Significant gaps in practise present despite higher level of public awareness in Antibiotic Use and Antimicrobial Resistance in the western province of Sri Lanka
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Background: Antibiotic misuse, influenced by urbanization and limited healthcare access, has accelerated antibiotic resistance, impacting global health. Surveillance in Sri Lanka's National Strategic Plan for Combating Antimicrobial Resistance (2017-2022) shows significant multi-drug resistance in hospitals, with 12.7% of the health budget (3.3 billion) spent on antimicrobials. This resistance complicates treatment and increases patient management costs, particularly in the Western Province, a focal area for analyzing antibiotic misuse. Objectives: To assess public awareness of antibiotic misuse and antimicrobial resistance in the Western Province of Sri Lanka. Methodology: A cross-sectional study was conducted on 200 adults in the Western Province from December 23, 2023, to January 16, 2024, using in-person interviews and a Google form questionnaire. Descriptive statistics were applied to analyze the data. Results: Of the respondents, 83% knew antibiotics combat bacterial infections, while 71.5% adhered to completing antibiotic courses. However, 28.5% opposed doing so, with 65.5% stopping antibiotics once they felt better. Regarding antimicrobial resistance, 60.5% recognized the term, and 61% acknowledged that unnecessary antibiotic use could increase bacterial resistance. Conclusion: Most participants understood antibiotics' role, though gaps in correct use and awareness of misuse consequences persisted. While there was a positive attitude toward antimicrobial resistance, further educational efforts are essential to address knowledge gaps, as recent studies show high resistance levels and limited progress in awareness. Keywords: AMR; Antibiotic resistance; antimicrobial resistance; Knowledge; Awareness; Sri Lanka
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Thank you for submitting your paper to Access Microbiology. It has now been reviewed and I would like you to revise the paper in line with the reviewers' reports.
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Comments to Author
Thank you for your continued work on this manuscript. The topic is timely and important, and the study offers useful insights into public knowledge and behaviours relating to antibiotics and antimicrobial resistance in Sri Lanka. The revisions made so far have strengthened the paper, and I appreciate the effort taken to address earlier comments. To help further improve clarity and reproducibility, I offer the following suggestions: 1. It would be helpful to expand on how participants were approached across different districts and whether any informal quotas or targets were used to enhance diversity within the convenience sample (Lines 192-198). 2. The pilot testing is clearly described, although the use of a university-student pilot group could be acknowledged more clearly as a limitation, given …
Comments to Author
Thank you for your continued work on this manuscript. The topic is timely and important, and the study offers useful insights into public knowledge and behaviours relating to antibiotics and antimicrobial resistance in Sri Lanka. The revisions made so far have strengthened the paper, and I appreciate the effort taken to address earlier comments. To help further improve clarity and reproducibility, I offer the following suggestions: 1. It would be helpful to expand on how participants were approached across different districts and whether any informal quotas or targets were used to enhance diversity within the convenience sample (Lines 192-198). 2. The pilot testing is clearly described, although the use of a university-student pilot group could be acknowledged more clearly as a limitation, given the difference from the target population (Lines 226-235), as highlighted in the discussion. 3. Including a brief note on the number of declined or incomplete responses would clarify the response rate (Lines 188-207). 4. The questionnaire itself, and especially the scoring system used to categorise "good" and "poor" knowledge, is not provided. Because this scoring underpins the logistic regression analysis, readers need access to these details to fully understand and reproduce the work. 5. The logistic regression also includes a large number of predictors in a relatively small sample. This appears to have resulted in very large odds ratios and wide confidence intervals in some instances (Table 6). Please describe how predictors were chosen and consider simplifying the model, or provide a stronger caution about limited stability of the model. 6. For Figures 1 and 2, the captions refer to colour-coded elements that may not be easily distinguishable when printed in greyscale or to colourblind readers. Adjusting captions could improve accessibility and you might consider alternative colours or crosshatching for accessibility (Lines 359-362). 7. In some places, results are interpreted rather than reported factually. For example, describing awareness as "high" seems inconsistent with the finding that 65.5% of participants stop antibiotics early (Table 2). It would be helpful to present these findings more neutrally in the Results section and explore interpretation in the Discussion.
Please rate the manuscript for methodological rigour
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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It has now been reviewed and I would like you to revise the paper in line with the reviewers' reports.
-
Comments to Author
Lines 134-140 appear to contain repetition of a similar theme and take away meaning from the text. The study is described as a cross-sectional descriptive study, but lacks a clear justification for why this design was chosen over alternatives (e.g., longitudinal or mixed-methods). Authour could include a rationale for the chosen design and discuss its limitations in capturing behavioral change over time. Agree with Reviewer 1 comments that the sample size was limited to 200 participants, below the recommended 400-600 for regional representation. This small sample size may reduce statistical power and the ability to detect meaningful associations. However, given the nature of the project and the meaningful output, I would suggest for the author to acknowledge this limitation more prominently within …
Comments to Author
Lines 134-140 appear to contain repetition of a similar theme and take away meaning from the text. The study is described as a cross-sectional descriptive study, but lacks a clear justification for why this design was chosen over alternatives (e.g., longitudinal or mixed-methods). Authour could include a rationale for the chosen design and discuss its limitations in capturing behavioral change over time. Agree with Reviewer 1 comments that the sample size was limited to 200 participants, below the recommended 400-600 for regional representation. This small sample size may reduce statistical power and the ability to detect meaningful associations. However, given the nature of the project and the meaningful output, I would suggest for the author to acknowledge this limitation more prominently within text and consider power calculations to justify sample adequacy. Data collection occurred over a very short period (January 12-20, 2024), in documentation - hwoever in the methodology abstract, states 23 December 2023 - 16 January 2024. This needs clarifying as one is incorrect. Timeframe of study is incredibly short and within a very specific window. This narrow window may not account for additional variables that could influence current knowledge (e.g., seasonal illness patterns, increased ABx information or public health campaigns). The author could acknowledge this limitation and suggest potential rationale as to why this would benefit. A pilot test was conducted, but the sample size and demographic profile of pilot participants are not specified. Author could include details on the pilot sample, how feedback was collected (if the same way as in the actual questionairre), and specific changes made to the questionnaire. The study employed a convenience sampling method across three districts in urban/semi urban areas. This sampling technique may introduce selection bias and limit the generalisability of findings. This may exclude rural or marginalised populations, skewing results toward more educated or health-aware individuals. The study describes the survey as interviewer-administered, but the appendix refers to it as self-administered via Google Forms. This inconsistency may confuse readers and raise questions about data collection integrity. The authors should clarify the exact mode of administration and ensure consistency across all sections. Despite previous comments in review, only descriptive statistics and Chi-square tests were used. The absence of any multivariate analysis (e.g., logistic regression) limits the ability to control for confounding variables. Even with a small sample, exploratory regression models could provide deeper insights and strengthen these findings, whilst aknolwedging potential downfall to smaller sample sizes for a 'population wide' study. If this is not feasible, highlight this, and potential reasons as to why. The manuscript initially confused "antibiotic resistance" and "antimicrobial resistance." Although corrected in places, this may still cause confusion if not consistently applied throughout. For example, questions are asked around antimicrobial resistance, but titled under antibiotic resistance in Table 3. Ensure terminological consistency in all tables, figures, and discussion. That being said, the paper does go a long way to providing insight into antimicrobial knowledge in Sri Lankan communities. The use of a multilingual questionnaire increases inclusivity if the study whilst appropriate ethican and informed consent information are provided and handled correctly. The use of visualizations (bar charts, pie charts) enhances data presentation and provides good insight alongside written text and there is acknowledgment of limitations and student-led nature of the study. The study is well organised and flows mostly, except for areas highlighted.
Please rate the manuscript for methodological rigour
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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Thank you for submitting your paper to Access Microbiology. It has now been reviewed and I would like you to revise the paper in line with the reviewers' reports and any Editorial Office requirements below. The reviewer reports can be found at the bottom of the email.
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Comments to Author
Thank you for the opportunity to review this important manuscript addressing perceptions of antimicrobial resistance (AMR) in Sri Lanka. The topic is highly relevant and timely; however, I would like to offer the following suggestions to strengthen the study design and improve the overall impact of the article. Study Design Improvement: The current methodology would benefit from a more robust study design. It is recommended that the authors clearly define the target population, sampling strategy, and inclusion/exclusion criteria. Typically a sample size of 400-600 would be needed to ensure representation of the population in the region. Statistical Analysis: To enhance the significance and relevance of the findings, I suggest that the authors perform appropriate statistical analyses. These may …
Comments to Author
Thank you for the opportunity to review this important manuscript addressing perceptions of antimicrobial resistance (AMR) in Sri Lanka. The topic is highly relevant and timely; however, I would like to offer the following suggestions to strengthen the study design and improve the overall impact of the article. Study Design Improvement: The current methodology would benefit from a more robust study design. It is recommended that the authors clearly define the target population, sampling strategy, and inclusion/exclusion criteria. Typically a sample size of 400-600 would be needed to ensure representation of the population in the region. Statistical Analysis: To enhance the significance and relevance of the findings, I suggest that the authors perform appropriate statistical analyses. These may include: Descriptive statistics (means, medians, standard deviations) to summarize baseline characteristics. Chi-square tests or Fisher's exact tests for categorical data comparisons. Logistic regression analysis to identify predictors of antibiotic misuse or awareness. Confidence intervals and p-values should be included to support statistical validity. Language of the Survey: It would be helpful for the readers to know whether the survey was conducted in English, local languages such as Sinhala or Tamil, or both. If local languages were used, please specify which ones and whether the questionnaire was translated and back-translated to ensure accuracy and consistency. Data Visualization: To improve the clarity and visual impact of the article, I recommend converting key data presented in tables into graphical formats such as: Bar charts or pie charts for distribution of responses. Stacked bar graphs for comparative demographic trends. Effective visualizations will greatly enhance the readability and interpretability of your data. Sorting the data based on relevant parameters and comparing them in the form of graphs may provide important insights that may be overlooked in a table. These enhancements will not only improve the scientific rigor of your article but also increase its appeal and accessibility to a broader audience.
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?
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
-
Comments to Author
Overall, the manuscript is an insightful study on antibiotic use and AMR awareness in Sri Lanka. It is well-conceived and relevant to local and international audiences. Some refinements to language, data presentation, and depth of analysis would improve readability and impact. The language is generally understandable, although would benefit from review to improve clarity and maintain an academic and professional tone. Some sentences were repeated multiple times in the Introduction, Discussion and Conclusion. 'Antibiotic resistance' and 'antimicrobial resistance' are sometimes used interchangeably, and whilst related, the distinction should be made clear from the outset. Check for inconsistencies in descriptions, e.g. listing 1/5th as 33.5% is confusing without additional context. Likewise, …
Comments to Author
Overall, the manuscript is an insightful study on antibiotic use and AMR awareness in Sri Lanka. It is well-conceived and relevant to local and international audiences. Some refinements to language, data presentation, and depth of analysis would improve readability and impact. The language is generally understandable, although would benefit from review to improve clarity and maintain an academic and professional tone. Some sentences were repeated multiple times in the Introduction, Discussion and Conclusion. 'Antibiotic resistance' and 'antimicrobial resistance' are sometimes used interchangeably, and whilst related, the distinction should be made clear from the outset. Check for inconsistencies in descriptions, e.g. listing 1/5th as 33.5% is confusing without additional context. Likewise, describing a value of 48% as 'minute' is confusing. Try to be consistent with British versus American English spellings and grammar. The introduction presents the issue of AMR and sets up the study's significance. It would be helpful to frame how the Western Province of Sri Lanka represents a relevant study area in the international context. To be clear - I think it absolutely is an important study area - but it would be helpful to mention how similar issues are observed worldwide to frame where this study sits within the wider context of global AMR. The methods section is detailed. It would be helpful to see more information around the sampling process and questionnaire validation. It is helpful to know that the survey was adapted from a similar study in Ethiopia; why was this survey chosen as the baseline? How was your survey adapted? How did you pre-test the questionnaire for local relevance? It would also be helpful to understand any statistical tests or analysis methods used, even if no inferential statistics were preformed. The methods describes the survey as interview-administered, however, confusingly, the Appendix describes it as self-administered. The limitations are well-considered, although would be more clear if we could understanding your sampling process. The results section is very detailed. It would be helpful to standardise how you report sample sizes (n) and percentages throughout this section. It is very descriptive and may benefit from more detailed and nuanced analysis. For example, are there any links whereby certain groups were more likely to respond the same way? Also, ensure that the focus remains on key findings rather than extraneous details. The discussion is detailed and covers a range of relevant topics. In several places, the discussion would benefit from deeper interpretation and critical analysis, rather than descriptive comparison. For example, when discussing the reasons why some populations, despite high access to antibiotics through prescription, fail to complete the full course: is this due to cultural beliefs? Perceived side-effects? Something else? In the next subsection, the comparison to other countries is interesting, but it is not clear why you are comparing these countries. What insights are you trying to convey? For example, are you trying to explore socioeconomic and cultural differences impact antibiotic usage across these countries? Or something else? Similarly what are you trying to convey when discussing awareness of AMR amongst healthcare students compared to the public? The discussion may also benefit if you can link the findings back to global AMR efforts. How can your findings inform national and international strategies in combatting AMR?
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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