Knowledge and Perceptions Regarding the use of Antibiotics and Self-diagnosis: A Comparative Study of the Urban and Suburban Communities in Karawang, Indonesia

1. INTRODUCTION

In 2013, the prevalence of acute respiratory infection (ARI) was approximately 25% [1], and the incidence of ARI in West Java Province, Indonesia’s most populous province, is currently the highest among other diseases, with a prevalence of 33.44% in the Karawang Regency [2]. According to the data from disease eradication programs, there were 14,397 patients diagnosed with ARI in Karawang Regency in 2014 and 175,891 in 2016 [3]. Even without a prescription, antibiotic use is common in patients with respiratory tract infections [4]. Increased antibiotic consumption in patients with ARI results in a 50%–100% increase in excessive and irrational antibiotic use in various countries [5]. Additionally, antibiotics comprised 33% of the total prescriptions that were prescribed to outpatients at Abepura General Hospital [6]. It is, therefore, critical to evaluate inappropriate and excessive antibiotic use to avoid drug resistance, as 90% of antibiotics used were amoxicillin, ciprofloxacin, and cefadroxil [7]. This is because improper antibiotic use can increase mortality, morbidity, and financial costs while contributing to antibiotic resistance [8]. This is a major global concern and a persistent problem in several developing countries, including Indonesia [9, 10], where 84% of hospitalized patients are prescribed antibiotics, with 46% of the prescription being inappropriate [11].

Antibiotic misuse indicates a general lack of education and knowledge on the subject [12]. Knowledge regarding antibiotics has been found to be significantly associated with demographic characteristics such as gender, race, education level, and health care occupation [13]. In comparison, inadequate antibiotic knowledge has been associated with inappropriate and erroneous antibiotic use behaviors and perceptions regarding ARI [14]. Additionally, education, occupation, age, interests, experiences, culture, and information have the potential to improve knowledge [15].

The purpose of this study was to examine the relationships and differences in knowledge and perception regarding antibiotics for ARI in urban and suburban communities in the Karawang Regency of Indonesia.

2. METHODS

3. RESULTS

3.2. Antibiotics Knowledge and Perception

Table 2 shows the respondents’ knowledge and perception of ARI. We observed differences in knowledge and perceptions between urban and suburban areas (p < 0.05) that were related to physicians’ diagnoses before antibiotic use. Furthermore, our results showed that there was no statistically significant difference in knowledge and perception regarding what constitutes a correct therapy (p > 0.05). We also categorized respondents into groups (Table 2) based on their knowledge and perceptions related to self-diagnosis or non-self-diagnosis and correct or incorrect self-diagnosis (Fig. 1).

We also recorded data on incorrect ARI knowledge and perceptions from 204 and 264 respondents in urban and suburban areas, respectively, whereas correct ARI knowledge and perceptions were identified in 236 and 200 respondents, respectively, thus highlighting significant differences between urban and suburban areas (p < 0.005). Table 3 demonstrates differences in knowledge and perception regarding self-diagnosis or non-self-diagnosis in urban and suburban areas (Table 3).

Table 2.

Statement	Area	Responses and number of respondents (percentages)					p-value
		Strongly agree	Agree	Not sure	Disagree	Strongly disagree
I know I need antibiotics before I visit my doctor*	Urban (n = 440)	12 (2.73%)	105 (23.86%)	41 (9.32%)	271 (61.59%)	11 (2.5%)	0.000
	Suburban (n = 464)	15 (3.23%)	122 (26.29%)	49 (10.56%)	195 (42.03%)	83 (17.89%)
I will recover faster if I take antibiotics when I have a cold or flu+	Urban (n = 440)	97 (22.05%)	180 (40.91%)	48 (10.91%)	102 (23.18%)	13 (2.95%)	0.310
	Suburban (n = 464)	88 (18.97%)	176 (37.93%)	50 (10.78%)	136 (29.31%)	14 (3.02%)

*Knowledge and perception statements of self-diagnosis or no self-diagnosis ⁺Knowledge and perception statements that are correct or incorrect

Table 3.

Respondent Groups		I know I need antibiotics before I visit my doctor*		I will recover faster if I take antibiotics when I have a cold or flu+		Antibiotics cure most bacterial infections		Antibiotics cure all viral infections		Antibiotics have side effects		Resistant bacteria are difficult to treat with antibiotics		Resistant bacteria are found in hospitals and the general public
		Urban	Sub Urban	Urban	Sub urban	Urban	Sub urban	Urban	Sub urban	Urban	Sub urban	Urban	Suburban	Urban	Suburban
Self- diagnosis	Mean ± SD	-		22.82 ± 11.73	24.82 ± 12.13	23.50 ± 10.53	20.15 ± 8.31	24.70 ± 10.63	23.80 ± 8.92	29.06 ± 10.34	33.58 ± 11.16	24.96 ± 12.84	28.39 ± 11.00	24.79 ± 11.42	25.62 ± 9.92
No self-diagnosis	Mean ± SD	-		24.98 ± 11.43	26.42 ± 11.63	25.51 ± 9.75	21.87 ± 8.09	26.47 ± 8.66	25 ± 10.38	31.08 ± 11.27	31.16 ± 11.66	21.95 ± 10.35	26.18 ± 10.58	21.86 ± 9.37	24.28 ± 9.10
Differences between self-diagnosis and no self- diagnosis	Mean difference p-value**	- -		2.16 0.06	1.60 0.182	2.01 0.03**	1.72 0.039**	1.77 0.03**	2.04 0.045**	2.02 0.07	2.42 0.040**	3.01 0.05**	2.21 0.042**	2.93 0.02**	1.34 0.160
Incorrect therapy	Mean ± SD	32.44 ± 8.16	34.36 ± 11.55	-	-	23.27 ± 7.31	20.57 ± 7.95	25.66 ± 9.14	24.43 ± 9.77	31.85 ± 9.88	33.41 ± 11.12	25.37 ± 9.47	29.43 ± 11.14	23.80 ± 7.22	25.80 ± 9.83
Correct therapy	Mean ± SD	30.04 ± 12.99	34.7 ± 11.51	-	-	24.85 ± 7.35	22.40 ± 8.40	23.74 ± 9.41	26.30 ± 10.24	30.04 ± 11.27	29.85 ± 11.84	23.45 ± 10.15	23.40 ± 9.16	22.64 ± 9.51	23.20 ± 8.49
Differences between correct and incorrect therapy	Mean difference p-value**	2.40 0.05**	0.34 0.751	- -	- -	1.56 0.003**	1.83 0.013++	1.91 0.041**	1.37 0.046**	1.81 0.08	3.56 0.001**	1.92 0.03**	6.03 0.000**	1.17 0.039**	2.60 0.003**
Self-diagnosis and incorrect therapy	Mean ± SD	-		-	-	22.18 ± 9.82	19.88 ± 7.24	23.68 ± 9.29	22.77 ± 8.16	29.43 ± 9.07	35.54 ± 9.53	24.14 ± 11.77	31.57 ± 10.76	21.95 ± 9.75	27.47 ± 9.98
Self-diagnosis and correct therapy	Mean ± SD	-		-	-	23.60 ± 8.29	20.56 ± 9.79	26.67± 7.30	25.37 ± 9.85	31.17 ± 9.02	30.56 ± 12.80	26.67 ± 8.98	23.52 ± 9.55	20.99 ± 7.86	22.78 ± 9.20
No self-diagnosis and incorrect therapy	Mean ± SD	-		-	-	24.41 ± 8.12	20.88± 8.25	26.78 ± 9.33	25.19 ± 10.36	29.07 ± 10.70	32.43 ± 11.67	23.05 ± 11.51	28.45 ± 11.20	26.02 ± 10.14	25.03 ± 9.7
No self-diagnosis and correct therapy	Mean ± SD	-		-	-	28.71 ± 11.96	23.08± 7.75	26.29 ± 10.47	26.64 ± 10.39	32.18 ± 13.83	29.59 ± 11.50	17.98 ± 10.44	23.36 ± 9.04	21.37 ± 11.14	23.36 ± 8.24
All respondents	Mean ± SD p-value++	- -		- -		24.98 ± 9.99 0.00++	21.51± 7.49 0.016++	26.00 ± 9.25 0.062	25.02 ± 9.84 0.047	30.55 ± 11.06 0.081	31.88 ± 11.56 0.002++	22.75 ± 11.13 0.00++	26.88 ± 10.76 0.000++	22.64 ± 10.03 0.00++	24.68 ± 9.36 0.005++

*: Statements to determine self-diagnosis/no self-diagnosis +: Statements to determine correct and incorrect therapy SD: Standard deviation **: p-value from independent t-test ++: p-value from Kruskal Wallis test

Based on independent t-tests, we observed significant differences (p < 0.005) between the self- and non-self-diagnosis groups in terms of knowledge and perceptions related to antibiotics in both communities. Data included the antibiotics’ ability to treat bacterial and/or viral infections and the notion that resistant bacteria were difficult to treat with antibiotics. More specifically, our results indicate that urban communities exhibited no differences in knowledge and perceptions regarding antibiotics having side effects (p > 0.005), whereas differences were recorded in the suburban areas (p < 0.005). Furthermore, differences in knowledge and perception regarding resistant bacteria in hospitals and the general public were recorded in the suburban communities (p < 0.005).

In both correct and incorrect groups pertaining to their ARI knowledge and perceptions, we observed significant differences (p < 0.005) in both urban and suburban communities regarding the knowledge that antibiotics can treat most bacterial infections, antibiotics can be used for all viral infections, and resistant bacteria were difficult to treat with antibiotics and the knowledge of resistant bacteria in hospitals and the general public. Moreover, we did not find any significant differences in knowledge and perception regarding antibiotic side effects in the urban areas, as opposed to the suburban areas where significant differences were noted.

Based on the Kruskal Wallis analyses to determine knowledge and perception differences in all respondents (self-diagnosis but incorrect therapy, self-diagnosis, and correct therapy, no self-diagnosis but incorrect therapy, no self-diagnosis, and correct therapy), no significant differences were recorded regarding the statement that antibiotics could induce side effects. Correlations between respondents’ characteristics and knowledge, and perceptions from each area are described in Table 4.

Table 4.

Characteristics	Respondent groups
	Self-diagnosis and correct therapy		No self-diagnosis but incorrect therapy		Self-diagnosis but incorrect therapy			No self-diagnosis and correct therapy		p-value
	Urban	Suburban	Urban	Suburban	Urban	Suburban		Urban	Suburban	Urban	Suburban
Gender
Female	70	51	85	35	65	111	79		103	0.17	0.325
Male	41	32	33	19	22	70	45		43
Age Group
18–44 years	76	54	85	35	51	116	103		92	0.002	0.559
45–64 years	31	29	27	17	26	59	17		46
≥65 years	4	0	6	2	7	6	4		8
Education level
Did not finish elementary school	0	5	0	1	0	11	0		4	0.005	0.011
Elementary School	32	45	24	35	32	100	13		78
Junior High School	22	18	34	14	20	38	35		24
Senior High School	47	13	50	1	28	27	60		36
Vocational School	6	0	4	3	2	4	9		1
Bachelor and Postgraduate degree	3	0	5	0	3	1	7		3
Others	1	0	1	0	2	0	0		0
Occupation
Student	0	0	4	0	3	0	1		2	0.036	1. 0.235
Teacher/Lecturer	2	1	3	2	2	1	4		0
Private Employee	12	4	13	3	15	9	28		7
Employers/Self-Employed	21	11	20	7	13	34	20		13
Civil Servants/Police/Military	0	0	5	1	1	1	4		1
Housewife	73	49	64	29	46	87	59		86
Laborer	0	7	0	9	0	23	0		19
Others	3	11	9	3	7	26	8		18
Income
<Rp 1,250,000	42	47	35	32	34	95	40		90	0.401	0.380
Rp 1,250,000–Rp 3,500,000	44	24	57	18	29	70	29		43
≥Rp 3,500,000	25	12	26	4	25	16	35		13
Health insurance
Yes	62	53	64	32	60	116	79		90	0.106	0.910
No	49	30	54	32	27	65	45		56

In urban areas, we observed significant correlations (p < 0.005) between age and occupation and knowledge and perception, whereas, in suburban areas, no differences were found. In both areas, the education level was significantly correlated with knowledge and perception, as opposed to gender, income, and insurance status.

4. DISCUSSION

It is critical to conduct community studies to ascertain public knowledge and perceptions about antibiotics in ARI. According to a recent study, 79% of 203 patients taking ARI antibiotics used their medication incorrectly [18]. This erroneous use, likely to result in antibiotic resistance and exacerbate disease severity [19, 20], appears to be defined by community knowledge and perceptions on the subject [13].

In urban areas, the proportion of respondents with incorrect knowledge and perception was lower than the proportion with correct responses, whereas, in suburban areas, the situation was completely reversed. This is in accordance with a previous study, wherein the respondents in suburban areas used antibiotics when they suffered from flu [4]. According to Oh et al., 67.2% of their study respondents believed antibiotics could be used to treat viral infections and were unable to differentiate between viral and bacterial diseases [21].

Although antibiotics are not always necessary, they are frequently used in patients with respiratory infections [22, 23]. Our study found no correlation between respondents' age and their antibiotic knowledge and perceptions. An Australian study reported no significant correlations between age, public knowledge, and perception regarding antibiotic use [14]. Additionally, an Ecuadorian study found that mothers (respondents) aged 18–44 years had a higher level of knowledge about antibiotic use in children than mothers (respondents) aged <18 years [24]. Another study conducted in Jordan found that respondents aged 18–39 took improved self-medication measures, particularly concerning antibiotics, and that age was associated with antibiotic use [25]. Conversely, education levels were found to be significantly associated with antibiotic knowledge and perceptions. In this regard, a recent study also reported similar correlations between education and knowledge regarding antibiotic use [26]. Similarly, our findings indicate that respondents with lower educational attainment and those living in rural areas had significantly lower levels of knowledge about antibiotics [27]. Additionally, a European study suggested that respondents with low levels of education harbor a decreased awareness regarding antibiotics [28].

Thus, the level of education of respondents was found to be associated with their knowledge and perceptions about antibiotics. Previous research has revealed a knowledge and perception gap between communities and health care providers [13]. One factor influencing knowledge is occupation, implying that individuals may gain experience and knowledge through their work environments [15].

However, there was no correlation between knowledge and perception, and income [29]. Additionally, we observed no correlation between health insurance status and knowledge and perceptions of antibiotic use. However, previous studies have demonstrated that patients without health insurance exhibited inappropriate behaviors concerning antibiotic use [30]. Thus, health insurance may play a significant role in determining antibiotic use and associated erroneous practices [11]. On the other hand, in rural communities in China, some parents demonstrated a lack of knowledge about antibiotics while harboring a high prevalence of self-medicating their children with antibiotics [31].

The current study also examined subjects’ knowledge and perceptions regarding antibiotics, which can be influenced by geographical factors. Simandan (2016) explained that certain distances and geographic locations affect the subjectivity and objectivity of knowledge and perception. Additionally, the uncertainty of factors such as positionality, partiality, reflexivity, crossing, and strongly politicalized positioning aided in subject knowledge. In another study, Simadan (2020) confirmed the role of geography and diversity in personal and social change [32-34].

CONCLUSION

Our study used a self-administered questionnaire, and data were derived from respondents’ recall and memory. While this may introduce some subjectivity, the data indicated that respondents in both urban and suburban areas generally agree that antibiotics should not be taken based on self-diagnosis. Consequently, it is necessary to increase awareness and promote the proper use of antibiotics in the community.

REFERENCES