Study on knowledge, attitudes and behavioral practices of antimicrobial usage and resistance in animals and humans in Bahir Dar City, Northwest Ethiopia
Antimicrobials, which target bacteria, viruses, fungi, and parasites, have the ability to inhibit or eradicate microorganisms. The use of antimicrobials began in 1928 when Alexander Fleming discovered penicillin, an event that revolutionized medicine . Since then, the discovery and development of antimicrobial medications have been an ongoing process, marked by significant milestones in the treatment of infectious diseases. However, the injudicious and excessive use of antimicrobials has led to the emergence of drug-resistant microorganisms, posing a serious global health threat . Antimicrobial resistance (AMR) is a significant global health threat. AMR occurs when a microorganism develops resistance to an antimicrobial agent that was previously effective against it . This issue is not new; antibiotic resistance was observed within a decade of penicillin’s clinical introduction, with more than 50% resistance reported in Staphylococcus aureus by the late 1940s . The misuse and overuse of antimicrobial agents in healthcare and agriculture are major contributors to the development of AMR . Microbial strains that mutate to develop resistance are more likely to survive and reproduce in the presence of these drugs . For several decades, antimicrobials have been used extensively, not only for treating diseases but also for non-therapeutic purposes such as promoting growth in livestock and preventing diseases in intensive farming . Over half of all medications globally are prescribed, dispensed, or sold inappropriately, often without adhering to the principles of rational drug use, and more than half of patients fail to follow the correct administration of these medications. Problems such as self-prescription, unnecessary use for viral infections, incorrect dosages, and prolonged treatment durations further aggravate the situation . AMR is a global phenomenon, with the rapid spread of multidrug-resistant infections being particularly evident in regions where antimicrobial use is high . Resistant bacteria can spread among humans, animals, and even across international borders . With increased international travel and trade, resistant bacteria originating in one region can easily spread to other parts of the world . Therefore, coordinated global initiatives are urgently needed to monitor and control the spread of these resistant strains . The challenge of AMR is especially critical in many low- and middle-income countries in Africa, where factors such as poverty, a high prevalence of infectious diseases, and unregulated use of antimicrobials in both humans and animals exacerbate the . According to WHO  disease surveillance report from health centers across Ethiopia indicated a rising trend of antimicrobial resistance. This increment of AMR associated with the awareness level of the community. For example, low level of awareness among patients about the proper antibiotics use and resistance in a hospital-based study in Northwestern Ethiopia was reported by Geta and Kibret . Another study conducted in Bahir Dar city indicated the presence of a high level of antibiotic resistance rate (95.08%) and this necessitates regular surveillance and intervention programs to improve the knowledge and practice level of the people regarding antimicrobial usage and resistance . However, the extent of knowledge, attitudes, and practices regarding antimicrobial use and resistance among humans and animals in the study area is not well understood. To address this knowledge gap, this study aims to evaluate the knowledge, attitudes, and practices concerning antimicrobial use and resistance in both humans and animals in Bahir Dar city, Northwest Ethiopia. Understanding these factors will help identify contributors to inadequate awareness and practices, ultimately leading to more informed interventions to mitigate the risks associated with AMR. 

Study area The study was carried out in Bahir Dar city, situated in the Northwestern region of Ethiopia. Bahir Dar is a dynamic urban center serving as the headquarters of the Amhara National Regional state. Its geographical coordinates lie approximately at 11.59°N latitude and 37.36°E longitude. Bahir Dar is positioned at a distance of 578 km to the Northwest of the capital, Addis Ababa. The area experiences an average annual precipitation ranging from 1200 to 1600 mm, with temperatures fluctuating between 8–31°C. The elevation within the area spans from 1500 to 2300 m above sea level (m.a.s.l.) . As per Tamrat et al . , the population of the city is estimated at 297,794 individuals (Fig. ). Study population The study population consisted of adult individuals of both genders, aged 18 years and above, residing in the selected kebeles for minimum of six months before the study was conducted. Study design A validated semi-structured questionnaire was employed for a community-based cross-sectional study design conducted from February to June, 2023. Sample size determination To determine the number of samples needed for this study, the Eq.  described by Thrusfield  was utilized. The parameters taken into consideration were a 95% confidence interval, a desired absolute precision of 5%, and an expected prevalence of 50%. 1 [12pt]{minimal}
				
				 
				 
				 
				
				
				
				
				$$n= ^{2}{P}_{exp}(1-{P}_{exp})}{{d}^{2}}$$ n = 1.96 2 P exp ( 1 - P exp ) d 2 where n = sample size Pexp = expected prevalence d = desired absolute precision Consequently, a total of 384 subjects residing in the selected four kebeles of Bahir Dar city were included in the study. However, accounting for a 5% non-response rate, the final sample size was adjusted to 400. Sampling strategy The study area, Bahir Dar, was selected purposively based on the population size and no previous research works. Four kebeles (namely kebele 03, 09, 11, and 15) were selected randomly from 17 kebeles. Household and participants were included using simple random strategy. One person who fulfilled the eligible criteria from each household were selected randomly. For individuals who were unable to participate on the scheduled date another opportunities or time was offered. Data collection A semi-structured questionnaire was utilized to collect data through interviews. The questionnaire was developed after a thorough examination of existing literature on the methodologies employed in conducting knowledge, attitude, and practice (KAP) surveys, as well as global studies pertaining to antimicrobials. Two experts in the field of epidemiology and public health internally evaluated the content validity of the questionnaire items. Based on their feedback and recommendations, necessary modifications were made to ensure appropriateness for the local population. The questionnaire comprised four sections, which encompassed the demographic information of the respondents, their knowledge, attitudes, and behavioral practices regarding antimicrobial use (AMU) and antimicrobial resistance (AMR). The majority of the questions were designed to elicit close-ended responses (Supplementary File 1). Measurement tools Socio-demographic data There were nine questions in this part. The questions include sex, age, education level, marital status, position of respondents in the household, occupation, animal ownership, household size, and ownership of the house. Knowledge on antimicrobial usage and resistance There were nine questions which was asked to know the knowledge level of the community on antimicrobial usage and resistance. Six of the questions were Likert scale while three were an open-ended question that allows respondents to express their perception. A correct answer for each close ended questions was given 3 score for correct answer, 2 uncertain and 1 score for a wrong answer. The score varied from 6–18 points and was classified into 3 levels according to the Blooms’  cut off point, 60–80% as follows: High level (80–100%) 15–18 scores, Moderate level (60–79%) 11–14 scores and Low level (less than 60%) 6–10 scores. Attitude on antimicrobial usage and resistance This part includes the attitude of people who live in Bahir Dar city towards antimicrobial usage and resistances. There was a total of eight questions, two positive and six negative statements with Likert scale options of choice ranging from agree to disagree. The rating scale was measured as knowledge scale. The scores varied from 8 to 24 and all individual answers were summed up for total and calculated for means. The scores were classified in to 3 levels (Positive Attitude, Neutral Attitude and Negative Attitude). Positive Attitude 19–24 scores (80%-100%), Neutral Attitude 15–18 scores (60%-79%) and Negative Attitude 8–14 scores (Less than 60%). Practice on antimicrobial usage and resistance Eleven questions have been included in this part. Of which ten questions were close ended, eight Likert, one yes/no and one multiple choice questions, and one open ended question were encompassed in this part. The rating scale for the responses was measured as previous one. The scores in measuring the practice of antimicrobial usage and resistance were varied from 8 to 24, and were classified into 3 levels according to the Bloom's cut off point, 60–80% . The levels of practice were: Good (80–100%) 19–24 scores, Fair (60–79%) 15–18 scores and Poor (Less than 60%) 8–14 scores. Data management and analysis The obtained data was subjected to classification, filtering, and coding procedures using Microsoft Excel® 2019. Subsequently, the data was exported to STATA version 17 (Stata Corp. Texas, USA) for the purpose of conducting appropriate statistical analyses. Descriptive statistics was employed to assess the socio-demographic characteristics of the study participants and to summarize open-ended question. Numerical data was presented as mean ± standard deviation. The association between the KAP and sociodemographic characteristics of the respondents, and the relationship among KAP was assessed using Chi square (χ2). A p -value less than 0.05 was considered as statistically significant. 

The study was carried out in Bahir Dar city, situated in the Northwestern region of Ethiopia. Bahir Dar is a dynamic urban center serving as the headquarters of the Amhara National Regional state. Its geographical coordinates lie approximately at 11.59°N latitude and 37.36°E longitude. Bahir Dar is positioned at a distance of 578 km to the Northwest of the capital, Addis Ababa. The area experiences an average annual precipitation ranging from 1200 to 1600 mm, with temperatures fluctuating between 8–31°C. The elevation within the area spans from 1500 to 2300 m above sea level (m.a.s.l.) . As per Tamrat et al . , the population of the city is estimated at 297,794 individuals (Fig. ). 

The study population consisted of adult individuals of both genders, aged 18 years and above, residing in the selected kebeles for minimum of six months before the study was conducted. 

A validated semi-structured questionnaire was employed for a community-based cross-sectional study design conducted from February to June, 2023. 

To determine the number of samples needed for this study, the Eq.  described by Thrusfield  was utilized. The parameters taken into consideration were a 95% confidence interval, a desired absolute precision of 5%, and an expected prevalence of 50%. 1 [12pt]{minimal}
				
				 
				 
				 
				
				
				
				
				$$n= ^{2}{P}_{exp}(1-{P}_{exp})}{{d}^{2}}$$ n = 1.96 2 P exp ( 1 - P exp ) d 2 where n = sample size Pexp = expected prevalence d = desired absolute precision Consequently, a total of 384 subjects residing in the selected four kebeles of Bahir Dar city were included in the study. However, accounting for a 5% non-response rate, the final sample size was adjusted to 400. 

The study area, Bahir Dar, was selected purposively based on the population size and no previous research works. Four kebeles (namely kebele 03, 09, 11, and 15) were selected randomly from 17 kebeles. Household and participants were included using simple random strategy. One person who fulfilled the eligible criteria from each household were selected randomly. For individuals who were unable to participate on the scheduled date another opportunities or time was offered. 

A semi-structured questionnaire was utilized to collect data through interviews. The questionnaire was developed after a thorough examination of existing literature on the methodologies employed in conducting knowledge, attitude, and practice (KAP) surveys, as well as global studies pertaining to antimicrobials. Two experts in the field of epidemiology and public health internally evaluated the content validity of the questionnaire items. Based on their feedback and recommendations, necessary modifications were made to ensure appropriateness for the local population. The questionnaire comprised four sections, which encompassed the demographic information of the respondents, their knowledge, attitudes, and behavioral practices regarding antimicrobial use (AMU) and antimicrobial resistance (AMR). The majority of the questions were designed to elicit close-ended responses (Supplementary File 1). Measurement tools Socio-demographic data There were nine questions in this part. The questions include sex, age, education level, marital status, position of respondents in the household, occupation, animal ownership, household size, and ownership of the house. Knowledge on antimicrobial usage and resistance There were nine questions which was asked to know the knowledge level of the community on antimicrobial usage and resistance. Six of the questions were Likert scale while three were an open-ended question that allows respondents to express their perception. A correct answer for each close ended questions was given 3 score for correct answer, 2 uncertain and 1 score for a wrong answer. The score varied from 6–18 points and was classified into 3 levels according to the Blooms’  cut off point, 60–80% as follows: High level (80–100%) 15–18 scores, Moderate level (60–79%) 11–14 scores and Low level (less than 60%) 6–10 scores. Attitude on antimicrobial usage and resistance This part includes the attitude of people who live in Bahir Dar city towards antimicrobial usage and resistances. There was a total of eight questions, two positive and six negative statements with Likert scale options of choice ranging from agree to disagree. The rating scale was measured as knowledge scale. The scores varied from 8 to 24 and all individual answers were summed up for total and calculated for means. The scores were classified in to 3 levels (Positive Attitude, Neutral Attitude and Negative Attitude). Positive Attitude 19–24 scores (80%-100%), Neutral Attitude 15–18 scores (60%-79%) and Negative Attitude 8–14 scores (Less than 60%). Practice on antimicrobial usage and resistance Eleven questions have been included in this part. Of which ten questions were close ended, eight Likert, one yes/no and one multiple choice questions, and one open ended question were encompassed in this part. The rating scale for the responses was measured as previous one. The scores in measuring the practice of antimicrobial usage and resistance were varied from 8 to 24, and were classified into 3 levels according to the Bloom's cut off point, 60–80% . The levels of practice were: Good (80–100%) 19–24 scores, Fair (60–79%) 15–18 scores and Poor (Less than 60%) 8–14 scores. 

Socio-demographic data There were nine questions in this part. The questions include sex, age, education level, marital status, position of respondents in the household, occupation, animal ownership, household size, and ownership of the house. Knowledge on antimicrobial usage and resistance There were nine questions which was asked to know the knowledge level of the community on antimicrobial usage and resistance. Six of the questions were Likert scale while three were an open-ended question that allows respondents to express their perception. A correct answer for each close ended questions was given 3 score for correct answer, 2 uncertain and 1 score for a wrong answer. The score varied from 6–18 points and was classified into 3 levels according to the Blooms’  cut off point, 60–80% as follows: High level (80–100%) 15–18 scores, Moderate level (60–79%) 11–14 scores and Low level (less than 60%) 6–10 scores. Attitude on antimicrobial usage and resistance This part includes the attitude of people who live in Bahir Dar city towards antimicrobial usage and resistances. There was a total of eight questions, two positive and six negative statements with Likert scale options of choice ranging from agree to disagree. The rating scale was measured as knowledge scale. The scores varied from 8 to 24 and all individual answers were summed up for total and calculated for means. The scores were classified in to 3 levels (Positive Attitude, Neutral Attitude and Negative Attitude). Positive Attitude 19–24 scores (80%-100%), Neutral Attitude 15–18 scores (60%-79%) and Negative Attitude 8–14 scores (Less than 60%). Practice on antimicrobial usage and resistance Eleven questions have been included in this part. Of which ten questions were close ended, eight Likert, one yes/no and one multiple choice questions, and one open ended question were encompassed in this part. The rating scale for the responses was measured as previous one. The scores in measuring the practice of antimicrobial usage and resistance were varied from 8 to 24, and were classified into 3 levels according to the Bloom's cut off point, 60–80% . The levels of practice were: Good (80–100%) 19–24 scores, Fair (60–79%) 15–18 scores and Poor (Less than 60%) 8–14 scores. 

There were nine questions in this part. The questions include sex, age, education level, marital status, position of respondents in the household, occupation, animal ownership, household size, and ownership of the house. 

There were nine questions which was asked to know the knowledge level of the community on antimicrobial usage and resistance. Six of the questions were Likert scale while three were an open-ended question that allows respondents to express their perception. A correct answer for each close ended questions was given 3 score for correct answer, 2 uncertain and 1 score for a wrong answer. The score varied from 6–18 points and was classified into 3 levels according to the Blooms’  cut off point, 60–80% as follows: High level (80–100%) 15–18 scores, Moderate level (60–79%) 11–14 scores and Low level (less than 60%) 6–10 scores. 

This part includes the attitude of people who live in Bahir Dar city towards antimicrobial usage and resistances. There was a total of eight questions, two positive and six negative statements with Likert scale options of choice ranging from agree to disagree. The rating scale was measured as knowledge scale. The scores varied from 8 to 24 and all individual answers were summed up for total and calculated for means. The scores were classified in to 3 levels (Positive Attitude, Neutral Attitude and Negative Attitude). Positive Attitude 19–24 scores (80%-100%), Neutral Attitude 15–18 scores (60%-79%) and Negative Attitude 8–14 scores (Less than 60%). 

Eleven questions have been included in this part. Of which ten questions were close ended, eight Likert, one yes/no and one multiple choice questions, and one open ended question were encompassed in this part. The rating scale for the responses was measured as previous one. The scores in measuring the practice of antimicrobial usage and resistance were varied from 8 to 24, and were classified into 3 levels according to the Bloom's cut off point, 60–80% . The levels of practice were: Good (80–100%) 19–24 scores, Fair (60–79%) 15–18 scores and Poor (Less than 60%) 8–14 scores. 

The obtained data was subjected to classification, filtering, and coding procedures using Microsoft Excel® 2019. Subsequently, the data was exported to STATA version 17 (Stata Corp. Texas, USA) for the purpose of conducting appropriate statistical analyses. Descriptive statistics was employed to assess the socio-demographic characteristics of the study participants and to summarize open-ended question. Numerical data was presented as mean ± standard deviation. The association between the KAP and sociodemographic characteristics of the respondents, and the relationship among KAP was assessed using Chi square (χ2). A p -value less than 0.05 was considered as statistically significant. 

Socio-demographic characteristics of the respondent The analysis of socio-demographic factors revealed that the majority of the participants, specifically 253(63.25%), were male. A substantial number of study participants, 125(31.25%), had attained a college or university education, and 246(61.5%) were married. Furthermore, a noteworthy portion of the participants, 131(32.75%), were employed in various governmental professions. Additionally, 186(46.5%) participants reported owning two different species of animals. Furthermore, it was reported by 131(32.25%) respondents that their immediate families consisted of less than three members (Table ). Respondent knowledge regarding antimicrobial use and resistance in Bahir Dar city Respondents provided responses to a total of six closed-ended, multiple-choice inquiries regarding the topic of antimicrobial resistance and usage. The average score for respondents' level of knowledge amounted to 13.095 out of a potential 18 points (SD = 2.86). The majority of participants in the study, specifically 194(48.5%), displayed a “moderate knowledge” level, while 147(36.75%) exhibited a “high knowledge” level. In contrast, a smaller percentage of respondents, 59(14.75%), possessed a “low knowledge” level pertaining to antimicrobial resistance and usage. Conversely, the data presented in Table illustrates that 236(59%) respondents concurred with the effectiveness of antimicrobials against bacteria. However, a significant number of respondents, 182(45.5%), expressed disagreement with the notion that speed up recovery from cold. Additionally, 45.5% of respondents disagreed with the idea that antimicrobials have any impact on viruses. Furthermore, 52% of respondents expressed disagreement with the notion of ceasing the use of antimicrobials when encountering side effects from drugs. A mere 75 respondents out of a total of 400 correctly responded with “Agree” to the question of whether the use of antimicrobials can escalate the likelihood of microbes developing resistance to them. Conversely, a staggering 214 respondents expressed disagreement with this statement (Table ). Findings from the open-ended questions revealed that 62.25% (249 out of 400) of respondents had knowledge of antimicrobials. However, only 44.5% correctly understood their purpose. Amoxicillin was identified as the most commonly used antibiotic among participants. The attitude of Bahir Dar city residents towards antimicrobial usage and resistance The distribution of respondents' attitudes towards the usage and resistance of antimicrobials reveals that a majority of the community (57.5%) have a positive attitude, while a significant portion (27.25%) have a neutral attitude and a smaller percentage (15.25%) have a negative attitude towards AMU and AMR. The average attitude score for all respondents was 18.41 out of a possible 24 points, with a standard deviation of 3.564. The results presented in Table demonstrate that the majority of respondents (56.25%) agree with the statement “I always complete the course of treatment with antimicrobials even if I feel better”. Additionally, a considerable number of respondents (68.5%) do not consider it appropriate to obtain antimicrobials from relatives or friends without consulting a medical doctor. Furthermore, the attitude of respondents towards purchasing antimicrobials from a pharmacy without a prescription is characterized by disagreement (75.25%), agreement (19.75%), and uncertainty (5%). A significant proportion of respondents (46%) do not view antimicrobials as completely safe drugs that can be commonly used, while a smaller percentage (36.5%) are uncertain and a minority (17.5%) agree with this statement. Moreover, the majority of respondents (53.5%) disagree with the statement “I prefer to keep unused antimicrobials at home in case there may be a need for them”. Additionally, a substantial proportion of respondents (42.75%) do not prefer to use an antimicrobial for minor illness in order to feel better (Table ). Practice of respondents regarding to AMU and AMR A total of 211 respondents (52.75%) had good practice, while 150 respondents (37.5%) had fair practice, and the remaining 39 respondents (9.75%) had poor practice. The mean practice score for all respondents was 18.293 out of a possible 24 points, with a standard deviation of 2.91. The findings indicate that a majority of respondents (54.5%) reported always consulting a doctor before starting an antimicrobial. However, a significant portion (36.5%) of participants reported sometimes seeking medical advice. In terms of checking the expiry date of antimicrobials before use, 61.75% of respondents reported always doing so. A substantial number of respondents (42.25%) reported sometimes saving the remaining antimicrobials for future use after feeling better. Similarly, a significant proportion of respondents (36.25%) reported sometimes giving leftover antimicrobials to others if they become ill. Moreover, 61.25% of respondents reported that they always complete the full course of treatment. Additionally, 52.25% of respondents reported sometimes taking their animals to a veterinary clinic. A notable proportion of respondents (43.75%) admitted to never completing the full course of antimicrobial treatment for their animals (Table ). Findings from the open-ended questions showed that 55.25% of respondents believed antimicrobials are used to treat bacteria, viruses, fungi, or protozoa. Among the 400 respondents, 180 (45%) reported their animals had been sick in the past 12 months, and of these, 70% (126) sought treatment from private veterinarians. Association between socio-demographic variables and AMU and AMR knowledge, attitude and practice The findings presented in Table demonstrate a statistically significant association ( p < 0.05) between respondents’ knowledge level and their education level, marital status, occupation, and position in the household (Table ). The attitude level of the respondents was significantly association ( p < 0.05) with their education level, marital status, occupation, ownership of the house, and position in the house (Table ). Furthermore, the practice level of the respondents was significantly associated with education level (χ2 = 181.51, p ≤ 0.001), position in the house (χ2 = 21.07, p = 0.021), and occupation (χ2 = 125.02, p ≤ 0.001) (Table ). Association between community knowledge, attitude and practice on AMU and AMR A statistically significant association (χ2 = 209.91, p ≤ 0.001) was observed between the knowledge and attitude levels of the respondents (Table ). Likewise, a significant association was found (χ2 = 160.43, p ≤ 0.001) between the knowledge and practice levels of the respondents (Table ). Additionally, attitude and practice were determined to be significantly associated (χ2 = 136.95, p ≤ 0.001) (Table ). 

The analysis of socio-demographic factors revealed that the majority of the participants, specifically 253(63.25%), were male. A substantial number of study participants, 125(31.25%), had attained a college or university education, and 246(61.5%) were married. Furthermore, a noteworthy portion of the participants, 131(32.75%), were employed in various governmental professions. Additionally, 186(46.5%) participants reported owning two different species of animals. Furthermore, it was reported by 131(32.25%) respondents that their immediate families consisted of less than three members (Table ). 

Respondents provided responses to a total of six closed-ended, multiple-choice inquiries regarding the topic of antimicrobial resistance and usage. The average score for respondents' level of knowledge amounted to 13.095 out of a potential 18 points (SD = 2.86). The majority of participants in the study, specifically 194(48.5%), displayed a “moderate knowledge” level, while 147(36.75%) exhibited a “high knowledge” level. In contrast, a smaller percentage of respondents, 59(14.75%), possessed a “low knowledge” level pertaining to antimicrobial resistance and usage. Conversely, the data presented in Table illustrates that 236(59%) respondents concurred with the effectiveness of antimicrobials against bacteria. However, a significant number of respondents, 182(45.5%), expressed disagreement with the notion that speed up recovery from cold. Additionally, 45.5% of respondents disagreed with the idea that antimicrobials have any impact on viruses. Furthermore, 52% of respondents expressed disagreement with the notion of ceasing the use of antimicrobials when encountering side effects from drugs. A mere 75 respondents out of a total of 400 correctly responded with “Agree” to the question of whether the use of antimicrobials can escalate the likelihood of microbes developing resistance to them. Conversely, a staggering 214 respondents expressed disagreement with this statement (Table ). Findings from the open-ended questions revealed that 62.25% (249 out of 400) of respondents had knowledge of antimicrobials. However, only 44.5% correctly understood their purpose. Amoxicillin was identified as the most commonly used antibiotic among participants. 

The distribution of respondents' attitudes towards the usage and resistance of antimicrobials reveals that a majority of the community (57.5%) have a positive attitude, while a significant portion (27.25%) have a neutral attitude and a smaller percentage (15.25%) have a negative attitude towards AMU and AMR. The average attitude score for all respondents was 18.41 out of a possible 24 points, with a standard deviation of 3.564. The results presented in Table demonstrate that the majority of respondents (56.25%) agree with the statement “I always complete the course of treatment with antimicrobials even if I feel better”. Additionally, a considerable number of respondents (68.5%) do not consider it appropriate to obtain antimicrobials from relatives or friends without consulting a medical doctor. Furthermore, the attitude of respondents towards purchasing antimicrobials from a pharmacy without a prescription is characterized by disagreement (75.25%), agreement (19.75%), and uncertainty (5%). A significant proportion of respondents (46%) do not view antimicrobials as completely safe drugs that can be commonly used, while a smaller percentage (36.5%) are uncertain and a minority (17.5%) agree with this statement. Moreover, the majority of respondents (53.5%) disagree with the statement “I prefer to keep unused antimicrobials at home in case there may be a need for them”. Additionally, a substantial proportion of respondents (42.75%) do not prefer to use an antimicrobial for minor illness in order to feel better (Table ). 

A total of 211 respondents (52.75%) had good practice, while 150 respondents (37.5%) had fair practice, and the remaining 39 respondents (9.75%) had poor practice. The mean practice score for all respondents was 18.293 out of a possible 24 points, with a standard deviation of 2.91. The findings indicate that a majority of respondents (54.5%) reported always consulting a doctor before starting an antimicrobial. However, a significant portion (36.5%) of participants reported sometimes seeking medical advice. In terms of checking the expiry date of antimicrobials before use, 61.75% of respondents reported always doing so. A substantial number of respondents (42.25%) reported sometimes saving the remaining antimicrobials for future use after feeling better. Similarly, a significant proportion of respondents (36.25%) reported sometimes giving leftover antimicrobials to others if they become ill. Moreover, 61.25% of respondents reported that they always complete the full course of treatment. Additionally, 52.25% of respondents reported sometimes taking their animals to a veterinary clinic. A notable proportion of respondents (43.75%) admitted to never completing the full course of antimicrobial treatment for their animals (Table ). Findings from the open-ended questions showed that 55.25% of respondents believed antimicrobials are used to treat bacteria, viruses, fungi, or protozoa. Among the 400 respondents, 180 (45%) reported their animals had been sick in the past 12 months, and of these, 70% (126) sought treatment from private veterinarians. 

The findings presented in Table demonstrate a statistically significant association ( p < 0.05) between respondents’ knowledge level and their education level, marital status, occupation, and position in the household (Table ). The attitude level of the respondents was significantly association ( p < 0.05) with their education level, marital status, occupation, ownership of the house, and position in the house (Table ). Furthermore, the practice level of the respondents was significantly associated with education level (χ2 = 181.51, p ≤ 0.001), position in the house (χ2 = 21.07, p = 0.021), and occupation (χ2 = 125.02, p ≤ 0.001) (Table ). 

A statistically significant association (χ2 = 209.91, p ≤ 0.001) was observed between the knowledge and attitude levels of the respondents (Table ). Likewise, a significant association was found (χ2 = 160.43, p ≤ 0.001) between the knowledge and practice levels of the respondents (Table ). Additionally, attitude and practice were determined to be significantly associated (χ2 = 136.95, p ≤ 0.001) (Table ). 

Antimicrobial usage and resistance are critical global health concerns, posing substantial challenges to healthcare systems worldwide. Understanding the public's knowledge, attitudes, and practices regarding antimicrobial usage is essential for developing effective strategies to combat resistance . This study utilized a questionnaire survey to assess the levels of knowledge, attitudes, and practices towards antimicrobial usage and resistance in Bahir Dar City, Ethiopia. The findings indicate that a majority of the participants, 62.25% of the 249 individuals surveyed, have some knowledge about antimicrobials. However, only 44.5% correctly understand the purpose of antimicrobials. Amoxicillin was identified as the most commonly used antibiotic among participants, consistent with findings from previous studies in various regions, including Ethiopia, Indonesia, Tanzania, Uganda, and Guatemala, as reported by Gebeyehu et al . , Widayati et al . , Sindato et al . , Ocan et al . , and Ramay et al . , respectively. Approximately 59% of participants responded that antimicrobials are effective against bacteria. However, this percentage is lower compared to previous studies conducted in Malaysia by Oh et al . , in Cyprus by Sullman et al . , in Italy by Bianco et al . , and in Northern Ireland by Shebehe et al . , who reported 76.7%, 82.5%, 91.2%, and 65%, of the participants, respectively responds that antibiotics being effective against bacteria. In this study, about 21.25% of respondents were uncertain about the effectiveness of antimicrobials against bacteria. This finding aligns with results from Kuwait, where 25.3% of individuals also lacked knowledge in this area, as reported by Awad and Aboud . This suggests that lower knowledge levels may be partly due to the absence of formal education or low literacy levels within the community. Approximately one-third (27.55%) of the participants in this investigation expressed the belief that antimicrobials could expedite the recuperation from the common cold. The current finding was higher than those of studies conducted in Cyprus by Sullman et al .  and in Northern Ireland by Shebehe et al. , which reported that 21.4% and 8% of the study participants, respectively, indicated that antibiotics are effective against the flu. In comparison, this level of understanding was marginally lower than that documented in India, where 32% of respondents agreed that antibiotics are effective for most coughs and colds . The current findings indicate a lower level of knowledge compared to a study conducted in Germany, where only 18.9% of individuals believed that taking antibiotics could lead to a quick improvement in symptoms of a common cold . However, the results of this study show an improvement over previous research conducted in Saudi Arabia by Yezli et al .  and in Harar, Ethiopia, by Jifar and Ayele . In those studies, 63% and 83% of participants, respectively, mistakenly believed that antimicrobials were effective in treating the common cold and influenza. Furthermore, only 30.25% of respondents in this study correctly identified that antimicrobials have no effect against viruses. This finding is consistent with a previous study in South Korea by Kim et al . , which found that only 31% of participants correctly understood that antibiotics cannot eradicate viruses. However, 45.5% of participants in the present study erroneously believed that antibiotics are effective against viruses. It is worth noting that this finding is higher than those reported by Yezli et al .  in Saudi Arabia, Sullman et al .  in Cyprus, Bianco et al .  in Italy, and Licata et al .  in Italy, where only 15%, 23%, 29.2%, and 38.3% of respondents, respectively, believed in the effectiveness of antibiotics against viruses. The observed disparities between these studies may be attributed to several factors, including varying levels of awareness, differences in the timing of the investigations, and variations in the socio-demographic characteristics of the study populations. A notable observation in the present study was the significantly low percentage (18.75%) of participants who believed that the use of antimicrobial agents contributes to the development of bacterial resistance. This finding contrasts sharply with previous research conducted in Bahir Dar, Ethiopia by Tesfaye , in Namibia by Pereko et al .  and in Cyprus by Sullman et al . , where 69.7%, 72%, and 86.1% of respondents, respectively, recognized the link between antimicrobial use and bacterial resistance. This disparity suggests varying levels of awareness and understanding about antimicrobial resistance and its underlying mechanisms among different populations. The findings of the present study highlight a predominantly positive attitude towards antimicrobial use and resistance, with 57.5% of participants expressing a positive stance. This suggests that a significant portion of the population recognizes the importance of using antimicrobials responsibly and understands the impact of antimicrobial resistance on public health. However, it is concerning that 34.5% of respondents believed patients should discontinue their treatment as soon as they start feeling better. This misconception about antibiotic use has been documented in previous studies. Comparing the current findings with prior research, the proportion of respondents who support early discontinuation of treatment is higher than in a study conducted in Bahir Dar, Ethiopia, by Gebeyehu et al . , where only 27% of the respondents held this belief. On the contrary, the results of the current study are lower than those reported by Dyar et al .  in Kuwait and Sakr et al .  in Lebanon, where 45% and 60% of the respondents, respectively, believed that patients should stop their treatment once they feel better. This misconception about prematurely stopping treatment poses significant risks, as it can lead to relapse with potentially drug-resistant bacteria . In this study, a majority of respondents (75.25%) disapproved of acquiring antimicrobials without a prescription. This proportion is slightly higher than the disapproval rates reported by Sakr et al .  in Lebanon and Awad and Aboud  in Saudi Arabia, where 65.1% and 66.6% of respondents, respectively, expressed similar views. Additionally, 19.75% of participants in the current study preferred the ability to obtain antimicrobials without a prescription from a physician. This percentage is lower than those reported in previous studies by Napolitano et al .  in Italy, and Aldhafar and Talat  in Saudi Arabia, where 32.7% and 28.8% of respondents, respectively, admitted to using antibiotics without a prescription. However, it is higher than the findings of You et al .  in Hong Kong, where only 9% believed they could obtain antimicrobials without a prescription. These inconsistencies may be due to differences in regulations and their enforcement across countries, as well as variations in socio-demographic factors. The present study reveals that only 58.25% of respondents believe that missing one or two doses of antimicrobials would affect their effectiveness. This finding is significantly lower than that of a study by Sakr et al .  in Lebanon, where 82.3% of the participants agreed with this statement. However, it aligns with the findings of Dejene et al . , who reported that 51% of respondents agreed. In Saudi Arabia, more than 80% of participants agreed that skipping even one or two doses of antibiotics contributes to the development of antibiotic resistance . The variations in attitudes observed across these studies could be due to differences in socio-demographic characteristics and educational levels among participants. Additionally, the most common immediate source of home-stored antimicrobials was the discontinuation of therapy due to either symptomatic improvement or missed doses . Moreover, community practices significantly influence the development and spread of AMR . The current study shows that just over half of the participants (52.75%) demonstrated good practices regarding AMU and AMR, which is encouraging as it suggests that a substantial portion of the community is adopting appropriate behaviors to combat AMR. Additionally, 54.5% of participants reported never using antimicrobials without consulting a healthcare provider, reflecting a positive attitude toward responsible antimicrobial use. Comparing these findings with international studies, the level of positive attitudes in the current study is lower than those reported by Cheaito et al .  in Lebanon, Al-Ramahi  in Palestine and Shehadeh et al .  in Jordan, where positive attitude levels ranged from 40.7% to 78%. However, the positive attitude level in this study was higher than those reported by Grigoryan et al.  in the USA, Licata et al. , Bianco et al . , and Bianco et al.  in Italy, You et al.  in Hong Kong, Oh et al .  in Malaysia, and Widayati et al .  in Indonesia, where attitude levels ranged from 2.1% to 25.5%. These discrepancies across various studies may be due to differences in sample size, educational levels, and socio-demographic characteristics of the study participants. In the present study, 247 (61.75%) of the participants reported checking the expiry date of antimicrobials before using them. However, the data also reveal that 24.25% of the participants admitted to not checking the expiry date. The present finding was lower when compared to the reports of Yezli et al .  in Saudi Arabia, who reported that 54% of the participants admitted to not checking the expiry date. The variation in findings may be attributed to differences in the educational level of the study participants across the different studies. The association between knowledge level and practice level among the participants is statistically significance. Individuals with high knowledge levels predominantly exhibited good practices (44.5%), followed by those with moderate knowledge levels (49.3%). In contrast, individuals with low knowledge levels had a significantly smaller proportion of good practices (6.2%). This suggests that higher levels of knowledge are strongly associated with better practices. About 57.3% respondents with moderate knowledge levels showed a fair practice. This indicates that individuals with moderate knowledge levels may be more likely to engage in practices that are considered fair . Limitation of the study The present study has had certain limitations such as the study relies heavily on self-reported data by the respondents and the study is localized to Bahir Dar city, which may limit the generalizability of the findings. In addition, although the findings showed that the level of knowledge has an impact on the practice level, the study may not certainly determine whether higher knowledge leads to better practices due to the cross-sectional nature of the study. 

The present study has had certain limitations such as the study relies heavily on self-reported data by the respondents and the study is localized to Bahir Dar city, which may limit the generalizability of the findings. In addition, although the findings showed that the level of knowledge has an impact on the practice level, the study may not certainly determine whether higher knowledge leads to better practices due to the cross-sectional nature of the study. 

The current study in Bahir Dar city, Ethiopia indicated moderate level of knowledge, positive attitude, and good practice regarding antimicrobial usage and resistance among the people. Respondents with a high educational level demonstrate good knowledge, positive attitude, and good practice. The findings can serve as a foundation for developing interventions to enhance awareness related to use and misuse of antimicrobial in animal and humans through targeted educational campaigns, and community trainings. 

Supplementary Material 1: Sup File 1. English Version of Questionnaire. 

