s2fieldsofstudy: Education Medicine

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Knowledge, Attitudes, and Practices of Antimicrobial Uses and Resistance Among Public University Students in Bangladesh

Background Antibiotics are lifesaving drugs, and inappropriate uses lead to the resistance that renders them ineffective. This study aims to understand knowledge, attitude, and practice (KAP) concerning antibiotic use and resistance among university students in Bangladesh. Methods A cross-sectional study was performed from January to April 2020 among students at Jahangirnagar University (JU), Bangladesh. Purposive sampling was conducted through an in-person interview using a structured questionnaire. Students from the faculties of biological sciences and non-biology background were included. The univariate ordinal regression technique was used to analyze the relationship between predictors and good knowledge about the antibiotics. A two-tailed p-value was calculated to determine statistical association. Results Out of 205 study participants, 92 and 113 responders were from biological science faculty and non-biology disciplines, respectively. Less than half of the students (42.4%) showed a good knowledge level (scores higher than 80%). Biology-background students possess better knowledge than non-biology students [odds ratio (OR) = 4.44, 95% confidence level (CL) (2.56, 7.70), p < 0.001]. A better attitude was noticed among all students. The self-medication rate was quite low, and more than 90% of students were found to consume antibiotics according to the physician’s prescription. Lack of treatment adherence was recorded, and students admitted to stop-taking antibiotics when symptoms disappeared (48.67% biology and 36.26% non-biology). Multivariate regression analysis was unable to detect any significant association between self-medication and gender, student category or the level of knowledge about antibiotics. Conclusion Students of biological science background possessed better knowledge indicating the importance of appropriate curriculum imparted in knowledge buildup. Introducing a short course about the risk and development of antibiotic resistance will grow the students’ awareness to avoid the resistance phenomenon.

Introduction
The emergence and spread of antibiotic resistant pathogens pose a big challenge to policy-makers, . . . . . .. transformation of health systems that evolved to provide easy access to these drugs into ones that encourage appropriate use of antimicrobials, whilst reducing the risk of resistance. 1 Antimicrobials have saved millions of lives and expanded humans' average life expectancy since penicillin's breakthrough in 1928 and other subsequent discovery of antimicrobial classes. 2 Besides treating infectious diseases, antibiotics ensured the safety of numerous emergency medical procedures, including surgery and organ transplant. However, the drugs' success is evaluated by the drugs' capacities to encounter the emergence of resistance in pathogenic bacteria. The resistance of bacteria to almost all antibiotic types is a worldwide public health problem. 3,4 It is estimated that around ten million deaths can occur every year by 2050 due to antibiotic-resistant bacteria. 5 Antimicrobial resistance (AMR) is responsible for thousands of deaths worldwide and economic loss due to the increased hospital stays, unnecessary drug consumption, and increased burden with diagnostic costs. The resistance of bacteria to antibiotics is a natural phenomenon, often caused by genetic mutations in chromosomes under selective pressure, and most importantly, this phenomenon can be transferred horizontally to other bacteria through the exchange of extrachromosomal resistant plasmids. 6 As the resistant bacteria have no "evolutionary disadvantage," it is unlikely that the bacteria will lose its resistance over time; therefore, scientists warn the appropriate use of antibiotics to prevent the emergence of primary resistance. 7 Availability of antibiotics from pharmacies without authorized prescription and overuse or misuse of antibiotics such as self-medication practice, non-adherence to the prescription, inappropriate prescribing, and lack of antibiotic susceptibility testing can play a vital role in the evolvement of antibiotic resistance. [8][9][10] Moreover, the uncontrolled antibiotics applications in animal husbandry as therapeutic, prophylactic, and growth enhancers can contribute to the emergence of resistant bacteria that enter humans through the food chain. 11 A study indicated that South East Asia is at the highest risk of developing and spreading antibiotic resistance, and it suggested One Health approach to address this problem. 12 A systematic review has identified a very high resistance to common antibiotics in Bangladesh with the prevalence of extended-spectrum beta-lactamase (ESBL) producing E. coli and methicillinresistant Staphylococcus aureus (MRSA). 13 The presence of antibiotic-resistant bacteria has been reported in different sources, including hospital waste, poultry, and environmental samples. [14][15][16] Inappropriate and incomplete prescription by physicians, non-compliance to the prescribed antibiotics, availability of antibiotics as nonprescription drugs in the pharmacies have been reported in Bangladesh. 17,18 Antimicrobial self-medication is frequently observed in low-and middle-income countries (LMICs), including Bangladesh. [19][20][21] It has been reported that although Bangladesh has possessed national drug 22 and health 23 policy, additionally, access to public healthcare reasonably good. 20 Nevertheless, a large portion of antimicrobials consumption in Bangladesh remains without a licensed medical doctor prescription. 24,25 Antimicrobials principally consumed in Bangladesh as self-purchased from community pharmacy snubbing national guiding principle. 19,26,27 Antimicrobials consumption as selfpurchased or imprudently prescribed frequently correlated with increased drug interactions, hiding symptoms of primary disease and expanding microbial resistance. [28][29][30] It has been reported that self-medication frequently correlated to unnecessary expenditure in both the public healthcare budget and individual and community. 31 Although any use of antimicrobials still rational and prudent contributes to the development of microbial resistance as the process of evolution, 3 extensive superfluous, irrational, and imprudent use frequently contribute to treatment challenges. 10,32,33 Multiple studies reported that poor knowledge regarding use of antibiotics frequently correlated with irrational consumption of antimicrobials even among medical students. [34][35][36] The causes of selfmedication with antimicrobials were identified as trivial illness, time-saving, possessing old prescriptions and high consultation fees. 37,38 The biggest challenge for the healthcare sector is to educate people about antibiotics, its side effects, and to encourage them to stop the misuse of antibiotics. The lack of knowledge about self-medication is the prime reason for mass scale antibiotic resistance tragedy. 31 Public awareness of antibiotic resistance is indispensable to mitigate this insidious problem. [39][40][41] As the World Health Organization (WHO) emphasized, the behavioral change towards the irrational use of antibiotics, otherwise any new addition to the antibiotic will become ineffective. 42 To understand the current public perception and habits, KAP-based studies on antibiotic prescribing, consumption, and antibiotic resistance are conducted in different countries on diverse groups, including medical students, university students, health workers, and common public. 36,43,44 Continuation of such studies is necessary to understand common cultural beliefs, knowledge gaps, and practice behavior of a particular social group. In Bangladesh, the young population plays a vital role in different societal movements. However, KAP on antibiotic use and antibiotic resistance of this group of people, especially among university students, are yet to be submit your manuscript | www.dovepress.com

DovePress
Infection and Drug Resistance 2021:14 520 explored. Therefore, we aimed to conduct a crosssectional study among the leading public university in Bangladesh to understand KAP concerning antibiotic uses and resistance. We also sought to know whether the students of biological science faculty have better KAP than other faculties.

Methods and Materials Study Design
A cross-sectional design was used in this study to collect information on knowledge and attitude regarding antibiotics among public university biology and non-biology students.

Sample Size
JU is a public university of Bangladesh that accommodates over 16,000 students. JU covers a broad range of disciplines, such as mathematical and physical sciences, biological sciences, arts and humanities, social sciences, business studies, and law. Sample size was calculated utilizing online sample size calculator Raosoft (http://www. raosoft.com/samplesize.html). The margin of error was 5% and CL 95%. After that the sample size was 376 as the total population was 16,000. We expect there will be drop out and noise data around 5%. Thereafter, this research firstly planned for 396 were sample population size.

Study Population
Mostly undergraduates' students approached through an in-person interview where answers were inscribed in a printed questionnaire ( Figure 3). A previously validated printed study instrument was used to gather data in the most time and cost-efficient way.

Sampling Method
Although this study group initially planned for random sampling, nevertheless, purposive sampling (mostly snowball technique) method was adopted for the current study because of the COVID-19 pandemic. Furthermore, to avoid selection bias this study we included all 16 residential halls.

Study Period
This cross-sectional study was performed from January to April 2020 among undergraduate and graduate JU university students during initial day of the COVID-19.

Preparation of Questionnaire
The questionnaire was prepared based on a literature review of similar studies conducted in different parts of the world, 36,45 with some modifications in the questions based on common practice knowledge in Bangladesh. The questionnaire was separated into four sections. The first section included the demographical information. The second section included seven questions to measure students' level of knowledge regarding antibiotics and antibiotic resistance. This section contained seven questions, evaluated using "true," "false," and "uncertain" responses. The third section was designed to understand the students' attitudes towards some common philosophy about preventing antibiotic resistance. In the third part, a three-point response scale by "agree," "disagree" and "uncertain" was used to determine the attitudes. The fourth section was created to understand the common practice among students related to antibiotic intake strategy, clinical phenomena when the antibiotic is used, and the failure to complete the course of antibiotics. The practices part further evaluated the student participants' habitude about antibiotic use and their adherence to dosing and treatment courses. The study instrument was pre-tested and validated in the local context involving 48 [16X3=48 (3 from each hall)] students. These students did not participate in the subsequent principal study. The questionnaire sections demonstrated acceptable values, with a range between 0.672 and 0.882, which indicated that both instruments possessed good internal consistency and reliability. Convergent validity was shown by the significant correlations between the items of each section and the total mean in each part (rs=0.332-0.718; p=0.05). The study pretested result corresponds with earlier studies. 46,47

Data Collection
To increase the survey's response rate, questionnaires were sent to students beforehand and collected through face-toface interviews. The interviewers were introduced to the questionnaire's aim and were instructed about how to ask these questions. Before the interview, written informed consent was taken from the responders. The aims of our study were explained to the participants before written consent was obtained. Attempts were made to include male and female students from the biological sciences faculty, including Microbiology, Pharmacy, Biochemistry & Molecular Biology, Public Health and Informatics, Botany, Zoology, and other non-biological disciplines. The personal information of the respondents was made anonymous by coding.

Data Analysis
The completed questionnaire data were verified and subsequently analyzed using IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp. The parameters from the knowledge, attitudes, perceptions, and practice sections were evaluated by calculating each response percentage among all the participants. In the questions relating to knowledge, correct responses to the knowledge parameters were "wrong" for Q2, and Q3 and the remaining were "right." The levels of knowledge were further estimated using a scoring system, where a score of 1 was considered for a correct response and 0 for an incorrect or uncertain response. For quantitative analysis, an obtained score higher than 80% was considered acceptable, between 60% and 80% was considered moderate, and less than 60% was considered low. 48 Questions relating to attitudes and perceptions were assessed using the three-point Likert scales with options of "agree," "disagree," and "uncertain." Similar Likert scales evaluation was used to assess the study participants' practices and habits. Response frequencies and percentages for each question were calculated to compare the KAP of biology and nonbiology background students. Missing data were excluded from the bivariate analysis. Pearson's chi-square test was used to test any association between categorical data. The univariate ordinal regression technique was used to analyze the relationship between predictors and good knowledge about antibiotics. Explanatory variables, including gender (male and female) and student category (biology and nonbiology), were regressed onto the knowledge level (low, moderate, and good) as a response variable. An OR greater than 1 (or less than 1) indicated a more significant probability (or lower probability) of having higher levels of knowledge about antibiotics compared to the reference category. Finally, a multiple ordinal regression model was introduced to identify the independent effects of explanatory variables, defined by univariate analysis, on the level of knowledge about antimicrobial use and resistance. Similarly, multivariate logistic regression analysis was performed to identify the predictors of self-medication with antibiotics. Explanatory variables included gender, student category and the level of knowledge about antibiotics. 95% confidence intervals (CI) were used as OR estimates. A two-tailed p-value was calculated to check statistical significance.

Ethics Statement
The Ethics and Research Review Committee of the Faculty of Biological Sciences, Jahangirnagar University, Savar, Dhaka-1342, Bangladesh approved this study [Reference No.: BBEC, JU/M 2020 11(1) dated 01.11.2020]. Written informed consent was obtained from all the study participants for collecting their knowledge, opinion, and recent practices of antimicrobial consumption. The personal identities of the participants were strictly anonymized to protect their privacy. Author six obtained verbal permission from the chairman of the ethical committee to collect the data before ethical approval certificate was obtained. It was granted because there is human intervention the study. It is because of COVID-19 respective office was closed and it took long time to get certificate.

Study Participants
Out of 396 potential respondents, 210 responded completed the questionnaires (53% response rate). Then, we excluded five questionnaires from the analyses because of incomplete data, and the final response rate became 51.77% (205⁄396). The final completed questionnaires encompass 106 collected from male respondents and 99 from female respondents. Ninety-two students studied in the different biological science faculty departments and 113 students in other non-biology disciplines. Over 90% of the students (186/205) participated in the study were undergraduate students. Current study response rates were at the same line with earlier studies. [49][50][51][52]

Levels of Knowledge
Most biology-background students had markedly better knowledge in the knowledge part of the questionnaire than non-biology students about antibiotics uses and antibiotic resistance. In six out of seven questions, biology students selected a higher percentage of correct answers. Very significant higher knowledge was observed in biological students in responses for three questions (No. 1, 2, and 3), and the other responses were higher but non-significant (#5, 6, and 7) ( In the combined score of knowledge, a median score of 5 (IQR: 4-6) was obtained from a maximum of 7. Less than half of students had good knowledge (42.4%) and over one-third had poor knowledge (34.1%) ( Table 2). This demonstrated an overall sub-standard knowledge of the uses and effects of antibiotics. The lower scores were observed in non-biology students compared to biologybackground students (Figure 1). A linear downtrend was towards higher scores (1 to 7) for non-biological students; however, the reverse was noticed for biological students regarding antibiotics knowledge-scores (Figure 1).
In a univariate analysis, gender and student category showed a statistically significant association with higher knowledge levels about antibiotics at p ≤ 0.05 and were included in a multiple regression analysis. In a multivariate analysis, the final model was a significant improvement in fit over the null [χ 2 (2) = 34.026, p<0.001]. The student category was a significant predictor in the model. Biology students were more than four times as likely to have higher levels of knowledge about antibiotics than non-biology students [

Levels of Attitudes and Beliefs
Most of the students accepted the recommendation and action plan that should be taken to prevent antibiotic resistance. Overall, about 91.7% of students believe that antibiotic resistance increases; the correct beliefs were found more in biology students than non-biology backgrounds (99.0% and 89%, respectively, p=0.019). Overall, 97.5% of students think we should be more cautious regarding the intake of antibiotics. The levels of this belief were recorded similarly in biology-and non-biology students (p=0.284). About 96.6% of students think the government should create more awareness to prevent antibiotic resistance and other 3.4% of respondents perceive the vital roles of other stakeholders than the government to generate awareness for preventing antibiotic resistance. Most of them (89.8%) agreed that antibiotics in the dairy and poultry industry should be regulated strictly. More percentage of biological students (95.6%) than non-biology students (87.5%) believed that regulation of inappropriate use of antibiotics in animal husbandry played an essential role in preventing the emergence of antibiotic resistance (Table 4). Respondents were divided

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into almost equal groups regarding their beliefs, whether physicians often prescribe antibiotics unnecessarily ( Table 4).

Levels of Practices
The survey identified that 93.47% of biological students and 92% of non-biological students used to take antibiotics according to authorized physicians' prescriptions (Table 5).
Of the 205 respondents, 21 (10.2%) had self-medicated with antibiotics over the study period. The wrongdoing was found slightly higher in non-biology students (11.5%) than in biology students (8.7%, p=0.509).
To recover from the fever, 49.8% of the students reported taking antibiotics. Using antibiotics to prevent the cough and common cold was documented in 36.1% of students. Other clinical episodes for which students took antibiotics included surgery (28.3%), pustules (22.9%), urine infection (21%), ear infection (19.5%), any kind of pain (17.1%), gastroenteritis (13.7%), and for other undisclosed reasons (6.8%). However, students have reported that they often fail to complete the dose of antibiotics, and for this failure, they have provided some reasons shown in Figure 2. The most reported reason is to stop taking antibiotics when they feel better. About 31.7% (n=65) of the students were found to take antibiotics in the last six months, of which 77.2% of students stated they had completed the course of antibiotics. The most common antibiotics consumed are, azithromycin (n=9), ciprofloxacin (n=5), cephalosporin (n=5), flucloxacillin (n=4) and amoxicillin (n=3). Among those who took antibiotics in the last six months, 36.8% had experienced different side effects during their medication course. The most common side effects were weakness, diarrhea, vomiting, loss of appetite, allergic reaction, and dizziness. In a multivariate regression analysis, there was no significant association between self-medication and gender, student category or the level of knowledge about antibiotics (Table 6).

Discussion
There is a need to tackle antibiotic resistance emergence and containment on levels ranging from individuals, households, and the communities, to health care facilities, the entire health sector, and finally to national and global levels. 53  Antibiotic resistance causes around 50,000 deaths each year in Europe and the USA alone; scientists warn that antibiotics resistance can lead us to an era where antibiotics no longer will work. 5 Unfortunately, not many natural or synthetic antibiotics are in the pipeline to combat pathogenic bacteria, and primary prevention is one of the best ways to lessen this problem. In this study, a total of 205 responses (68.3% response rate) were considered, of which 92 responders were from biological faculty, and 113 responders were from non-   In the knowledge section, the questions were to identify students' understanding of antibiotic resistance and the proper use of antibiotics. Less than half of the students (42.4%) showed the right knowledge level (scores higher than 80%), and about one-third of students (34.1%) indicated poor knowledge level (scores lower than 60%). In a study in Ethiopia, a substandard level of knowledge was found (54.8%) among the final year paramedical undergraduate students. 45 Two studies conducted in Malaysia showed different results regarding the knowledge level of medical students. In one study, 63.3% of medical students showed a moderate level of knowledge, whereas, in another study, 68% of medical students had a high level of knowledge. 54,55 One of the frequent misconceptions in the knowledge section was the effectiveness of antibiotics to treat viral diseases. Over 67.0% of biology students recognized this statement as false, while only 37.2% of non-biology students selected the correct statement. A similar misconception was documented in a study in China, where 64.52% of the medical students chose "antibiotics cannot treat a viral infection," compared to only 43.44% of non-medical students (p < 0.0001). 56 In another study in Nepal, 73.7% of medical students understood that antibiotics could not treat viral diseases, but only 34.2% of non-medical students agreed to this. 57 Most students (95.7% biology, 88.5% non-biology) believed that antibiotics consumption without a physician's prescription could cause antibiotic resistance. We found that 79.6% of non-biology students understood that overuse of antibiotics could lead to antibioticresistant; this rate is much higher for non-biological background students, as reported previously in Nepal. 57 Comparing knowledge score with the previously conducted studies is not always appropriate as there are variations in the type of questions asked, and educational background is also disparate. The educational background seems essential in most reported data as students of biological background and medical students were found to have better knowledge. Nonetheless, researchers believe that proper knowledge is often associated with better attitude and practice. 58 Students of both backgrounds showed a better attitude towards the understanding of antibiotic resistance. Most of the students (99% biology, 89.1% non-biology) believed that antibiotic resistance is increasing, and we should be more concerned regarding antibiotic consumption (99% biology, 96.4% non-biology). A similar attitude has been observed in earlier studies. 59 More than 95% of students Dear participant, you are giving consent to participate in this study by providing answers to the questions. Your answers will be kept confidential and will only be used for the scientific analysis. You have the full right to withdraw your consent of participation. thought that the government is responsible for generating more awareness about antibiotic resistance. In a study in Iran, 41.02% of medical students believed that developing educational workshops about antibiotic administration rationale is necessary to create knowledge. 43 Students were alarmed about the use of antibiotics in animal husbandry, and most of them were in favor of strict monitoring of this practice (95.6% biology, 87.5% non-biology). Indeed, this is an area of concern as numerous studies conducted in Bangladesh showed antibiotics in consumable meats, eggs, and fishes. 60,61 Respondents were divided into almost equal groups regarding their beliefs, whether physicians often prescribe antibiotics unnecessarily. Previous studies reported that physicians often prescribed two or more antibiotics, frequently with the higher generation; however, no study could depict that physicians prescribe antibiotics unnecessarily. [62][63][64] The majority of the students (93.47% biology, 92% non-biology) were found to take antibiotics only when prescribed by physicians; this practice coincides with the high level of knowledge that consuming antibiotics without a physician's prescription can lead to antibiotic resistance. In appropriate antibiotic practice, only 8.7% of biology students and 11.5% of non-biology students tended to self-medicate; the number is lower than those reported in previous Bangladesh studies. Two previous studies conducted in Bangladesh reported self-medication of antibiotics 23.5% and 26.7, respectively, and the self- chosen antibiotics were metronidazole, azithromycin, ciprofloxacin, and amoxicillin. 9,65 Compared to other countries, this lower self-medication rate is appreciative, as 70% of Indian medical students and 27% of Chinese medical students were found to self-medicate with antibiotics. 36,44 A study conducted in Malaysia showed more than 89% of students accepted self-medication with antibiotics. 66 In comparison to other countries, the lower self-medication rate that we found in our study is appreciative. Participants of the previously mentioned study were mainly medical students that might encourage them to self-medicate with confidence. A similar concept can be obtained from the study in Sri Lanka that indicated the rate of self-medication was higher in "pharmacology education group" students than in "non-pharmacology education group" students. 67 Moreover, the students of this study have access to free medical consultation; this provision might influence them to visit the doctor before buying antibiotics by themselves. However, the suggestion of drug sellers comes next to the physician's prescription. This is a matter of concern as drug sellers do not perceive enough knowledge regarding antibiotic resistance and its rational use. Unfortunately, antibiotics are easily available in Bangladesh in most pharmacies without prescription because of weak legislative regulations on the issue. 24 Students in the study reported incomplete doses of antibiotics sometimes, especially when they feel well (48.67% biology and 36.26% non-biology). Non-compliance to prescription is common in Bangladesh; one study indicated that a substantial portion of patients stop taking antibiotics when the symptoms alleviate. 68 A similar result was observed in the study conducted in Jordan, where 59.1% of students admitted that they stop taking antibiotics when they feel better. 69 However, non-compliance is a widespread practice among patients, which may cause pathogens to be resistant to antibiotics. WHO always encourages antibiotic course completion, even if the patient feels well. Hence, seeking a physician's suggestion was recommended strongly before withdrawing the medicine course when symptoms no longer persist. 70 Students also reported stopping taking antibiotics when they face side effects such as gastrointestinal disturbance or allergic reaction. Adverse drug reactions (ARDs) are common with antibiotics as the medicines can disrupt the gut's normal flora and increase the chance of infection with opportunistic pathogens such as Clostridium difficile, 71 and around 1 in 15 people consuming antibiotics face allergic reaction. 72 Despite rigorous screening and research, the continuous discovery of new natural and synthetic antibiotics seems scarce. Therefore, there is no alternative to increasing knowledge, perceive a better attitude, and practice accordingly. Our survey indicates that students of biological faculty have better knowledge about antibiotic application and resistance, though overall knowledge level is unsatisfactory with a chance of improvement. It is often found that educational background plays a crucial role in developing knowledge, and educational campaigns can improve antibiotic use and prescribing practice. 73 There are currently 46 public universities in Bangladesh, with around 3 million students. Thus, students can play a vital role in preventing antibiotic resistance if proper knowledge can be delivered to them. Enhanced educational training is often recommended for knowledge generation. Furthermore, a better attitude is observed when people are knowledgeable about the attitude object. 74 Therefore, introducing short courses or workshops for all tertiary level students can positively impact creating DovePress awareness of antibiotics' proper use. The current study did not find any significant co-relation between self-medication and gender, student category or the level of knowledge about antimicrobials. Current study findings were similar to earlier overseas studies. [75][76][77][78] Limitation of the Survey This survey was conducted in a single public university in Bangladesh; therefore, it may not represent the overall scenario of the Bangladeshi student community. The data set is small, consisting of data of 205 respondents. The study had the intrinsic limitations of the knowledge, attitude, practice survey. Students might face recall bias when answering the questions of antibiotic consumption in the last six months. The current study is cross-sectional type of known as observational study often utilize to determine prevalence and to infer causation. 79 Only describe the snap-shot of the research issue not a video picture. 80 Additionally, this is a cross-sectional study with its inherent the primary limitation. The cross-sectional study design assessed both the exposure and outcome simultaneously, there is generally no evidence of a temporal relationship between exposure and outcome. 81 Furthermore, the current study utilizes three point likert scale. The likert scale questionnaire had predetermined answer, thereby, if any research-respondent differs with mentioned answer that can not be determined. 82,83 Moreover, likert scale only gathers numerical data which unable to offer a comprehensive representation, especially of educational portents. 84

Conclusions
Students of biological backgrounds possessed better knowledge indicating the importance of curriculum in knowledge buildup. In this study, nearly half of the students of a public university in Bangladesh demonstrated the right knowledge level. Students were found to perceive a better attitude regarding antibiotic resistance and its misuse in different sectors. Although their self-medication rate was low, noncompliance to prescribed treatment was reported.

Recommendations
We recommend introducing a short course or workshop for university students of all faculties describing the importance of proper use of antibiotics, the adverse effect of improper use, and antibiotic resistance dangers. We also recommend performing more KAP-based studies in different social groups in Bangladesh to understand the overall scenario. Based on these studies, the government may create robust laws to restrain the selling and purchasing of antibiotics without an authorized physician's prescription. Awareness should be created among the physicians and consumers of all economic classes about antibiotic resistance through mass media (TV, Radio, Newspaper), workshops, and social media where applicable. There is an urgent need for inter and intra-sectoral collaboration and cooperation among all health-related stakeholders of both national and international level-based primary health care concept to minimize the risk of antimicrobial resistance. [85][86][87][88][89] Key Messages 1. Nearly half of the university students possessed a good knowledge of antibiotic resistance. 2. Students studying in departments of biological sciences perceived knowledge four times better than the students of non-biological faculty. 3. The majority of students demonstrated a better attitude in the prevention of antibiotic resistance. 4. Non-adherence to prescribed treatment was observed. 5. Educational intervention and social awareness are necessary to improve the KAP regarding proper antibiotics use.
accountable for all aspects of the work. Consent for Publication: all authors reviewed and approved the final version and have agreed to be accountable for all aspects of the work, including any issues related to accuracy or integrity.

Funding
This study was partially financed by the grant of University Grants Commission Bangladesh, 2019-2020 fiscal year.

Disclosure
The authors report no conflicts of interest for this work and declare that they do not have any financial involvement or affiliations with any organization, association, or entity directly or indirectly with the subject matter or materials presented in this article. This also includes honoraria, expert testimony, employment, ownership of stocks or options, patents or grants received or pending, or royalties.


Becoming reflective practitioners: Mathematics student teachers' experiences

The level of quality reflective practice remains low among student teachers majoring in Mathematics education. This paper aims to identify the levels of reflective practice possessed by Mathematics education student teachers in a teacher training program at higher learning institutions in Namibia. The professional status requires that teachers become reflective practitioners to develop their effectivenessa skill they can acquire during their training. A reflection framework was used to identify levels of reflective practices among Mathematics student teachers. This study is qualitative and employed a narrative inquiry approach to assess the effectiveness of reflective practice as experienced by student teachers. A total of ten third-year undergraduate students majoring in Mathematics Education participated in the study by generating reflective journals. The results show that student teachers have insufficient reflective skills which are limited to the first two levels of the reflection framework: technical reflection and reflection-in-andon-action. This could be due to little guidance offered on developing reflective skills and its use by student teachers. This study's findings will be used to improve the rationality, social and educational practices among the student teachers.

Introduction
Reflective practice (RP) and teachers becoming reflective practitioners are regarded as an essential professional attributes of teacher education globally (Aldahmash, Alshmrani & Almufti, 2017;Connelly & Clandinin, 2000;Harrison & Lee, 2011;White, 2004). However, the nature of reflection and effective practitioners' development in teacher training programs in developing countries remains a concern. Reflective practice demands taking thoughtful steps to partake in learning daily and recognizing one's responsibility for one's lifelong learning; it is alsoc oncerned with the promotion of skills and competencies necessary for the development of general capabilities and specific performance of any given task (Chapman, 2012;Sibahi, 2015). Skills and competences developed through http://journals.ums.ac.id/index.php/jramathedu training programs have a bearing on how well student teachers perform on their tasks and adapt their knowledge and competence to new tasks (Chapman, 2012). In an effort to improve professional competencies and assist in identifying personal strengths and relative limitations of student teachers, genuine reflection is imperative (Dotse, n.d). Through reflective practice, student teachers may have the opportunity to reflect on their teaching and learning events to improve classroom practices, assessment styles, lesson planning, and all components involved in the teaching and learning process. Thus, student teachers' skills, competence, and knowledge would be useful later on in their profession. Consequently, reflective practice allows student teachers to become skillful in making wellversed judgments and expert decisions about their teaching and ways of empowerment (Mathew, Mathew & Peechattu, 2017;Robins, Ashbaker, Enriquez & Morgan, 2003).
The practice of reflection is encouraged to improve teachers' education programs (Moore, 2004). Abovich (2016) noted that knowledge of the subject to be taught and how to teach it do not necessarily translate into becoming an effective teacher. Uzum and Berg (2014) urges teachers to be responsive to innovative practices to enhance their teaching practice capabilities. This can be achieved when teachers perform reflective actions in their teaching. Moreover, reflective practice is regarded as a highly sophisticated educational concept in the teaching and learning process (Khan, 2012), and efforts to implement it in teaching programs are extremely difficult to accomplish (Sleegers, Geijsel & den Berg, 2012). On that note, teacher educators have argued for the introduction of research in areas of reflection in teacher education programs so that student teachers enter the profession with dispositions and skills that will enable them to learn from experience and become better at teaching throughout their careers (Gore & Zeichner, 1991). In turn, teacher education is inextricably linked to teachers' lives and narrative inquiry studies (Craig, 2011).
Further, Craig calls for experiences to be told in narrative authority to reflect the knowledge generated over time and across contexts. The notion of reflective practice is not new in the Namibian education system. The institution of higher learning of interest advocates for reflective practice in teacher education programs (University of Namibia, 2020). Besides theory, student teachers at the same institution of higher learning are provided with a template with critical questions to guide reflection during their teacher training and practice. In addition, the Ministry of Education, through the National Institute for Educational Development (NIED) (2008), has included a component of reflection in the lesson preparation template; schools may modify the guidelines to fit their school environments. After graduation, student teachers may also influence reflective practices at schools where they are serving as teachers.
In post-colonial Namibia, teacher education was developed through a program known as the Integrated Teacher Training Programme (ITTP) funded by the Swedish International Development Agency (SIDA). The program aimed, amongst others, to prepare future teachers for social change in an independent Namibia. The ITTP adopted the four-guiding principle of accomplishing a critical and transformative pedagogy to achieve learner centeredness and democracy, integration and meaning, knowledge production, educational http://journals.ums.ac.id/index.php/jramathedu reflection, and critical constructivism (Dahlström, 2019). Further, Dahlström, stated that, from 1994Dahlström, stated that, from to 1996, the ITTP gave birth to the Basic Education Teacher Diploma (BETD). Through the BETD, teacher educators carried out practitioner inquiry through continuing professional development programs. Nyambe (1996) saw BETD as a conduit for a critical/transformative paradigm of teacher education, yet the system produced student teachers who lacked a critical approach to integrate a move towards re-defining transformative and active intellectuals. The status quo remained until the program was replaced with the Bachelors of Education program at the University of Namibia.
Researchers have noted with concern the teachers training program conducted in Namibia. O'Sullivan (2002) raised concerns about Reflective Practice (RP)'s appropriateness in a teacher training program at one of Namibia's higher learning institutions. Zeichner and Ndimande (2008) also contest the teacher training program noting that it imparts low-level skills to implement the prescribed curriculum and teaching methods. These contestations reflect the adaptation of misguided and inappropriate use/adoption of RP in Namibian teacher training program. However, a few instructors emphasised PR in their teaching approaches as it is left to their discretion to implement (Simasiku, 2013;Zeichner & Ndimande, 2008).
Further, Zeichner and Ndimande (2008) claim that "sending student teachers out to schools with little guidance and support and merely telling them to reflect can be just as much a disservice to teachers and their pupils as efforts to train them to carry out teaching scripts mindlessly" (p.333). Therefore, this study aimed to determine the levels of reflective practice among student teachers specializing in Mathematics and how they experience the learning process of becoming reflective practitioners. Mathematics is one of the compulsory subjects in the Namibian school curriculum, and it is a pre-requisite to many prestigious courses at higher learning institutions in the country. Hence, teachers need a combination of skills above the level of content and pedagogical knowledge to be effective and efficient in teaching Mathematics (Nambira, 2016). Thus, the goal of becoming effective reflective practitioners can be achieved if Mathematics teachers have acquired the necessary skills and competencies during pre-service or in-service training programs and using RP (Craig, 2011). However, this article will strictly focus on Mathematics teachers' RP skills level during pre-service training.
This study is critical as studies on RP in Namibia have only focused on professional teachers' perceptions (Amukugo, Likando, Shakwa, & Nyambe, 2010;Simasiku, Villet & Kapenda, 2015) on the relationship between learner achievement and qualification and training and experience of a teacher at the senior primary phase (Nambira, 2016;Shaningwa, 2005). Hence, this study's primary objective is to identify the reflective practice levels of Mathematics student teachers. Valli's (1992) reflective levels and Gore and Zeichner (1991) analytical model are combined to help identify student teachers' competency levels concerning RP and subsequently propose areas of improvement.

Literature review
Various scholars have theorized the process of becoming reflective practitioners. These views provided a structure that generally guided the process of reflection. Jasper http://journals.ums.ac.id/index.php/jramathedu (2013) developed a simple theory known as the Experience Reflection Action (ERA) cycle. According to Jasper, the reflection cycle begins with experiencing an event that is either bad or good, old or new, and also related to work or something else. After that, an individual is expected to reflect and take action which will result in another experience that is: 'What?', 'So what? 'Now, what?'. Driscoll believes that teachers should contextualize the situation/experience to present a clear understanding of the experience. Teachers are expected to reflect on their experience by asking 'so what?' concerning what is learned from an experience. They would then decide on the way(s) forward due to the reflection by either opting to change the behavior or persisting with the same practices. Gore and Zeichner (1991) built reflective practice frameworks beyond Cruickshank's (1985) and Schon's (1983Schon's ( , 1987Schon's ( , 1991 frameworks. The authors focused on the significance of both the quality and type of reflection undertaken by individuals, the reflection content and the criteria considered (Sellars, 2017). Gore and Zeichner (1991) stressed the following: a) academic version, b) social efficacy version, c) developmental version, and d) social reconstructionist version as four 'varieties' of teacher reflective practice. These domains indicate four significant aspects of professional work (Sellars, 2017). In their own words, Gore and Zeichner (1991) argued that: Neither Cruickshank (1985) nor Schon (1983Schon ( , 1987Schon ( , 1988 said much about what it is that teachers ought to be reflecting about, the kinds of criteria that should come into play during the process of reflection (e.g., what distinguishes good from unacceptable educational practice) and the degree to which teachers' deliberations should incorporate a critique of the institutional contexts in which they work (Richardson, 1990). In some extreme cases, the impression is given that as long as teachers reflect about something, in some manner, whatever they decide to do is acceptable, since they have reflected about it. (p. 120).
The academic domain focuses on teachers' reflection on their abilities to teach learning content in such a way so as to ease understanding for their learners maximally. The social efficacy domain emphasizes whether own teaching pedagogies and strategies are based on research findings and focuses on evidence-based practice that has proven to increase learners' academic success and meet learners' needs. The developmental domain primarily focuses on determining whether teaching strategies are appropriate for learners developmentally and whether they focus on learners' interests and thinking. Lastly, the social reconstructionist domain is regarded as a critical reflection (Gore & Zeichner, 1991) in which reflection is focused on analyzing the political and social issues of schooling and classroom interactions. These aspects are used to promote more significant learner equity and justice. Connelly and Clandinin (2001) emphasize teachers' knowledge, particularly as active agents required to produce knowledge from personal and social development perspectives. Teacher knowledge depicts image, rule practical principle, personal philosophy, metaphor, story unity, and rhythm. Pre-service teachers need to learn more about teacher knowledge by becoming self-conscious than the theories have learned in the academic teaching program. Hence the expectation that pre-service education should focus on what preservice teachers know and have found in professional practice (Clandinin & Connelly, 2000). Craig (2011) stresses the need for these experiences be told in narrative authority representing a generative instead of a one-size-fits-all approach to teacher development http://journals.ums.ac.id/index.php/jramathedu because knowledge generated from experience over some time and across contexts is imperative. Thus, teacher knowledge through RP should promote the ability to think critically and scrutinize experience and integrate knowledge with self-improvement insight (Krishnamurthy, 2007). Furthermore, Krishnamurthy opines that RP should help to create understanding by making conscious decisions concerning professional, social and ethical assumptions, among other attributes, in order to correct mistakes, examine actions, evaluate them against prescribed norms, alter, repeat success and revise and plan continually (p. 14).
Various scholars have documented different levels of reflection in the teaching and learning process proposed based on time, process, level, and stage (Farrell, 2004;Lee, 2005;Schon, 1983;Valli, 1992Valli, ,1997Van Manen, 1977). Van Manen (1977) had developed three levels of reflection; these are: technical, practical, and critical reflection, based on the work of Habermas as a hierarchical structure (Sellars, 2017). The technical level is the lowest level of reflection in which the teacher considers the effectiveness of the practices to accomplish lesson goals and objectives (Alsuhaibani, 2019). The teacher reflects on context-specific teaching and learning at the practical level such as classroom experience, incidents, and specific students' actions. The critical level of reflection is the highest and incorporates the first two levels, but more positively, it considers moral and ethical considerations to support learners without personal bias. On one hand, in terms of time frames, Schön (1983), proposed concepts of reflection-on-action and reflection-in-action. Reflection-in-action happens while the action of teaching is taking place in the classroom. Reflection-on-action is teachers' reflection after teaching has occurred in the classroom.
On the other hand, Valli (1992) built on Schon's and Van Manen's frameworks to establish five reflection levels. These are: (a) technical reflection, similar to as described by Van Manen (1977), individuals at technical level match own competencies to professional standards, graduate competencies, the external goals and competencies of teaching amongst others. (b) The second level is reflection-in-and-on-action, a combination of the two domains that requires ongoing reframing, reconsideration, and self-discussion of the teaching process Schon (1983). Further, (c) at deliberative reflection level, teachers reflect on various viewpoints concerning pedagogical decision-making. The fourth level, (d) personalistic reflection, focuses on relationships with learners and personal growth in terms of emotions, intuitions, and self-knowledge towards learners and learning. The final level is (e) critical reflection which incorporates the development of open-mindedness, rational judgment, and creativity in the reflection process. In addition to the hierarchical levels of reflection, Lee (2005) calls for consideration of alternative teaching and learning methods in line with future improvement.
Critical thinking, related to mathematical skills such as problem-solving, questioning and analysis, is an essential part of Mathematics education (Driscoll, 2015;Wahyudin, Ahman, Rusmono, Rahmawati, 2017). Reflection is not a practice in many Mathematics classrooms (Erdogan, 2019;Posthuma, 2012;). In an earlier study by Posthuma (2011), it was noted that Mathematics teachers have limited understanding of the concept of reflection and there was therefore no evidence that teachers reflect-for-action neither reflected on-action verbally or in writing. Furthermore, Posthuma (2011) found that at http://journals.ums.ac.id/index.php/jramathedu least three out of five teachers reflected-in-action while teaching. The researcher further found teachers who reflected at the critical level to be focused on learners' thinking about Mathematics and how their instruction might have influenced their understanding of Mathematics. However, Posthuma noted an increase in self-knowledge and found new ways of teaching Mathematics which lead to learners' acquisition of inquiry and problemsolving skills. This implies that after reflection, teachers were able to identify the skills gap in their teaching practices. Also, Driscoll (2015) narrated that the Mathematics teachers' reflection process and professional learning can lead to classroom practice changes such as promoting and sustaining conditions that further support student learning.
Notwithstanding, the teaching philosophy of individual lecturers determines the teaching and learning process. According to Wahyudin et al. (2017), lecturers' epistemological beliefs and openness to dispositions to engage student teachers to be aware of reflective practice's epistemic value are solely their responsibility. In that light, lecturers at an Indonesia-based university were found to keep updating teaching materials to include relevant reflective practice aspects as evidenced in their lesson plans, planning, and evaluation reports.
Cavanagh and Prescott (2010) used Lee's reflection levels to interpret interview responses of three beginning secondary Mathematics teachers. Their results showed that teachers developed a greater capacity for reflection in their first year of teaching. However, in their first year, student teachers did not demonstrate critical reflection. This is because it was possible that they did not possess the disposition to become reflective practitioners. Erdogan's (2020) findings on prospective middle school mathematics teachers' reflective thinking skills showed that prospective teachers' reflective thinking skill level is moderate (neutral) with an average score of 3.08. Lau (2018) examined the reflective practice of 22 pre-service Mathematics teachers (PMTs). The results indicated that the PMTs mostly focused on content reflection followed by process reflection. Lau noted that relatively few PMTs engaged in premise reflection.
Considering the studies in Namibia on reflective practice as implemented in universities' teaching programs, it was noted that the skills acquired are deficient and limited to technical skills. However, reflective practice discourse includes various concepts aimed to demonstrate self-consciousness and reflection, the practice of tacit and tactic knowledge (academic), and social reconstruction among other factors to build a more skilled teachers' workforce. This study focuses on describing the different levels of reflective practices through experiences a group of Mathematics student teachers' over a period of a minimum of three years in the teaching program.

Research Methods
The study is qualitative using an action research approach and self-reflective narrative inquiry by participants. Further, a criterion sampling method was used to select information-rich cases from individual students by recording their experiences in the following domains: rationality, social and educational practices. Selected participants were in their third year of undergraduate studies, studying towards an honors degree in http://journals.ums.ac.id/index.php/jramathedu Education, with Mathematics as one of the subjects of specializations at the target institution of higher learning. Further, participants had completed Phase 2 of their teaching practice during which they teach and observe experienced teachers' lessons. To obtain more information of the student teachers' experiences, 10 (ten) members of the Teaching Methods of Mathematics class (Cohen, Manion & Morrison, 2007) were sampled.
Initially, the students had been taught a course, Teaching Methods of Mathematics, covering teaching strategies as the primary focus. The taught strategies include different types and levels of reflection. After Teaching Practice Phase 2, student teachers had completed reflective journals as per the course requirements and the journals were submitted together with their lesson plans. Furthermore, students were required to provide narratives of their teaching practice experiences as per Gore and Zeichner (1991) guidelines with reference to school, social efficacy, and development. By using narratives, the researchers embraced the view that writing is a method of inquiry-a way of knowing, and a discovery method (Richardson, 2000) thereby reflecting on student teachers teaching practices.
Transcripts were analyzed using a case-cross data analysis approach considering similarities and differences found at different levels of reflection and progress in developing quality reflective practice during the teaching program. The popular reflection type among student teachers denoted the five-level respected categories. Also, we selected certain events in order to hear multiple voices. Clandinin and Connely (2001) emphasize that we need to see student teachers as univocal and not tied to one theoretical structure that will make them appear uni-dimensional, considering representation and meaningmaking text to reflect student teachers' experiences. Thus, a comparison was drawn by way of significant divergence or similarities (Cohen, Manion, & Morrison, 2007) to present a crystallized prologue to recognize life worlds' diversity and shared reasoning. Ethical approval was sought and obtained from the University of Namibia's Ethical Clearance Committee. In addition, consent was sought and obtained from the student teachers who participated in the study. All participants were reassured of confidentiality and anonymity in reporting the results and that they could withdraw their participation from the study at any time without penalty.

Results and Discussion
This section presents the results of student teachers' reflective journals. Examples from journal entries are presented as evidence of noteworthy incidences in line with the identified levels. All names used are pseudonyms and addressed as Student Teacher (ST)hence forth, ST1; ST2; ST3.
Generally, descriptive entries by student teachers varied due to the difference in total journal entries submitted. Even though each participant was encouraged to email one reflective teaching journal at the end of the course, a week after their teaching practice, not all participants had returned the questionnaires duly. The students cited reasons such as lack of time, preparation of lesson plans, and assignments that were due during data collection. http://journals.ums.ac.id/index.php/jramathedu The results show that student teachers focused on technical reflection and reflectionin-and-on-action level by stating how well the teaching methodology course and other related modules were conducted. Student Teacher 1 recounted: In addition, ST9 recalls: The teaching methodology modules have made a big improvement to my experience as a Math student teacher. I thought teaching Mathematics was just a simple task that I will just stand and start doing, but I actually realized that is something that involves a lot of planning, skills and creativity as well. I have been taught a lot of teaching strategies that I'm going to use in my teaching. At the moment, I am now able to come up with a lesson plan. However, apart from teaching strategies, I also learned different assessment strategies and assessing learners. The important thing I have learned is that learners are not the same, and they do not have the same learning strategies; that is why I have to vary my teaching to accommodate all the learners' needs.
However, ST5 had a fairly different experience regarding acquisition of the necessary skills.
However, on the aspect of innovation and creativity, I feel like I am not fully equipped. More emphasis has to be placed in these two concepts. Yes, lecturers do talk about it, but they don't go deeper into it.

They need to guide us into it; give us examples just to open up our minds
In essence, student teachers expressed technical reflection in their journals as they matched their own competencies to teaching professional standards. Some student teachers were aware of the need to reflect in line with specific teaching strategies needed to increase learners' academic success. For example, ST4 recalls, I discovered that using a learner-centered approach is best; you engage them in a discussion to promote participation and critical thinking skills. As a result, about 80% of the class grasped the concept [not mentioned] in which almost everyone performed very well, and a few managed to go half way although they missed the final steps to the answer.
In another entry ST5 noted the following: During Phase Two of teaching practices, I have picked up a few things that prove essential in subject delivery. For example, these are after class tutorials for learners, discussion during classes, and allowing learners to express themselves freely in class. Things that have proven to increase academic success are extra classes and exposing learners to real-world mathematical situations such as taking them to banks when dealing, for example, on money and finance.
http://journals.ums.ac.id/index.php/jramathedu Contrary to the two reflections, ST9 expressed insufficient skills acquired over time as follows: No, I did not yet pick up enough teaching skills during my teaching practice because as a teacher, you remain a learner for life. Some of the skills I will discover as I go on with the process of teaching as long as I remain reflecting on my own work that is when I will realize what I am supposed to and what I am not supposed to; therefore, I am still in the process of discovering more skills.
The critical reflection level required incorporating the development of openmindedness, rational judgment, and creativity in the reflection process. However, these characteristics lack in the entries as evidenced below: ST4: Implementing what one has been taught can be a challenge since apart from dealing with the intellectual part, you are dealing with different kinds of behavior which can be quite challenging and might hinder the learning process if not handled accordingly. The behavioral approach we learned was shallow due to time. I had created a friendly environment with handouts to help learners get in the learning atmosphere as some believed that math is a complicated subject. I also tried to give them short motivational speech in class. Students have demonstrated insufficient reflective skills which are limited to the first two levels of the RP model. At the technical level, individual student teachers matched their competencies to professional standards and concentrated on teaching amongst other tasks. At the second level, a combination of constant engagement with reflection-in-action and reflection-on-action was noted demonstrating the capacity to teach. However, a skills gap was identified in terms of reframing and reconsidering the teaching process. This finding is in line with Posthuma (2011) andDriscoll (2015) who noted an increase in self-knowledge and emphasized new teaching methods to learners to enhance classroom practice. However, the need to support appropriate learning mechanisms was noted due to insufficient teaching materials at the university.

ST1: The purpose and functions of teaching Mathematics in
Student teachers seemed to have combined the constant engagement with reflectionin-action and reflection-on-action domains by stressing the need for ongoing learning. Acquiring the two domains requires student teachers to reconsider their efforts towards enhancing learner performance through active participation in numerous leaning processes and exposing them to real-life situations. This makes Mathematics relevant to real-life situations and enhances critical thinking. It can therefore be deduced that student teachers have demonstrated self-discussion of the teaching process. The excerpts at level two are reflected in Clandinin and Connely (2001) for student teachers' experiences to demonstrate diverse views and representations culminating into meaning-making. The third and fourth levels of Valli (1997) had few entries showing deliberative and http://journals.ums.ac.id/index.php/jramathedu personalistic reflections accordingly. However, this is not surprising as Erdogan (2020) and Lau (2018) found that student teachers did not possess the disposition to become reflective practitioners.
Student teachers noted that the skills acquired during the teaching program needed an upgrade in classroom management to create a conducive environment for learningmore so for slow learners. In addition, student teachers reflected more on the curriculum's content concerning what could be more appropriate for teaching to contribute to national development. This finding is similar to Lau (2018) who concluded that student teachers mostly focused on content reflection followed by process reflection and less on rational judgment and critical thinking. A few alternative ways of teaching and learning were demonstrated in line with Lee's (2005) suggestions for improving teaching and learning. Suggestions for improvements of teaching and learning are necessary so that student teachers that exit the teacher training program do not lack a critical approach to integrate a move towards re-defining transformative and active intellectuals (Nyambe,1996). Also, teaching competencies are based on reflective practices, subject knowledge, attitude, experience and values. Failure to acquire these skills will have detrimental effects on the quality of Mathematics teachers serving in Namibian schools.

Conclusion
This study concludes that most student teachers reflected at a technical level as they matched their competencies to professional teaching standards. Some student teachers demonstrated the need to reflect in line with specific teaching strategies needed to increase learners' academic success-illustrating the teaching process' self-discussion. However, skills necessary for the third and fourth level of Valli (1997) were negated. This could be attributed to lack of disposition to become reflective practitioners. There is a need to enhance teaching mechanisms that will generate open-mindedness, rational judgment, and creativity. The study further suggests a need to strengthen and avail opportunities that would promote and intensify reflective practices in the teacher training program at the University of Namibia.


extfieldsofstudy:
Sociology
Medicine
Computer Science

text:
Why, What and How to Help Each Citizen to Understand Artificial Intelligence?

A critical understanding of digital technologies is an empowering competence for citizens of all ages. In this paper we introduce an open educational approach of artificial intelligence (AI) for everyone. Through a hybrid and participative MOOC we aim to develop a critical and creative perspective about the way AI is integrated in the different domains of our lives. We have built and now operate a MOOC in AI for all the citizens from 15 years old. The MOOC aims to help understanding AI foundations and applications, intended for a large public beyond the school domain, with more than 20,000 participants engaged in the MOOC after nine months. This study addresses the pedagogical methods for designing and evaluating the MOOC in AI. Through this study we raise four questions regarding citizen education in AI: Why (i.e., to which aim) sharing such citizen formation? What is the disciplinary knowledge to be shared? What are the competencies to develop? How can it be shared and evaluated? We finally share learning analytics, quantitative and qualitative evaluations and explain to which extent educational science research helps enlighten such large scale initiatives. The analysis of the MOOC in AI helps to identify that the main feedback related to AI is “fear”, because AI is unknown and mysterious to the participants. After developing playful AI simulations, the AI mechanisms become familiar for the MOOC participants and they can overcome their misconception on AI to develop a more critical point of view. This contribution describes a K-12 AI educational project or initiatives of a considerable impact, via the formation of teachers and other educators. Supplementary Information The online version contains supplementary material available at 10.1007/s13218-021-00725-7.

Introduction
All citizens are impacted by digital technologies derived from computer science and this takes a new qualitative and quantitative turn with what is named artificial intelligence (AI). We must allow everyone to understand how AI mechanisms work in order to develop a critical and creative perspective towards digital technologies. For this objective, we develop a participative MOOC aiming to develop computational thinking competency and machine learning (ML) initiation. The MOOC initiative is inspired by the Finnish initiative to train 1% of its population on the AI domain [1], but also on the success in providing previous open access to computational thinking education resources for teachers and citizens not familiar with computer science. The AI MOOC we introduce in this paper is operated as a citizen training in AI in the broad sense, intended to a large public beyond the school domain, reaching more than 20,000 participants with a satisfaction level higher than 90% [2]. Through this initiative we aim to achieve an ubiquitary citizen university in digital culture and digital sciences [3].
Why (i.e., to which aim) helping everyone to understand artificial intelligence? Most of us simply use it, do we need to understand how it works? As discussed in [4] for kid initiation regarding AI, or pointed out in [5] at a societal level, and when introducing teaching resources such as [6] the need of "acculturation" is often simply settled as mandatory. This is also true at a more general level for STEM [7]. We agree, but it is worth making explicit the reason why. Let us point out two reasons: -With the disruptive behavior of such AI mechanisms, one tends to personify such machines [8,9] or even put oneself down as "less intelligent" than the machine [5]: This could be a lever for domination (by humans) able to manipulate such systems, as opposed to critical thinking development (the notion is discussed in, e.g., [10]). Understanding AI can thus be considered as a mandatory (know-why) social skill. And we are going to observe that the main issue is related to "fear": Being unknown and mysterious, AI was frightening, while thanks to this MOOC, "playing" with AI allows one to make these mechanisms familiar. -Applications of these technologies seem endless in potentially all domains, at both an individual and collective level. We however can obviously consider that one will not be able to innovate without mastering the "how it works" [5,7] beyond using it as a black-box, because some key behaviors (e.g., adversariality [8]) are counterintuitive and must be understood to avoid spurious usage. AI thus yields domain-specific knowledge (know-what) and technical (know-how) skills, which are mandatory.
A step further, while the two previous points intersect with all STEM, AI raises a specific issue: It questions also our vision 1 of human intelligence [8] by trying to model some cognitive human processes that are not restricted to computational thinking [11]. Current models of human creativity, for instance, can be questioned by AI models [12]. Moreover, when modeling some aspects of algorithmic intelligence, we are also advancing in a better understanding of human intelligence.
What to share regarding AI popularization is extensively discussed, for youngsters, e.g., in [4]. It is now well established, e.g., by Druga [13] that starting to "play" (i.e., experiment with and "program") with such a system allows one to develop the know-why, know-what and know-how skills pointed out previously. Available adult formations are more technical, as e.g. with Element of AI [1,14] which is now a worldwide reference in terms of AI popularization, or are simply "talking about" AI. We however consider that there is a lack: Adults also need to "play" with AI mechanisms to deconstruct misconceptions and construct pertinent representations of the underlying mechanisms, as proposed here.
How to share such know-why, know-what, and know-how skills is also already widely reported (see again [4] for an inventory of existing resources for youngsters, and [14] for a general positioning of our proposal with respect to the two other major resources). Here the key point is that we consider, following [15], a MOOC with game based learning components, dedicated to citizen formation as developed in [16] for another subject. Our pedagogical approach is in link with social learning, and promoting engagement as studied in [17]: Active learning including unplugged activities (see, e.g., [18]), promoting peer interactions, proposing "takeaway" reusable resources, this with a clear problem-centric learning objective.
In order to report how we answered these three questions, we are going first to explain our position sketching what is to be shared with everyone and then to detail more concretely in link with twenty-first century skills what is proposed in this formation, before presenting the method and results and discussing perspectives.

Artificial Intelligence and the Twenty-First Century Skills
As introduced, AI initiation of everyone is a key regarding what is called twenty-first century skills 2 as explained in Fig. 1 and developed in [11]. With respect to this disruptive technology we need critical thinking to make the distinction between beliefs and effective tools, computational thinking skills to understand how it works in order to understand what happens when using it, problem solving capability to interact with these objects at the application level, creativity to develop and create our own usage of AI mechanism (and not only undergo the imposed uses), and collaboration because all this can not be managed alone.
Wondering how a machine would learn to solve such a complex task, comparing natural and artificial intelligence is also a great opportunity to ask how we, humans, could solve "mechanically" a complex task, a very interesting way of thinking in a reflective way how a human brain can solve it systematically. This is in direct link with computational thinking [11], and this aspect is highlighted in the proposed formation.
We detail in the supplementary material the learning objectives of the formation and develop how it is implemented. Let us simply highlight our specificity: with respect to other offers in the field [1], the content is less technical (e.g., machine learning programming in Python is proposed only as an extension), but not only a verbal introduction, while effective activities, including unplugged activities (i.e., without a computer using low-tech everyday tools), are proposed to understand how-it-works. We not only address AI at the conceptual level but the learner is engaged in practicing with different programs to learn the fundamentals of AI. As an example, in Fig. 2, we summarize the level of technical explanation given for an activity using the http:// playg round. tenso rflow. org interface, where participants are invited to build and train their own small deep neural network to solve a categorization task, while other activities with images or sounds are proposed, learning by doing.
This formation has primary targets and secondary targets: the primary targets are "science outreach mediatory actors" (médiateur·e·s scientifique, in French), involved in AI K-12  Left: an elementary computation (e.g., predicting whether the person head is feminin or masculin) is implemented via a computation unit (i.e., neurons) taking into account several input data X (e.g., the hair length, face pilosity, mensurations, …), each up to certain weight W depending on their pertinence or robustness (e.g., pilosity more than hair length) and combine then before providing an output y, based on statistical adjustment. Right: combining many computation units in layers (i.e. deep-network, when many layers), allows to realize complex robust computations (e.g., face recognition or categorization) providing that all information has been "put in numbers" (i.e., quantified), with results that can be interpreted at a semantic level by humans. Images re-edited from https:// pixees. fr and https:// playg round. tenso rflow. org 1 3 initiation, while many citizens (e.g., parents of K-12 pupils) used this MOOC in order to transmit what they learnt.
An important aspect is the fact that all materials are open resources, in the sense of [19]. Beyond publishing under a CC-BY licence, and considering the different aspects of open educational resources (OER) as reviewed in [20], we share our resources at different levels, enriching the link between OER and MOOC as stated in [21], with three aspects. Granularization: embedded in a scenario, our resources are also modular and have been indexed and re-edited in order to be integratable as components of other scenarios, thus with suitable documentation to reuse the proposed bean. Contamination: one lever of the formation is the "teach to learn" paradigm, i.e., invite the learner to share her or his new skill in order to consolidate it, thus making the resource bean not only "open" but also easily reusable at the level reached by a person finishing the formation. Collaboration: the formation is not only "asynchronous" but also used in hybrid (online or in real life) synchronous sessions, raising another challenge: not only reuse the resource, forking some resource if needed, including merging to enhance the resource, but also take the opportunity to have a common use of the resource to collaborate as in Class′Code [22], in a given (geographical or online structural) territory.

Learning by Doing Through Concrete AI Related Activities
Each of the three chapters of the course is illustrated by concrete activities that bring learners to train their own machine learning models and interact with real life applications of AI. For the first part of what artificial intelligence is, participants develop a first understanding of AI through training a visual recognition neural network model. In order to frame the activity, we designed an integrated tool to control the training of the model. This experiment is sequenced in three steps. In the first step the learners create a model that differentiates between two categories of images by feeding the model images from a dataset of samples given to them. This first step helps dispel preconceived ideas we have noticed in children with whom we did this activity such as the idea of an AI is a robot that can recognize anything in an image. They are led to realize that the AI they have trained can not recognize categories it was not trained on by testing it on images that do not represent one of the two categories known to the AI. In the second step the children understand that with few examples the machine learning model struggles to generalize the concepts represented by the images by testing it on images that match one of the categories but in a different context or position (a drawing of a lion instead of a photo of a lion for example). The last step is making them train a model on their own dataset with the classes and examples they choose and find.
The second activity around how AI is developed aims to highlight the central role of data in the making of machine learning applications through experimenting with biases in datasets. We have created a dataset of images with two categories: women and men with an obvious bias (women have long hair and men have short hair). After training a first model with this dataset and seeing it fail, the participants are then invited to reflect on the wrong inferences and create their own dataset to train a better model. They select data, train their model, test and iterate until they're satisfied with the result. Then, to emphasize the importance of data, participants are invited to build datasets to train machine learning models to recognize subjective categories, for example "cute cat vs ugly cat" and thereby understand the responsibility that fall on the humans creating AI's and the importance of questioning the data behind the AI applications they might encounter.
The last part about the interactions between AI and humans is illustrated by a series of activities where children experiment with real life AI applications. They are first exposed to painting generated by a Generative Adversarial Networks model and the painting made by a human painter the model was trained on. They are asked to try to differentiate the human paintings from the AI generated paintings. Then they get to modify the YOLO (You Only Look Once) model using a camera based real time image recognition model. They finally interact with a chatbot. These activities aim to broaden their understanding of the applications of machine learning and question how they can help humans.

Method and Production
Contents allow us to gain a first understanding of what AI means and what it is not, understand the principles of machine learning and the crucial role played by data, taking into account the societal issues of AI. Learners are invited to question themself, beyond preconceived ideas, and really understand the ground of AI; perform activities and manipulate AI programs to build their own vision; acquire a minimal scientific and technical culture (concepts, history of humans and ideas). As an outcome they are able to discuss the subject, question applications, choose some framework to contribute to the development (or not) of AI applications: -Questioning Deciphering the discourse around AI to move from preconceived ideas to questions on which to rely to understand. -Experimenting Perform activities and manipulate AI programs to make up our own mind, with both online and unplugged activities [10].
-Discovering Share a minimal culture, scientific and technical, to become familiar with concepts through the history of humans and their ideas. -Appropriating Being able to discuss the subject, its applications, its framework with various interlocutors to contribute to the construction of AI applications.
We produced a hybrid, participative, performative and contaminating training: -Freely accessible online training course with free of charge attestation of attendance; online exchange forum, to share and help each other, when training on these subjects; online and in real life hangouts to extend this sharing and serve local projects on these subjects, all content items being also reusable to derive and build other resources. -Hybrid Because online resources are designed to derive in situ activities. As a consequence, there are no "time limited sessions" but people join when they want and return when they need. -Participative In the sense that not only "scientists and engineers" with professional video and content producers have co-created the resources, but also "end-users" such as teachers or parents, while the content is adapted considering the participant feedbacks, including new resources creation (a kind of "wiki" where participants provide their input via forum messages and we take care of the shaping). -Performative Because students are taught to be their own teacher, while helping each other, and we also consider "how to learn to learn" mechanisms (e.g., find some answers on the web, discover some elements by themself during problem solving activities). -Contaminating Because students are invited to "pay" for this course by … sharing the contents with people from their surrounding.
Nothing "new" here, just the fact we not only propose a xMOOC "course" but also dedicate enough time resources to discuss with the participants, beg external person to contribute when needed, and do not restrain our participation to "our" MOOC but are willing to export also some resources or dialog into other initiatives of the same kind (e.g., driven by https:// www. reseau-canope. fr or other https:// class code. fr partners), i.e., not only "with us" but also "at the others", using an approach known as cMooc [17].
This formation is hybrid and each chapter is illustrated by activities that bring learners to train their own machine learning models and interact with real life applications of AI, as detailed in the previous section. The formation is also performative and contaminating in the sense that an adult benefits from this training and then in his-her family or in his-her business, association, structure shares what s-he has discovered with his or her children or the seniors, or the other way round. Part of the training exercises is to be able to transmit what has been learned. Which is also a good way to learn. In Fig. 3, we show such an activity that can be redone with family or friends.
Regarding unplugged activities, it is often said that we should limit screen time, avoid digital passivity, and develop critical thinking about the digital world. A paradigm exists in which neither hardware nor software are required: unplugged computing (see [10] which has an English version as supplementary material for details). During unplugged or computerless activities, 3 we learn concepts, often by playful Fig. 3 Left: the "Nim game" is a simple strategy game in which two players (here a human and the "machine") take turns removing (or "nimming") 1, 2 or 3 objects (here rods), the loser making the last nimming. This setup allows us to understand what an algorithm is (including algorithmic recursivity). Right: this "AI" machine is made of "balls and bowls" (or any equivalent objects). Each box corresponds to the number of remaining rods. The machine is "trained" by just putting a red or blue ball, depending on the game issue (win or lose), in the bowl corresponding to each move. After training, the whole game policy is stored in the "machine" and the artificial player just has to choose what to play, counting the balls in the corresponding bowl. This allows us to understand what is called "reinforcement learning", and why a mechanism can "learn" a non-trivial rule (in fact, "always leaving a multiple of 4 rods"), without understanding anything. Images from https:// pixees. fr as open CC-BY resources activities to develop computational thinking competence [11] as a way of solving problems, in which computers are not the end in themselves. Unplugged computing activities have the advantage of not requiring costly equipment or the skills to operate it, relieving the cognitive cost to invest to make them work, allowing us to concentrate on the content. It is also the best proposal for so-called "contaminating" activities. In artificial intelligence initiation, it has also the major advantage to demystify and unpersonify the machine.
Concretely the resources (as exemplified in Fig. 4) are made of short videos freely reusable, synthetical texts, quiz to auto-evaluate what has been shared and also to find by yourself some elements, activities online to manipulate machine learning algorithms via graphical interfaces, and unplugged activities to be performed in the family, with friends or in educational contexts (as exemplified in Fig. 3); such activities are designed to be also realized by youngers (typically K6-K12). At last, a mind-map, peer-to-peer corrected, is proposed in order to summarize what has been learnt via such a key-word graphical representation. A step further, the forum is an important tool: quiz questions are discussed (some of them have been improved after the first answers), and notions are re-explained or re-formulated, up to the point of enriching the core resources with re-writing of shared information: the goal for this citizen formation is to be improved by citizens.

First Results and Analysis
After three months of activity, more than 13,000 persons have been engaged in the AI MOOC (37% female, 62% male, 1% not binary) with more than 1600 persons active (answering to the first quiz) and about 600 persons having completed the full MOOC.
Working time is 10-20 h on average (about 50% of the people spend from 2 up to 5 h per week, during about 3 weeks, while 25% spend less and 25% more), and above 94% of people having their expectation satisfied (43% fully satisfied), and 82% of them state that they could recommend this MOOC.
These statistics come from a start-of-course (1140 respondents) and end-of-course (217 respondents) surveys completed anonymously by participants on a voluntary basis. We should note that there is a bias in this survey since it is expected that it is people who are really invested in MOOC, and probably-as a result-the people with the best track record, who responded. This survey was presented as a tool to listen to participants' opinions, allowing us to know them better and improve training over time.
On the forum, more than 500 persons have been or are active while more than 3100 are reading, and there are about 370 discussions, more than half being on the course contents (e.g., strong versus weak AI, symbolic versus numeric methods, societal issues, …). More than 10 online hangouts of 30 to 200 persons have been organized already by one of the 70 partners of the Class′Code project [22], during this covid-19 confinement. Several pieces of this Fig. 4 Two examples of open reusable resources. Left: one thumbnail of the videos, based on a 3-4 min dialog between Guillaume, who is the "citizen", and a researcher. She answers the question, gives some explanations, and invites him and us to question, experiment, discover and discuss each topic. Right: an example of the first screen of an interactive animation, guiding step by step to the discovery of a content, and some manipulation. The key point is that these resources are modular in order to be reused in other courses developed by the teachers (in the wide sense) using this resource for their formation. Images from https:// class code. fr/ iai as open CC-BY resources resource start to be reused to build other resources, e.g., to enrich textbooks 4 and their digital supplementary material.
Detailed evaluation results are given in the supplementary material of this paper, leading to following analysis.
Qualitatively, beyond very nice and encouraging positive feedbacks, through the constant evaluation of the course by the users, we are invited to take several improvements into account: (1) extend the existing formation with more operational tutorials, (2) manage some technical weakness because we integrate state of the art recent external resources, some still to be consolidated, (3) complete the existing contents to better help the learner progression. And we will, since this is a long term open course (probably more than 2 years). We have also a several questions on application domains of AI (i.e., in education, regarding democracy governance, or disabled assisting tools), which are a bit beyond what we can offer in reasonable time, because each third party domain requires a lot of prerequisites before considering AI related tools. Our idea is to offer "plugins" to other courses, i.e., participate regarding AI issues, the first project already in preparation being on GreenIT. For all these considered extensions, the present course acts as the core curriculum.
Qualitative observations, reading the different participant feedbacks available in our open data set, confirms our hypothesis that citizens now have a better understanding of AI. As pointed out, the main feedback is related to "fear": being unknown and mysterious, AI was frightening, while "playing" with AI allows one to make these mechanisms familiar. At the end, apprehensiveness is still present but regarding the human use of AI, not about "the" AI itself. Another shift concerns technophoby versus technophily. At the end, we did not notice than people "changed their mind" but all of then were more "technocritic", i.e., considering that the true answer is in the middle. A step further, several feedbacks concerned the fact "it does not always work": we have several pertinent observations from people noticing how easy it could be to defeat the estimation, not because the algorithm was "wrong" but because the performances were limited, and easily biased by the training data. Regarding soft-skills we have no counter-example at the end of the course of people still "personifying" AI mechanisms, but these persons may have left the course if too far from their a-priori convictions. We are not able to really evaluate to which extent the know-why skills really improved, but can easily report participants to have generally the feeling they did. Regarding know-what skills, asserted by quiz answers, we have pretty good results, it is clear that this part of the formation has been successful, with one reservation: our participants were mainly relatively well educated persons, as detailed in the appendix, thus were expected to succeed, regarding knowledge acquisition or consolidation. We also have no precise evaluation of what has been "discovered" (versus already partially known or well known) but can feedback about several persons "surprised" by a part of what they found. Regarding the know-how skills, the situation is contrasted and depends whether or not people did have time to invest in the activities. If yes, results are really good and participants came back with a request to "go further on". This is in favor of our assumption that this formation may be a gate towards more technical initiation such as [1,14]. All together, we can only affirm that self-evaluation and peer to peer evaluations lead to good results, and to witness that participants have the strong feeling to have a better understanding of AI.
A few participants did not find what they expected, either because they are not interested in redoing activities with young people (of any age;)) to better understand or because they were looking for professional formation. In fact, we mainly reached rather highly educated persons, while we target popularisation, which seems to be more the case now, but slowly. In both cases, when a person joins, the content is always considered as accessible, and useful ("good to know"). The hard point is thus convincing yourself to join. We hope that in real life hangouts and also community approaches will help, and work on this aspect [24,25].
On our side, we are really delighted to participate on these researcher-citizen exchanges and shares, with very interesting questions, sometimes on crucial subjects, always kind and moderated (no troll, 5 yet ;)).
We also better understand the real educational needs regarding AI foundation and applications. People clearly first want to clarify their belief about such a topic, understand what is true, what is coming and what is putative only. They then want to link such knowledge with concrete applications, e.g., what can be done regarding visual or audio processing, or not. This was easily covered for generic applicative tools, this is less easy to address for specific domain applications (e.g., justice or medicine) because this strongly depends on many other specific aspects of how it can be used. They finally are generally surprised but then highly convinced that they must "play with it" to build their own correct representations, and are rather proud to succeed.
With respect to other studies on MOOC engagement the present success seems to be related, as expected, to the "important role that instructors, course resources and pedagogic practices that focus on providing problem-centric and active learning play in engaging online students" [17] yielding good behavioral, cognitive and affective engagement, even if the didactic objective is specific but rather wide (here "understanding AI" with respect to, e.g., learning a given programming language), while peer interactions were really poor. Further studying this engagement, as performed in, e.g., [17] is a perspective of the present work.

Conclusion and Perspectives
We have reported on a citizen AI formation, detailing the pedagogical choices (linking everyday life elements to fundamental concepts, understanding the "how it works" via online or unplugged concrete activities, making explicit how understanding the "science underneath" allows to better discuss the societal impacts) and the pedagogical method. (e.g.: small conceptual videos, contaminating activities to be redone in real life, …).
We may consider our offer as the "grown up" counterpart of what is usually proposed to kids [4,6,13], i.e., a more accessible gate for non technophile targets, as an intermediate step before courses allowing the use of AI at work, such as [1,14], and as an alternative for more superficial presentation of AI only in "words". It seems to cover a real need, as quantified in Sect. 6, and our goal is to really multiply the audience, either within the MOOC itself or by contributing to other initiatives, thanks to the openness of our resources.
Regarding AI-K12 education, our experience (including for other connected formations of Class´Code, such as [2] reviewed in [3]) is that such a MOOC is not directly usable as it. It has however three usages: (1) it allows the formation of the teachers in the wide sense (including parents, through family activities). (2) It provides also reusable resources for these learners to prepare activities. (3) Several modular beans of resources (videos, interactive animations, selfcontained texts) of the MOOC can be exploited by K8-K12 persons in an autonomous way. Building a "MOOC for youth" is another challenge, probably to be designed on the basis of game based learning MOOCs as studied by one of the co-author [15]. Examples (unpublished yet) of escape games involving STEM and including AI aspects, that seem to work well have been reported to us. It is a perspective of our work [26]. The need for the educators to gain a scientific and technical culture before deploying learning activities, was the first priority.
This "popular education" initiative is a contribution to the idea of a "ubiquitary citizen university in digital science and culture" [3], i.e., the fact that, beyond schooling, our society has a real need of "formation throughout life". And this is something that must be participative, performative and contaminant, in the sense developed in Sect. 5, contributing to everyone's twenty-first century education in the sense reviewed in Sect. 3, regarding AI competencies and beyond.
As next steps, we are going to invite a MSc student to deeply analyze the available learning analytics in order to better understand how to pursue (for at least 2 years) this initiative. We also are going, within the https:// www. cai. commu nity project, to further work on the online community aspects, targeting teachers (we must make a choice in terms of community), and this will drive us toward not only considering teaching AI, but also teaching the way to teach AI, including using AI frameworks (both symbolic and numeric) to better model the human learning process.
And for those who still believe that AI will generate a dystopia or some utopia, we will carry on explaining that this is neither wrong nor true, but a belief (anyone is free to have his or her own belief), and the best way to clarify, see go further, such belief, is to understand intelligently artificial intelligence.