Abstract
Background:
Antimicrobial resistance (AMR) is a major global public health threat, disproportionately affecting low- and middle-income countries such as Nigeria. Clinical healthcare students represent a critical target for antimicrobial stewardship (AMS), as prescribing behaviours developed during training often persist into practice. However, evidence on AMR and AMS knowledge across multiple health disciplines in Nigerian clinical training settings is limited. This study aimed at assessing AMR and AMS knowledge among clinical students and identify factors associated with poor knowledge.
Methodology:
A descriptive cross-sectional study was conducted among 422 clinical students in Medicine, Pharmacy, and Nursing at a Nigerian College of Health Sciences. Data were collected using a structured questionnaire adapted from the WHO AMR awareness tool. Knowledge was assessed using a 13-item score and categorized as good (≥70%), fair (50–69%), or poor (<50%). Associations were tested using chi-square, while independent predictors were identified using multivariate logistic regression.
Results:
Most participants were aged 21–25 years (68.0%) and female (62.1%). Although 96.9% recognised AMR as a global health problem and 92.4% correctly identified the purpose of stewardship, important gaps were identified. Only 47.2% correctly defined AMR, 36.0% recognized poor infection prevention and control as a driver, and misconceptions persisted regarding antibiotic use in viral infections (40.8%) and uncomplicated malaria (41.7%). Overall, 5.0% had good knowledge, 73.0% fair, and 22.0% poor. On bivariate analysis, level of study (χ2=15.358, p<0.001), department (χ2=7.981, p=0.018), and awareness of Nigeria’s National AMR Action Plan (χ2=6.496, p=0.011) were significantly associated with knowledge. Higher level of study (AOR=0.438; p=0.001) and awareness of the national AMR action plan (AOR=0.497; p=0.012) were independently associated with better knowledge.
Conclusion:
Despite high awareness of the AMR threat, significant knowledge gaps and misconceptions persist among clinical students. Strengthening AMR education through integrated curricula, active learning approaches, and improved dissemination of national policies is essential.
Keywords: Antimicrobial resistance, Antimicrobial stewardship, Knowledge gaps, Clinical students
Introduction
Antimicrobial resistance (AMR) is a major and escalating global public health challenge, threatening the effective prevention and treatment of infectious diseases and undermining decades of medical progress. The World Health Organization (WHO) has identified AMR as one of the top ten global health threats, driven largely by the misuse and overuse of antibiotics in human health, agriculture, and animal husbandry [1]. In low- and middle-income countries, including Nigeria, the burden of infectious diseases remains high, and widespread access to antibiotics without prescription further accelerates the emergence and spread of resistant pathogens [2].
Antimicrobial stewardship (AMS) has been promoted as a key strategy to optimize antibiotic use, improve patient outcomes, and reduce resistance. Effective stewardship depends largely on healthcare providers’ knowledge, attitudes, and prescribing behaviors [3]. Clinical students, particularly those in medicine and pharmacy, represent future prescribers and dispensers of antimicrobial agents, making their training period a critical window for shaping appropriate practices. Evidence suggests that prescribing habits are often formed during undergraduate training and may persist into professional practice [4].
Despite increasing global awareness, important gaps remain in AMR and AMS knowledge among healthcare trainees. A multi-country survey by the WHO reported that while awareness of AMR was generally high, only about 64% of respondents correctly understood that antibiotics are ineffective against viral infections, highlighting persistent misconceptions [5]. Similarly, a study among medical students in the United States found that although over 90% recognized AMR as a significant problem, only 41% felt adequately prepared to prescribe antibiotics appropriately, indicating a gap between awareness and practical competence [6]. In another study among Chinese medical students, only 61% demonstrated good knowledge of antibiotic use, with notable deficiencies in understanding appropriate indications and duration of therapy [7]. A study by Wuraola Akande-Sholabi et al.[8] evaluated AMR knowledge and antibiotic use among healthcare students in a Nigerian university, reporting only moderate knowledge levels. In their study, students across all levels were used, not specifically focusing on those in clinical classes who would soon become antibiotic prescribers.
In Nigeria, studies assessing AMR knowledge among healthcare students are relatively limited and often focus on single disciplines or preclinical populations. Few have specifically examined clinical students who are already engaged in patient care and expected to apply stewardship principles. Moreover, there is a paucity of data from Colleges of Health Sciences, where multidisciplinary training occurs, and where opportunities exist for integrated antimicrobial stewardship education. This gap is important, as deficiencies at this stage may translate into inappropriate prescribing practices after graduation, thereby contributing to the growing burden of AMR.
Given the critical role of future healthcare providers in combating antimicrobial resistance, there is a need for setting-specific evidence to identify knowledge gaps and inform targeted educational interventions. This study, therefore, aimed to assess gaps in antimicrobial resistance and stewardship knowledge among clinical students at a College of Health Sciences and to identify factors associated with poor knowledge.
Materials and Methods
Study Design and Setting
This study was a descriptive cross-sectional study conducted among clinical students at a College of Health Sciences in Nigeria. The College comprises students from the Faculties of Medicine, Pharmacy, and Nursing, who are undergoing clinical training and have prior exposure to pharmacology and infectious disease-related courses.
Study Population
The study population included clinical-level students from Medicine (500 and 600 levels), Pharmacy (400 and 500 levels), and Nursing (400 and 500 levels). These groups were selected because they are actively engaged in clinical training and are expected to have foundational knowledge of antimicrobial use and stewardship.
Sample Size Determination
The sample size was determined using Cochran’s formula for cross-sectional studies, assuming a 95% confidence level, a margin of error of 5%, and a conservative prevalence estimate of 50%.[9] This yielded a minimum sample size of 384. After adjusting for a possible 10% non-response rate, the sample size was increased. A total of 422 students were ultimately recruited across study groups.
Sampling Technique
A stratified sampling technique with proportionate allocation was employed. The study population was first stratified by discipline (Medicine, Pharmacy, and Nursing) and further by level of study. The number of participants selected from each stratum was determined proportionately to the size of the stratum relative to the total population. Figure 1 illustrates the participant selection process. The student population by level of study is presented in the first box, with a total population of 572. The proportion selected from each stratum to achieve the required sample size was calculated, as shown in the fourth box, using the formula: n/N × total sample size, where n represents the population in each class and N the total population of clinical students (572). Participants were then selected within each stratum using simple random sampling to meet the allocated sample size. A 100% response rate was achieved. The final sample consisted of 422 students distributed across the different disciplines and levels.
Figure 1.
Selection of study participants.
Data Collection
A structured, pre-tested, self-administered questionnaire adapted from the WHO antimicrobial resistance awareness, and knowledge, attitude and practice (KAP) questionnaire, with modifications to suit the local setting, was used for data collection.[10] The questionnaire consisted of three sections on sociodemographic characteristics, knowledge of AMR, and knowledge of AMS. Each knowledge question had one correct answer; a score of one was assigned for each correct response and zero for incorrect. A composite knowledge score (0–13) was computed for each participant based on 13 knowledge questions. Each respondent’s total score out of 13 was converted to a percentage. We categorized knowledge as “good” if the score was ≥70%, “fair” if between 50%-70%, and “poor” if <50%, adapted from Bloom’s taxonomy criteria as used in similar studies.[11] In our analysis, we further grouped “good” and “fair” knowledge together (since there was low frequency (n=20 out of 422) in the good category) to compare against “poor” knowledge.
Validity and Pretesting of the Questionnaire
The questionnaire was assessed for both face and content validity. The instrument was reviewed by experts in public health, clinical pharmacology, and infectious disease to ensure that the questions appear appropriate and relevant to the study objectives. For the content validity, the items included in the knowledge section were developed based on an extensive review of existing literature, WHO guidelines on AMR, and AMS. Feedback from subject-matter experts was used to refine the questions, ensuring they comprehensively cover the dimensions of AMR and AMS. The questionnaire was pretested among a sample of 21 Nursing students at Babcock University for clarity, simplicity, and appropriateness of the questions.
Data Analysis
Data were analyzed using the Statistical Package for Social Sciences (SPSS) version 27. Descriptive statistics (frequencies, percentages) were used to summarize demographic and outcome variables. Chi-square tests and logistic regression were used to assess associations between independent variables (e.g., discipline, year of study) and knowledge. The level of significance was set at < 0.05.
Ethical approval and consent to participate
Ethical approval was obtained from Olabisi Onabanjo University Teaching Hospital Health Research Ethics Committee on 26th February, 2026, with the approval number OOUTH/HREC/05/010/E208/2026AP. Participation was voluntary, and informed consent was obtained from all participants. Data were anonymized and securely stored for confidentiality.
Results
Sociodemographic Characteristics
A total of 422 clinical students participated in the study. The participant selection process is presented in Figure 1. The majority of respondents were aged 21–25 years (68.0%), followed by those ≤20 years (21.8%). Females constituted a higher proportion of respondents (62.1%). In terms of discipline, pharmacy students accounted for the largest group (45.5%), and most respondents were in their 500 level (55.2%). A high proportion of respondents (82.9%) reported having received lectures or training on antimicrobial resistance (AMR). However, only 26.3% had participated in AMR-related seminars, workshops, or symposia in the past year (Table 1).
Table 1.
Sociodemographic characteristics of the respondents
| Characteristics | Frequency | Percentage |
|---|---|---|
| Age Group (years) | ||
| ≤20 | 92 | 21.8 |
| 21-25 | 287 | 68.0 |
| 26-30 | 39 | 9.2 |
| >30 | 4 | 0.9 |
| Gender | ||
| Male | 160 | 37.9 |
| Female | 262 | 62.1 |
| Department | ||
| Medicine | 161 | 38.2 |
| Nursing | 69 | 16.4 |
| Pharmacy | 192 | 45.5 |
| Level | ||
| 400 | 130 | 30.8 |
| 500 | 233 | 55.2 |
| 600 | 59 | 14.0 |
| Have you received any lectures or training on antimicrobial resistance (AMR) | ||
| Yes | 350 | 82.9 |
| No | 72 | 17.1 |
| Have you participated in any AMR-related seminar, workshop, or symposium in the past year? | ||
| Yes | 111 | 26.3 |
| No | 311 | 73.7 |
Awareness of AMR Guidelines
Awareness of AMR-related guidelines varied among respondents. While a substantial proportion had general awareness of AMR during the course of lectures and training, awareness of specific national and global action plans was comparatively lower, at 22.0% and 26.5% respectively (Figure 2).
Figure 2.
Awareness of AMR guidelines
Knowledge of Antimicrobial Resistance and Stewardship
Overall, knowledge of AMR and antimicrobial stewardship (AMS) showed mixed patterns across different domains (Table 2). A very high proportion of respondents recognized that AMR is a global health problem (96.9%) and correctly identified the role of stewardship as promoting rational antibiotic use (92.4%). Similarly, most participants acknowledged key drivers of AMR such as antibiotic overuse (91.5%) and incomplete antibiotic courses (81.8%). However, notable knowledge gaps were observed. Less than half (47.2%) correctly defined antibiotic resistance as bacterial adaptation to antibiotic exposure. Only 36.0% identified poor infection prevention and control as a contributor to AMR. Misconceptions regarding antibiotic use persisted, as only 59.2% correctly stated that antibiotics have no role in viral infections, and 58.3% correctly identified that antibiotics do not improve outcomes in uncomplicated malaria.
Table 2.
Knowledge on Antimicrobial resistance and stewardship
| Knowledge Questions | Correct Answer | Correct Frequency, n | Correct Percentage (%) |
|---|---|---|---|
| Antibiotic resistance occurs when | Bacteria change in response to the use of antibiotics | 199 | 47.2 |
| Which of the following contributes to the development of AMR? | Overuse of antibiotics | 386 | 91.5 |
| Incomplete courses antibiotic | 345 | 81.8 | |
| Poor infection prevention and control | 152 | 36.0 | |
| Prescribing antibiotics for viral infections | 239 | 56.6 | |
| Which of these is a major consequence of AMR? | All of the above | 302 | 71.6 |
| What is the role of antibiotics in treating viral infections? | No role | 250 | 59.2 |
| Which of these infections is most commonly associated with resistant bacteria in hospitals? | Urinary Tract Infection (UTI) | 227 | 53.8 |
| AMR is a global health problem | Yes | 409 | 96.9 |
| What is the purpose of AMR stewardship? | Promote rational antibiotic use | 390 | 92.4 |
| Antibiotics will improve the outcome of the treatment of uncomplicated malaria | No | 246 | 58.3 |
| Antibiotics can cure viral infections likethe common cold | No | 313 | 74.2 |
| Which associated of these with bacteria AMR? is commonly | All of the above | 239 | 56.6 |
Knowledge regarding specific clinical scenarios was also suboptimal, with only 53.8% identifying urinary tract infections as commonly associated with resistant organisms in hospitals, and 56.6% correctly identifying organisms commonly linked to AMR. Overall knowledge categorization (Figure 3) showed that a majority of respondents had good/fair knowledge, although a significant proportion still demonstrated poor knowledge
Figure 3.
knowledge categories
Factors Associated with Knowledge of AMR and AMS
Bivariate analysis (Table 3) showed that level of study (χ2= 15.358, p < 0.001), department (χ2= 7.981, p = 0.018), and awareness of Nigeria’s National Action Plan for AMR (χ2= 6.496, p = 0.011) were significantly associated with knowledge levels. Students in higher levels (particularly 600-level) demonstrated better knowledge compared to those in lower levels. Similarly, differences were observed across departments, with medical students showing relatively better knowledge than nursing and pharmacy students. Age, gender, and awareness of the global action plan were not significantly associated with knowledge.
Table 3.
Association between sociodemographic characteristics and knowledge of AMR and AMS among the participants.
| Parameters | Knowledge | Category | χ2 | p |
|---|---|---|---|---|
| Good/Fair | Poor | |||
| Age | 7.582 | 0.055 | ||
| ≤20 | 63 | 29 | ||
| 21-25 | 231 | 56 | ||
| 26-30 | 31 | 8 | ||
| >30 | 2 | 2 | ||
| Gender | 1.432 | 0.231 | ||
| Male | 119 | 41 | ||
| Female | 208 | 54 | ||
| Department | 7.981 | 0.018* | ||
| Medicine | 136 | 25 | ||
| Nursing | 48 | 21 | ||
| Pharmacy | 143 | 49 | ||
| Level | 15.358 | 0.000* | ||
| 400 | 90 | 40 | ||
| 500 | 181 | 52 | ||
| 600 | 56 | 3 | ||
| Awareness on NNAP | 6.496 | 0.011* | ||
| No | 63 | 30 | ||
| Yes | 264 | 65 | ||
| Awareness on WGAP | 2.333 | 0.127 | ||
| No | 81 | 31 | ||
| Yes | 246 | 64 |
χ2: Chi square; *: Significant.
Predictors of Knowledge of AMR
Multivariate logistic regression analysis (Table 4) identified the level of study and awareness of Nigeria’s National Action Plan as independent predictors of knowledge. Students at higher academic levels had significantly lower odds of poor knowledge (AOR = 0.438; 95% CI: 0.272–0.706; p = 0.001), and this is therefore associated with better knowledge. Similarly, awareness of the national AMR action plan was associated with better knowledge (AOR = 0.497; 95% CI: 0.288–0.858; p = 0.012). Department of study was not a statistically significant predictor after adjusting for other variables (p = 0.448).
Table 4.
Multivariate logistic regression on knowledge
| Variables in the Equation | B | S.E. | Wald | df | Sig. | Exp(B) | 95% C.I. for EXP(B) | |
|---|---|---|---|---|---|---|---|---|
| Lower | Upper | |||||||
| Step 1a | ||||||||
| Department | -0.131 | 0.173 | 0.575 | 1 | 0.448 | 0.877 | 0.625 | 1.231 |
| Level | -0.826 | 0.244 | 11.498 | 1 | 0.001* | 0.438 | 0.272 | 0.706 |
| Awareness Action Plan of for Nigeria's AMR? National | -0.699 | 0.279 | 6.287 | 1 | 0.012* | 0.497 | 0.288 | 0.858 |
| Constant | 4.188 | 1.583 | 7.000 | 1 | 0.008 | 65.892 | ||
*: significant.
Discussion
This study assessed gaps in antimicrobial resistance (AMR) and antimicrobial stewardship (AMS) understanding among clinical students and identified key determinants of better knowledge. The findings reveal a concerning disconnect between general awareness of AMR as a public health threat, factual knowledge of core stewardship concepts and resistance drivers, and applied clinical competence in translating that knowledge into appropriate prescribing-related judgments. While awareness was high, important misconceptions and deficiencies in foundational understanding persisted, suggesting that recognition of AMR as a problem does not necessarily equate to adequate conceptual mastery or readiness for effective stewardship practice. This gap between awareness, knowledge, and clinical application may have implications for future prescribing behaviours.
The very high proportion of respondents who recognized AMR as a global health problem (96.9%) is consistent with global trends and reflects increasing advocacy efforts led by organizations such as the WHO. Similar findings have been reported among healthcare students in different settings, with persistent deficiencies in stewardship-related understanding and practice.[12-14] This suggests that awareness campaigns alone may be insufficient without deeper educational reinforcement. Within the Nigerian context, this distinction may partly reflect the structure of undergraduate medical and health professional curricula, where antimicrobial prescribing principles are often taught in fragmented fashion across microbiology, pharmacology, and clinical rotations rather than through integrated longitudinal stewardship training. This compartmentalized approach may promote awareness without ensuring coherent conceptual integration or practical stewardship competence.
A critical finding in this study is the poor understanding of the fundamental concept of antibiotic resistance, with less than half of the respondents correctly identifying that resistance occurs when bacteria adapt to antibiotic exposure. This gap in foundational knowledge has also been reported in studies among medical students in Ethiopia and other LMICs, where students demonstrated superficial understanding of AMR despite high awareness levels.[12,15] Such deficiencies are significant, as a clear understanding of resistance mechanisms is essential for rational prescribing and effective antimicrobial stewardship.
Although most respondents correctly identified antibiotic overuse and incomplete treatment as drivers of AMR, fewer recognized poor infection prevention and control (IPC) as a contributing factor. This finding highlights a critical disconnect between AMR and IPC knowledge. Infection prevention and control play a central role in limiting the spread of resistant organisms, particularly in healthcare settings. Previous studies have similarly documented inadequate integration of IPC concepts into AMR education among healthcare trainees.[16,17] Strengthening this linkage within training curricula is essential to ensure a more comprehensive understanding of AMR control strategies. This finding is particularly relevant in Nigeria, where the National Action Plan on AMR, coordinated through the Nigeria Centre for Disease Control, explicitly prioritizes infection prevention, antimicrobial stewardship, and surveillance, yet implementation at institutional and training levels has been uneven. Gaps in translating national strategic priorities into undergraduate curricula and hospital-based teaching may contribute to the weak linkage between IPC and AMR understanding observed in this study.
The persistence of misconceptions regarding antibiotic use in viral infections and malaria is particularly concerning. A substantial proportion of respondents incorrectly believed that antibiotics could improve outcomes in such conditions. This aligns with findings from studies in Nigeria and other LMICs, where inappropriate beliefs about antibiotic effectiveness remain common among healthcare students.[6,18] These misconceptions may translate into inappropriate prescribing practices, contributing to the growing burden of antimicrobial resistance.
Furthermore, knowledge related to the clinical application of AMR concepts was suboptimal. Only about half of the respondents correctly identified infections commonly associated with resistant organisms. This suggests that while theoretical awareness exists, the ability to apply this knowledge in clinical contexts is limited. Similar gaps have been reported among final-year medical students in other settings, indicating that current training approaches may not sufficiently emphasize practical stewardship competencies.[19] This may also reflect limited student exposure to formal antimicrobial stewardship rounds, antibiogram-guided prescribing, and multidisciplinary stewardship decision-making, which remain inconsistently implemented across Nigerian teaching hospitals.
Despite a high proportion of students reporting prior exposure to AMR lectures, participation in seminars, workshops, and symposia was low. This indicates that didactic teaching methods alone may not be sufficient to ensure comprehensive understanding. Evidence suggests that interactive and experiential learning approaches, such as case-based learning, simulation exercises, and antimicrobial stewardship programs, are more effective in improving knowledge retention and influencing prescribing behavior.[20] Therefore, there is a need to incorporate more active learning strategies into undergraduate training. This is particularly important given that formal institutional stewardship programs in many Nigerian teaching hospitals remain at varying stages of development. They are often constrained by limited microbiology support, inadequate stewardship personnel, and weak integration of stewardship activities into clinical teaching. Embedding students within emerging stewardship programs could help bridge the gap between theoretical instruction and practical competence.
The study also demonstrated that the level of training is a significant predictor of knowledge, with students in higher clinical levels exhibiting better knowledge. This finding is consistent with previous studies showing that increased clinical exposure enhances understanding of AMR and rational antibiotic use.[14,21] However, the progressive improvement in knowledge with advancing level suggests that AMR education may not be adequately emphasized in earlier stages of training. Early and continuous integration of AMR and AMS concepts into the curriculum is therefore crucial.
Awareness of Nigeria’s National Action Plan (NAP) on AMR was also identified as an independent predictor of better knowledge. This underscores the importance of policy awareness in shaping knowledge and attitudes. Students who are familiar with national AMR strategies are more likely to appreciate the broader public health implications of antimicrobial misuse. However, the relatively low awareness of such policies observed in this study indicates a gap in their dissemination within academic institutions. Similar findings have been reported in other LMICs, where awareness of national AMR frameworks among healthcare trainees remains limited.[22]
Although the department of study was significant at the bivariate level, it was not an independent predictor after adjustment. This suggests that differences across disciplines may be attributable to variations in exposure and level of training rather than inherent differences in curriculum. This finding supports the need for standardized, interdisciplinary AMR education across all health-related programs, consistent with global recommendations for a One Health approach to antimicrobial stewardship.[1,23] This is pertinent in Nigeria, where interprofessional stewardship education remains underdeveloped despite increasing recognition that effective antimicrobial stewardship depends on coordinated contributions from medicine, pharmacy, nursing, microbiology, and public health. Strengthening interdisciplinary training models within Colleges of Health Sciences and linking them to institutional stewardship programs in teaching hospitals may provide a practical pathway for operationalizing One Health stewardship principles.[23]
Overall, this study highlights important gaps in both foundational knowledge and clinical application of AMR concepts among future healthcare professionals. Addressing these gaps requires a multifaceted approach, including curriculum reform, integration of IPC and stewardship principles, increased use of interactive teaching methods, and improved dissemination of national and global AMR policies. Without these interventions, the capacity of future prescribers to effectively combat antimicrobial resistance may remain inadequate.
Strengths and Limitations
This study has several notable strengths. The stratified sampling design with proportionate allocation across disciplines and academic levels ensures representation of the target population, and the adequate sample size (n = 422) provides sufficient statistical power for the analyses conducted. The multidisciplinary setting is a particular strength, enabling concurrent comparison of AMR knowledge across Medicine, Pharmacy, and Nursing, which is a combination rarely examined in a single Nigerian study.
Some limitations should, however, be acknowledged. First, the study was conducted at a single institution, which may limit the generalizability of findings to other Nigerian colleges or settings with different curricula and resource environments. Second, knowledge was assessed through self-administered questionnaire responses, which are susceptible to social desirability bias and may not accurately reflect practical prescribing competence. Reliability testing of the questionnaire was not performed. This was, however, an omission on the part of the authors. Finally, the cross-sectional design precludes causal inference between identified predictors and knowledge levels. Future multi-institutional studies incorporating longitudinal follow-up and objective clinical assessments would substantially strengthen the evidence base.
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