Effectiveness of a Structured Educational Training Program on Antimicrobial Resistance Among Community Health Workers in India

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In India, Accredited Social Health Activists (ASHAs) play a vital role in community healthcare and have the potential to promote antimicrobial stewardship practices in their local communities effectively. This study aimed to evaluate the impact of structured training program for ASHAs' on AMR and antibiotic use and its integration into community-level health promotion. A pre-post educational intervention study was conducted among 103 ASHAs from selected Primary Health Centres (PHCs). A three-day structured training was conducted, and pre- and post-training KAP were assessed using a validated questionnaire. Training impact was evaluated through observation checklists, supervisor feedback, and community surveys. Quantitative Data were analyzed using SPSS. 25, and qualitative data were thematically analyzed. Statistically significant improvements were observed across all KAP domains. Misconceptions, such as using antibiotics for viral infections, declined (from 67.9% to 14.6%; p = 0.002), while confidence in providing AMR-related guidance increased to 61.1% (p < 0.001). Practice scores improved significantly (p < 0.001), with post-training responses changing towards “always” and “sometimes.” Spearman’s correlation indicated a positive association between post-training knowledge and both attitude (ρ = 0.14, p = 0.001) and practice (ρ = 0.221, p < 0.001). Community feedback showed high engagement and understanding, with 92% willing to follow ASHAs' advice. Observational data confirmed strong adherence to training content. The training improved ASHAs' skills to promote AMR awareness and rational antibiotic usage, highlighting their importance in community-level antimicrobial stewardship. Antimicrobial resistance ASHA workers antibiotic use prevention Figures Figure 1 INTRODUCTION Common infections are becoming more difficult to treat due to antimicrobial resistance (AMR), which is a escalating issue in global public health. Infection control and treatment outcomes are seriously threatened by the emergence and spread of drug-resistant bacteria, viruses, parasites, and fungi, which frequently result in longer illness duration, higher mortality rates, and higher healthcare expenses [1,2]. The improper use of antibiotics, which frequently results from irrational and inappropriate use, is one of the primary causes of AMR. In low- and middle-income countries (LMICs) like India, antibiotics are readily available without a prescription, there is a lack of public awareness, and regulatory enforcement is lax, this is particularly pertinent [3]. To combat this issue, India introduced the National Action Plan on Antimicrobial Resistance (NAP-AMR) in 2017. In order to enhance antimicrobial stewardship (AMS) at all levels of healthcare, the plan highlights public involvement, education, and training [4]. Accredited Social Health Activists (ASHAs), who are part of India's National Health Mission (NHM), provide primary healthcare services in an effort to effect change at community level. They are crucial for promoting connection between people in rural and urban areas, preventing disease, and promoting health [5,6]. ASHAs are in a good position to change people's behaviour and promote responsible antibiotic use because they are so closely connected to their communities. However, a lack of training and widespread misconceptions, like using antibiotics for viral infections or stopping drugs when symptoms go away, may limit their ability to effectively promote behaviour change linked to AMR [7]. Previous studies have mostly focused on improving the health of mothers and children, but there is little data on AMR-related capacity-building programs for frontline community health workers [8,9]. This study evaluates the impact of a structured AMR training program on improving ASHAs’ knowledge, attitude, and practice concerning antibiotic use, while additionally exploring the integration of these concepts into their regular outreach activities. We hypothesized that the training would lead to measurable improvements in AMR-related knowledge and community engagement practices. By assessing both individual learning and field-level application, this study contributes to the growing evidence on community-based interventions for AMR control and highlights the significant role of ASHAs in addressing global health challenges through grassroots-level initiatives. MATERIALS & METHODS Study Design and Setting A pre-post educational intervention study was conducted among ASHAs from selected urban primary health centres (UPHCs) in Mysuru City, Karnataka, India. Study participants A total of 103 ASHAs participated in the study. Participants were selected using a convenience sampling method from UPHCs where community engagement activities were ongoing. Inclusion criteria: · A ASHAs actively working in selected UPHCs under NHM in Mysuru City. Exclusion criteria: · ASHAs with less than one year of experience. · ASHAs not willing to participate in the study. Overview of training program A structured educational program was developed to assist ASHAs to become more capable and involved in the fight against AMR. The aim of this program was to enable ASHAs to become more knowledgeable about and competent in infection prevention and control (IPC), AMS, and the prudent use of antibiotics. National and international guidelines, including the Indian Council of Medical Research's Antimicrobial Stewardship Guidelines (ICMR-AMS) and WHO's AMR Toolkit, formed the foundation for the training [10,11]. It was designed to serve as a useful model that could be used in different community meetings. The study was a component of a larger initiative to increase primary care settings' awareness of AMR. Development and validation of KAP questionnaire A structured KAP questionnaire was developed to assess ASHAs' understanding and behaviour related to antibiotic use and AMR, both before and after the educational intervention. The development process began with a comprehensive literature review to identify validated tools that had previously assessed similar domains among community health workers and frontline health providers [12-15]. This review guided the content selection and contextual adaptation of questions appropriate for ASHAs working in both rural and urban PHCs in Mysuru. Responses on the Knowledge and Attitude parts were assessed using a 5-point Likert scale, from 1 (Strongly Disagree) to 5 (Strongly Agree). To reduce response bias, certain negatively worded statements were reverse-coded during analysis. For the Practice section, a 3-point frequency scale was used: 1 (Never), 2 (Sometimes), and 3 (Always), enabling a nuanced evaluation of how often specific community-facing behaviours were performed. The developed questionnaire underwent a rigorous validation process to ensure its relevance, clarity, and applicability. A panel of 15 experts, including ASHAs, faculty members, and research scholars from the Department of Pharmacy Practice, assessed each topic for relevance, clarity, simplicity, and ambiguity applying a four-point Likert scale, as advised by Yaghmaie[16]. Item-level content validity index (I-CVI) and scale-level content validity indices (S-CVI) were calculated using responses compiled in Microsoft Excel. Reliability was assessed through Cronbach’s alpha, with values ≥0.8 considered acceptable, indicating strong internal consistency across domains. The pre-final Kannada version was pretested with 10 ASHAs to evaluate comprehension, feasibility, and clarity. Feedback informed minor revisions, ensuring the tool's suitability for field-level use among the ASHA workforce. Development of training module The training module was developed by a team of experts from various fields. The team included public health experts, infectious disease specialists, pharmacists and field trainers. The final curriculum covered subjects that were in line with national IPC guidelines and the proper use of antibiotics. The materials were reviewed by two external experts in AMR and IPC to ensure that they were scientifically and contextually acceptable. Training Structure and Content The training program was conducted over three days in the form of workshops at certain PHCs. The sessions were designed to be interactive and hands-on. The most important topics were 1. Introduction to microbes and antimicrobials 2. Understanding AMR 3. Principles of IPC 4. Rational use of antibiotics 5. Role of ASHAs in antimicrobial stewardship and health promotion On each day, there were interactive lectures, group discussions, demonstrations and role-playing activities. The ASHAs participated in hands-on activities to practise giving AMR awareness messages at community meetings like MAS (Mahila Arogya Samiti) and UHND (Urban Health and Nutrition Day). ASHAs were provided with printed training manuals and role-play scripts to support the key points. All materials were intended for use in communities with limited resources and low levels of literacy. Additionally, trainers conducted short review sessions at the end of each day. Method of Training Evaluation Validated KAP questionnaire was administered to participants before the training and again 4 weeks post-training to assess knowledge retention and behaviour change. ASHAs were observed during routine outreach activities such as UHND & MAS meetings to assess how well they applied the training content. A checklist-based monitoring and evaluation tool was used to document the delivery of AMR messages, use of educational materials, and interaction with community members. Observations were conducted by trained research officers familiar with local health activities. Data Analysis Quantitative data from the KAP responses were analysed using SPSS (Version 25.0). Descriptive statistics were calculated, and pre-post comparisons were performed using paired t-tests. Spearman’s correlation analysis was done to assess relationships between knowledge, attitudes, and practices. Qualitative data from interviews and observation notes were analyzed thematically to identify key implementation patterns and barriers. RESULTS A total of 103 ASHAs participated in the study, with a mean age of 37.03 ± 7.00 years. Most were aged 31–40 years (42.7%), married (89.3%), and had completed pre-university education (57.3%). Nearly 38.8% reported 1–5 years of work experience. (Table 1 ) Table 1 Demographic details of ASHAs Characteristics Frequency (n = 103) Percentage (%) Age group 21–30 25 24.3 31–40 44 42.7 41–50 31 30.1 51–60 3 2.9 Marital status Married 92 89.3 Widowed 11 10.7 Divorced 0 0 Qualification Secondary School 3 2.9 High School 30 29.1 Pre-university 59 57.3 Undergraduate 11 10.7 Years of experience as an ASHA 1–5 40 38.8 6–10 33 32 11–15 29 28.2 16–20 1 1 ASHAs' KAP towards antibiotic use and AMR before and after training The post-training assessment demonstrated a significant improvement in ASHAs’ knowledge towards antibiotic use and AMR. Misconceptions such as using antibiotics for all germs and treating the common cold among participants decreased from 54.3–1.9% (p = 0.012) and from 67.9–14.6% (p = 0.002), respectively. Additionally, the majority of participants correctly identified that improper antibiotic use and non-adherence can contribute to the development of AMR (p = 0.001 and p = 0.035) (Supplementary Table 1). Significant improvements were observed in ASHAs’ attitudes toward antibiotic use and AMR. Post-training, 62.1% of participants expressed confidence in naming commonly used antibiotics at their primary health centre, from 5.8% before training (p < 0.001). Similarly, agreement on the importance of guiding patients to complete antibiotic courses increased from 0–61.1% (p < 0.001) (Supplementary Table 2). The practice scores of ASHAs demonstrated a significant improvement following the training, with all four practice-related questions showing statistically significant changes (p < 0.001). Before the intervention, the majority of participants responded with “Never” for all practices related to antibiotic use. Post-intervention, there was a marked shift towards “Sometimes” and “Always” responses (Supplementary Table .3) A weak but significant positive association was identified in post-training between knowledge and attitude (= 0.14, p = 0.001) and between knowledge and practice (= 0.221, p 0.001) based on Spearman's correlation analysis. In pre-training, knowledge and attitude were weakly negatively correlated (ρ = − 0.093, p = 0.034), while other correlations were not statistically significant (Table 2 ). Table 2 Correlation of pre & post training knowledge, attitude and practice Pre- Training Post- Training Spearman's rho p-value Spearman's rho p-value Knowledge - Attitude -0.093 0.034 0.14 0.001 Attitude - Practice 0.07 0.153 -0.082 0.098 Practice-Knowledge 0.038 0.438 0.221 0 Implementation and evaluation of training provided to ASHAs The evaluation of ASHA-led sessions on antibiotic use and AMR using four tools—community feedback, supervisor assessments, and observation checklist yielded highly encouraging results. Among 132 community members surveyed, over 84% understood the correct use of antibiotics, nearly 90% recognized that antibiotics are not effective for viral infections such as the common cold or fever, and more than 90% found the sessions clear and helpful. Additionally, 92% expressed willingness to follow the ASHA’s advice. (Fig. 1 ) Supervisor feedback from 30 respondents confirmed that 80% of ASHAs used appropriate materials, 63% demonstrated excellent communication, and 100% successfully engaged the community, with very few instances of misinformation. (Supplementary Tables. 4 & 5) Observation of 30 ASHA-led sessions showed high adherence to training protocols—nearly 97% explained antibiotics correctly, over 83% addressed AMR, 87% used IEC tools effectively, and 90% followed infection control practices. Collectively, the results highlight the successful implementation and impact of the ASHA-led AMR awareness initiative, while suggesting a need for periodic reinforcement training. (Table. 3) Table 3 Direct monitoring and observation checklist summary Questions Category Frequency (n = 30) Percentage ASHA used any training materials Yes 24 80 No 6 20 Explained what antibiotics are and when they should be used Yes 30 100 No 0 0 Clearly stated that antibiotics don’t treat viral infections (cold, flu, etc.) Yes 29 96.7 No 1 3.3 Talked about AMR and dangers of misuse of antibiotics Yes 25 83.3 No 5 16.7 Encouraged community interaction or answered questions Yes 26 86.7 No 4 13.3 Delivered session confidently and in local language Yes 26 86.7 No 4 13.3 Community members appeared attentive/engaged Yes 21 70 No 9 30 Session completed within expected time (10–15 minutes) Yes 20 66.7 No 10 33.3 Any misinformation or incorrect messages observed Yes 2 6.7 No 28 93.3 DISCUSSION The demographic distribution of ASHAs participating in this study highlights the characteristics of India’s frontline health workforce. A significant proportion of participants were in the 31–40 age group (42.7%), aligning with previous studies that ASHAs are often mid-career women with sufficient life experience to earn trust within their communities [ 17 , 18 ]. The majority of ASHAs (89.3%) were married, which reflects the National Health Mission’s (NHM) eligibility preferences, which prioritise married, resident women to ensure long-term commitment and community acceptance [ 19 ]. The educational background of the participants was significant, with 57.3% completed pre-university education and an additional 10.7% holding undergraduate degrees. These figures are significantly higher than the minimum qualification of Grade 8 for ASHA recruitment, indicating that the majority of the selected ASHAs have the necessary educational background to effectively convey and understand public health information [ 19 ]. The baseline data showed major gaps in antibiotic knowledge and practices among ASHAs. Although 83.5% reported being aware of antibiotics, only 34% correctly understood how to use them. This discrepancy between awareness and practical knowledge aligns with data from community-based studies from Nepal and Ethiopia, where essential familiarity with medications failed to result in appropriate antibiotic usage [ 20 , 21 ]. One of the most critical misconceptions corrected through the intervention was related to the duration of antibiotic use. Initially, a majority (75.7%) believed that antibiotics should be used for ≤ 3 days, which could potentially contribute to under-treatment and resistance. Post-intervention, 64% correctly identified ≤ 7 days as appropriate, aligning with evidence-based treatment duration. Counselling practices also improved remarkably, from only 6.8% of ASHAs reporting that they counsel patients about antibiotic use pre-intervention to 94.2% post-intervention. This supports findings from AY Binsaleh et al., where family care givers who underwent training showed increased confidence in engaging patients and promoting responsible antibiotic use [ 22 ]. Such behavioural changes are crucial for the sustainability of AMS programs at the community level. Misconceptions based on knowledge were also greatly impacted by the intervention. For example, there was a significant decline in the percentage of ASHAs who incorrectly thought that antibiotics were beneficial against viral infections like the common cold. Other global studies have revealed that such beliefs are significant factors contributing to the irrational use of antibiotics by individuals [ 23 ]. The attitude part showed that ASHAs were more responsible as they were more aware of their role in fighting AMR. Even though the question about attitudes toward using antibiotics without a doctor's advice didn't reveal a statistically significant change, more ASHAs believed they disagreed after the intervention. This is comparable to the results that were observed in Kenya's national AMR curriculum implementation, which indicated that changes in strongly held attitudes may take longer but are helped by frequent training and supportive supervision [ 24 ]. The practice-based outcomes in this study were arguably the most impressive. All four practice indicators showed statistically significant enhancements (p < 0.001), with ASHAs transitioning from “Never” to “Sometimes” and “Always” in teaching, counselling, and following up with patients. These findings support earlier AMS initiatives in Ghana and the UK, wherein behavioural interventions integrated with educational tactics effectively enhanced healthcare personnel's antibiotic-related practices [ 25 , 26 ]. The evaluation of the ASHA-led community sessions on antibiotic use and AMR demonstrated strong evidence of successful implementation, with high community uptake and appropriate delivery of key messages. Over 90% of community members reported clarity in the sessions, recognised the inappropriateness of antibiotics for viral infections, and expressed willingness to adopt the ASHAs’ recommendations, affirming their trust in local health workers and the relevance of the content delivered. Findings from supervisor observations and direct monitoring reinforced the fidelity of training implementation. Most ASHAs used IEC tools effectively, maintained message accuracy (97%), and promoted interaction during sessions. These outcomes resonate with the results of Abdel-All et al. (2018), where a similar model of training ASHAs for hypertension education led to improved knowledge, behaviour change, and confidence in leading community meetings [ 27 ]. The ASHAs in this study demonstrated the ability to transfer learned concepts into practice, aligning with Kirkpatrick’s model of training evaluation, particularly the behaviour and result domains. As in prior health worker capacity-building interventions across India and LMICs, including hypertension management [ 24 , 28 ]. Our findings affirm that brief, structured, and interactive training can result in significant improvements in knowledge translation and community-level impact. This study had few limitations. The study adopted a convenience sampling strategy, thus limiting the generalisability of the findings beyond the selected ASHAs and PHCs. The follow-up examination was completed only four weeks post-training. Hence, the long-term retention of knowledge and the sustainability of behaviour change were not assessed. Future research should explore the long-term impact of AMR training among ASHAs by conducting follow-ups at 6- and 12-month post-intervention. Scaling the intervention across different states and socio-cultural contexts will help validate its adaptability and effectiveness. CONCLUSION The training program significantly improved the awareness and practice of ASHAs towards AMR and the proper use of antibiotics. ASHAs demonstrated strong potential to act as community-level antimicrobial stewards by effectively integrating AMR awareness into their routine outreach activities. Community feedback, supervisor evaluations, and field observations confirmed high implementation fidelity and strong community engagement. This study strengthens the importance of frontline health workers in AMR prevention and offers a scalable model for community-based antimicrobial stewardship efforts in LMICs. Declarations Conflicting interest: The authors declare no conflicts of interest. Acknowledgements: The authors acknowledge the support and cooperation of the primary healthcare staff, ASHA workers, and administrative authorities who facilitated the training and data collection process. Author contributions RR: Conceptualisation/design, Methodology, Investigation, Data curation, Writing– original draft. SMS: Conceptualization/design, Methodology. GEV: Methodology, data analysis. PKT: review & editing, Supervision Funding NIL Ethical approval and accordance: The authors confirm that the study was conducted in compliance with the principles outlined in the Declaration of Helsinki. Ethical clearance for the project was obtained from Institutional Ethics Committee of JSS Medical College, JSS Academy of Higher Education & Research, Mysuru (Ref No: JSSMC/IEC /110523/ 16 NCT /2023-24). Consent to participate Before data collection and the training program, written informed consent was obtained from all participating ASHAs. Consent for publication : Not applicable Competing interests : NIL Data availability Data used in this study are available from the corresponding author (SMS) upon reasonable request. References Sartorius B, Gray AP, Weaver ND, et al. The burden of bacterial antimicrobial resistance in the WHO African region in 2019: a cross-country systematic analysis. The Lancet Global Health .2024; 12(2):e201-16. https://doi.org/10.1016/S2214-109X(23)00539-9 World Health Organization (2023). Antimicrobial resistance. Word Health organization. https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance Laxminarayan R, Chaudhury RR. Antibiotic Resistance in India: Drivers and Opportunities for Action. PLoS Med . 2016;13(3): e1001974. https://doi.org/10.1371/journal.pmed.1001974 Willemsen A, Reid S, Assefa Y (2022). A review of national action plans on antimicrobial resistance: strengths and weaknesses. Antimicrobial Resistance and Infection Control, 11(1):90. https://doi.org/10.1186/s13756-022-01130-x Ministry of Health and Family Welfare (2005). About Accredited Social Health Activist (ASHA). http://nrhm.gov.in/communitisation/asha/about-asha.html World Health Organization . (2021) ASHA—the driving force behind India's public health services. World Health Organization. https://www.who.int/india/news-room/feature-stories/detail/asha-the-driving-force-behind-india-s-public-health-services#:~:text=Under%20India's%20National%20Health%20Mission,system%20at%20the%20community%20level. Chalkidou A, Lambert M, Cordoba G, Taxis K, Hansen MP, Bjerrum L. Misconceptions and knowledge gaps on antibiotic use and resistance in four healthcare settings and five European Countries—A modified Delphi study. Antibiotics , .2023;12(9):1435. https://doi.org/10.3390/antibiotics12091435 Nadella P, Subramanian SV, Roman-Urrestarazu A. The impact of community health workers on antenatal and infant health in India: a cross-sectional study. SSM-population health. 2021 1;15:100872. https://doi.org/10.1016/j.ssmph.2021.100872 Gauba A, Singh M. A Quasi-Experimental Study to Assess the Effectiveness of a Structured Training Program on Newborn Care Based on ASHA Module 7-“Skills That Saves Lives” in Terms of Reported Practice among ASHA Workers in a Selected Community of Delhi. Indian Journal of Community Medicine. 2021 Apr 1;46(2):277-80. DOI: 10.4103/ijcm.IJCM_722_20. Indian Council of Medical Research. Antimicrobial Stewardship Program (AMSP): ICMR guidelines. New Delhi: ICMR; 2018. Available from: https://www.icmr.gov.in/icmrobject/custom_data/pdf/resource-guidelines/AMSP_0.pdf World Health Organization. AMR Education Toolkit. In: World Antimicrobial Resistance Awareness Week 2019. Geneva: WHO; Available from: https://www.who.int/campaigns/world-amr-awareness-week/2019/amr-education-toolkithttps://www.who.int/campaigns/world-amr-awareness-week/2019/amr-education-toolkit. Christanti JV, Setiadi AP, Wibowo YI, et al, (2021). A cross-sectional assessment of Indonesian female health cadres’ knowledge and attitude towards antibiotics. The Journal of Infection in Developing Countries . 2021;15(10):1453-6. https://doi.org/10.3855/jidc.14325 Nepal A, Hendrie D, Robinson S, Selvey LA (2019). Knowledge, attitudes and practices relating to antibiotic use among community members of the Rupandehi District in Nepal. BMC Public Health . 2019;19:1-2. https://doi.org/10.1186/s12889-019-7924-5 Dejene H, Birhanu R, Tarekegn ZS (2022). Knowledge, attitude and practices of residents toward antimicrobial usage and resistance in Gondar, Northwest Ethiopia. One Health Outlook . 2022; 4(1):10. https://doi.org/10.1186/s42522-022-00066-x Rana S, Kaur KN, Narad P, et al(2024). Knowledge, attitudes and practices of antimicrobial resistance awareness among healthcare workers in India: a systematic review. Frontiers in Public Health . 12:1433430. https://doi.org/10.3389/fpubh.2024.1433430 Yaghmaie F. Content validity and its estimation. J Med Educ. 2003;3(1):25–27. Kok MC, Kane SS, Tulloch O, Ormel H, Theobald S, Dieleman M, Taegtmeyer M, Broerse JE, de Koning KA. How does context influence the performance of community health workers in low-and middle-income countries? Evidence from the literature. Health research policy and systems. 2015; 13:1-4. https://doi.org/10.1186/s12961-015-0001-3 Scott K, Beckham SW, Gross M, Pariyo G, Rao KD, Cometto G, Perry HB. What do we know about community-based health worker programs? A systematic review of existing reviews on community health workers. Human resources for health. 2018; 16:1-7. https://doi.org/10.1186/s12960-018-0304-x Ministry of Health & Family Welfare-Government of India. About Accredited Social Health Activist (ASHA):: National Health Mission. Available from: https://nhm.gov.in/index1.php?lang=1&level=1&sublinkid=150&lid=226#:~:text=ASHA%20will%20provide%20information%20to,function%20without%20adequate%20institutional%20support Sitotaw B, Philipos W. Knowledge, Attitude, and Practices (KAP) on Antibiotic Use and Disposal Ways in Sidama Region, Ethiopia: A Community‐Based Cross‐Sectional Survey. The Scientific World Journal. 2023;(1):8774634. https://doi.org/10.1155/2023/8774634 Parajuli A, Garbovan L, Bhattarai B, Arjyal A, Baral S, Cooke P, Latham S, Barrington DJ, Mitchell J, King R. Exploring community insights on antimicrobial resistance in Nepal: a formative qualitative study. BMC Health Services Research. 2024;24(1):57. https://doi.org/10.1186/s12913-023-10470-2 Binsaleh AY, Abdallah MS, Osman BM, Bahaa MM, Alsubaie N, Elmasry TA, Yasser M, Eldesoqui M, Gadallah AN, Hamouda MA, Eltantawy N. Antimicrobial Stewardship Intervention for the Family Caregiver Attending Primary Health Care Setting: A Quasi-Experimental Study. Antibiotics. 2024;13(12):1145. https://doi.org/10.3390/antibiotics13121145 Chalkidou A, Lambert M, Cordoba G, Taxis K, Hansen MP, Bjerrum L. Misconceptions and knowledge gaps on antibiotic use and resistance in four healthcare settings and five European Countries—a modified Delphi study. Antibiotics. 2023;12(9):1435. https://doi.org/10.3390/antibiotics12091435 Njeru J, Odero J, Chebore S, Ndung’u M, Tanui E, Wesangula E, Ndanyi R, Githii S, Gunturu R, Mwangi W, Mutonga D. Development, roll-out and implementation of an antimicrobial resistance training curriculum harmonizes delivery of in-service training to healthcare workers in Kenya. Frontiers in Microbiology. 2023; 14:1142622. https://doi.org/10.3389/fmicb.2023.1142622 Sneddon J, Afriyie D, Sefah I, Cockburn A, Kerr F, Byrne-Davis L, Cameron E. Developing a sustainable antimicrobial stewardship (AMS) programme in Ghana: replicating the Scottish triad model of information, education and quality improvement. Antibiotics. 2020;9(10):636. https://doi.org/10.3390/antibiotics9100636 Seaton D, Ashiru-Oredope D, Charlesworth J, Gemmell I, Harrison R. Evaluating UK pharmacy workers’ knowledge, attitudes and behaviour towards antimicrobial stewardship and assessing the impact of training in community pharmacy. Pharmacy. 2022 ;10(4):98. https://doi.org/10.3390/pharmacy10040098 Abdel-All M, Thrift AG, Riddell M, Thankappan KR, Mini GK, Chow CK, Maulik PK, Mahal A, Guggilla R, Kalyanram K, Kartik K. Evaluation of a training program of hypertension for accredited social health activists (ASHA) in rural India. BMC Health Services Research. 2018;18:1-1. https://doi.org/10.1186/s12913-018-3140-8 Gamage DG, Riddell MA, Joshi R, Thankappan KR, Chow CK, Oldenburg B, Evans RG, Mahal AS, Kalyanram K, Kartik K, Suresh O. Effectiveness of a scalable group-based education and monitoring program, delivered by health workers, to improve control of hypertension in rural India: a cluster randomised controlled trial. PLoS Medicine. 2020;17(1):e1002997. https://doi.org/10.1371/journal.pmed.1002997 Additional Declarations No competing interests reported. Supplementary Files Supplementaryfile1.docx Cite Share Download PDF Status: Published Journal Publication published 08 Oct, 2025 Read the published version in Discover Public Health → Version 1 posted Editorial decision: Revision requested 15 Sep, 2025 Reviews received at journal 14 Sep, 2025 Reviewers agreed at journal 09 Sep, 2025 Reviewers agreed at journal 07 Sep, 2025 Reviewers agreed at journal 07 Sep, 2025 Reviews received at journal 29 Aug, 2025 Reviewers agreed at journal 23 Aug, 2025 Reviewers agreed at journal 21 Aug, 2025 Reviewers agreed at journal 19 Aug, 2025 Reviewers invited by journal 18 Aug, 2025 Editor assigned by journal 16 Aug, 2025 Submission checks completed at journal 15 Aug, 2025 First submitted to journal 15 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7315492","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":505200026,"identity":"2ac5813f-d0fe-4458-8f84-d89f4d3c8a00","order_by":0,"name":"Rosy Raju","email":"","orcid":"","institution":"JSS College of Pharmacy, JSS Academy of Higher Education \u0026 Research","correspondingAuthor":false,"prefix":"","firstName":"Rosy","middleName":"","lastName":"Raju","suffix":""},{"id":505200027,"identity":"da380dec-d543-45fc-ac8c-d7138649dec5","order_by":1,"name":"Srikanth Malavalli Siddalingegowda","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+UlEQVRIiWNgGAWjYLCChANAQoL5gAGIwwZigxEhLTwSbAkkaGEAa+ExgPPxqtftP/7sw4Mzdnn20j0fCn/8OZzHx8B88DYPg0UeLi1mN3KMZyTcSC7mkTm7wZi37XAxGwNbsjUPg0Qxbi08zAwJH5gTeyRyNxgzNhxObGPgMZMGaklswKXl/PHHQC31QC05DwyBDgNq4f+GX8uBBGOGhBuHQVoYDHjYwLaw4dcC9AtDwpnjiT030gyAfklPbGNmM7acY4DfYYw/jlUnts9IfgZ0mHXi/PbmhzfeVNTh1IIM2CARwwwiDPCqhAPmB8SpGwWjYBSMgpEGAB9AVbDwZ/crAAAAAElFTkSuQmCC","orcid":"","institution":"JSS College of Pharmacy, JSS Academy of Higher Education \u0026 Research","correspondingAuthor":true,"prefix":"","firstName":"Srikanth","middleName":"Malavalli","lastName":"Siddalingegowda","suffix":""},{"id":505200028,"identity":"fe0d6207-412e-4192-bc00-5ede87ab5ab1","order_by":2,"name":"Gabriella Edina Veronica","email":"","orcid":"","institution":"Independent Researcher","correspondingAuthor":false,"prefix":"","firstName":"Gabriella","middleName":"Edina","lastName":"Veronica","suffix":""},{"id":505200029,"identity":"c1be83d8-4f22-4311-b743-fed8c7c24f8b","order_by":3,"name":"Pramod Kumar Tegginamath","email":"","orcid":"","institution":"JSS College of Pharmacy, JSS Academy of Higher Education \u0026 Research","correspondingAuthor":false,"prefix":"","firstName":"Pramod","middleName":"Kumar","lastName":"Tegginamath","suffix":""}],"badges":[],"createdAt":"2025-08-07 06:53:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7315492/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7315492/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12982-025-01001-x","type":"published","date":"2025-10-08T15:58:06+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":89919499,"identity":"184c945d-7bd7-4b7b-9a32-190fe324a575","added_by":"auto","created_at":"2025-08-26 12:26:48","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":31886,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCommunity feedback on ASHA-led sessions\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7315492/v1/f7e8ac49ca0d15b692f1808c.png"},{"id":93419779,"identity":"65d32b22-14f0-4308-8956-f2a7b4a98624","added_by":"auto","created_at":"2025-10-13 16:07:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":767450,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7315492/v1/ef88cc97-8ea8-4fee-96a3-d459f299b0f4.pdf"},{"id":89919744,"identity":"1e918a5e-34d0-4f42-8ca0-6657542890c8","added_by":"auto","created_at":"2025-08-26 12:34:48","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":33974,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7315492/v1/ad4afbfd7f23eceb4b249dd7.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effectiveness of a Structured Educational Training Program on Antimicrobial Resistance Among Community Health Workers in India","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eCommon infections are becoming more difficult to treat due to antimicrobial resistance (AMR), which is a escalating issue in global public health. Infection control and treatment outcomes are seriously threatened by the emergence and spread of drug-resistant bacteria, viruses, parasites, and fungi, which frequently result in longer illness duration, higher mortality rates, and higher healthcare expenses [1,2]. The improper use of antibiotics, which frequently results from irrational and inappropriate use, is one of the primary causes of AMR. In low- and middle-income countries (LMICs) like India, antibiotics are readily available without a prescription, there is a lack of public awareness, and regulatory enforcement is lax, this is particularly pertinent [3].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo combat this issue, India introduced the National Action Plan on Antimicrobial Resistance (NAP-AMR) in 2017. In order to enhance antimicrobial stewardship (AMS) at all levels of healthcare, the plan highlights public involvement, education, and training [4]. Accredited Social Health Activists (ASHAs), who are part of India's National Health Mission (NHM), provide primary healthcare services in an effort to effect change at community level. They are crucial for promoting connection between people in rural and urban areas, preventing disease, and promoting health [5,6]. ASHAs are in a good position to change people's behaviour and promote responsible antibiotic use because they are so closely connected to their communities. However, a lack of training and widespread misconceptions, like using antibiotics for viral infections or stopping drugs when symptoms go away, may limit their ability to effectively promote behaviour change linked to AMR [7].\u003c/p\u003e\n\u003cp\u003ePrevious studies have mostly focused on improving the health of mothers and children, but there is little data on AMR-related capacity-building programs for frontline community health workers [8,9]. This study evaluates the impact of a structured AMR training program on improving ASHAs’ knowledge, attitude, and practice concerning antibiotic use, while additionally exploring the integration of these concepts into their regular outreach activities. We hypothesized that the training would lead to measurable improvements in AMR-related knowledge and community engagement practices. By assessing both individual learning and field-level application, this study contributes to the growing evidence on community-based interventions for AMR control and highlights the significant role of ASHAs in addressing global health challenges through grassroots-level initiatives.\u003c/p\u003e"},{"header":"MATERIALS \u0026 METHODS","content":"\u003cp\u003e\u003cstrong\u003eStudy Design and Setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA pre-post educational intervention study was conducted among ASHAs from selected urban primary health centres (UPHCs) in Mysuru City, Karnataka, India.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 103 ASHAs participated in the study. Participants were selected using a convenience sampling method from UPHCs where community engagement activities were ongoing.\u003c/p\u003e\n\u003cp\u003eInclusion criteria:\u003c/p\u003e\n\u003cp\u003e· A ASHAs actively working in selected UPHCs under NHM in Mysuru City.\u003c/p\u003e\n\u003cp\u003eExclusion criteria:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e· ASHAs with less than one year of experience.\u003c/p\u003e\n\u003cp\u003e· ASHAs not willing to participate in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOverview of training program\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA structured educational program was developed to assist ASHAs to become more capable and involved in the fight against AMR. The aim of this program was to enable ASHAs to become more knowledgeable about and competent in infection prevention and control (IPC), AMS, and the prudent use of antibiotics. National and international guidelines, including the Indian Council of Medical Research's Antimicrobial Stewardship Guidelines (ICMR-AMS) and WHO's AMR Toolkit, formed the foundation for the training [10,11]. It was designed to serve as a useful model that could be used in different community meetings. The study was a component of a larger initiative to increase primary care settings' awareness of AMR.\u003c/p\u003e\n\u003cp\u003eDevelopment and validation of KAP questionnaire\u003c/p\u003e\n\u003cp\u003eA structured KAP questionnaire was developed to assess ASHAs' understanding and behaviour related to antibiotic use and AMR, both before and after the educational intervention. The development process began with a comprehensive literature review to identify validated tools that had previously assessed similar domains among community health workers and frontline health providers [12-15]. This review guided the content selection and contextual adaptation of questions appropriate for ASHAs working in both rural and urban PHCs in Mysuru. Responses on the Knowledge and Attitude parts were assessed using a 5-point Likert scale, from 1 (Strongly Disagree) to 5 (Strongly Agree). To reduce response bias, certain negatively worded statements were reverse-coded during analysis. For the Practice section, a 3-point frequency scale was used: 1 (Never), 2 (Sometimes), and 3 (Always), enabling a nuanced evaluation of how often specific community-facing behaviours were performed.\u003c/p\u003e\n\u003cp\u003eThe developed questionnaire underwent a rigorous validation process to ensure its relevance, clarity, and applicability. A panel of 15 experts, including ASHAs, faculty members, and research scholars from the Department of Pharmacy Practice, assessed each topic for relevance, clarity, simplicity, and ambiguity applying a four-point Likert scale, as advised by Yaghmaie[16]. Item-level content validity index (I-CVI) and scale-level content validity indices (S-CVI) \u0026nbsp;were calculated using responses compiled in Microsoft Excel. Reliability was assessed through Cronbach’s alpha, with values ≥0.8 considered acceptable, indicating strong internal consistency across domains. The pre-final Kannada version was pretested with 10 ASHAs to evaluate comprehension, feasibility, and clarity. Feedback informed minor revisions, ensuring the tool's suitability for field-level use among the ASHA workforce.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDevelopment of training module\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe training module was developed by a team of experts from various fields. The team included public health experts, infectious disease specialists, pharmacists and field trainers. The final curriculum covered subjects that were in line with national IPC guidelines and the proper use of antibiotics. The materials were reviewed by two external experts in AMR and IPC to ensure that they were scientifically and contextually acceptable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTraining Structure and Content\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe training program was conducted over three days in the form of workshops at certain PHCs. The sessions were designed to be interactive and hands-on. The most important topics were\u003c/p\u003e\n\u003cp\u003e1.\u0026nbsp; \u0026nbsp;Introduction to microbes and antimicrobials\u003c/p\u003e\n\u003cp\u003e2.\u0026nbsp;Understanding AMR\u003c/p\u003e\n\u003cp\u003e3.\u0026nbsp;Principles of IPC\u003c/p\u003e\n\u003cp\u003e4.\u0026nbsp;Rational use of antibiotics\u003c/p\u003e\n\u003cp\u003e5.\u0026nbsp;Role of ASHAs in antimicrobial stewardship and health promotion\u003c/p\u003e\n\u003cp\u003eOn each day, there were interactive lectures, group discussions, demonstrations and role-playing activities. The ASHAs participated in hands-on activities to practise giving AMR awareness messages at community meetings like MAS (Mahila Arogya Samiti) and UHND (Urban Health and Nutrition Day). ASHAs were provided with printed training manuals and role-play scripts to support the key points. All materials were intended for use in communities with limited resources and low levels of literacy. Additionally, trainers conducted short review sessions at the end of each day.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod of Training Evaluation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eValidated KAP questionnaire was administered to participants before the training and again 4 weeks post-training to assess knowledge retention and behaviour change. ASHAs were observed during routine outreach activities such as UHND \u0026amp; MAS meetings to assess how well they applied the training content. A checklist-based monitoring and evaluation tool was used to document the delivery of AMR messages, use of educational materials, and interaction with community members. Observations were conducted by trained research officers familiar with local health activities.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQuantitative data from the KAP responses were analysed using SPSS (Version 25.0). Descriptive statistics were calculated, and pre-post comparisons were performed using paired t-tests. Spearman’s correlation analysis was done to assess relationships between knowledge, attitudes, and practices. Qualitative data from interviews and observation notes were analyzed thematically to identify key implementation patterns and barriers.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 103 ASHAs participated in the study, with a mean age of 37.03\u0026thinsp;\u0026plusmn;\u0026thinsp;7.00 years. Most were aged 31\u0026ndash;40 years (42.7%), married (89.3%), and had completed pre-university education (57.3%). Nearly 38.8% reported 1\u0026ndash;5 years of work experience. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic details of ASHAs\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFrequency (n\u0026thinsp;=\u0026thinsp;103)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePercentage (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e21\u0026ndash;30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e31\u0026ndash;40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e41\u0026ndash;50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e51\u0026ndash;60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e89.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWidowed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDivorced\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eQualification\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSecondary School\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHigh School\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePre-university\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e57.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUndergraduate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eYears of experience as an ASHA\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u0026ndash;5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e38.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u0026ndash;10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e11\u0026ndash;15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e16\u0026ndash;20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eASHAs' KAP towards antibiotic use and AMR before and after training\u003c/h3\u003e\n\u003cp\u003eThe post-training assessment demonstrated a significant improvement in ASHAs\u0026rsquo; knowledge towards antibiotic use and AMR. Misconceptions such as using antibiotics for all germs and treating the common cold among participants decreased from 54.3\u0026ndash;1.9% (p\u0026thinsp;=\u0026thinsp;0.012) and from 67.9\u0026ndash;14.6% (p\u0026thinsp;=\u0026thinsp;0.002), respectively. Additionally, the majority of participants correctly identified that improper antibiotic use and non-adherence can contribute to the development of AMR (p\u0026thinsp;=\u0026thinsp;0.001 and p\u0026thinsp;=\u0026thinsp;0.035) (Supplementary Table\u0026nbsp;1).\u003c/p\u003e\u003cp\u003eSignificant improvements were observed in ASHAs\u0026rsquo; attitudes toward antibiotic use and AMR. Post-training, 62.1% of participants expressed confidence in naming commonly used antibiotics at their primary health centre, from 5.8% before training (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Similarly, agreement on the importance of guiding patients to complete antibiotic courses increased from 0\u0026ndash;61.1% (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Supplementary Table\u0026nbsp;2). The practice scores of ASHAs demonstrated a significant improvement following the training, with all four practice-related questions showing statistically significant changes (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Before the intervention, the majority of participants responded with \u0026ldquo;Never\u0026rdquo; for all practices related to antibiotic use. Post-intervention, there was a marked shift towards \u0026ldquo;Sometimes\u0026rdquo; and \u0026ldquo;Always\u0026rdquo; responses (Supplementary Table .3)\u003c/p\u003e\u003cp\u003eA weak but significant positive association was identified in post-training between knowledge and attitude (=\u0026thinsp;0.14, p\u0026thinsp;=\u0026thinsp;0.001) and between knowledge and practice (=\u0026thinsp;0.221, p 0.001) based on Spearman's correlation analysis. In pre-training, knowledge and attitude were weakly negatively correlated (ρ = \u0026minus;\u0026thinsp;0.093, p\u0026thinsp;=\u0026thinsp;0.034), while other correlations were not statistically significant (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCorrelation of pre \u0026amp; post training knowledge, attitude and practice\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003ePre- Training\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003ePost- Training\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSpearman's rho\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSpearman's rho\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKnowledge - Attitude\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-0.093\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.034\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAttitude - Practice\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.153\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-0.082\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.098\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePractice-Knowledge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.038\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.438\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.221\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eImplementation and evaluation of training provided to ASHAs\u003c/h3\u003e\n\u003cp\u003eThe evaluation of ASHA-led sessions on antibiotic use and AMR using four tools\u0026mdash;community feedback, supervisor assessments, and observation checklist yielded highly encouraging results. Among 132 community members surveyed, over 84% understood the correct use of antibiotics, nearly 90% recognized that antibiotics are not effective for viral infections such as the common cold or fever, and more than 90% found the sessions clear and helpful. Additionally, 92% expressed willingness to follow the ASHA\u0026rsquo;s advice. (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eSupervisor feedback from 30 respondents confirmed that 80% of ASHAs used appropriate materials, 63% demonstrated excellent communication, and 100% successfully engaged the community, with very few instances of misinformation. (Supplementary Tables. 4 \u0026amp; 5)\u003c/p\u003e\u003cp\u003eObservation of 30 ASHA-led sessions showed high adherence to training protocols\u0026mdash;nearly 97% explained antibiotics correctly, over 83% addressed AMR, 87% used IEC tools effectively, and 90% followed infection control practices. Collectively, the results highlight the successful implementation and impact of the ASHA-led AMR awareness initiative, while suggesting a need for periodic reinforcement training. (Table. 3)\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDirect monitoring and observation checklist summary\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQuestions\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFrequency\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePercentage\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eASHA used any training materials\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e80\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eExplained what antibiotics are and when they should be used\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e100\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eClearly stated that antibiotics don\u0026rsquo;t treat viral infections (cold, flu, etc.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e96.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eTalked about AMR and dangers of misuse of antibiotics\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e83.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eEncouraged community interaction or answered questions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e86.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eDelivered session confidently and in local language\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e86.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCommunity members appeared attentive/engaged\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e70\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSession completed within expected time (10\u0026ndash;15 minutes)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e66.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e33.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAny misinformation or incorrect messages observed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e93.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe demographic distribution of ASHAs participating in this study highlights the characteristics of India\u0026rsquo;s frontline health workforce. A significant proportion of participants were in the 31\u0026ndash;40 age group (42.7%), aligning with previous studies that ASHAs are often mid-career women with sufficient life experience to earn trust within their communities [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The majority of ASHAs (89.3%) were married, which reflects the National Health Mission\u0026rsquo;s (NHM) eligibility preferences, which prioritise married, resident women to ensure long-term commitment and community acceptance [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The educational background of the participants was significant, with 57.3% completed pre-university education and an additional 10.7% holding undergraduate degrees. These figures are significantly higher than the minimum qualification of Grade 8 for ASHA recruitment, indicating that the majority of the selected ASHAs have the necessary educational background to effectively convey and understand public health information [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe baseline data showed major gaps in antibiotic knowledge and practices among ASHAs. Although 83.5% reported being aware of antibiotics, only 34% correctly understood how to use them. This discrepancy between awareness and practical knowledge aligns with data from community-based studies from Nepal and Ethiopia, where essential familiarity with medications failed to result in appropriate antibiotic usage [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. One of the most critical misconceptions corrected through the intervention was related to the duration of antibiotic use. Initially, a majority (75.7%) believed that antibiotics should be used for \u0026le;\u0026thinsp;3 days, which could potentially contribute to under-treatment and resistance. Post-intervention, 64% correctly identified\u0026thinsp;\u0026le;\u0026thinsp;7 days as appropriate, aligning with evidence-based treatment duration.\u003c/p\u003e\u003cp\u003eCounselling practices also improved remarkably, from only 6.8% of ASHAs reporting that they counsel patients about antibiotic use pre-intervention to 94.2% post-intervention. This supports findings from AY Binsaleh et al., where family care givers who underwent training showed increased confidence in engaging patients and promoting responsible antibiotic use [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Such behavioural changes are crucial for the sustainability of AMS programs at the community level.\u003c/p\u003e\u003cp\u003eMisconceptions based on knowledge were also greatly impacted by the intervention. For example, there was a significant decline in the percentage of ASHAs who incorrectly thought that antibiotics were beneficial against viral infections like the common cold. Other global studies have revealed that such beliefs are significant factors contributing to the irrational use of antibiotics by individuals [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe attitude part showed that ASHAs were more responsible as they were more aware of their role in fighting AMR. Even though the question about attitudes toward using antibiotics without a doctor's advice didn't reveal a statistically significant change, more ASHAs believed they disagreed after the intervention. This is comparable to the results that were observed in Kenya's national AMR curriculum implementation, which indicated that changes in strongly held attitudes may take longer but are helped by frequent training and supportive supervision [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe practice-based outcomes in this study were arguably the most impressive. All four practice indicators showed statistically significant enhancements (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with ASHAs transitioning from \u0026ldquo;Never\u0026rdquo; to \u0026ldquo;Sometimes\u0026rdquo; and \u0026ldquo;Always\u0026rdquo; in teaching, counselling, and following up with patients. These findings support earlier AMS initiatives in Ghana and the UK, wherein behavioural interventions integrated with educational tactics effectively enhanced healthcare personnel's antibiotic-related practices [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe evaluation of the ASHA-led community sessions on antibiotic use and AMR demonstrated strong evidence of successful implementation, with high community uptake and appropriate delivery of key messages. Over 90% of community members reported clarity in the sessions, recognised the inappropriateness of antibiotics for viral infections, and expressed willingness to adopt the ASHAs\u0026rsquo; recommendations, affirming their trust in local health workers and the relevance of the content delivered. Findings from supervisor observations and direct monitoring reinforced the fidelity of training implementation. Most ASHAs used IEC tools effectively, maintained message accuracy (97%), and promoted interaction during sessions. These outcomes resonate with the results of Abdel-All et al. (2018), where a similar model of training ASHAs for hypertension education led to improved knowledge, behaviour change, and confidence in leading community meetings [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe ASHAs in this study demonstrated the ability to transfer learned concepts into practice, aligning with Kirkpatrick\u0026rsquo;s model of training evaluation, particularly the behaviour and result domains. As in prior health worker capacity-building interventions across India and LMICs, including hypertension management [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Our findings affirm that brief, structured, and interactive training can result in significant improvements in knowledge translation and community-level impact.\u003c/p\u003e\u003cp\u003eThis study had few limitations. The study adopted a convenience sampling strategy, thus limiting the generalisability of the findings beyond the selected ASHAs and PHCs. The follow-up examination was completed only four weeks post-training. Hence, the long-term retention of knowledge and the sustainability of behaviour change were not assessed. Future research should explore the long-term impact of AMR training among ASHAs by conducting follow-ups at 6- and 12-month post-intervention. Scaling the intervention across different states and socio-cultural contexts will help validate its adaptability and effectiveness.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe training program significantly improved the awareness and practice of ASHAs towards AMR and the proper use of antibiotics. ASHAs demonstrated strong potential to act as community-level antimicrobial stewards by effectively integrating AMR awareness into their routine outreach activities. Community feedback, supervisor evaluations, and field observations confirmed high implementation fidelity and strong community engagement. This study strengthens the importance of frontline health workers in AMR prevention and offers a scalable model for community-based antimicrobial stewardship efforts in LMICs.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflicting interest:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors acknowledge the support and cooperation of the primary healthcare staff, ASHA workers, and administrative authorities who facilitated the training and data collection process.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRR: Conceptualisation/design, Methodology, Investigation, Data curation, Writing\u0026ndash; original draft. SMS: Conceptualization/design, Methodology. GEV: Methodology, data analysis. PKT: review \u0026amp; editing, Supervision\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNIL\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval and accordance: \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors confirm that the study was conducted in compliance with the principles outlined in the Declaration of Helsinki. Ethical clearance for the project was obtained from Institutional Ethics Committee of JSS Medical College, JSS Academy of Higher Education \u0026amp; Research, Mysuru (Ref No: JSSMC/IEC /110523/ 16 NCT /2023-24).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBefore data collection and the training program, written informed consent was obtained from all participating ASHAs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eNIL\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData used in this study are available from the corresponding author (SMS) upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eSartorius B, Gray AP, Weaver ND, et al. The burden of bacterial antimicrobial resistance in the WHO African region in 2019: a cross-country systematic analysis. \u003cem\u003eThe Lancet Global Health\u003c/em\u003e.2024; 12(2):e201-16. https://doi.org/10.1016/S2214-109X(23)00539-9\u003c/li\u003e\n \u003cli\u003eWorld Health Organization (2023). Antimicrobial resistance. Word Health organization. https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance\u003c/li\u003e\n \u003cli\u003eLaxminarayan R, Chaudhury RR. Antibiotic Resistance in India: Drivers and Opportunities for Action. \u003cem\u003ePLoS Med\u003c/em\u003e. 2016;13(3): e1001974. https://doi.org/10.1371/journal.pmed.1001974\u003c/li\u003e\n \u003cli\u003eWillemsen A, Reid S, Assefa Y (2022). A review of national action plans on antimicrobial resistance: strengths and weaknesses. \u003cem\u003eAntimicrobial Resistance and Infection Control,\u003c/em\u003e 11(1):90. https://doi.org/10.1186/s13756-022-01130-x\u003c/li\u003e\n \u003cli\u003eMinistry of Health and Family Welfare (2005). About Accredited Social Health Activist (ASHA). http://nrhm.gov.in/communitisation/asha/about-asha.html\u003c/li\u003e\n \u003cli\u003eWorld Health Organization\u003cstrong\u003e.\u003c/strong\u003e (2021) ASHA\u0026mdash;the driving force behind India\u0026apos;s public health services. World Health Organization. https://www.who.int/india/news-room/feature-stories/detail/asha-the-driving-force-behind-india-s-public-health-services#:~:text=Under%20India\u0026apos;s%20National%20Health%20Mission,system%20at%20the%20community%20level.\u003c/li\u003e\n \u003cli\u003eChalkidou A, Lambert M, Cordoba G, Taxis K, Hansen MP, Bjerrum L. Misconceptions and knowledge gaps on antibiotic use and resistance in four healthcare settings and five European Countries\u0026mdash;A modified Delphi study. \u003cem\u003eAntibiotics\u003c/em\u003e, .2023;12(9):1435. https://doi.org/10.3390/antibiotics12091435\u003c/li\u003e\n \u003cli\u003eNadella P, Subramanian SV, Roman-Urrestarazu A. The impact of community health workers on antenatal and infant health in India: a cross-sectional study. SSM-population health. 2021 1;15:100872. https://doi.org/10.1016/j.ssmph.2021.100872\u003c/li\u003e\n \u003cli\u003eGauba A, Singh M. A Quasi-Experimental Study to Assess the Effectiveness of a Structured Training Program on Newborn Care Based on ASHA Module 7-\u0026ldquo;Skills That Saves Lives\u0026rdquo; in Terms of Reported Practice among ASHA Workers in a Selected Community of Delhi. Indian Journal of Community Medicine. 2021 Apr 1;46(2):277-80.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eDOI:\u0026nbsp;\u003c/em\u003e10.4103/ijcm.IJCM_722_20.\u003c/li\u003e\n \u003cli\u003eIndian Council of Medical Research. Antimicrobial Stewardship Program (AMSP): ICMR guidelines. New Delhi: ICMR; 2018. Available from: https://www.icmr.gov.in/icmrobject/custom_data/pdf/resource-guidelines/AMSP_0.pdf\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. AMR Education Toolkit. In: World Antimicrobial Resistance Awareness Week 2019. Geneva: WHO; Available from: https://www.who.int/campaigns/world-amr-awareness-week/2019/amr-education-toolkithttps://www.who.int/campaigns/world-amr-awareness-week/2019/amr-education-toolkit.\u003c/li\u003e\n \u003cli\u003eChristanti JV, Setiadi AP, Wibowo YI, et al, (2021). A cross-sectional assessment of Indonesian female health cadres\u0026rsquo; knowledge and attitude towards antibiotics. \u003cem\u003eThe Journal of Infection in Developing Countries\u003c/em\u003e. 2021;15(10):1453-6. https://doi.org/10.3855/jidc.14325\u003c/li\u003e\n \u003cli\u003eNepal A, Hendrie D, Robinson S, Selvey LA (2019). Knowledge, attitudes and practices relating to antibiotic use among community members of the Rupandehi District in Nepal. \u003cem\u003eBMC Public Health\u003c/em\u003e. 2019;19:1-2. https://doi.org/10.1186/s12889-019-7924-5\u003c/li\u003e\n \u003cli\u003eDejene H, Birhanu R, Tarekegn ZS (2022). Knowledge, attitude and practices of residents toward antimicrobial usage and resistance in Gondar, Northwest Ethiopia. \u003cem\u003eOne Health Outlook\u003c/em\u003e. 2022; 4(1):10. https://doi.org/10.1186/s42522-022-00066-x\u003c/li\u003e\n \u003cli\u003eRana S, Kaur KN, Narad P, et al(2024). Knowledge, attitudes and practices of antimicrobial resistance awareness among healthcare workers in India: a systematic review. \u003cem\u003eFrontiers in Public Health\u003c/em\u003e. 12:1433430. https://doi.org/10.3389/fpubh.2024.1433430\u003c/li\u003e\n \u003cli\u003eYaghmaie F. Content validity and its estimation. J Med Educ. 2003;3(1):25\u0026ndash;27.\u003c/li\u003e\n \u003cli\u003eKok MC, Kane SS, Tulloch O, Ormel H, Theobald S, Dieleman M, Taegtmeyer M, Broerse JE, de Koning KA. How does context influence the performance of community health workers in low-and middle-income countries? Evidence from the literature. Health research policy and systems. 2015; 13:1-4. https://doi.org/10.1186/s12961-015-0001-3\u003c/li\u003e\n \u003cli\u003eScott K, Beckham SW, Gross M, Pariyo G, Rao KD, Cometto G, Perry HB. What do we know about community-based health worker programs? A systematic review of existing reviews on community health workers. Human resources for health. 2018; 16:1-7. https://doi.org/10.1186/s12960-018-0304-x\u003c/li\u003e\n \u003cli\u003eMinistry of Health \u0026amp; Family Welfare-Government of India. About Accredited Social Health Activist (ASHA):: National Health Mission. Available from: https://nhm.gov.in/index1.php?lang=1\u0026amp;level=1\u0026amp;sublinkid=150\u0026amp;lid=226#:~:text=ASHA%20will%20provide%20information%20to,function%20without%20adequate%20institutional%20support\u003c/li\u003e\n \u003cli\u003eSitotaw B, Philipos W. Knowledge, Attitude, and Practices (KAP) on Antibiotic Use and Disposal Ways in Sidama Region, Ethiopia: A Community‐Based Cross‐Sectional Survey. The Scientific World Journal. 2023;(1):8774634. https://doi.org/10.1155/2023/8774634\u003c/li\u003e\n \u003cli\u003eParajuli A, Garbovan L, Bhattarai B, Arjyal A, Baral S, Cooke P, Latham S, Barrington DJ, Mitchell J, King R. Exploring community insights on antimicrobial resistance in Nepal: a formative qualitative study. BMC Health Services Research. 2024;24(1):57. https://doi.org/10.1186/s12913-023-10470-2\u003c/li\u003e\n \u003cli\u003eBinsaleh AY, Abdallah MS, Osman BM, Bahaa MM, Alsubaie N, Elmasry TA, Yasser M, Eldesoqui M, Gadallah AN, Hamouda MA, Eltantawy N. Antimicrobial Stewardship Intervention for the Family Caregiver Attending Primary Health Care Setting: A Quasi-Experimental Study. Antibiotics. 2024;13(12):1145. https://doi.org/10.3390/antibiotics13121145\u003c/li\u003e\n \u003cli\u003eChalkidou A, Lambert M, Cordoba G, Taxis K, Hansen MP, Bjerrum L. Misconceptions and knowledge gaps on antibiotic use and resistance in four healthcare settings and five European Countries\u0026mdash;a modified Delphi study. Antibiotics. 2023;12(9):1435. https://doi.org/10.3390/antibiotics12091435\u003c/li\u003e\n \u003cli\u003eNjeru J, Odero J, Chebore S, Ndung\u0026rsquo;u M, Tanui E, Wesangula E, Ndanyi R, Githii S, Gunturu R, Mwangi W, Mutonga D. Development, roll-out and implementation of an antimicrobial resistance training curriculum harmonizes delivery of in-service training to healthcare workers in Kenya. Frontiers in Microbiology. 2023; 14:1142622. https://doi.org/10.3389/fmicb.2023.1142622\u003c/li\u003e\n \u003cli\u003eSneddon J, Afriyie D, Sefah I, Cockburn A, Kerr F, Byrne-Davis L, Cameron E. Developing a sustainable antimicrobial stewardship (AMS) programme in Ghana: replicating the Scottish triad model of information, education and quality improvement. Antibiotics. 2020;9(10):636. https://doi.org/10.3390/antibiotics9100636\u003c/li\u003e\n \u003cli\u003eSeaton D, Ashiru-Oredope D, Charlesworth J, Gemmell I, Harrison R. Evaluating UK pharmacy workers\u0026rsquo; knowledge, attitudes and behaviour towards antimicrobial stewardship and assessing the impact of training in community pharmacy. Pharmacy. 2022 ;10(4):98. https://doi.org/10.3390/pharmacy10040098\u003c/li\u003e\n \u003cli\u003eAbdel-All M, Thrift AG, Riddell M, Thankappan KR, Mini GK, Chow CK, Maulik PK, Mahal A, Guggilla R, Kalyanram K, Kartik K. Evaluation of a training program of hypertension for accredited social health activists (ASHA) in rural India. BMC Health Services Research. 2018;18:1-1. https://doi.org/10.1186/s12913-018-3140-8\u003c/li\u003e\n \u003cli\u003eGamage DG, Riddell MA, Joshi R, Thankappan KR, Chow CK, Oldenburg B, Evans RG, Mahal AS, Kalyanram K, Kartik K, Suresh O. Effectiveness of a scalable group-based education and monitoring program, delivered by health workers, to improve control of hypertension in rural India: a cluster randomised controlled trial. PLoS Medicine. 2020;17(1):e1002997. https://doi.org/10.1371/journal.pmed.1002997\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Antimicrobial resistance, ASHA workers, antibiotic use, prevention","lastPublishedDoi":"10.21203/rs.3.rs-7315492/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7315492/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eGlobally, antimicrobial resistance (AMR) is escalating due to the frequent and inappropriate consumption of antibiotics. In India, Accredited Social Health Activists (ASHAs) play a vital role in community healthcare and have the potential to promote antimicrobial stewardship practices in their local communities effectively. This study aimed to evaluate the impact of structured training program for ASHAs' on AMR and antibiotic use \u0026nbsp;and its integration into community-level health promotion. A pre-post educational intervention study was conducted among 103 ASHAs from selected Primary Health Centres (PHCs). A three-day structured training was conducted, and pre- and post-training KAP were assessed using a validated questionnaire. Training impact was evaluated through observation checklists, supervisor feedback, and community surveys. Quantitative Data were analyzed using SPSS. 25, and qualitative data were thematically analyzed. Statistically significant improvements were observed across all KAP domains. Misconceptions, such as using antibiotics for viral infections, declined (from 67.9% to 14.6%; p = 0.002), while confidence in providing AMR-related guidance increased to 61.1% (p \u0026lt; 0.001). Practice scores improved significantly (p \u0026lt; 0.001), with post-training responses changing towards “always” and “sometimes.” Spearman’s correlation indicated a positive association between post-training knowledge and both attitude (ρ = 0.14, p = 0.001) and practice (ρ = 0.221, p \u0026lt; 0.001). Community feedback showed high engagement and understanding, with 92% willing to follow ASHAs' advice. Observational data confirmed strong adherence to training content. The training improved ASHAs' skills to promote AMR awareness and rational antibiotic usage, highlighting their importance in community-level antimicrobial stewardship.\u003c/p\u003e","manuscriptTitle":"Effectiveness of a Structured Educational Training Program on Antimicrobial Resistance Among Community Health Workers in India","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-26 12:26:43","doi":"10.21203/rs.3.rs-7315492/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-15T14:36:33+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-14T14:44:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"277801768135950508482856855119649750314","date":"2025-09-09T13:26:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"279258055536031965075768112108135463572","date":"2025-09-08T01:45:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"314352074892663341090560733099747079986","date":"2025-09-07T21:38:48+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-29T04:56:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"104476814140414113483048132106833896758","date":"2025-08-23T05:31:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"213502509108542735724528591232270574586","date":"2025-08-21T06:34:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"136443199664113346544346350327521547125","date":"2025-08-19T04:49:30+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-18T04:58:26+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-16T10:05:16+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-15T06:02:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Public Health","date":"2025-08-15T05:59:48+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ff1c2116-e403-49d5-a327-bd9755bee99e","owner":[],"postedDate":"August 26th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-13T16:02:32+00:00","versionOfRecord":{"articleIdentity":"rs-7315492","link":"https://doi.org/10.1186/s12982-025-01001-x","journal":{"identity":"discover-public-health","isVorOnly":false,"title":"Discover Public Health"},"publishedOn":"2025-10-08 15:58:06","publishedOnDateReadable":"October 8th, 2025"},"versionCreatedAt":"2025-08-26 12:26:43","video":"","vorDoi":"10.1186/s12982-025-01001-x","vorDoiUrl":"https://doi.org/10.1186/s12982-025-01001-x","workflowStages":[]},"version":"v1","identity":"rs-7315492","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7315492","identity":"rs-7315492","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}