthcare systems and economies worldwide. Shimla, a picturesque region nestled in the Indian state of Himachal Pradesh, is not immune to this threat. Evaluating the awareness and knowledge regarding antimicrobial resistance among the general public in Shimla is vital to address this pressing concern and safeguard the health of current and future generations.[1-2]

Antimicrobial resistance occurs when bacteria, viruses, fungi, and parasites evolve mechanisms to resist the drugs designed to eliminate them. This resistance reduces the effectiveness of treatments, leading to prolonged illnesses, increased mortality rates, and escalated healthcare costs. According to the World Health Organization (WHO), AMR is responsible for approximately 700,000 deaths annually, with estimates predicting it to become a leading cause of mortality, surpassing cancer and diabetes, by 2050 if left unaddressed.[3-6]

Furthermore, the urgency of addressing AMR is underscored by global initiatives and policies aimed at combatting this challenge. International organizations, including the WHO and the Food and Agriculture Organization of the United Nations (FAO), have recognized AMR as a priority and have called for coordinated efforts to mitigate its impact. India has also initiated the "National Action Plan on Antimicrobial Resistance," emphasizing the importance of both government and public engagement in tackling this issue.[7-9]

Shimla, renowned for its natural beauty and cultural heritage, also faces the repercussions of AMR. The misuse and overuse of antimicrobial agents, including antibiotics, in Shimla's healthcare settings, agriculture, and animal husbandry contribute to the emergence and spread of drug-resistant pathogens. Additionally, inadequate public awareness about responsible antimicrobial usage further exacerbates this issue.

To tackle AMR effectively, it is essential to gauge the levels of awareness and knowledge about this issue among the general population of Shimla. This study aims to provide valuable insights into the understanding of AMR, its implications, and the measures needed to mitigate its impact. By identifying knowledge gaps, misconceptions, and areas requiring education, we can tailor public health campaigns and interventions that empower individuals and communities to act as responsible stewards of antimicrobials.

In this context, this study seeks to assess the level of awareness and knowledge about antimicrobial resistance among Shimla's general public. As AMR continues to evolve and affect healthcare globally, periodic evaluations of public awareness are essential for adapting and refining public health strategies. This research endeavors to contribute to the development of informed, proactive, and responsible communities in Shimla, working towards the preservation of effective antimicrobial treatments and the protection of health for generations to come.

Objectives of the Study:

The objective of this study is to gauge the levels of awareness and knowledge about antimicrobial resistance among the general population of Shimla.

• Research Approach -Descriptive

• Research Design-  Cross-sectional survey design

• Study area:  District Shimla, Himachal Pradesh

• Study duration- between April 2023 to June 2023

• Study population: The study's target population encompassed all adults aged 18 and above who had been residents of District Shimla for a minimum of 12 months

• Sample size- A robust sample size of 400 adults was determined using a 95% confidence level, an estimated knowledge level of 50% regarding antimicrobial resistance, a precise 5% absolute error margin, and a conservative 5% non-response rate. 

• Study tool: A google form questionnaire consisting of questions regarding socio-demography and knowledge regarding antimicrobial resistance was created. The questionnaire was initially pre-tested on a small number of participants to identify any difficulty in understanding by the respondents. 

• Description of Tool- 

1. Demographic data survey instrument: The demographic form elicited information on participants’ background: age, marital status, religion, employment, education and many more.

2. Questionnaire: The questionnaire contains 20 structured knowledge related questions regarding antimicrobial resistance. One mark was given for each correct answer and zero for incorrect answer. The maximum score was 20 and minimum score was zero. Scoring was done on the basis of marks as >80%(16-20)=very good,60-79%(12-15) =Good,41-59% ( 8-11)=Fair,<40% (< 8)=poor

• Validity of tool - by the experts in this field

• Data collection- Data was collected under the guidance of supervisors. The google form questionnaire was circulated among the residents of District Shimla, Himachal Pradesh for responses using online modes like e-mail and social media platforms like Whatsapp groups, Facebook, Instagram and Linkedin till the 400 responses were collected. 

• Data analysis- Data was collected and entered in Microsoft excel spread sheet, cleaned for errors and analyzed with Epi Info V7 Software with appropriate statistical test in terms of frequencies and percentage. 

• Ethical Considerations- Participants confidentiality and anonymity was maintained. 

The primary objective of this study was to gauge the understanding of antimicrobial resistance (AMR) among the general population of Shimla through a non-experimental descriptive survey. A total of 400 participants took part in the study, with 271 (67.75%) residing in urban areas and 129 (32.25%) in rural areas.

Table-1: Knowledge regarding antimicrobial resistance among study participants

In the present study 24.5% (98) participants had very good knowledge (16-20 marks) towards antimicrobial resistance, 25.5% (102) had good knowledge (12-15 marks), 33.5% (134) had fair knowledge  (8-11 marks) and 16.5% (66) having poor knowledge  (<8 marks).

Table-2: Knowledge scores towardsantimicrobial resistance among study participants

Antimicrobial resistance (AMR) is a global public health concern with far-reaching implications for healthcare, economies, and society at large. This study aimed to assess the levels of awareness and knowledge regarding AMR among the general public in Shimla, Himachal Pradesh, recognizing the importance of informed communities in combatting this issue.

The study's findings reveal a diverse range of knowledge among respondents regarding AMR. Approximately 50.5% of participants understood the concept of AMR and its significance for public health. This indicates a basic awareness of the issue, which is promising as it suggests that a substantial portion of the population recognizes AMR as a health concern.

When examining knowledge about the factors contributing to AMR, 34.75% correctly identified these factors. However, the majority of respondents did not have a clear understanding of what drives the development of AMR. This underscores the need for education and awareness campaigns to elucidate the complex interplay of factors contributing to this problem.

Concerningly, only 21.75% of participants could name at least three types of microorganisms that can become resistant to antibiotics. This lack of knowledge regarding the diversity of microorganisms susceptible to resistance highlights a significant knowledge gap. It is crucial for the public to understand that AMR extends beyond bacteria, encompassing viruses, fungi, and parasites, to appreciate the full scope of this issue.

The consequences of living in a world with widespread AMR were understood by 41.25% of respondents. Recognizing these consequences is essential to motivate individuals and communities to take action against AMR. A higher level of awareness in this regard would likely lead to more responsible antimicrobial use.

While 43.5% of participants could describe the difference between antibiotics and antiviral medications, there is room for improvement in understanding these distinctions. Additionally, 45% correctly acknowledged that antibiotics are not effective against viral infections like the common cold or flu. This is an important aspect of AMR awareness, as the inappropriate use of antibiotics for viral infections contributes to resistance.

Nearly half of the participants (47.75%) recognized the role of individuals in preventing the spread of AMR, demonstrating an understanding of personal responsibility in combating this issue. However, specific best practices for using antibiotics responsibly were known to only 38% of respondents, suggesting a need for education on this critical aspect of AMR prevention.

Understanding the importance of completing a full course of antibiotics as prescribed was acknowledged by 43.25% of participants. This knowledge is essential to prevent the development of resistance during incomplete treatment.

Respondents' knowledge regarding alternatives to antibiotics for treating certain infections was relatively low (31.75%), indicating the need for more information on non-antibiotic treatments and preventive measures.

Healthcare professionals play a pivotal role in preventing AMR, as recognized by 49% of participants. This finding highlights the importance of training and guidelines for healthcare workers to ensure responsible antimicrobial use.

Awareness of how AMR affects the treatment of common infections, such as urinary tract infections or pneumonia, was demonstrated by 47.75% of respondents. Understanding these practical implications is essential to motivate individuals to act responsibly.

The study also revealed that 30% of participants recognized the importance of reducing antibiotic use in agriculture, an issue that contributes significantly to AMR. This suggests that a considerable portion of the population is aware of the link between agricultural practices and AMR.

However, knowledge of international organizations or initiatives focused on combating AMR was relatively low (20.5%). Increasing awareness of global efforts in this area may foster a sense of collective responsibility.

Improved hygiene and sanitation practices, which can help prevent infections and subsequently reduce the need for antibiotics, were understood by 32% of participants. This indicates some recognition of the role of hygiene in AMR prevention.

Acknowledging AMR as a global problem was demonstrated by 26% of respondents, although a substantial portion did not perceive it as such. AMR is indeed a global challenge, and enhancing this understanding is crucial for coordinated efforts.

Only 12.25% of participants were aware of specific regulations or guidelines in their country to address AMR, suggesting that more information about national policies and actions is needed.

Efforts to raise awareness about AMR and its prevention at the individual and community levels were recognized by 40.5% of respondents. This indicates a willingness to engage in awareness campaigns and education initiatives.

However, knowledge of successful strategies or examples of AMR prevention from the region or country was limited (7.25%). Sharing success stories and practical strategies can inspire proactive measures within communities.

Comparing these findings with other studies conducted in various regions, Shimla's residents exhibit a relatively moderate level of awareness and knowledge regarding AMR.^10-12 While some aspects, such as the recognition of personal responsibility and the understanding of AMR as a global problem, align with findings from other studies, there are notable gaps in knowledge about specific factors contributing to AMR and practical best practices for responsible antibiotic use.

In Shimla, Himachal Pradesh, this study has shed light on the varying levels of awareness and knowledge among the general public regarding antimicrobial resistance (AMR). While there is a foundational understanding of AMR as a public health concern, significant knowledge gaps exist, particularly in identifying the factors contributing to AMR, distinguishing between types of microorganisms involved, and recognizing best practices for responsible antibiotic use.

To address these knowledge gaps and enhance awareness, tailored public health campaigns and educational initiatives are warranted. These efforts should aim to elucidate the complexities of AMR, emphasize personal and collective responsibility, and provide practical guidelines for responsible antimicrobial use. Additionally, highlighting the global nature of AMR and sharing success stories from other regions can inspire proactive measures within Shimla's communities.

Ultimately, fostering a well-informed and engaged public is crucial for combatting AMR, preserving the efficacy of antimicrobial treatments, and safeguarding the health of current and future generations in Shimla. Collaboration between public health authorities, educational institutions, and community organizations is essential in achieving these goals and aligning with global strategies to address AMR effectively.

The authors declare that they have no conflict of interest

No funding sources

The study was approved by the Indira Gandhi Medical College.

1. World Health Organization. (2021). Antimicrobial resistance. https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance

2. O'Neill, J. (2016). Tackling drug-resistant infections globally: Final report and recommendations. Review on Antimicrobial Resistance. https://amr-review.org/sites/default/files/160525_Final%20paper_with%20cover.pdf

3. Food and Agriculture Organization of the United Nations. (2018). The FAO action plan on antimicrobial resistance 2016-2020. http://www.fao.org/3/a-i5996e.pdf

4. Ministry of Health and Family Welfare, Government of India. (2017). National action plan on antimicrobial resistance (NAP-AMR). https://main.mohfw.gov.in/sites/default/files/National%20Action%20Plan%20on%20AMR%20-%20Final%20%281%29.pdf

5. Government of India. (2017). National Action Plan on Antimicrobial Resistance (NAP-AMR). https://www.pib.gov.in/PressReleaseIframePage.aspx?PRID=1539870

6. Smith, R. A., M'ikanatha, N. M., Read, A. F. (2015). Antibiotic Resistance: A Primer and Call to Action. Health Communication, 30(3), 309-314.

7. Centers for Disease Control and Prevention (CDC). (2019). Antibiotic Resistance Threats in the United States, 2019. https://www.cdc.gov/drugresistance/pdf/threats-report/2019-ar-threats-report-508.pdf

8. World Health Organization (WHO). (2015). Global Action Plan on Antimicrobial Resistance. https://www.who.int/antimicrobial-resistance/publications/global-action-plan/en/

9. The Review on Antimicrobial Resistance. (2014). Antimicrobial Resistance: Tackling a Crisis for the Health and Wealth of Nations. https://amr-review.org/sites/default/files/AMR%20Review%20Paper%20-%20Tackling%20a%20crisis%20for%20the%20health%20and%20wealth%20of%20nations_1.pdf