Antimicrobial Resistance (AMR) is an existential threat to modern medicine. The number of deaths associated with AMR is estimated to be around 4.95 million per year in 2019, out of which 1.27 million can be directly attributed to it (1). It is estimated cause 39 million deaths between 2025 and 2050, with directly attributable deaths rising to 1.91 million annually by 2050 (2). This is significantly higher than previous estimates and makes AMR a bigger problem than Human Immunodeficiency Virus (HIV) infection or Malaria (3). Besides mortality, it also increases morbidity through longer hospital stays, higher likelihood of admission to Intensive Care Units and more instances of treatment failures (4). The cost of treating infections with multi-drug resistant bacteria is also significantly higher, when compared to susceptible microorganisms (5). There is an economic cost to AMR, primarily due to the loss of productivity associated with morbidity and premature mortality and the cost of healthcare. The World Bank estimates that AMR will reduce global Gross Domestic Product (GDP) between 1.1 and 3.7%, after 2030 (6). The issue is driven by inappropriate antimicrobial use in multiple sectors- human healthcare, food animal production, horticulture and aquaculture. Environment often plays the role of a disseminator and amplifier of resistance, as most of the antimicrobials used in various sectors end up in the environment (7). Therefore, AMR is truly a One-Health problem and warrants concerted action from various sectors to effectively mitigate it.

The emergence and spread of AMR is closely linked to drinking water, hygiene and sanitation. Poor access to clean drinking water and proper sanitation can increase the likelihood of infections in the community, which increases the requirement of antimicrobials. Inadequate sanitation can also result in antimicrobial residues, antimicrobial resistance genes and resistant microorganisms interacting with each other in the environment, with a higher risk of novel AMR pathogens emerging and spreading (8). Improper waste management in farms, poor quality infection prevention & control (IPC) in healthcare delivery sites and sub-optimal sewage treatment are other interfaces between AMR and hygiene (9). Therefore, inadequate water, sanitation and hygiene (WASH) practices and provisions influences AMR in all associated sectors- human health, animal health, agriculture and environment. Improving hygiene and sanitation practices becomes important in the fight against AMR and has been acknowledged in the Global Action Plan on Antimicrobial Resistance (GAP-AMR) published by World Health Organization (WHO) (10).

There are several calls for greater community engagement on AMR, acknowledging that the current narratives of AMR action plans are mostly top down and there is a need to complement them with bottom-up approaches (11). Since AMR is largely an invisible issue and the framing is complex, the communities find it difficult to prioritize AMR (12), and hygiene can be used as a theme to create interest and drive the AMR agenda in local contexts, especially in Low and Middle Income Country (LMIC) contexts (13). If the linkage between AMR and WASH is clearly evident to the public and local level decision makers, they may be motivated to act on it. Hygiene can also be used as an entry point for awareness-raising and public engagement on AMR issues. But there are no standardized sources of information for in-depth information on household level hygiene and antimicrobial use practices in countries like India. Therefore, a multi-dimensional assessment of drinking water, hygiene and sanitation practices in communities, using an AMR-lens, was conducted in a rural community in south India to understand the hygiene practices, and its linkage, if any, with antimicrobial use practices.

The study was conducted in 2022–23. Most (258, 65%) of the informants were females and all of them were literate. A vast majority of them (83%) were not educated beyond high school, with almost 60% of them not being a part of the labor market. Regarding the households which were included in the study, almost all (393, 98%) of the participants owned their own houses or land. A significant number (136, 34%) of respondents mentioned that their households had three-generations, but none were joint families (Table 1).

Only 15.5% of the households reported use of antimicrobials at least once in the last 12 months and they reported that they had obtained it using prescriptions from medical practitioners. The commonest reason cited for the use of antimicrobials was fever (33.8%), followed by upper respiratory infections (17.7%) and urinary tract infection (12.9%). We did not include the doxycycline prophylaxis for leptospirosis, albendazole prophylaxis for helminthiasis and the diethylcarbamazine prophylaxis for Filariasis in these statistics, as it is almost universally given in the area by the health department of the state government. Only 4 (5%) of the animal keeping households reported antimicrobial use, and the medicines were reported to have been obtained with a prescription in all of the instances (Table 2).

The households were dependent on piped water and protected wells for their drinking water needs; and availability of water was not an issue. Access to proper sanitation was also universal in the area, with all the households having flush/pour toilets. Soap for handwashing was also available universally in the toilets in the households and there was good usage of the hand washing facilities. The area was well covered by teams engaged for collection, segregation and disposal of waste; and most (396, 99%) households use the services. Since they do not collect organic waste, households (384, 96%) practice open dumping in their yards. All the households dispose medicines including antimicrobials, using the same methods as general household waste (Table 3).

According to the survey, only 62 (15.5%) of the households had consumed antimicrobials for any indication in the preceding 12 months. Some of the baseline characteristics of the household were selected for tests of association, based on plausibility and reports in literature. Out of the characteristics which were tested, household size of 4 or more (p < 0.001, OR 3.39, 95% CI- 1.84 to 6.23) and presence of children in the household (p < 0.001, OR- 2.57, 95% CI- 1.46 to 4.51) increased the risk of antimicrobial consumption, while poor occupational status of the head of the family (p- 0.026, OR- 0.54, 95% CI- 0.31 to 0.93) decreased the risk (Table 4).

A binary logistic regression was done to account for confounding variables, since many of the baseline characteristics of the household are closely linked to each other. In the regression model, only household size (p- 0.012, Adjusted OR- 0.367, 95% CI- 0.167 to 0.804) was significantly associated with antimicrobial use in the household (Table 5).

The proportion of households reporting antimicrobial use is significantly lower than other estimates (24) from India, though the period of recall has been different. A similar study from Bangladesh reported that 70% of the population has previously taken antibiotics, with 21% reporting use within the last one month of the survey (25). Household level antimicrobial use has been reported to be significantly higher, from other low and middle income countries like Ghana (26), Malawi (27) and Kenya (28), even though the socio-economic indices may be different from that of Kerala, India. A study done in Burkina Faso showed that 49% of the households procured and stored antibiotics, for it to be used as self-medication for several health issues (29). Since the survey was conducted after the Covid19-induced lockdowns of 2020 and 2021, this may have reflected in the antimicrobial use statistics. Though there are several studies showing inappropriate use of antimicrobials during Covid19, the lockdowns and higher adherence to hygiene measures may have had an impact on the incidence of other infections. This may have reduced the requirement of antimicrobials overall (30). Another important finding is that the antimicrobials were obtained with prescriptions from medical practitioners. Since we relied on self-reported information without any objective verification system, there may have been a conformity bias. Even then, this is significantly different from the findings reported from other parts of the country (31) and internationally from high-income contexts (32), where some or most of the antimicrobials are sold without a prescription. This may be partially due to the better regulatory system and stricter implementation of regulations that we see in the state of Kerala and also because of Schedule H1 guidelines. Schedule H1 is a list of prescription only medicines, mostly newer generation antimicrobials, anti-tuberculosis drugs and non-opioid hypnotics, published by the Government of India in 2013. This is subjected to stringent oversight, with an aim of preventing its misuse (33). Along with cultural factors unique to the state, this may have positively impacted the general awareness about antimicrobial misuse among retail pharmacists and prevented dispensing of antimicrobials without a valid prescription. The indication for antimicrobial use is similar to the findings of many other studies done in the country. Fever and upper respiratory infection syndromes are the most common reasons for antimicrobial use, especially in primary care settings (34). Since the area does not have commercial food animal farms, the use of antimicrobials in animals is also not a prominent finding.

The area had good access to clean drinking water and sanitation facilities. Households mostly depended on piped water supply and protected wells for their drinking water and household water requirements. Majority of the households (278, 69.5%) had piped water coming to their households, which is a high proportion compared to the rest of the country (35). This water supply system is maintained by the panchayat and the purification is done by chlorination only. Therefore, there can be water quality and turbidity issues during flooding, as there is no filtration system as a part of the purification process. Although 89% of the respondents mentioned that availability of drinking water is not a problem, most households store water in steel containers before consumption. Another significant aspect is that all households use boiling as a method to disinfect drinking water before consumption. These practices are significantly better than findings from the National Sample Survey done in 2017–18, showing the general understanding of the community regarding safe drinking water, and disinfection process. The frequent flooding and the subsequent inundation of the wells may also be the reason behind all households boiling the water before consumption. These optimal WASH practices may be the reason for lower household-level antimicrobial use in the community, as reported in results.

All the households had access to improved sanitation (36) and had soap to wash their hands after use of toilets. Though open defecation has been consistently decreasing after the launch of the Swachh Bharat programme by the Government of India, many parts of the country still have poor access to toilets (37). Launched in 2014, Swachh Bharat programme is a multi-billion dollar project to ensure universal access to sanitation in the country (38). Kerala has been a front-runner in eliminating unrecommended methods of disposing human waste and was declared Open Defecation Free (ODF) in 2018 (39). Since Niranam is a low-lying area with frequent flooding, it is likely that open defecation increases the likelihood of water-borne diseases. This may be the reason for prioritization of sanitation in the area. The adherence to sanitation norms may have been reinforced by the onset of Covid19 pandemic. There are adequate provisions of hand washing with soap and water inside the houses too, with high levels of compliance. The good practices related to hygiene and sanitation may also be reflective of the advanced human development indicators and high levels of social development in the state (40). Kerala has consistently performed well for almost all health indicators among bigger states in India (41).

There is an organized system for collecting and disposing household waste, led by a group of government supported self-help groups called Haritha Karma Sena. This group is active in the area and charges Rs. 50 (US$0.6) a month for collecting household waste. However, Haritha Karma Sena does not collect biodegradable waste from the houses and this creates a problem for households which do not have provision to dispose them off otherwise. Therefore, disposal in the household yard or elsewhere is practiced by 96% of the households covered through the survey. Though none of the participants of the survey indicated that they practice open dumping, there were piles of garbage seen in some side-roads in the panchayat. This is a serious public health concern, since this can be a driver for water-borne diseases in community settings, especially since the area is low lying and prone to frequent flooding. One of the challenges identified through the survey was the disposal of unused or expired medicines, including antimicrobials. It was found that antimicrobials were disposed along with household garbage and there was no specialized system for collection of medicines. Therefore, solid waste management and a specialized public system for disposal of medicines is a priority for the area.

On a bivariate analysis, it was found that household size of 4 or more (p < 0.001) and presence of children in the household (p < 0.001) increased the risk of antimicrobial consumption, while poor occupational status of the head of the family (p- 0.026) decreased the risk. Some previous studies done in LMIC settings have also indicated that household size (42) and presence of children (43) increase antimicrobial consumption in households and various demographic groups. However other studies have yielded different results when we looked at the relationship between educational/occupational status and antimicrobial consumption. Poor educational status is usually considered as a risk factor for inappropriate use of antimicrobials (44). The difference seen in our study may have been due to access issues affecting households in which head of the family has poor occupational status. However, on a binary logistic regression model, it was found that only household size of 4 or more (p- 0.012) was significantly associated with antimicrobial consumption in the household. The association between antimicrobial use and hygiene practices were not assessed since hygiene practices were nearly universally followed and positively skewed.

The study was an attempt to assess the linkage between community-level antimicrobial use and practices related to hygiene in households in India. The systematic random sampling followed in the study can reduce the selection bias and give representative insights on the practices in the community. The data was collected by trained community health workers, and this helped to improve the rapport with the respondents since the households were already familiar with the interviewers. There were limitations to the study too. The survey was conducted after the onset of Covid19, and this may have affected the results. There are several studies showing that Covid19 had increased the overall community and personal hygiene indicators; and reduced the incidence of other upper respiratory infections (45, 46). This may have reduced the antimicrobial consumption and increased the adherence to hygiene practices in the households. The recall period and whether the patients were able to correctly differentiate antimicrobials from other medicines was also a challenge for the study, leading to a possibility of information bias.

The study showed that antimicrobial use, especially those procured over-the-counter, is low in communities with reasonable access to healthcare services and robust water, sanitation & hygiene facilities. Hygiene was a priority for the households, as shown by high adherence to several critical practices about disinfecting drinking water, safe sanitation and handwashing. Community hygiene to prevent infections should be considered an ‘entry point’ for improving the awareness about antimicrobial use and AMR. This philosophy is also reflected in India’s National Action Plan on AMR 2025–29, launched in November 2025, which calls for promoting behavior change toward sanitation and hygiene in communities through social mobilization (47). Any awareness-raising efforts on AMR or community-based intervention on AMR should have a component of infection prevention, along with key messages on appropriate use of antimicrobials. Hygiene should be an integral part of the action plans on AMR, especially those in sub-national and district settings.