Examining antibiotic use in Kenya: farmers’ knowledge and practices in addressing antibiotic resistance

Background Antibiotics hold the promise of mitigating the spread of livestock diseases while enhancing productivity. However, there is global concerns surrounding the improper handling and administration of antibiotics, which has led to an alarming rise in antimicrobial resistance (AMR). Kenya is currently listed as an AMR hotspot. This study assesses farmers’ knowledge and practices on antibiotics in livestock production, knowledge on AMR as well as factors influencing farmers’ knowledge of antibiotic safety and resistance, and antibiotics use. Methods A across-sectional, quantitative survey was employed with 319 farming households in five counties in Kenya. Multivariate regression analysis was used to identify explanatory factors. Results About 80% of households use antibiotics in their livestock, and 58% administer the antibiotics themselves. The vast majority of farmers buy antibiotics without a prescription. Antibiotics are used for both therapeutic and non-therapeutic purposes, the latter mainly in form of growth promoters and feed enhancers in poultry. The withdrawal periods reported by farmers are shorter than the officially recommended periods. Although the majority of farmers reported risky antibiotic practices, most (76%) were well aware of bacterial AMR. Nineteen of 21 knowledge statements on AMR and safe use of antibiotics were answered correctly by 55–89% of respondents, indicating considerable farmer knowledge on different aspects of antibiotics risk, while certain knowledge gaps remain. Number of live-stock owned was the factor most positively influencing farmers’ knowledge on AMR and safe use. Conclusion Kenya has made notable progress towards creating knowledge and awareness of farming communities on the risks and requirements associated with antibiotic use in livestock. Nonetheless, farmers’ antibiotics practices continue to constitute considerable risk of further AMR development. This shows that knowledge is not enough to ensure fundamental behavioral change. There needs to be an enabling environment driven by (1) effective policy interventions and enforcement to ensure compliance with set guidelines for antibiotic use; (2) research on and deployment of alternatives, such as probiotics, vaccinations and disease prevention measures, (3) continued public awareness raising and education using multiple channels to reach farmers and, (4) strengthened cross-sector, multi-stakeholder collaboration to address the multi-dimensional complexities of AMR.


Background
On a global scale, livestock contributes around 40% of total agricultural output in developed countries and 20% in the developing countries.The sector also employs approximately 1.3 billion people worldwide.Livestock is crucial socioeconomically in Africa, supporting the livelihoods of 250-300 million people who rely on it for a living.Notably, the African cattle sector accounts for between 30 and 80% of the continent's agricultural GDP.Sub-Saharan Africa alone accounts for nearly 85% of the world's livestock keepers (Erdaw 2023).Despite its economic importance, cattle productivity in Africa remains poor, owing in part to pest and disease outbreaks aggravated by climate change.Antibiotics have been frequently utilized in this context to reduce the spread of numerous cattle diseases and increase productivity (Durso and Cook 2014).However, the use of antibiotics in livestock has sparked public debate globally, primarily due to concerns about inappropriate use and the associated risk of antimicrobial resistance (AMR) (Livermore 2009).AMR poses a significant threat to effective infection treatment, in humans and animals, leading to increased morbidity and mortality rates, as well as escalated healthcare costs (O'Neill 2014; Murray et al. 2022).
Livestock stands as the primary and growing consumer of antibiotics, a trend that aligns with the escalating global demand for meat, particularly in developing regions of the world (van Boeckel et al. 2015).Van Boeckel et al. (2015) estimate that between 2010 and 2030, the global consumption of antimicrobials will witness a 67% increase, soaring from 63,151 ± 1560 tons to 105,596 ± 3605 tons.The surge in antibiotic usage within animal husbandry has raised concerns about further rise in the development of AMR, environmental contamination, and threats to food safety.Murray et al. (2022) found out that the largest burden rates of bacterial AMR were in Sub-Saharan Africa, and that the size of AMR as a health problem is comparable to, if not greater than, HIV and malaria.Kenya is classified as an AMR hotspot (Kariuki et al. 2022), and the rising rate of antibiotic resistance in Kenya is primarily attributed to a lack of and/or ineffective enforcement of existing regulations, resulting in antibiotic overuse and misuse in patients, livestock, and agriculture, as well as their unrestricted release into the environment (Kariuki et al. 2013;Ayukekbong et al. 2017).Antibiotics are heavily used by chicken producers for preventative purposes, to increase productivity, and for self-prescription (Kariuki et al. 2023;Mutua et al. 2023).Antibiotic misuse is enabled in Kenya by the availability of antibiotics without a prescription and through unregulated supply chains (Kemp et al. 2021;Omolo et al. 2023).The prevalence of resistant bacteria in humans, animals, food, and the environment, combined with inadequate infection management, hygienic conditions, and incorrect food handling techniques, all contribute to the spread of AMR.Furthermore, the Kenya Veterinary Association (KVA) estimated in 2009 that 33% of antibiotics on the shelves were substandard or counterfeit, increasing the risk of resistance and other negative effects (KVA 2016).According to a comprehensive review (Tang et al. 2017), there is a substantial association between elevated AMR levels in livestock and the following consequences for farm production, either as a drop in overall productivity or an increase in disease treatment costs.However, data from Africa are conspicuously sparse, with only one study from the 179 analyzed coming from the continent.Thus, despite widespread recognition of the difficulties associated with antibiotic usage in cattle in Kenya, quantifiable research on the socioeconomic and environmental consequences of bacterial AMR is lacking.
Kenya has taken proactive measures to combat AMR, including the formation of the National Antimicrobial Stewardship Interagency Committee (NASIC) in 2015 and the adoption of the National Policy for the Prevention and Containment of Antimicrobial Resistance in 2017, which was accompanied by a corresponding National Action Plan covering the period 2017-2022.These initiatives create a shared framework for collaborative action in Kenya among all stakeholders and sectors to prevent AMR.Reinforcing AMR surveillance, increasing research and development, engaging in lobbying and public education, supporting the rational use of antimicrobials, guaranteeing robust regulation and quality assurance, and facilitating education and training programs are among the key initiatives (WHO 2022).
Despite these concerted efforts, significant challenges persist with regard to achieving the desired antimicrobial stewardship standards (Hughes et al. 2023).A prevailing gap is the limited evidence on key stakeholders' awareness, knowledge and practices related to antibiotic risks and safe use in livestock in Kenya.This paper examines key knowledge areas among farmers, identifies factors associated with that knowledge and certain behaviours.The purpose of this study was: (i) to investigate the knowledge and practices of Kenyan livestock farmers regarding the use of antibiotics, and their awareness of AMR; (ii) to assess factors contributing to the existing knowledge and practices on antibiotics and safe use among users; and (iii) to recommend further steps towards an effective response to the complex AMR problem.The study aims to provide insights that can inform targeted interventions and policy recommendations for addressing AMR in the livestock sector.

Methods
A farmer survey was carried out in Kenya between July and August of 2021.An interdisciplinary research team comprised of CABI socio-economists, animal health experts from Vétérinaires Sans Frontières Suisse (VSF Suisse), and technical support from the University of Warwick developed and implemented the study.Primary data collection employed a cross-sectional survey design.

Study location
Primary data were collected from five Kenyan counties: Trans Nzoia and Elgeyo Marakwet in the North Rift region, Narok in the South Rift region, and Machakos and Isiolo in the Eastern region (see Fig. 1).These counties comprise a diverse mix of smallholder and large-scale farmers, as well as a significant proportion of livestock farmers, primarily engaged in dairy production.These locations encompass a spectrum of environments, ranging from semi-arid areas in Isiolo to regions with higher rainfall in Trans Nzoia.Consequently, there are distinct variations in biophysical characteristics, including rainfall patterns, water availability, and accessibility to markets.These differences are pivotal in shaping the production systems adopted in different regions.These systems include pastoralist communities in Isiolo and large-scale, intensive mixed crop and livestock farmers in Narok, among others.

Data collection
A systematic sampling approach was employed to ensure an unbiased representation of the target population, comprising livestock farmers in the specified counties, regardless of farm size.Following Singh's 2014 method for sample determination, a sample size of 319 was determined, with 50 respondents from large farms and 269 from small farms.
Sampling was carried out at the ward level for each of the five counties.The process involved listing the number of wards in each sub-county within every county, followed by the random selection of 3 wards in each sub-county by picking every other 5th ward from a list of all the wards.In collaboration with community leaders, ward extension officers compiled comprehensive lists of households that accurately represented the target population within each county.
For the household selection, a random sampling process was utilized where, while in the field of study, walking along rural roads, and picking the second household and skipping the next on both sides of the road alternately.This resulted in the selection of 269 small-scale livestock producers from the prepared lists, while 50 large farm owners were purposefully selected from within the wards (10 large farms in each county).

Household survey
Data were collected through face-to-face interviews using a researcher-administered questionnaire.A structured questionnaire was developed and coded on Open Data Kit (ODK) data collection app on tablet computers.The survey gathered data on various aspects, including the respondents' knowledge about antibiotics, their antibiotic use in livestock, and the associated risks.Additionally, the survey collected data on actions taken by farmers to promote prudent antibiotic use, prevent the emergence and spread of AMR.
During the interviews, household heads, spouses, or any family member responsible for making farming decisions, such as crop selection, input usage, and sales decisions, were targeted for interviews.Prior to full deployment, the questionnaire underwent a rigorous pretesting phase to ensure its reliability and effectiveness in gathering relevant information.

Empirical methods
Farmers were asked a number of questions to assess their knowledge on specific aspects of AMR and safe use.Respondents' knowledge on antibiotics resistance was rated on a 3-point Likert scale; 1 = true, 2 = false and 3 = don't know.Regarding safe use, respondents were to select 1 = agree, 2 = disagree and 3 = don't know.The knowledge statements were coded by assigning 1 to correct and 0 to incorrect responses.Using Principal Component Analysis (PCA), indices for the two knowledge categories were developed.In order to estimate the effect of interaction between user's knowledge on resistance and safe use, multiple regression models were estimated with indices for antibiotics safe use and resistance as the dependent variables.The model was specified as: where y i is an index for the knowledge questions for household i, independent variables included; antibiotics resistance_i and is a vector for safe use (1 = yes, 0 = otherwise), and ε is the error term.Other explanatory variables, x was included in the model; sociodemographic characteristics (sex of respondent, age category, education level, production system, income levels), and geographical location of respondent i.
We further estimated the factors that determine a farmer's use of antibiotics, to guide design of future awareness programs.Probit regression model was estimated.The probit model assumes that while we only observe the values of 0 and 1 for the variable Y, there is a latent, unobserved continuous variable Y′ that determines the value of Y. Thus, for this study we assume that use of antibiotics (Y′) can be specified as follows: And that: where x i is a set of explanatory variables for respondent i, β represent a vector of unknown parameters, and u represent a random disturbance term.

Data analysis
Quantitative survey data was downloaded from ODK as xls files.Analysis was done using MS Excel for descriptive statistics and STATA 16.1 to compare means, t test and multiple regression to determine factors that influenced knowledge and practice on antibiotics safe use and resistance.

Ethical considerations
All informants provided oral consent.Prior to requesting consent, the enumerators explained the study and its aims.Participants were informed of the research purposes including the benefits and risks of participation.It was explicitly explained that participation was voluntary and no cash or direct benefits would be expected.The respondents were also assured of their (1) right to withdraw from study participation at any point, and necessary precautions were made to ensure and maintain confidentiality and anonymity throughout the study.
Ethical clearance was obtained from the University of Warwick, Humanities and Social Sciences Research Ethics Committee (RE: HSSREC 162/20-21), and research permit in Kenya was granted by National Commission for Science, Technology and Innovation (NACOSTI), (Permit: NACOSTI/P/21/11152).

Farmer demographic characteristics
The characteristics of survey respondent are summarized in Table 1.Overall, 56% of respondents were male across all counties, varying from 43% in Elgeyo Marakwet to 82% in Narok.The average household size was found to be 6 people, varying from 5 to 7 across counties.The majority of respondents, comprising 46%, fell within the age category of 36-55 years, while individuals over 55 years constituted 24%, and the youth aged 26-35 represented 23%.This demographic distribution indicates that livestock keeping in the study areas predominantly involves mature individuals, accounting for approximately 70% of the respondents.The vast majority of respondents in four of the five counties live in rural settings, reflecting the predominantly agrarian nature of the surveyed regions.However, in Trans Nzoia, over half of the respondents live in sub-urban environments, indicating a higher level of urbanization or proximity to urban centres in that county.Educational attainment among the respondents varied, with 33% having attained primary education, followed by secondary education (28%), and tertiary education (13%).Livestock was reported to be kept by majority of respondents, with the majority (90%) engaging in poultry keeping, 52% involved in sheep farming, 44% in goats, 48% in cattle, and 35% in dairy farming.However, crop production was found to be the primary source of income across all counties, with Machakos, Elgeyo Marakwet, and Trans Nzoia showing a particularly strong reliance on crop agriculture.In contrast, Narok and Isiolo demonstrated a relatively higher contribution from livestock farming.Monthly household incomes varied from KES5000 to KES40,000 for the majority of households, translating to an annual income between KES60,000 and KES480,000 (approximately US$600-US$4800).Narok County stands out with a significantly higher number of Tropical Livestock Units (TLU) at 21.9 (SD 35.2), surpassing the average TLU of 7.4 (SD 18.2) across all the surveyed counties.Following closely is Isiolo County, which also exhibits a slightly elevated TLU of 5.0 (SD 6.1).This pattern is anticipated, given that these counties are predominantly pastoral, and a substantial portion of their residents engage in livestock keeping as a primary livelihood (FAO 2023).The higher TLU values in Narok and Isiolo may indicate a higher likelihood of increased antibiotic use in livestock due to the intensive and widespread practice of livestock farming in these counties, highlighting the potential for greater antibiotic resistance concerns in these pastoral regions.

Farmers' knowledge and practices on antibiotics use Antibiotics use
Among the surveyed farmers, 80% use antibiotics agents in their animal production practices, and 58% reported to administer antibiotics themselves, a household member, or a neighbour without having sought the guidance from a trained professional.On the other hand, 42% reported to rely on technical personnel like veterinarians or extension officers for administration.The vast majority of farmers (95%) bought antibiotics without a prescription.They relied on over-the-counter antibiotics, contributing to the risk of treating undiagnosed problems, administering wrong products, and/or over-or under-dosing.As such, a considerable proportion of antibiotic use in livestock occurs without professional guidance, potentially leading to improper dosing and misuse (Oluwasile et al. 2014;Kemp et al. 2021).
The prevalent use of antibiotics for non-therapeutic purposes, notably as growth promoters in poultry, was noted as a common practice among the surveyed farmers.This finding aligns with patterns observed in other African countries, such as Ghana, Rwanda, and Nigeria, where antibiotics are routinely administered at sublethal doses, leading to concerns about the potential emergence of AMR due to continuous exposure to low levels of antibiotics (Van et al. 2020).
The continuous exposure of bacteria to antibiotics, even at levels insufficient to cause immediate death, creates an environment conducive to the evolution of antibiotic-resistant strains.Our results highlight the need for heightened awareness and regulatory measures to address the non-therapeutic use of antibiotics in agricultural practices.While acknowledging the potential benefits of appropriate antibiotic use for treatment and prevention, the study underscores the critical importance of proper diagnosis before initiating treatment.This precautionary approach is essential to avoid unnecessary antibiotic use and, subsequently, the development of antibiotic resistance (De Bruyne et al. 2014 ).
Approximately 61% of respondents were unable to recall any name of the antibiotics used and lacked labels to assist the research team in determining the antibiotics used, indicating a lack of awareness and tracking of antibiotic usage.Over 60 antibiotic products were commonly used by those who provided names (specific trade names not shown), representing six different antibiotic classes (Table 2).Although anticoccidials are not antibiotics, they are included here, since most manufacturers mix them with an antibiotic for potentiated sulfa in poultry.Tetracyclines were the most prevalent, found in 61% of the reported products, followed by penicillin (26%).Similar usage patterns were found by Kisoo et al. (2023) and Samuel et al. (2023) among livestock holders in Kenya and Uganda.Tetracycline's popularity can be attributed to its broad-spectrum activity and low cost, making it a commonly used antibiotic in animal health practice.
We categorised reported antibiotics based on the classification by the Antimicrobial Advice Ad Hoc Expert Group (AMEG) of the European Medicines Agency (EMA) for antibiotics used in animals: A-Avoid, B-Restrict, C-Caution and D-Prudence.This classification considers the importance of the antibiotic class in human medicine, knowledge of factors influencing the likelihood of resistance transfer, as well as the importance and availability of alternative antibiotics in veterinary medicine (EMA 2020).The colour coding in Table 2 shows that the reported antibiotics largely fall in the groups "Caution" (5-8% use by product) and "Prudence" (1-61% use by product), while "others" (19%) could not be categorized.For category C substances, there are in general alternatives in human medicine in the EU, but there are few alternative antibiotics in veterinary medicine for certain indications (EMA 2020).Although most of the reported products in this study are in the lower risk categories, there is considerable risk associated with the common use patterns of these antibiotics in livestock in East Africa as demonstrated by Samuel et al. (2023) who found alarmingly high resistance levels in E. coli against tetracycline, ampicillin and sulphonamides in western Uganda.
Antibiotic use varied by county, with some counties showing a preference for certain antibiotics over others.For example, Elgeyo Marakwet had higher anticoccidial use, while Isiolo and Narok had higher tetracycline use.The observed difference in antibiotic use, specifically higher anticoccidial use in Elgeyo Marakwet compared to higher tetracycline use in Isiolo and Narok, may be attributed to various factors such as local farming practices, prevalent livestock diseases, and regional variations in agricultural systems.The choice of antibiotics is often influenced by the specific health challenges faced by livestock in a given region.For instance, Elgeyo Marakwet may experience a higher incidence of coccidiosis, a disease caused by protozoan parasites, leading to an increased use of anticoccidials.On the other hand, Isiolo and Narok may encounter conditions that necessitate the frequent use of tetracycline for effective disease management.Factors like veterinary practices, access to veterinary services, and awareness campaigns in different regions may contribute to variations in antibiotic preferences among farmers (Emes et al. 2023).
In addition to using antibiotics to treat sick animals, 24% of respondents reported routinely adding antibiotics to animal feed or water as a preventive measure.The administration frequency of antibiotics to water/feed exhibited considerable variation among respondents, with the majority (79%) reporting doing so less than five times per month.However, a notable 5% of respondents reported a much higher frequency, adding antibiotics to livestock/poultry feed or water more than 20 times per month.This practice of frequent, preventive antibiotic use raises significant concerns about the potential consequences of prolonged exposure and the associated risk of the emergence of AMR, as highlighted by O'Neill (2014).The study's findings underscore the need for heightened awareness and regulatory measures to address the frequency and purpose of antibiotic use in agriculture.Promoting responsible antibiotic practices, emphasizing proper diagnosis before treatment, and implementing guidelines to limit preventive antibiotic use are crucial steps in mitigating the risks associated with AMR.Policymakers, veterinary professionals, and farmers alike play essential roles in ensuring the judicious use of antibiotics to preserve their effectiveness and prevent the escalation of AMR.

Sources of antibiotics
The majority of households surveyed (78%) acquired antibiotics from agro-vet shops, making these establishments the primary source of antibiotics for farmers.Veterinarians were the second most common source (37%) (multiple responses).A small proportion of respondents (2%) reported obtaining antibiotics from other sources, such as the government, friends, family, or previous purchases.The survey shows widespread, unguided use of antibiotics in Kenya to treat bacterial diseases in domestic animals and as growth promoters.This practice enhances the risk of incorrect dosages being administered, and withdrawal periods before slaughter or milking not being observed, which may contribute to the development of AMR (Muriuki et al. 2001).The data further indicates that a small proportion, specifically 6% of the respondents from Elgeyo Marakwet and Trans-Nzoia counties, who reported that agro-vet shops required a prescription for purchasing antibiotics but rely on farmers history.This finding is noteworthy as it suggests a potential gap in the regulation and enforcement of antibiotic sales in agro-vet shops in these areas.The low demand for prescriptions aligns with the study conducted by Akande-Sholabi and Oyesiji (2023), which found that antibiotic usage was often guided by past prescriptions from doctors or other healthcare professionals.The lack of prescription requirements in agro-vet shops raises concerns about the responsible use of antibiotics in livestock farming.Without proper oversight, there is a risk of indiscriminate and uninformed antibiotic use, which can contribute to the development of AMR.The findings therefore underscore the importance of strengthening regulatory mechanisms and promoting responsible antibiotic stewardship practices in the agricultural sector among both the agro-vet shops and farmers to be able to seek professional advice and prescriptions before using antibiotics for their livestock.

Withdrawal period
The recommended withdrawal period for antibiotics is variable, depending on the type, product, and animal.For example, oxytetracycline has a minimum withdrawal period of 3 days (Hassan 2012), while our findings indicate a minimum of 1 day by most farmers.Similarly, amoxicillin has a recommended minimum withdrawal period of 3 days compared to our findings that showed farmers only withdrew products for a minimum of 1 day.Non-adherence to these withdrawal periods heightens the risk of antibiotic residues persisting in animal products.In our study, observed withdrawal periods for most antibiotics were shorter than recommended.For instance, Tetracycline had a mean withdrawal period of 4 days, constituting a quarter of the recommended maximum withdrawal of 12 days (Table 3).This suggests an increased risk of antibiotic residues in consumed milk and meat, potentially compromising food safety.A comparable trend was noted in Tanzania, where varying levels of adherence to withdrawal periods were reported (Anika et al. 2019;Caudell et al. 2020).These findings underscore the need for awareness and legal enforcements to ensure adherence to recommended withdrawal periods among livestock farmers.Observing proper withdrawal periods is vital for minimizing the presence of antibiotic residues in animal products, contributing to overall food safety, and aligning with efforts to combat AMR.

Awareness and knowledge on AMR
Our study revealed a considerable awareness among respondents, with 76% being aware of AMR.Family or friends emerged as the most common source of information on AMR, accounting for 46% of respondents seeking information from this informal network.About a third of farmers (31%) received information from medical doctors and other health professionals, while only 24% received AMR information from trained veterinarians and animal health workers (Table 4).This finding highlights an opportunity for enhancing the role of veterinarians, animal health workers and other sources in disseminating accurate and up-to-date information on AMR to farmers.Strengthening the capacity of these professionals to communicate effectively with farmers could improve the overall understanding and responsible use of antibiotics.Omulo et al. (2017) showed that obtaining information from reliable sources, such as clinicians and community pharmacists, positively influenced views on antibiotic use, leading to better practices such as consulting a clinician, not using non-prescribed antibiotics, and completing antibiotic courses.Multiple other information sources, such as media, schools, agro-vets, extension workers, accounted for 2-15% of the responses.These sources represent critical entry points for both legal enforcement and raising awareness about the safe use of antibiotics.By disseminating information on AMR via school curricula, agro-vet shops, media outlets, and extension services, it is possible to reach a wider audience and create a culture of responsible antibiotic use in the agricultural sector and beyond.
A 3-point scale was used to assess farmers' knowledge of AMR.The farmers were presented with statements about AMR and asked to rate them as true, false or 'don't know' (Table 5).The statements covered topics such as how AMR develops, how resistant bacteria spread, and potential sources of such bacteria.Care was taken when formulating the questions to avoid introducing bias, as all but three of the statements were true.
Farmers had varying levels of knowledge regarding AMR.For instance, as many as 88% of farmers correctly rated the statement "AMR occurs when your body  becomes resistant to antibiotics and they no longer work as well" as false (statement 1), showing that these farmers were aware that AMR is not related to the body's resistance, but rather the ability of bacteria and fungi to develop mechanisms to withstand the effects of the drugs.
Farmers displayed knowledge of some aspects of AMR while lacking knowledge in others.It is worth noting that the lowest proportion of correct responses was related to the scope of the problem (statement 5), with 55% answering that 'resistance only affects those who take antibiotics regularly' to be false.In contrast, the proportion of correct responses was relatively high (65-88%) for all other statements related to hygiene, transmission and consequences of AMR.This finding demonstrates the need for addressing the misconceptions about the selective impact of AMR and emphasizing the broader consequences of AMR for both individuals and the broader community.As such, our paper recommends leveraging on the existing knowledge base, to implement educational efforts that build upon these foundations, offering more comprehensive insights into the multifaceted nature of AMR and its implications.
To assess farmers' knowledge and awareness of antibiotic safety, a series of true-false knowledge statements on antibiotic use were presented to them, and they were asked to indicate whether they agreed, disagreed, or didn't know about each statement.The results showed that, on average, majority of farmers had good knowledge on antibiotic safety.A majority (84-89%) answered correctly to statements on sources of spread and the importance of certain safeguarding practices, including withdrawal periods (Table 6).These results are in stark contrast to some of the risky practices that majority of farmers reported, including, purchase of antibiotics without prescription, and non-adherence to withdrawal periods.
Notable knowledge gaps were revealed as well.As many as 77% incorrectly believe that they are not at risk of getting infected with resistant bacteria as long as they take their antibiotics correctly.Also, 57% of farmers incorrectly agreed with the statement "It's okay to buy the same antibiotics you used to treat your animal when they had the same symptoms before, " indicating a tendency to rely on previous experiences rather than seeking professional advice before administering antibiotics.Additionally, only 34% of farmers disagreed with the statement "people should not keep antibiotics and use them later for other livestock diseases, " highlighting the practice of using leftover antibiotics for different purposes, which is not recommended and can contribute to AMR (Table 6).
Overall, this study indicates a growing awareness and understanding among Kenyan farmers of several AMR aspects.Kariuki et al. (2022) and WHO (2022) point out that Kenya, driven by its national action plan on AMR, has made considerable progress over the last years to build public awareness and knowledge on AMR and risky antibiotics use.However, more needs to be done.This survey showed a need for targeted education and awareness-raising to address specific knowledge gaps, and to ensure that accurate information reaches farmers through multiple channels, including trained veterinarians and animal health workers.Importantly, more research is needed to understand farmers' perceptions and decision-making processes.For example, what motivates farmers to apply practices that they know are potentially harmful to their animals and themselves?And, what would stimulate a change towards safer practices?What systemic failures prevent farmers from adopting healthier practices?

Factors influencing knowledge on AMR and safe use
The multivariate regression analysis, conducted to explore factors influencing farmers' knowledge on antibiotic safe use and resistance, yielded unexpected outcomes.Both gender and education level were found to have no significant impact on farmers' knowledge in the realms of antibiotic safe use and resistance.This implies that, within the studied population, factors other than gender or educational background played a more influential role in shaping farmers' understanding of antibioticrelated issues.Diversity and number of livestock owned, particularly sheep, poultry, and cattle, showed a notable and statistically significant positive influence on farmers' knowledge of antibiotic safety and resistance (P < 0.01) (Kisoo et al. 2023;Emes et al. 2023).This finding suggests that individuals who manage a larger number and diverse livestock, especially, are likely to exhibit an elevated level of awareness regarding issues related to antibiotic use and resistance.The positive correlation indicates that as the number of livestock increases, farmers are more likely to possess a wider understanding of matters pertaining to antibiotics use (Hossain et al. 2022).Location also played a role in influencing farmers' knowledge.Those in rural areas appeared to have lower levels of knowledge compared to their peri-urban counterparts.Additionally, whether antibiotics were administered by trained veterinarians or not had an impact on farmers' understanding of AMR.This finding highlights the importance of proper antibiotic administration practices and the role of trained professionals in ensuring responsible antibiotic use.Furthermore, advice from government extension agents had a significant influence on farmers' knowledge on AMR (P < 0.01).This suggests that the extension agents, who are knowledge influencers in the community, play a crucial role in disseminating information on antibiotic safety and resistance among livestock users (Table 7).
Apart from these factors, the study underscores the significance of farmers' lack of education on antibiotic use and resistance, limited awareness programs, and widespread reliance on antibiotics, all of which contribute to the expansion of the AMR problem.This is consistent Overall, the study sheds light on the complex interplay of various factors that influence farmers' knowledge and practices related to antibiotic safety and resistance.It suggests that targeted educational interventions, particularly involving livestock owners, trained veterinarians, and government extension agents, can play a critical role in promoting responsible antibiotic use and curbing the emergence and spread of AMR in Kenya's livestock sector.Moreover, raising awareness through comprehensive awareness programs can contribute to better practices and safeguard both animal and human health in the long run (Table 7).

Factors influencing the use of antibiotics
The multivariate regression analysis conducted to examine the factors influencing the use of antibiotics among farmers yielded significant and noteworthy findings.Livestock numbers emerged as a highly significant factor (P < 0.01) impacting farmers' decision to use antibiotics suggesting that farmers with larger livestock numbers are more inclined to use antibiotics, possibly due to the increased risk of disease outbreaks and the need for disease prevention and treatment in larger herds (Kiambi et al. 2021).
Another highly significant factor influencing antibiotic use among farmers was their knowledge on antibiotics resistance (P < 0.01).Farmers who demonstrated better awareness of antibiotics resistance tended to exercise more caution and responsibility in their antibiotic practices.They were more likely to adopt practices that avoid contributing to AMR, which is a crucial concern for public health and agriculture.
Education level also play a highly significant role in antibiotic use among farmers (P < 0.01).Farmers with higher levels of education had higher knowledge on antibiotic use.These farmers were more responsible in their use of antibiotics, which is likely to contribute to low AMR risk.Similarly, Omulo et al. (2017) demonstrated that education level plays a vital role in influencing farmers' antibiotic practices, with higher education potentially leading to more informed and responsible use.
Surprisingly, gender exhibited a negative correlation with antibiotic use among farmers, indicating that there may be distinct patterns or factors influencing antibiotic use based on the gender of the farmers.To better understand the reasons behind this gender disparity, further research is warranted.Exploring the underlying factors will provide valuable insights and pave the way for tailored interventions that address the specific needs of both male and female farmers in antibiotic use practices.
The location where farmers reside, particularly in rural areas, was found to be a significant factor influencing antibiotic use at a 10% level of significance.Rural farmers face different challenges and disease patterns compared to their urban counterparts, which may influence their decisions regarding antibiotic use.Tailored interventions that address the specific needs of farmers in different regions are crucial in promoting responsible and sustainable antibiotic use (Table 8).
Advisory services provided by extension workers regarding livestock health and antibiotic use were shown to significantly influence farmers' antibiotic decisions (P < 0.01).Farmers who received guidance from extension workers were more likely to make informed choices about antibiotic use, suggesting the importance of extension services in promoting responsible antibiotic practices.Farmers with incomes ranging from 101 to 400 USD were found to have a higher likelihood of using antibiotics in the treatment of their animals, and this association was statistically significant at a significance level of P < 0.05.This suggests that the financial capacity of farmers may influence their decisions and practices related to antibiotic use in animal care.
Our study reveals the multifaceted nature of factors influencing antibiotic use among livestock farmers in Kenya.The significant influence of advice from family members or own indicates the importance of social networks and personal experiences in shaping farmers' decisions on antibiotic use.Farmers may rely on the experiences and practices of family members or themselves, which can impact their antibiotic use behaviour.This discovery aligns with the research conducted by Irungu et al. (2011), Boamah et al. (2016), Farrell et al. (2023), underscoring the impact of both internal and external factors on the antibiotic usage patterns of farmers.The implications of these findings extend to policymakers, extension workers, and other stakeholders, offering valuable insights for the development of evidence-based strategies.Such strategies can aim to encourage judicious antibiotic use, ensuring both the well-being of animals and the preservation of public health and environmental safety.

Conclusions and recommendations
Our survey on antibiotics use in Kenyan livestock farming highlights critical patterns and challenges on the state of antibiotic practices, awareness on antimicrobial resistance (AMR), and factors influencing farmers' decisions.A majority (80%) of farmers use antibiotics in their livestock production, with a notable reliance on overthe-counter options (95%).This prevalent use, often for non-therapeutic purposes like growth promotion and disease prevention, raises concerns about the emergence of AMR due to continuous sublethal exposure.Furthermore, farmers demonstrated a high degree of non-adherence to recommended withdrawal periods, posing risks of antibiotic residues in animal products and compromising food safety.
Regional variations in antibiotics use were evident, suggesting that local farming practices, prevalent livestock diseases, and regional agricultural systems significantly influence farmers' choices of antibiotics.Farmers' antibiotic use practices were influenced by factors such as livestock numbers, knowledge on antibiotics resistance, education level, and location.While a considerable awareness of the causes and effects of AMR was observed among farmers, there is a need for targeted education to address specific knowledge gaps and misconceptions about antibiotic use and AMR.However, it was also clear that knowledge alone is not enough to create change.Further research into farmers' perceptions and decisionmaking processes, as well as systems' factors preventing farmers from adopting safer practices, will yield insights into the drivers behind risky practices and required solutions.
Recommendations derived from the findings include tailoring interventions to regional and gendered variations, and implementing targeted educational and awareness interventions.Public awareness campaigns, using various channels, should target not only farmers but also stakeholders and the general public, highlighting the consequences of antibiotic misuse in animal production to its impact on human health, food safety, animal welfare, and environmental sustainability.Strengthening regulatory mechanisms is crucial to ensure proper antibiotic control and monitoring in the industry.Stricter enforcement will discourage the availability of antibiotics over-the-counter and promote adherence to prescription-only practices, ensuring that Promoting research and development into antibiotic alternatives, such as probiotics, vaccines, and improved hygiene practices, is essential to reduce the reliance on antibiotics in animal production.In conclusion, addressing the complex interplay of factors influencing antibiotic use in Kenyan livestock farming requires a multifaceted approach involving education, regulatory measures, and targeted interventions.By implementing these recommendations, stakeholders can contribute to the sustainable and responsible use of antibiotics, safeguarding both animal, human and environmental health in the long run.

Fig. 1
Fig. 1 Map of Kenya showing study counties (county borders marked in red)

Table 2
Most commonly used antibiotics in the study counties (% responses) (n = 319, multiple responses) a AMEG categorisation, 1 C-caution; 2 D-prudence; 3 category varies depending on type of penicillin: A-avoid, C-caution, or D-prudence b Not an antibiotic but most manufacturers mix with an antibiotic for potentiated sulfa in poultry c Include sulfa/pyrimethamine and sulfa/trimethoprim combinations

Table 3
Withdrawal periods (days), recommended, and observed by farmers, for the most commonly reported types of antibiotics.
a Withdrawal period varies depending on type of animal and product e.g.eggs, milk, meat, offal

Table 4
Farmers' sources of information on AMR (% responses) (n = 319, multiple responses) a Others: mainly own experience (e.g., one said practically from experience on his livestock in relation to ticks that have become resistant).Other farmer groups, pharmaceutical companies

Table 5
Farmers' knowledge of AMR (% responses) (n = 319) 12.You can become sick with bacterial infections that are resistant to antibiotics if you handle unclean animals and don't wash your hands 73 9 18 13.One can become sick with bacterial infections that are resistant to antibiotics if you touch or use unclean surfaces and don't wash your hands 74 9 17

Table 7
Factors influencing knowledge on AMR and safe use of antibiotics