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Effect of Antimicrobial Stewardship Education on Appropriate Antibiotic Use among Healthcare Workers in Nigeria

Abstract

Antimicrobial resistance (AMR) is a major public health concern because inappropriate and excessive use of antibiotics contributes to the emergence and spread of drug-resistant microorganisms, reducing the effectiveness of available treatments and increasing the risk of prolonged illness, complications, healthcare costs, and preventable deaths. Healthcare workers play a central role in antimicrobial use because prescribing, dispensing, administering, and monitoring antibiotic therapy are important components of healthcare delivery. Antimicrobial stewardship education provides healthcare workers with knowledge and practical skills relating to appropriate antibiotic selection, indication, dosage, route, duration, de-escalation, culture and susceptibility testing, documentation, monitoring of treatment response, prevention of unnecessary antibiotic use, and adherence to institutional antimicrobial stewardship guidelines. Appropriate antibiotic use refers to the use of antibiotics when clinically indicated and in accordance with recommended principles regarding drug selection, dosage, route, timing, duration, and monitoring. In Nigeria, inappropriate antibiotic use may be influenced by limited antimicrobial stewardship training, diagnostic constraints, empirical prescribing, patient expectations, availability of antibiotics without appropriate clinical evaluation, inadequate institutional guidelines, and weak monitoring systems. Effective antimicrobial stewardship education may improve healthcare workers' knowledge, prescribing and treatment decisions, and adherence to recommended antibiotic-use practices. Against this background, this study investigates the effect of antimicrobial stewardship education on appropriate antibiotic use among healthcare workers in Nigeria. The study is anchored on Social Cognitive Theory, the Health Belief Model, and the Theory of Planned Behaviour. Social Cognitive Theory emphasizes the interaction between knowledge, self-efficacy, behavioural capabilities, social influences, and environmental conditions in shaping healthcare workers' antibiotic-use behaviour. The Health Belief Model explains preventive health behaviour through perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and cues to action, providing a basis for understanding healthcare workers' recognition of the consequences of inappropriate antibiotic use and antimicrobial resistance. The Theory of Planned Behaviour explains how knowledge, behavioural attitudes, subjective norms, and perceived behavioural control can influence healthcare professionals' intention and performance of appropriate antibiotic-use behaviours. Collectively, these theoretical perspectives provide a suitable framework for explaining how antimicrobial stewardship education may influence appropriate antibiotic use among healthcare workers in Nigeria. The study will adopt a quantitative quasi-experimental research design. Primary data will be collected from healthcare workers involved in prescribing, dispensing, administering, or monitoring antibiotic therapy in selected public and private healthcare facilities in Nigeria using a structured self-administered questionnaire, antimicrobial stewardship knowledge assessment, and an appropriate antibiotic-use assessment tool. A multistage sampling technique will be employed to select states, local government areas, healthcare facilities, departments, and eligible healthcare workers. Where feasible, selected healthcare facilities or healthcare worker groups will be assigned to intervention and comparison groups. Healthcare workers in the intervention group will receive structured antimicrobial stewardship education covering principles of antimicrobial stewardship, appropriate indications for antibiotic therapy, selection of appropriate antibiotics, dosage and route, treatment duration, culture and susceptibility testing, de-escalation, documentation, monitoring of treatment response, prevention of unnecessary antibiotic use, and adherence to institutional and national antimicrobial-use guidelines. Appropriate antibiotic use will be assessed using indicators such as appropriate clinical indication, selection of antibiotic, dosage, route of administration, treatment duration, timing, documentation, review of therapy, de-escalation where appropriate, and adherence to established antimicrobial stewardship guidelines. Where feasible, objective data such as prescription records, patient treatment records, or medication charts will be reviewed to complement self-reported information and improve measurement accuracy. Descriptive statistics will be used to summarize healthcare workers' sociodemographic and professional characteristics, antimicrobial stewardship knowledge, exposure to education, and antibiotic-use practices. Inferential statistical techniques, including chi-square tests, paired-sample tests, independent-sample tests, and logistic or multiple regression analysis, will be used to determine the effect of antimicrobial stewardship education on appropriate antibiotic use. Where appropriate, pre-intervention and post-intervention antibiotic-use measures will be compared. Diagnostic tests will also be conducted to assess the reliability of the research instruments, model assumptions, goodness of fit, and robustness of the findings. The study is expected to find that antimicrobial stewardship education has a significant positive effect on appropriate antibiotic use among healthcare workers in Nigeria. Healthcare workers exposed to structured antimicrobial stewardship education are expected to demonstrate improved knowledge and greater adherence to recommended antibiotic-use principles. Education may improve appropriate antibiotic selection, dosage, route, treatment duration, documentation, review of therapy, use of microbiological information, de-escalation practices, and avoidance of unnecessary antibiotic prescribing or administration. It may also improve healthcare workers' understanding of antimicrobial resistance and the consequences of inappropriate antibiotic use. However, education alone may not guarantee sustained appropriate antibiotic use because healthcare workers may continue to face barriers such as limited diagnostic capacity, lack of microbiology services, medicine shortages, patient expectations, workload pressures, inadequate antimicrobial stewardship teams, limited access to treatment guidelines, and weak prescription monitoring systems. Consequently, antimicrobial stewardship education is expected to be most effective when supported by functional antimicrobial stewardship programmes, accessible diagnostic services, evidence-based treatment guidelines, prescription monitoring, regular audit and feedback, and institutional leadership support. The study is expected to contribute to the literature on antimicrobial stewardship, antimicrobial resistance, antibiotic-use practices, healthcare worker education, infection prevention and control, patient safety, health education, and public health in Nigeria by providing empirical evidence on the effect of antimicrobial stewardship education on appropriate antibiotic use among healthcare workers. The findings will provide useful information to the Federal Ministry of Health and Social Welfare, Nigeria Centre for Disease Control and Prevention, National Agency for Food and Drug Administration and Control, National Primary Health Care Development Agency, state ministries of health, hospital management authorities, antimicrobial stewardship committees, healthcare professional associations, pharmacists, physicians, nurses, microbiologists, public health practitioners, development partners, and policymakers regarding strategies for promoting responsible antibiotic use. The study will also provide evidence-based recommendations for strengthening antimicrobial stewardship education, improving access to diagnostic services, implementing antibiotic-use guidelines, strengthening prescription monitoring and audit systems, expanding antimicrobial stewardship programmes, and promoting appropriate antibiotic use across healthcare facilities in Nigeria.

Keywords: Antimicrobial stewardship education, appropriate antibiotic use, healthcare workers, antimicrobial resistance, antibiotic stewardship, antibiotic prescribing, infection prevention and control, healthcare education, patient safety, antimicrobial use, public health, Nigeria.