Knowledge, Attitudes, and Practices of Antimicrobial Use and Resistance among Village Animal Health Workers and Veterinary Drug Retailers in Cambodia ()
1. Introduction
Misuse and overuse of antimicrobials or antibiotics (ATBs) in agriculture and food production is a significant driver of antimicrobial/antibiotic resistance in humans. Resistant bacteria are transferred to humans through multiple pathways including direct contact with farmed animals; animal waste; the spreading of manure from livestock production as fertilizers on crops; and ingested food produced at the farm contaminated by resistant bacteria [2]. Rising levels of AMR are threatening key areas of global health, food security, economic growth and development. If no action is taken, AMR will impact human and animal health with excess deaths and suffering [3]. It is estimated that approximately 10 million people will die annually due to infection related to AMR by 2050 [4].
The demand for nutritious food animal sources is increasing with emerging economies in low- and middle-income countries (LMIC) and the highest antimicrobial use (AMU) to food-producing animals is seen in Asia, and a 10.3% increase is expected by 2030 [5]. In Cambodia, one of the LMIC, the increased public demand for animal products and the government’s policy of self-sufficiency has led to an increase in livestock enterprises especially pig and poultry farming. This has led to increased use of antibiotics for therapeutic, prophylactic and metaphylactic treatments. All animal health services including medicines and drugs are provided by the village animal health workers (VAHWs) and veterinary drug retailers (VDRs) to the smallholder farmers [6] [7] [8]. Therefore, both VAHWs and VDRs play a critical role in the use of antibiotics in animals’ smallholder farming.
It is reported that there are 11,747 of VAHWs present in Cambodia. However, only 4,150 of them have been reported to actively practicing the profession [9]. Most of the VAHWs (the government delegated training to diverse NGOs) received the short training provided by the private services in Cambodia such as Agronomes et Vétérinaires Sans Frontières (AVSF). So far 2,100 VAHWs are trained on technical skills related to animal health and production including disease prevention and treatment for chicken, pig and cattle, as well as animal production techniques and epidemiology and disease surveillance [10].
In Cambodia, VDRs open the shops under registration from the General Directorate of Animal Health and Production under Prakas No. 051 PRK.MAFF [11]. VDRs, generally, purchase drugs from two main sources; established Cambodian veterinary companies and informal middlemen supply products from foreign companies [12]. VDRs are not only selling veterinary medicine and vaccines, but also focus on selling fodder, equipment for raising animals and other agricultural inputs [12]. VDRs offer services to smallholder farmers, commercial farms, and VAHWs/veterinarians. VDRs advice medicine to smallholder farmers mainly on selection and application.
There are very few published studies regarding knowledge, attitudes and practices (KAP) on AMU and AMR among VAHWs and VDRs in Cambodia. The study by [13] indicated that VDRs had a low level of knowledge of AMR suggesting a suitable target group for AMR awareness since they seem to be influential actors in the antimicrobial network. Another study by [6] showed that limited knowledge and poor biosecurity practices of VAHWs or district veterinarians (DVs) were found to include physical service material management and medicine storage. Studies from other countries indicate the importance of KAP for animal health workers to understand the level of their knowledge in judicious use of antibiotics and prevention of resistance development [14]. For instance, studies in Bhutan indicated that veterinarians and para-veterinarians have poor knowledge of AMU and AMR [15]. Similarly, a study in Nigeria showed that veterinarians have limited awareness on AMR and also the role and use of biosecurity and prophylactic antibiotic use in the prevention of infection was poorly understood [16]. These two studies suggested that regular awareness such as workshops or trainings must be intervened.
To the authors’ knowledge, this is the first survey on KAP among VAHWs and VDRs in Cambodia. Therefore, the main objective of this study was to assess the current KAP associated with AMU and AMR among VAHWs and VDRs. The findings from this study will be useful to get information on antibiotic prescribing trends among VAHWs and VDRs, which will help in designing an evidence-based education and advocacy plan for the prevention of AMR in the country.
2. Materials and Methods
2.1. Study Location
The present study was carried out in the southern part of Cambodia (bordered by Vietnam) within five provinces including Kampong Spue, Takeo, Kandal, Prey Veng, and Svay Reing same areas as the study by [17] (Figure 1). The study was carried out during the rainy season with the average temperature ranging from 26 - 28 degree Celsius [18]. The study was conducted from August to November 2020.
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Figure 1. Geographical map of the 5 provinces where the study was conducted.
2.2. Sample Size and Respondent Selection
VAHWs and VDRs were selected for an interview using the KAP questionnaire to explicit their knowledge, attitudes, and practices with regards to AMU and AMR. A single proportion estimation was applied from sample size calculation based on [1], with a 95% confidence interval, 10% margin of error, and an assumption of that 50% (p = 0.5). The sample size required was 96 respondents. In the present study, a total of 108 VAHWs and VDRs (66 VAHWs and 42 VDRs) have been surveyed.
In each province, three districts, the same study areas by [17] were selected. Within those districts, the VAHWs and VDRs were selected based on volunteerism within an indication by the district/provincial veterinarian at each province. One additional district of Takeo was selected for the VDRs. Although Feed and veterinary drug retailers are common in Cambodia, feed retailers were excluded from the study.
2.3. Questionnaire Design and Data Collection
Survey questionnaires were designed in either Khmer or English containing both positive and negative statements to explore the individual KAP of respondent. A consensus regarding the contents and wording of the questionnaire was achieved during the consultative workshop of experts from research university, government, and NGO who work closely related to AMU and AMR sector. The questionnaire was orally administered by trained research team and students from the Faculty of Veterinary Medicine, Royal University of Agriculture (RUA), Phnom Penh, Cambodia.
The VAHWs and VDRs were selected based on volunteerism and coordination from district/provincial veterinarian of each province. The interview lasted for about 30 minutes. VAHWs were surveyed either at the VAHWs’ house or district’s house; while DVRs were surveyed at their shops. The questions on the survey include 1) general information (e.g. age, gender, education, and experience), 2) knowledge about AMU (e.g. key term about AMU, proper use, non-therapeutic use, and storage), 3) attitudes towards AMU (e.g. proper management, using vaccination, veterinarian supervision, proper use, and consequences of ATBs for VAHWs; store and product registration, prescription/veterinarian availability, proper use of ATBs for VDRs), 4) practice on AMU (e.g proper use of ATBs and non-therapeutic use for VAHWs; proper dispensing ATBs practices, storage of ATBs, screening ATBs in accordance with local guideline for VDRs), 5) knowledge on AMR (e.g. misuse of ATBs in relation with AMR and the AMR consequences).
2.4. Data Analysis
Data obtained from interviews were entered into the MS Excel spread sheet for cleaning, processing, and further analysis. All data regarding demographic characteristics and current KAP on AMU and AMR were analyzed through descriptive statistics.
KAP key individual’s answers were scored and categorized following Bloom’s cut-off score as indicated in Table 1.
3. Results
A total of 66 VAHWs and 42 VDRs were interviewed with all being male for VAHWs and 43% being female for VDRs (Table 2). The average age of VAHWs and DVRs was 48-year-old and 41-year-old respectively. However, VAHWs had more experiences (15 years on average) compared to DVRs (8 years on average) in providing the service according to their jobs. In terms of education, about half of the VAHWs completed secondary school; while about one-fourth percent completed high school. About 10% of them completed primary or undergraduate program. Only 2% of VAHWs completed graduate program. For VDRs, 36% completed high school; while about 22% completed secondary or undergraduate program. Less than 10% completed primary and graduate program. Only 2% of VDRs never attended school.
VAHWs and VDRs had moderate knowledge of ATBs and their related use (Table 3). About 70% or more of VAHWs and VDRs could only identify correctly the use of ATBs. However, most of them (85% - 95%) missed the perception
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Table 1. Awareness evaluation by bloom cut off point.
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Table 2. Demographic information of VAHWs and VDRs in study area.
Note: N = total number; () = percentage.
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Table 3. Frequency of corrected responses of key individual’s knowledge on AMU in the study.
Note: N = total number; () = percentage. *Statement reverse respond score.
that the ATBs are used for the treatment of inflammation. More than 80% of VAHWs and VDRs were aware of withdrawal period when using ATBs. Between 70% to 80% of VAHWs and VDRs indicated that there will be consequences when the use of ATBs in the form of non-therapeutic and ATB resistant bacteria may be attributed from the use of ATBs. Most of VAHWs and VDRs understood correctly how to store ATB properly and full dosage and duration of ATBs used in animals should be applied (67%).
Table 4 provides the inclusive summary of the attitudes of VAHWs toward AMU and its related consequences. Overall, VAHWs were concerned about AMU and its consequences (83%). Interestingly, most of the VAHWs were much concerned that proper management, using vaccination, veterinarian’s advice, and correct dosage of ATB are the key to preventing/proper use of ATB in
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Table 4. Frequency of corrected responses of VAHWs’ attitude on AMU in the study (N = 66).
Note: N = total number; () = percentage. *Statement reverse respond score.
animals. VAHWs were likely neutral belief about the adverse effects on animals, human, and environment due to the misused of ATB (74%). Unlikely, the non-therapeutic use of ATB in prevention was not much concern (64%).
Table 5 indicated that the VDRs showed a relatively good attitude on the AMU. VDRs strongly belief that store and product registration, available prescription and veterinarian at the store were good criteria when considering dispensing ATBs. Furthermore, they were concerned about withdrawal period and other advice on using for only treatment. The non-therapeutic use as prevention and its consequences and for the improper use seems to be neutral attitude.
The practices of VAHWs on AMU appeared to be fair (Table 6). Most of the VAHWs applied good action regarding the AMU including the proper dosage, duration, route of administration, clinical evaluation prior to use ATBs, and use/recommend according to the recommendation on the label. About two-thirds of VAHWs practiced proper management of dead animals die under ATBs
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Table 5. Frequency of corrected responses of VDRs’ attitude on AMU in the study (N = 42).
Note: N = total number; () = percentage. *Statement reverse respond score.
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Table 6. Frequency of corrected responses of VAHWs’ practices on AMU in the study (N = 66).
Note: N = total number; () = percentage. *Statement reverse respond score.
treatment or withdrawal period. However, about one fourth of VAHWs did not apply well either on the proper written prescriptions or use of self-made mixture of ATBs.
The practices of VDRs on AMU appeared to be low (Table 7). About 40% of them dispense ATBs without a prescription, while about 20% of them recommend using a mixture of more than one ATBs to their customers. About one-fourth of VDRs would dispense ATBs to customer as requested or change ATBs by their own decision. Most of VDRs practiced well with the screening of ATBs and asking for clinical history prior to purchased and dispense of ATBs. Most of VDRs applied well on proper storage of ATBs. About 60% of VDRs provide the written instruction on ATBs to customers.
The assessment of AMR knowledge of VAHWs and VDRs was mainly on misused and the consequences. All/almost all of VAHWs and VDRs have heard about AMR term. However, the knowledge of AMR appeared to be fair and low for VAHWs and VDRs respectively (Table 8). For VAHWs, more than 80% of
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Table 7. Frequency of corrected responses of VDRs’ practices on AMU in the study (N = 42).
Note: N = total number; () = percentage. *Statement reverse respond score.
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Table 8. Rate of corrected responses of key individual’s knowledge on AMR in the study.
Note: N = total number; () = percentage. *Statement reverse respond score.
them indicated that improper use and more frequent use of ATBs would cause adverse effects like emergence of resistant bacteria. More than half of VAHWs realized that ATB resistant bacteria found in animals could contribute for public health risk or even connected from animals to others including human and environment. Only half of the VAHWs were aware that the development of resistance comes from the use of ATBs in animals. For VDRs, about 74% of them indicated that improper use and more frequently use of ATBs would cause adverse effects like emergence of resistant bacteria. About 40% of VDRs realized that ATB resistant bacteria found in animals could contribute to public health risks or even connect animals to others including human and environment. Similar to VAHWs, half of VDRs were aware that the development of resistance comes from the use of ATBs in animals.
4. Discussion
The study was conducted to explore the KAP of AMU and AMR among VAHWs and VDRs in Cambodia. We found that knowledge regarding to AMU appeared to be moderate. Fair/Poor in practice on AMU but good attitude regarding to AMU among the VAHWs and VDRs. VAHWs had moderate knowledge on AMR, while VDRs had low knowledge on AMR.
Our study demonstrated that both VAHWs and VDRs had moderate knowledge on ATBs and its use (Table 3). Many of them could identify the use of ATBs for bacterial infection. However, most of them still perceive it as the inflammatory treatment. Although many VAHWs were trained in technical skills related to animal health and production—disease prevention and treatment for chicken, pig and cattle, as well as animal production techniques and epidemiology and disease surveillance [10]. Also, VDRs received the training/short course from the Department of Animal Health and Production or GDAHP, provincial authorities, NGOs and private companies, these trainings or short courses may not be enough as new drugs and new diseases still occurred [12]. Thus, it is likely that the knowledge on AMU and AMR is not well attached to the training. Thus, the gap on technical knowledge on inflammatory treatment may be missed conception. Many VAHWs and VDRs were well aware of the withdrawal period when using/advising ATBs (Table 3) but not many VAHWs and VDRs applied written prescription to farmers (Table 6 and Table 7). However, ensuring farmers/producers followed the prescription or advice may not be applicable. Poor adherence to recommended instructions may increase the risk of AMR [19] [20] as well as drug residue [21]. Study by [17] [22] indicated that a proportion of pig and poultry farmers/producers were not well comprehended about withdrawal period when using ATBs even there is available product’s instruction or veterinary prescription/advice. Both VAHWs and VDRs were well aware of proper storage of ATBs. This suggests that they have good knowledge of safe storage of ATBs. It is reported that 100% of VDRs in Cambodia kept vaccine as required as indication of the products and most of them had vaccines and medicines properly separated from other products [12]. However, the majority of VDRs (65%) store the medicine in the cabinet that can be in sunlight for at least part of the day [6].
Both VAHWs and VDRs had a good attitude towards AMU (Table 4 and Table 5). VAHWs believed that proper management, vaccination program, veterinary advice, and proper dosage of ATBs are the key to preventing/proper use of ATBs in animal production. Such good animal husbandry, effective biosecurity, and efficient and relevant vaccinations are the keys to preventing diseases without antimicrobials [23] [24]. If these have put into practices by VAHWs when providing the service, it would gradually decrease the use of antimicrobials and substantially reducing the AMR occurrence. VDRs strongly believed that registration of shop and medicine and availability of veterinarian/prescription are contributed to dispensing ATBs. This positive attitude has been compliant with the World Organization of Animal Health guideline recommendation [25]. However, this may need an effective national regulation to make sure all VDRs take this into practices.
The practice of VAHWs on AMU appears to be fair (Table 6). Most of them applied good practice regarding to ATBs administration including dosage, duration, and routes of administration. However, we found self-mixture of ATBs has been practiced by many VAHWs. This practice may contribute to the misuse of ATBs if there was no supervision or scientific support. Self-mixture of ATBs could be made if there are available scientific supports [26]. We also found not many VAHWs applied written prescription to the animal owners. This indicated that there are a knowledge gap and practice when prescribing the ATBs. It is recommended that animal practitioners should apply written prescription when considering using ATBs aiming to responsible use of ATBs [26]. The practice of VDRs appeared to be moderate (Table 7). About 40% of them dispense ATBs without a prescription while some of them recommended using mixture of more than one ATBs. These indicated that poor in practices by the VDRs. Distributors or VDRs should distributes ATBs base on the prescription of a veterinarian or other suitably trained person authorized in accordance with the national legislation and under the supervision of a veterinarian. Also, all products should be appropriately labelled and recorded and even when there is a mixture of ATBs [26].
VAHWs had moderate knowledge on AMR, while VDRs had low knowledge on AMR (Table 8). Similar study has been indicated by [15] for VAHWs and by [13] for VDRs. Not many of VDRs were aware of the relationship or consequences related to animal, human, or environmental health resulting from the AMR, although many of them understood about the relatively use or more frequently use of ATBs driven to AMR. Recent studies in low-income countries indicated that a knowledge gap on the subject of AMR, including among veterinarians and para-veterinarians [15] and pig and poultry farmer/producers [17] [21] [27] [28]. This highlights the fact that a lack of knowledge regarding AMR is not limited to the farmers/producers, but is widespread also among veterinary professionals. Although many of VDRs asked for the clinical signs from their clients, they still dispensed ATBs according the demands and substitution other ATBs when the first treatment fail by the clients. These may consider as poor practices. Prescribing of ATBs based on the client demand without clinical observations of the animals and/or no prescription is considered a bad practice which may aggravate the AMR problem [15] [29]. In our study, although many VAHWs and VDRs were aware improper use and more frequently use of ATBs would cause adverse effects like emergence of resistant bacteria, not many of them had appropriate knowledge about consequences on animals, humans, and environment health resulting from AMR. This suggests that more training or awareness on AMR should be applied for them [15].
This study has some limitations. As KAP survey tool enables large amounts of data collection from participants for a short period of time, data collected may misrepresent true dispositions and practices. Data may sometimes bias if the subject matter concerns a contentious topic or practice as well as the level of understanding of the individual question.
5. Conclusion
Overall, we found that VAHWs and VDRs in Cambodia had moderate knowledge and good attitude in regard to AMU; however, they still applied moderate practices toward AMU. Furthermore, moderate/low level of knowledge of AMR has been investigated. This could lead to inappropriate use of antimicrobials. Thus, such interventions including regular awareness of proper use, prudent use and AMR stewardships of AMU and AMR via training/workshops must be taken into account for both VAHWs and VDRs throughout Cambodia.
Acknowledgements
The work was funded by Cambodia Higher Education Improvement Project (Credit No. 6221-KH). The author also would like to thank the veterinary graduate and undergraduate students who helped in conducting the survey. The author also thanks Mr. Ly Pitou for assisting with the survey and producing the map for the study.
Ethical Consideration
Respondents in this study were informed in writing about the study and its objectives in local language. The informed consent form was clearly read/explained to respondents. Only individual who agreed to participate and who signed the informed consent form was included in the study.