Team:IISc-Bangalore/Survey
Survey
To gauge people's awareness of antibiotics, antibiotic resistance, phage therapy and the laws concerning them we designed a survey and propagated it among as many people as we could in the month of July. As we were more interested to know the stakeholders' (medical professionals and researchers) viewpoint, the survey was distributed keeping that in mind. That is the only source of bias in the survey, and is completely unintentional.
Aims of the Survey
- To know more about antibiotic usage – frequency and type.
- To gauge public awareness about antibiotic resistance – especially across people engaged in Medical Sciences and Research.
- To sample people’s awareness about alternatives to antibiotics to combat bacterial infections, especially bacteriophages and phage therapy.
- To determine public knowledge about the laws (if they exist) that regulate antibiotic resistance and phage therapy.
Survey Design Considerations
Our questions were designed to extract maximum information from the least number of questions to minimize the time it takes for a respondent to fill it to the best of his/her knowledge.
To accomplish this, we did a Pre-test, with a few potential respondents. Based on their feedback, we optimized our questions to give the essence of a Linkert Scale type question, wherever possible.
Our optimization efforts led to the average time required to fill the survey to drop down to 6 minutes.
We tried our best to keep the questions unbiased, understandable, fair and to the point, which ensured no frivolity to waste our respondents’ time.
The survey was analyzed using the New Dale – Chall readability index, which gave the result as 9th to 10th Grade understanding[1], and the Readability consensus which is a combination of 8 readability tests (SMOG, Gunning Fog, Coleman-Liau test etc.) which gave the result as 8th Grade understanding[2]. This just indicated that to understand the questions of our survey, a person needs to have an education of a tenth grader. This is a very reasonable requirement of our respondents, given the target audience, and ensures there is no bias due to low understanding of the questions.
Name was asked to ensure the uniqueness of the respondents even though this information wasn’t used anywhere in the analysis part of the survey-the survey was completely anonymous and does not make use of any private details.
Profession was asked to segregate the data into medical, research and others. This was done essentially to separate the stakeholders from the general population to gauge their views and integrate them into our project.
Area of expertise of the respondents allowed us to know what the respondents did for a living, thereby helping us to check how workplace determines their views and knowledge about the questions asked in the survey. The distribution of expertise, while certainly large, got slightly skewed towards a few occupations due to the method of dissemination of the survey.
Experience of the respondents also helped us in the better analysis due to segregation of data and see if the awareness of people has changed over time or not. It also helped determine the proportion of our respondents in various stages of their career.
The other questions were necessary for information collection and have been designed for that purpose.
Our Survey
Please download the attached PDF to view our survey questionnaire
RESULTS
Close to half our respondents were medical professionals, while another 18% of the respondents were researchers in various fields – ranging from physics to biology. These respondents are of special importance to us as they are the primary stakeholders – it is the researchers who develop newer methods of treatment, while it is the medical professionals who use them, making them both equally important.
Our respondents are concentrated in the two extremes of our given experience classification – Close to 90% are concentrated in these two brackets – another artifact of our method of distribution. This helps us to study the evolution of viewpoints and awareness across times.
Assuming an average age of 22 for a college graduate beginning a job, we get 43.4% concentrated in the age group 22 to 27, and another 47.3% above the age of 37. That can be another measure for the determination of the required information.
Antibiotic Usage
The antibiotic with the highest incidence of usage is Amoxicillin, with 75% of respondents having used it. Azithromycin is a close second, with approximately 60% having used it, with other antibiotics following in order. The fact that there are just a few other antibiotics mentioned shows their dominance in the Indian Market.
71% of the survey takers report that they take antibiotics a few times a year, with a further 23% saying that they take it less frequently than that. 3% take them daily and a further 3% take them monthly, showing an extraordinary lack of awareness of the negative effects of antibiotic overuse. Efforts must be made to rectify this.
Among the respondents, who are majority medical professionals and researchers, only 4% have never heard of antibiotic resistance – a very small number, as expected. Considering that 33% are neither, it shows an admirable public awareness, at least about the presence of antibiotic resistance, if not the details of it.
52% of the Doctors and Researchers claimed to have encountered an antibiotic-resistant case, with almost all of them agreeing that the incidence of such cases is on the rise. The details ranged from horrific accounts of XDR (Extremely Drug Resistant) Tuberculosis to the now widespread, but no less horrific, MRSA (Methicillin-resistant Staph Aureus).
73% of our respondents believe that the best way to combat antibiotic resistance is to make law reforms and enforce them, with research on alternative therapies a distant second. Our respondents seem to have a less of a belief in antibiotic research, as only about 20% felt that that was the way to go forward.
Approximately 54% of the respondents have no idea about the laws governing antibiotic resistance. Only 4% claimed to know the laws and believe in their sufficiency, while a massive 42% believe the laws are insufficient. This shows a tremendous lack of knowledge and belief in the laws existing for this purpose and must be rectified.
Close to 90% of the respondents have little to no idea about phage therapy, with just a measly 11.4% claiming to know about it. This just shows the extreme success that antibiotics have had – so much so that one of the most prominent alternative therapies is almost unknown. The fact that approximately 50% have at least heard of it, is a positive, as that implies that awareness is growing.
A clear majority of people believe that viruses should be used only when we are confirmed about them not infecting us. While this is a pragmatic answer, it shows a lack of knowledge on the respondents’ part about viral specificity. Close to one – fifth of the respondents recognize the risks of the situation and believe in the importance of bacterial viruses. About a tenth believe biological agents shouldn’t be used for therapeutics – a paranoid belief - while a minuscule minority (approximately 3%) believe all viruses are dangerous.
People who claim they know about phage therapy are accurate in a bare-bones sort of understanding of phage therapy. It is evident that a lot of education is required before certifying competency. But almost all of them are woefully uninformed about the laws governing them, with close to half (34 out of 77 respondents) saying they have absolutely no idea about it.
Conclusions
- The spread of antibiotic usage is heavily skewed in favour of the antibiotics mentioned in the graph – Amoxicilin and azithromycin are used enough in the Indian market for an antibiotic resistance flag to be raised about them, for their potential misuse. Considering most of the respondents were the medical professionals, further shows the need to specifically evaluate their consumption.
- Antibiotics should be limited to an average of less than nine daily doses a year per person in a bid to prevent the rise of untreatable superbugs.[3] Among our respondents, 94% adhere to it, which is a highly positive takeaway, yet at the same time, the survey being an online one may have its limitations in projecting these numbers to the actual Indian population.
- Most of our respondents had heard of antibiotic resistance quite early in their education, which is again a positive takeaway. The awareness campaigns undertaken by several groups seems to have an impact, as the second highest percentage comprised of people who had heard of AMR in the past 5 years.
- Majority of the respondents agree that the cases of antibiotic resistance have risen alarmingly in the recent years – from untreatable skin infections to transplants and from XDR-TB to MRSA.
- More than half the respondents did not know about the laws governing antibiotic resistance, and of even those who did, 91% believed that the laws are insufficient. Considering the occupations of the respondents, we would like to emphasize the need to have a look at the laws governing them.
- Close to 90% of our respondents have little to no knowledge about phage therapy. Given that phage therapy has been touted to be the best alternative we have to antibiotics, this is a concerning issue as laws governing them are undergoing review around the world.
- 73% of our respondents believe law and order changes would ameliorate the issue of antibiotic resistance, despite most admitting that they were unaware of the current laws. This seems to place the onus for tackling antibiotic resistance onto the policymakers, whereas change would need to be implemented at the grassroots level to have the necessary effect. Antibiotic research funding is considered the best by a far fewer percentage than expected, showing that the stakeholders might finally be deciding to move beyond the obvious solutions and explore alternatives like phage therapy and nanomaterials.
- People also seem to have a very negative viewpoint about viruses, with most people associating viruses with “cause deadly infection”. While true for humans, this shows a dangerous lack of information, as bacteriophages are viruses themselves, and there were few people who brought up the possibility of the viruses targeting organisms different from humans. This suggests the need to consider the environmental and ecological implications of phage therapy.
- Ignorance pervades people’s viewpoints about viruses – a lack of trust is displayed on their usage – not recognizing the large diversity among viruses. A proper education goes a long way in clearing off misinformation that threatens to derail introduction of any phage-based treatments, which is likely to happen if these misconceptions are not cleared.
Thus, keeping in mind the aforementioned Results and Conclusions, we prepared a host of undertakings to actively participate in the process of increasing awareness among the general public about antibacterial resistance, bacteriophages and phage therapy, as continued ignorance would be a major obstacle in overcoming the looming threat of widespread antimicrobial resistance. We also incorporated these concerns into the design of lab experiments to further investigate the issues which our survey brought forth.
References
[1] http://www.readabilityformulas.com/free-dale-chall-test.php
[2] http://www.readabilityformulas.com/free-readability-formula-tests.php
[3] https://www.independent.co.uk/news/science/antibiotic-resistance-superbugs-united-nations-penicillin-doses-limit-a7197841.html