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 WHO 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. It provides a theoretical framework, practical suggestions, and 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 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; Use data as evidence to influence design of health education campaigns (such as on antibiotic resistance) and choice of content for training health professionals.
Example case: Conducting a behavioral analysis on the utilization of diagnostics for infectious diseases
Background: Physicians in a pediatric outpatient department often order diagnostic tests for their patients to help determine the cause of illness and need for antibiotics. However, physicians have noticed that many patients never return for test results and follow-up. To understand why, a behavioral analysis using the Behaviour Change Wheel and its integrated COM-B model for understanding behavior was done. Observations and semi-structured interviews were used to capture the complexities of diagnostic service provision and the contextual and behavioral factors shaping diagnostic use and delivery.
Context: Caregivers of children coming to the outpatient department of a rural tertiary teaching hospital in central India.
Finding: Diagnostics are generally accepted and their purpose understood by the caregivers of the children. However, the organization of diagnostic services (opening hours, waiting times), direct and indirect costs hinder them from using the diagnostics. Improvements in accessibility and affordability may increase caregiver motivation to use diagnostics and return for follow-up. The findings will inform next steps in choosing appropriate interventions and implementation strategies to improve the utilization of diagnostics in this setting.
Example case: 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.
- 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.
KABP surveys: Tools, templates and guidelines
|The KAP Survey Model (Knowledge, Attitudes, and Practices)||Manual to knowledge, attitudes and practice studies. Contains an explanation of what KAP studies are, step-by-step guidance on how to prepare and conduct a study and highlights some common pitfalls.|
|The KoBoToolbox||Open-source and free mobile data collection tool for use in challenging and low-resource environments. Examples showing how the KoBoToolbox has been harnessed for designing and analyzing surveys that evaluated knowledge, attitudes, beliefs, and practices can be found here.|
|AMUSE livestock, version 2 – Antimicrobial use in livestock production: A tool to harmonise data collection on KAP||Questionnaire. A generic questionnaire (30-40 min) to assess knowledge, attitudes and practices relating to antimicrobial use among individuals managing livestock in LMICs. Can be used across species and food animal production systems. Targets animal keepers in LMICs.|
|Antibiotic prescribing and resistance: Views from low- and middle-income prescribing and dispensing professionals (PDF 0,8MB)||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.|
|Hand Hygiene: Monitoring tools||Tools and templates from WHO for evaluation and feedback on hand hygiene interventions, including:
Targets 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. Targets 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. Targets 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. Targets human health professionals.|
|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 ). Targets the public.|
|Antimicrobial Resistance Module for Population-Based Survey (PDF 0,5MB)||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. Targets 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. Targets 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. Targets the public.
|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:
|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. Targets 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. Targets 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. 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:
|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.|
|Conducting KAP Surveys: A Learning Document Based on KAP Failures||Guide from ACF international, focusing on valuable lessons learned from work with knowledge, attitudes and practices (KAP) surveys. Provides advice on how to avoid common pitfalls, and describes usual problems in study design, data analysis and reporting.|
|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.|