Antibiotic use and antimicrobial resistance: Knowledge, Attitude and Practices survey of medical students to evaluate undergraduate training curriculum
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Introduction. A better understanding of knowledge, attitude and practices of undergraduate medical students towards antimicrobial resistance (AMR) is necessary to identify gaps in the current training curriculum.
Methods. A 20-point Likert scale-based questionnaire divided into three parts, knowledge, attitude and practices, relating to antibiotic use and resistance was devised. Students attending each year of the undergraduate medical programme were approached to participate in the study over a 1-week period. Knowledge, Attitude and Practices scores of each year were compared through logistic ordinal regression and the Kruskal–Wallis (KW) test.
Results. Two hundred and eight students participated in the study. Overall, knowledge of about intended use of antibiotics, fixed drug combinations and awareness about AMR was good (average score of 73.75%). Steady improvement in knowledge scores was observed from the first year (−0.441) to the final year (0.00). The medical students had favourable attitude towards rational antimicrobial use (Likert score ≥4), including the need to spread awareness about AMR amongst students and the public and following doctor’s prescriptions. Self-medication was reported by 28.4% of students and hoarding of leftover doses by 49.1%. Attitude score had a direct correlation with the knowledge score on the KW test ( χ 2 =29.6, P ≤0.5) but had no significant correlation with antimicrobial practices ( χ 2 =3.9, P ≥0.5). The gaps identified in students’ practices included self-medication, skipping of dosing and hoarding of leftover medication.
Conclusion. As improvement in knowledge did not correlate with better personal behaviours regarding antibiotics, the current curriculum needs to include AMR as a focus area to ensure good antibiotic prescribing practices in future practitioners.
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I am pleased to tell you that your article has now been accepted for publication in Access Microbiology. The work presented is clear and the arguments well formed.
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Comments to Author
This is now a much stronger and clearer paper. Excellent work on revisions.
Please rate the manuscript for methodological rigour
Good
Please rate the quality of the presentation and structure of the manuscript
Very good
To what extent are the conclusions supported by the data?
Strongly support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
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The reviewers have highlighted major concerns with the work presented. Please ensure that you address their comments.
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Comments to Author
The gap highlighted between knowledge and medical student personal practices is interesting. lines 95-97: total response rate for # of students offered to participate vs surveys collected should be stated. Is it ~ 42 out of the ~ 180/ year stated in the introduction? Lower response rates are common in medical education but should still be stated and the potential for responder bias acknowledged in the discussion of limitations of the study. 94-97 Background-wise, are these medical students representative in terms of background, gender, other demographics, or was this information not collected as part of the survey aside from year in school? This can be helpful to understand how and whether results can be extrapolated to other populations. Is there an institutional research board review or …
Comments to Author
The gap highlighted between knowledge and medical student personal practices is interesting. lines 95-97: total response rate for # of students offered to participate vs surveys collected should be stated. Is it ~ 42 out of the ~ 180/ year stated in the introduction? Lower response rates are common in medical education but should still be stated and the potential for responder bias acknowledged in the discussion of limitations of the study. 94-97 Background-wise, are these medical students representative in terms of background, gender, other demographics, or was this information not collected as part of the survey aside from year in school? This can be helpful to understand how and whether results can be extrapolated to other populations. Is there an institutional research board review or similar? 105: The results and discussion merge is unusual. Preference that is likely shared by many readers is to consolidate the data into the results section and then expound upon potential meanings and interpretations as well as future directions and limitations in the discussion. Lines 105-127, 182-184,for example, share many findings of the study and offer comparisons to other studies from other countries. A discussion positing why some of those differences might exist would be interesting, potentially grounded in the types of education on the subject that the students in this study had received. 151-153 curious if there is a better way to report these statistics than the ordinal regression scale, which is confusing. The average score of 5.9 out of 8- what does this translate to? 154-161: gratifying to see the change in scores over the clinical years. How might this inform education? Is there any training that contributes to this specifically in the clinical years or clinical exposure in general? In the comparison studies cited, are the same questions used? (IE lines 197-198 about self-medication, is this difference due to how the question was asked or favored to be a true difference in practice?) Where the questions used in this study from previously used/validated scales or developed independently? I see back in the methods 81 that the questionnaire was pre-designed, what does this mean precisely? Surveys are typically designed prior to their implementation in a study- does the "pre" in this case mean a pre-existing survey? Were prior surveys from the studies in other countries cited in the results/discussion consulted? 231- knowledge scores had no correlation to attitude or practices score. This is interested and somehow not terribly surprising, some discussion about this would be helpful, as the next paragraph notes a need for more teaching methods (236-239) however if knowledge does not affect attitudes it's unclear that this will help, isn't it. 240: in the conclusion section, would like to see discussion of strengths/limitations of this study and future directions. Overall, this is an interesting study and likely contributory to knowledge of antimicrobial resistance and stewardship among medical students in India. It would be strengthened by elaborating upon the discussion as above with recommendations about next steps for how this information can be translated into educational practice (either what actions should be taken directly in education based on these results or what further research is needed in order to operationalize this knowledge into new informed educational practices?). I am ended by reading the prior response to reviewers, I see the request for discussion/results separation has come up before and I see the response. The results could still contain the comparison to other studies with the discursive results then expanded upon separately in a discussion section. I see similar prior confusion about the 5.9/8. The clarification is that the yes/no questions on knowledge are viewed as having a correct and an incorrect answer, and the average student scored 5.9/8 correctly. This was not clear to me, nor to the prior reviewer it seems on first review. It would be helpful to spell this out for future readers to make it easier to comprehend on first pass.
Please rate the manuscript for methodological rigour
Satisfactory
Please rate the quality of the presentation and structure of the manuscript
Satisfactory
To what extent are the conclusions supported by the data?
Strongly support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
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Comments to Author
1. Methodological rigour, reproducibility and availability of underlying data:Authors have conducted a KAP surveillance of antibiotic usage and resistance amongst undergraduate medical students. They have verified the self-administered questionnaire was verified before use and as such the data can be reproduced. 2. Presentation of results: Results are presented in a comprehensive and easily understandable figures and tables 3. How the style and organization of the paper communicates and represents key findings:The results are well communicated.Key findings are organised in sections related to knowledge, attitude and practice 4. Literature analysis or discussion: Relevant to the findings 5. Any other relevant comments
Please rate the manuscript for methodological rigour
Very good
Comments to Author
1. Methodological rigour, reproducibility and availability of underlying data:Authors have conducted a KAP surveillance of antibiotic usage and resistance amongst undergraduate medical students. They have verified the self-administered questionnaire was verified before use and as such the data can be reproduced. 2. Presentation of results: Results are presented in a comprehensive and easily understandable figures and tables 3. How the style and organization of the paper communicates and represents key findings:The results are well communicated.Key findings are organised in sections related to knowledge, attitude and practice 4. Literature analysis or discussion: Relevant to the findings 5. Any other relevant comments
Please rate the manuscript for methodological rigour
Very good
Please rate the quality of the presentation and structure of the manuscript
Good
To what extent are the conclusions supported by the data?
Strongly support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
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The work presented is clear and the arguments well formed. I invite you to address the comments from reviewer 1, especially in terms of making figures' colours more accessible.
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Comments to Author
This is a descriptive study of the knowledge and attitudes of medical students in India to aspects of antimicrobial resistance and stewardship. I believe it has been submitted as a short communication though no word-count is shown. Short communication would be the appropriate article type rather than a research article. The structure of the paper requires some revision. Currently the results section is heavily interspersed with discursive comments. The results should be presented first, followed by the discussion, in which comparisons may be made with previous studies, etc. The figures need to be improved by replacing the cross-hatched effects with more clearly demarcated grey-scale, for both the bar charts and the pie chart. They are difficult to read currently. Figure 3 is identical to Figure 2, I …
Comments to Author
This is a descriptive study of the knowledge and attitudes of medical students in India to aspects of antimicrobial resistance and stewardship. I believe it has been submitted as a short communication though no word-count is shown. Short communication would be the appropriate article type rather than a research article. The structure of the paper requires some revision. Currently the results section is heavily interspersed with discursive comments. The results should be presented first, followed by the discussion, in which comparisons may be made with previous studies, etc. The figures need to be improved by replacing the cross-hatched effects with more clearly demarcated grey-scale, for both the bar charts and the pie chart. They are difficult to read currently. Figure 3 is identical to Figure 2, I believe the wrong figure has been inserted. Other comments: There are numerous grammar and syntax errors requiring correction, I have not highlighted these. Abstract, Page 2, line 32: there appears to be an error in the knowledge score reported for final year students (recorded as 0.0) and also it is not clear how the knowledge score reported for 1st years (0.44) relates to the overall score recorded of 5.9 out of 8. This all needs clarification. What is a 'favorable attitude towards rational antimicrobial use' - does this mean 'students understood the importance of rational antimicrobial use'? Please clarify. Abstract page 2, Line 38, Conclusion: The first sentence of the conclusion is a result and should move to results section. The second sentence should be reworded to 'Improvement in knowledge did not correlate with better personal behaviours regarding antibiotics. The current undergraduate medical curriculum needs to include AMR….' Introduction, page 3, line 62: The existence of published recommended agreed AMS competencies for medical students should be mentioned: McMaster, D, Courteney M, Santucci, C, Davies, AP, Kirby, A, Seddon, O et al. 2020. JAC-AMR Consensus-based antimicrobial resistance and stewardship competencies for UK undergraduate medical students. 2020. JAC-Antimicrobial Resistance https://doi.org/10.1093/jacamr/dlaa096. These provide an agreed framework for medicals schools to apply. Results, page p 5, lines 100 -105: This section should go in the methods. Line 104: Refer to 208 students here (not the 211, of which 3 were excluded) Table 1, 3rd cell down in '1st year' column: Should this read '0%' or is '0' an error? Either way, please correct. Results, page 8, lines 132 - 142 - the discussion of drug combinations is not a result and should go into the discussion section. Line 135 - 'irrational combinations' - give an example. Results, page 8, lines 142 - 144: this is discussion not results. Results page 8 & 9, lines 145-146 and Figure 1: please improve Figure 1 by using block grey scale rather than cross-hatching. There is a problem with the question asked of the students here. If they were asked 'What is the most common cause…' they had to pick one of several factors all of which they might know were contributing to AMR. Therefore it is not possible from such a response to state that 'students were unaware about the abuse of antibiotics in animals and agriculture…' - they may simply have though that abuse in humans was a more common problem. Please rephrase this section to accurately reflect the information gathered. Results p 9 line 162: 'attitude of students towards antimicrobial use was favourable…': as in the abstract, the meaning of this is unclear, please clarify. Results p 10, line 168-170: this is discussion, not results Figure 2: please make the figure clearer by using block grey scale rather than cross hatching. Clarify in the Figure legend the corresponding scores on Likert scale (is 'strongly agree' a score of 5?). The data in the 6th column ('Skipping a few doses should not affect development of AMR' does not correspond with the same data presented in the text in lines 179-180 - please correct. Page 10/11 lines 180 - 181: this is discussion Page 11: most of this page is discussion rather than results Figure 3 is identical to Figure 2.
Please rate the manuscript for methodological rigour
Satisfactory
Please rate the quality of the presentation and structure of the manuscript
Poor
To what extent are the conclusions supported by the data?
Partially support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
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