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Toolbox  –  Measure

Knowledge, attitudes, beliefs and practices

Understanding knowledge, attitudes, beliefs and practices (KABP) regarding bacteria, antibiotic use, and antibiotic resistance in different target audiences can provide practical information when planning and evaluating interventions to influence behavior change.

Here you find resources and tools to help develop surveys to investigate knowledge, attitudes, beliefs and practices among the general public, students and professionals working in the human and animal sectors.

How to set up a Knowledge, Attitude, Perception (KAP) study – Learning from the Stop TB Partnership

The World Health Organization published in collaboration with the Stop TB Partnership “a guide to developing knowledge, attitude and practice surveys for advocacy, communication and social mobilization for tuberculosis control”. This tool was designed to assist countries’ in collecting and utilizing data on knowledge, attitudes and practices to help them plan, implement and evaluate initiatives. The guide provides a theoretical framework, practical suggestions, and a handful of resources that could be useful in developing similar surveys for antibiotic resistance. A brief discussion of the steps follows:

  • Step 1, define the objectives: Answer the question “what do you want to accomplish by the conducting the initiative?”; Be specific when defining your study population and sampling strategy
  • Step 2, develop the protocol: Your survey protocol and design should match the purpose of your survey; Identify an appropriate ethical review board
  • Step 3, design the questionnaire: Keep the questionnaire as short as possible; Phrase questions carefully and simple; Pre-test questionnaires to ensure that they are easily understood
  • Step 4, conduct the KAP study: Consider the number of interviewers and length of interviews; Train interviewers through role-plays to ensure mutual understanding of their role.
  • Step 5, analyse the data: identify errors that occurred during data entry before starting with the analysis; Use cross-tabulations to highlight differences between groups or categories of your survey
  • Step 6, use the data: Survey report should be understandable for the target audience; Organise stakeholders’ meeting to disseminate results of the survey; Use data as evidence to influence design of health education campaigns (such as on antibiotic resistance) and choice of content for training health professionals.

A study to assess perceptions and intentions to reduce antimicrobial usage among pig farmers in Europe:

Pig farmers and veterinarians in six European countries were asked questions about their practices and knowledge.

Farmers were asked to estimate how much antibiotics were used on their farm compared to other farms, if they had experienced incidents related to resistance, the benefits and risks of using antibiotics and how much the current use could be reduced while still being economically manageable. Veterinarians were asked about their continued training in addition to questions on use and resistance.

Key results:

  • Farmers and veterinarians perceived the risks and benefits of using antimicrobials in a similar way
  • But, farmers where less optimistic about possibilities to reduce use.
  • For pig farmers, the most important factor for willingness to reduce antibiotic use was efficiency of alternative measures. In other words, what are the alternatives and how well do they work, for example stricter hygiene and having their pigs vaccinated.

Recommendation for more prudent use: 1) Educational efforts for farmers that suggest which measures that can be introduced and how beneficial these are. 2) Strengthened advisory role of veterinarians, including abilities to support and educate farmers.

Tools, templates and guidelines are collected below, also indicating the target groups for the resource.

Selected Resources

KABP surveys: Tools, templates and guidelines

Resource Description
Antibiotic resistance: Multi-country public awareness survey Templates. This public awareness survey on the use of antibiotics and knowledge of antibiotic resistance was conducted in 12 countries in 2015, commissioned by the WHO. For inspiration to set up your own public awareness survey, see Annex 1 “full questionnaire” (p. 46 in report. Mix of online and face-to-face interviews ). Targeting the public.
Antimicrobial Resistance Module for Population-Based Survey (PDF) Templates. This module generates household-level information on knowledge and behavior regarding antimicrobial medicines and raises awareness on resistance among communities. Provides questionnaires and data collectors guide, and also describes pretest done in Zambia. Targeting the public.
Development and assessment of a questionnaire for a descriptive cross – sectional study concerning parents’ knowledge, attitudes and practises in antibiotic use in Greece Journal article with template. Describes the process of developing a questionnaire to assess parents’ Knowledge, Attitude and Practices on the role of antibiotics when children suffer from upper respiratory infections. Also evaluates response rates, completeness and reliability (Cronbach) of the questionnaire. Includes questionnaire. Targeting the public.
A study assessing public knowledge, belief and behavior of antibiotic use in an Omani population Journal article with questions. A 12-item self-administered questionnaire is available here that was used to assess public knowledge, belief and behavior towards antibiotics use in a general population in the Sultanate of Oman. Targeting the public.
Antibiotic prescribing and resistance: Views from low- and middle-income prescribing and dispensing professionals (PDF) Report with interview questions. Summarizes 9 studies assessing awareness of resistance and knowledge of antibiotics among 246 prescribers or dispensers in LMICs (India, Philippines, Vietnam, Sierra Leone, Nigeria and Ethiopia). Qualitative methods were used including semi-structured interview and rapid ethnographic observation. Appendix 1 provides selected useful interview questions. Targets animal and human health professionals.
Clean Care is Safer Care: Tools for evaluation and feedback Tools and templates from WHO for evaluation and feedback on hand hygiene interventions, including:

  • Perception Survey for Health-Care Workers
  • Perception Survey for Senior Managers
  • Data Entry Analysis Tools

Targeting health care workers and managers

Knowledge of antibiotic resistance and antibiotic prescription practices among prescribers in the Brong Ahafo Region of Ghana; a cross-sectional study Journal article with template. A study investigating knowledge and practices among prescribers from public and private health care facilities in Ghana using quantitative and qualitative methods. Questionnaire included as an additional file that can be downloaded for inspiration and adaption to other contexts. Targeting prescribers.
Antibiotic Prescribing in DR Congo: A Knowledge, Attitude and Practice Survey among Medical Doctors and Students Journal article with templates: Knowledge, attitudes and practices of antibiotic prescribing surveyed through self-administered questionnaires in Kisangani, DR Congo. Table S1 contains the survey questionnaire in French and English. Targeting prescribers and students.
Effects of Knowledge, Attitudes, and Practices of Primary Care Providers on Antibiotic Selection, United States Journal article with tools: Methodology for in-depth interviews with primary care providers in the United States (physicians, nurse practitioners, and physician assistants) to explore knowledge, attitudes, and self-reported practices on antibiotic resistance and antibiotic selection for common infections. The technical appendix provides support materials for the interviews such as clinical cases to assess compliance with guidelines. Targeting human health professionals.
Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU Templates. This report describes results of the ARNA (‘Antimicrobial resistance and the causes of non-prudent use of antibiotics’) project, focusing on reasons for non-prescription use of antibiotics in the EU, and actions to prevent such use. Carried out under a contract with the European Commission. Appendix A and B provides questionnaires used in the surveys:

  1. Questionnaire Member State survey: Non-prudent use of antibiotics in Europe: public health measures and legislation
  2. Patient questionnaire
  3. General Practitioners questionnaire
  4. Pharmacist questionnaire
Knowledge, attitude and practice of antibiotics: a questionnaire study among 2500 Chinese students Journal article with template. Questions and the grading standard of the questionnaire are included with this study that analyzes the present status of KAP of Chinese medical and non-medical students on the use of antibiotics, and examines the influence of the Chinese medical curriculum on appropriate usage of antibiotics among medical students. Targeting students.
Medical students’ views on the current and future antibiotic resistance situation (PDF, 2MB) Study report: Medical students’ views on the current and future antibiotic resistance situation. Questionnaire at the very end of report. Targeting students.
Improving Medicines Access and Use for Child Health -A Guide to Developing Interventions Practical manual for those developing interventions to improve access to and use of medicines, including antibiotics, for child illness. Special focus on low-resource settings. Different tools and methods are described that can be used to measure appropriate use and access to medicines, such as:

  • Key questions and indicators when assessing quality of child health care
  • Hypothetical example of rating a set of problems identified during an assessment
  • Example of Focus Group Discussion Guide
Advocacy, communication and social mobilization for TB control: A guide to developing knowledge, attitude and practice surveys Guide and tools that provides a theoretical framework, practical suggestions, and a handful of resources for conducting KAP studies for tuberculosis control, which can be useful in developing similar surveys for antibiotic resistance. Published by WHO in collaboration with the Stop TB Partnership.
TREND statement and checklist Checklist: 22 item list to guide standardized reporting of nonrandomized evaluations of behavioral and public health interventions, developed by the Transparent Reporting of Evaluations with Nonrandomized Designs (TREND) group.
1.
Pearson M, Doble A, et al. Antibiotic prescribing and resistance: Views from low- and middle-income prescribing and dispensing professionals [Internet]. 2018. Available from: https://www.who.int/antimicrobial-resistance/LSHTM-Antibiotic-Prescribing-LMIC-Prescribing-and-Dispensing-2017.pdf
1.
Paget J, Lescure D, Versporten A, Goossens H, Schellevis F, van Dijk L. ARNA Final Report: Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU [Internet]. 2017 [cited 2017 Nov 15]. Available from: https://www.nivel.nl/en/publicatie/antimicrobial-resitance-and-causes-non-prudent-use-antibiotics-human-medicine-eu
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Stop TB Partnership, World Health Organization - WHO. Advocacy, communication and social mobilization - A guide to developing knowledge, attitude and practice surveys [Internet]. 2008 [cited 2015 Aug 6]. Available from: http://www.who.int/tb/publications/tb-advocacy-report/en/
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TREND group. Transparent Reporting of Evaluations with Nonrandomized Designs (TREND), statement and checklist [Internet]. [cited 2017 Nov 21]. Available from: https://www.cdc.gov/trendstatement/
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World Health Organization - WHO. Clean Care is Safer Care: Tools for evaluation and feedback [Internet]. WHO - Clean care is safer care. [cited 2017 Nov 17]. Available from: http://www.who.int/gpsc/5may/tools/evaluation_feedback/en/
1.
Asante KP, Boamah EA, Abdulai MA, Buabeng KO, Mahama E, Dzabeng F, et al. Knowledge of antibiotic resistance and antibiotic prescription practices among prescribers in the Brong Ahafo Region of Ghana; a cross-sectional study. BMC Health Serv Res [Internet]. 2017 Jun 20;17(1):422. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28633631
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Management Sciences for Health, Macro International, Inc. Antimicrobial Resistance Module for Population-Based Surveys [Internet]. 2008 [cited 2016 Feb 17]. Available from: http://projects.msh.org/http://dhsprogram.com/What-We-Do/Survey-Types/upload/AMR_Mod_8_5_8_FINAL.pdf
1.
Kållberg C. Medical students’ views on the current and future antibiotic resistance situation [Internet]. [Gothenburg]: University of Gothenburg; [cited 2015 Jul 8]. Available from: http://www.reactgroup.org/wp-content/uploads/2016/10/Medical-students’-views-on-the-current-and-future-antibiotic-resistance-situation.en_.319.pdf
1.
Ross-Degnan D, Vialle-Valentin C, Briggs J. Improving Medicines Access and Use for Child Health—A Guide to Developing Interventions [Internet]. Systems for Improved Access to Pharmaceuticals and Services, editor. Management Sciences for Health; 2015 [cited 2016 Apr 12]. Available from: http://www.msh.org/resources/improving-medicines-access-and-use-for-child-health%E2%80%94a-guide-to-developing-interventions
1.
Visschers VHM, Backhans A, Collineau L, Loesken S, Nielsen EO, Postma M, et al. A Comparison of Pig Farmers’ and Veterinarians’ Perceptions and Intentions to Reduce Antimicrobial Usage in Six European Countries. Zoonoses and Public Health [Internet]. 2016 [cited 2016 Apr 5];n/a-n/a. Available from: http://doi.wiley.com/10.1111/zph.12260
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World Health Organization - WHO. Antibiotic resistance: Multi-country public awareness survey [Internet]. Geneva, Switzerland: World Health Organization - WHO; 2015 Nov [cited 2015 Nov 20] p. 51. Available from: http://www.who.int/drugresistance/documents/baselinesurveynov2015/en/
1.
Panagakou SG, Theodoridou MN, Papaevangelou V, Papastergiou P, Syrogiannopoulos GA, Goutziana GP, et al. Development and assessment of a questionnaire for a descriptive cross-sectional study concerning parents’ knowledge, attitudes and practises in antibiotic use in Greece. BMC Infect Dis [Internet]. 2009;9:52. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19413902
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Thriemer K, Katuala Y, Batoko B, Alworonga J-P, Devlieger H, Van Geet C, et al. Antibiotic prescribing in DR Congo: a knowledge, attitude and practice survey among medical doctors and students. PLoS ONE [Internet]. 2013;8(2):e55495. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23441152
1.
Huang Y, Gu J, Zhang M, Ren Z, Yang W, Chen Y, et al. Knowledge, attitude and practice of antibiotics: a questionnaire study among 2500 Chinese students. BMC Med Educ [Internet]. 2013;13:163. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24321449
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Jose J, Jimmy B, Alsabahi AGMS, Al Sabei GA. A study assessing public knowledge, belief and behavior of antibiotic use in an omani population. Oman Med J [Internet]. 2013 Sep;28(5):324–30. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3769127/
1.
Sanchez GV, Roberts RM, Albert AP, Johnson DD, Hicks LA. Effects of Knowledge, Attitudes, and Practices of Primary Care Providers on Antibiotic Selection, United States. Emerging Infectious Diseases [Internet]. 2014 [cited 2015 Mar 11];20(12):2041–7. Available from: http://wwwnc.cdc.gov/eid/article/20/12/14-0331_article.htm