The discovery of antibiotics revolutionized modern medicine, transforming once-deadly infections into treatable conditions. However, decades of overuse, misuse and improper prescribing have led to the alarming rise of antibiotic resistance-a global health threat that compromises the effectiveness of these life-saving drugs. Antibiotic resistance occurs when bacteria evolve mechanisms to withstand the effects of antibiotics, rendering standard treatments ineffective, prolonging illnesses, increasing medical costs and elevating the risk of mortality. Today, antibiotic-resistant infections claim hundreds of thousands of lives annually and are projected to become a leading cause of death worldwide if immediate corrective action is not taken [1-3].

In India, antibiotic resistance has reached critical levels, fueled by factors such as self-medication, easy over-the-counter availability, incomplete antibiotic courses, lack of public awareness and insufficient regulatory enforcement. Rural and semi-urban areas like Mandi district in Himachal Pradesh face unique challenges: limited access to qualified healthcare professionals, reliance   on informal healthcare providers and deeply entrenched misconceptions about antibiotic use. Common practices such as prematurely stopping antibiotics once symptoms subside, using antibiotics for viral infections like the common cold or demanding antibiotics without prescriptions-exacerbate the problem at the community level [4-6].

Despite government initiatives and awareness campaigns, gaps in public understanding persist. Many individuals remain unaware of the importance of completing prescribed antibiotic courses, the dangers of unnecessary antibiotic use and the long-term societal impact of resistance. As antibiotic resistance transcends individual health and poses a collective threat, understanding public attitudes and behaviors becomes crucial for designing effective interventions [7,8].

This study aims to assess the level of awareness, misconceptions and practices related to antibiotic use and resistance among the residents of Mandi. By identifying knowledge gaps and behavioral trends, the research seeks to inform targeted educational strategies and policy actions that can curb misuse and promote responsible antibiotic practices at the grassroots level.

Study Design

This study employed a descriptive, cross-sectional design to evaluate public awareness, misconceptions and practices related to antibiotic use and resistance among residents of Mandi district, Himachal Pradesh. The objective was to gather baseline data that could inform local health promotion efforts aimed at combating antibiotic misuse and resistance.

Study Area and Population

The study was conducted in Mandi, a geographically diverse district with a mix of urban and rural populations. The target participants included adults aged 18 years and above, encompassing various educational and socioeconomic backgrounds. Both individuals with prior antibiotic use and those with no recent antibiotic exposure were included to capture a broad range of experiences and perceptions.

Study Duration

Data collection was carried out over a three-month period from January to March 2025, ensuring sufficient coverage across different community settings, including marketplaces, health centers, educational institutions and residential areas.

Sample Size and Sampling Technique

A sample size of 400 participants was determined using a 95% confidence level, a 5% margin of error and an anticipated 50% prevalence of basic antibiotic awareness, ensuring statistical reliability. Participants were selected through a combination of purposive and snowball sampling methods, leveraging community health workers, local NGOs and social networks to maximize reach across urban and rural settings.

Inclusion and Exclusion Criteria

Inclusion Criteria:

• Residents of Mandi district aged 18 years and older

• Ability to understand and respond in Hindi or English

• Willingness to provide informed consent

Exclusion Criteria

• Healthcare professionals (to minimize professional bias)

• Individuals unable to provide informed consent due to cognitive or communication impairments

Data Collection Tool

A structured, pre-validated questionnaire was developed in consultation with infectious disease specialists and public health experts. The bilingual questionnaire (Hindi and English) comprised four sections:

• Demographics: Age, gender, education, occupation, residential setting (urban/rural)

• Knowledge Assessment: Questions on basic concepts of antibiotics, resistance, necessity of completing courses and correct indications for antibiotic use

• Perceptions and Misconceptions: Beliefs about the efficacy of antibiotics against viral infections, use of leftover antibiotics and self-medication practices

• Behavioral Practices: Frequency of antibiotic use, adherence to prescribed courses, sources of antibiotics and consultation behaviors

Data Collection Procedure

Data were collected through face-to-face interviews conducted by trained surveyors for participants with limited literacy and self-administered questionnaires for literate participants. Both online (via Google Forms) and offline (paper-based) modes were employed to ensure inclusivity, particularly for digitally disconnected populations in rural areas.

Scoring and Data Classification

Responses to knowledge and perception items were scored as correct or incorrect. Cumulative scores were classified into four categories: Very Good (≥80% correct responses), Good (60–79%), Fair (41–59%) and Poor (<40%). Behavioral data were analyzed to identify patterns of safe and unsafe antibiotic use practices.

Data Analysis

Data were entered into Microsoft Excel and analyzed using SPSS version 26.0. Descriptive statistics, including frequencies, percentages and means, were used to summarize the findings. Cross-tabulations were performed to explore associations between demographic factors and awareness levels.

Ethical Considerations

Participation was voluntary and anonymous, with informed consent obtained digitally or verbally before data collection. No personal identifiers were collected and confidentiality was strictly maintained. Ethical approval was secured from a recognized institutional ethics committee prior to commencement of the study.

Table 1 presents the socio-demographic profile of the 400 participants surveyed in Mandi district. The majority of respondents (39.5%) belonged to the 26–35 age group, followed by 25.5% aged 36–45 years and 22.8% aged 18–25 years, reflecting a largely young to middle-aged adult population. Gender distribution was almost equal, with females accounting for 51.0% and males for 49.0%. Educational attainment varied, with 35.3% having completed secondary education and 29.8% holding an undergraduate degree, while 7.3% had no formal education. In terms of occupation, homemakers formed the largest group (34.3%), followed by self-employed individuals (22.3%) and students/unemployed (21.3%). A significant rural representation was observed, with 66.0% of respondents residing in rural areas, emphasizing the study's focus on semi-urban and rural healthcare awareness.

Table 2 summarizes the awareness and knowledge of antibiotic use and resistance among participants. Overall, knowledge levels were encouraging, with 78.0% correctly identifying antibiotics as drugs for bacterial infections and 71.8% understanding that antibiotics cannot treat viral infections. Awareness of critical issues such as the role of early antibiotic cessation in promoting resistance (81.5%), dangers of self-medication (75.3%) and necessity of prescriptions (84.8%) was notably high. Positive responses were also seen regarding misconceptions like sharing antibiotics (83.0%) and reusing leftover medications (76.0%). However, gaps remained regarding the transmission of resistant bacteria (65.5%) and the long-term impact on future generations (62.8%). These results reveal a generally strong awareness foundation, but highlight specific misconceptions that need targeted correction.

Table 3 classifies participants based on their overall knowledge scores. A substantial 41.8% demonstrated a "Good" level of knowledge (60–79% correct responses), while 32.3% achieved a "Very Good" score (≥80%), indicating a promising level of public understanding. However, 19.0% fell into the "Fair" category (41–59%)  and 7.0% into the "Poor" category (<40%), suggesting that approximately one-fourth of the population still holds significant misconceptions or inadequate knowledge about antibiotic resistance. These insights underscore the necessity for continuous public education campaigns, especially targeted at the lower-knowledge segments.

Table 1: Socio-Demographic Characteristics of Participants

The findings of this study provide valuable insights into the current levels of awareness, misconceptions and practices surrounding antibiotic use and resistance among the residents of Mandi district. Given the growing public health threat posed by antibiotic resistance globally and nationally, it is encouraging to observe that a substantial proportion of the study population demonstrated a good to very good understanding of basic antibiotic concepts. Notably, 78% correctly identified antibiotics as drugs for bacterial infections and over 80% recognized that stopping antibiotics prematurely can contribute to resistance. These figures suggest that fundamental public health messages have begun to penetrate community consciousness, likely due to increased media exposure, health campaigns and interactions with healthcare providers.

However, despite this foundational awareness, significant gaps remain. Alarmingly, nearly 30% of respondents still harbored misconceptions, such as believing antibiotics can treat viral infections and about one-third did not fully grasp the concept of bacterial resistance transmission. Similarly, only 62.8% were aware that antibiotic resistance could impact future generations, indicating a limited understanding of the broader societal consequences of antibiotic misuse. This gap between basic awareness and in-depth knowledge points to the superficial nature of current information dissemination efforts-people may have heard about antibiotic resistance but lack a comprehensive understanding of its implications.

Educational attainment appeared to correlate positively with knowledge scores, as individuals with secondary education or higher were more likely to fall into the "Good" or "Very Good" categories. Nevertheless, the high rural representation (66%) in the sample also revealed the persistent challenges faced by semi-urban and rural populations in accessing accurate health information. In rural settings, where reliance on informal healthcare providers and pharmacies is common, misconceptions about the need for prescriptions, the safety of self-medication and the reuse of leftover antibiotics are especially concerning. Although 84.8% agreed that antibiotics should only be taken with a prescription, anecdotal evidence and national trends suggest that enforcement of prescription-only policies remains weak in practice.

Behavioral practices also highlight a worrying trend: while the majority knew about the dangers of self-medication and incomplete courses, previous studies and the findings here suggest that knowledge does not always translate into behavior. Economic constraints, convenience and ingrained habits often lead individuals to purchase antibiotics without prescriptions, share medications with others or discontinue usage once symptoms abate. These risky behaviors not only endanger individual health but also contribute to the silent evolution of resistant bacterial strains within the community.

Table 2: Awareness and Knowledge of Antibiotic Resistance Among Participants

Table 3: Knowledge Score Classification

Another critical observation is the over-reliance on media and family members for antibiotic-related information, with healthcare professionals accounting for only a part of the information sources. Although 79.8% acknowledged healthcare workers as educators on antibiotic resistance, informal and non-expert advice still plays a considerable role, underlining the importance of strengthening the role of healthcare providers and community health workers as trusted messengers of accurate antibiotic stewardship principles.

The study findings underscore the urgent need for multifaceted intervention strategies. Public education campaigns must move beyond basic awareness to deeper, behavior-focused messaging that emphasizes the consequences of misuse and the importance of completing antibiotic courses. School-based education, community workshops and mass media campaigns tailored to rural literacy levels and local languages could significantly enhance understanding. Additionally, stricter regulation and monitoring of over-the-counter antibiotic sales, coupled with pharmacist training to reinforce prescription-only policies, are necessary structural changes.

Finally, while this study's robust sample size and balanced representation of urban and rural residents enhance the generalizability of the findings, certain limitations exist. The exclusion of healthcare professionals, although methodologically justified to avoid bias, also excluded a potential perspective on healthcare system gaps. Moreover, the self-reported nature of the questionnaire may introduce social desirability bias, where respondents overstate good practices. Nevertheless, the insights gathered serve as a crucial baseline for public health authorities, indicating both progress made and areas requiring intensified efforts to curb antibiotic resistance at the grassroots level.

This study highlights that while a substantial portion of Mandi's residents possess a good foundational understanding of antibiotics and antibiotic resistance, significant knowledge gaps and behavioral inconsistencies persist particularly regarding misconceptions about antibiotic use for viral infections, transmission of resistance and the societal impact on future generations. Although awareness of prescription-only use, completion of antibiotic courses and the dangers of self-medication was encouraging, the persistence of unsafe practices underscores the urgent need for more intensive, behavior-focused educational interventions. Rural populations, in particular, require targeted outreach through culturally appropriate, community-driven programs to deepen understanding and promote responsible antibiotic use. Strengthening healthcare provider engagement, enforcing prescription regulations and integrating antibiotic stewardship into local health policies are crucial steps toward mitigating the growing threat of antibiotic resistance at the grassroots level. Ultimately, sustainable change will depend on bridging the gap between knowledge and practice, ensuring that awareness translates into consistent, responsible behaviors that protect both individual and public health.

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