Correlation of Knowledge and Beliefs to Adherence with Antibiotic Use in Adult Patients at a Private Hospital in Sidoarjo

Infectious diseases are one of the top ten causes of death in the world. Antibiotic therapy is administered for infectious diseases, but if bacteria are exposed to antibiotics continuously, then the bacteria are able to adapt to the medication, thereby resulting in antibiotic resistance. This condition results in an increase in mortality, long hospitalization period, and increased cost of antibiotic therapy and health services. Adherence to using antibiotics may be influenced by knowledge and beliefs about them. This study aimed to understand correlation between knowledge and belief with adherence to antibiotic use at a private hospital in Sidoarjo. This cross-sectional study, the data collected in three months period, was conducted with a questionnaire for assessment knowledge and belief. A pill count method was applied for assessment adherence to using antibiotics prescribed by doctors. The study results show that knowledge of the respondents was adequate for 76 people (69.7%), belief was adequate for 74 people (67.9%), and adherence to antibiotic use for 79 people (72%). Regression analysis showed that the variable that significantly influenced the adherence of patients in using antibiotics was perceived threat (p-value = 0,029). Sex, age, education, income, occupation, and marital status have no contribution to antibiotic knowledge, belief, and adherence.


Introduction
Infectious diseases are the world's leading cause of death, with 3.2 million mortality rate for lower respiratory tract infection and 1.4 million mortality rate for tuberculosis infection.Antibiotics are a therapy provided to treat infectious diseases. 1However, the bacteria exposed to antibiotics continuously adapt to this type of medication, thereby resulting in antibiotic resistance.
Antibiotic resistance can lead to an increase in mortality rate, long and costly hospital stay, and increased costs of antibiotic therapy and healthcare.Data from the World Health Organization (WHO) in 2014 in Thailand indicates an increase in the treatment cost of E. coli resistance to cephalosporine and quinolones from USD 108 to USD 528.An increase in the length of hospital stay to 4.65 days was also observed due to infections caused by methicillin-resistant Staphylococcus aureus. 2 Strategies to reduce the incidence of antibiotic resistance, based on the WHO 2015 strategy, are improving awareness and knowledge of antibiotic resistance, strengthening knowledge through surveillance and re-search, reducing infection transmission, using antibiotics optimally, as well as investing in new drug discovery, diagnostic tools, and vaccines to fight antibiotic resistance. 3,4Conducting inter-sector coordination among healthcare practitioners, financial departments, governments, and patients is necessary to achieve optimal results. 3The implementation of the WHO strategy aims to perform an Antibiotic Stewardship Program.In hospitals, policies and guidelines on the rational use of anti biotics are needed to prevent antibiotic resistance. 4he Health Belief Model (HBM) suggests that a person's health behavior is influenced by factors that can be modified (age, sex, ethnicity, level of education, and knowledge), beliefs, actions triggered by the media, and other factors. 5,6Previous studies conducted in Lithuania showed that 1,005 adult patients (61% of survey respondents) had low levels of knowledge about antibiotics. 7A study in Maryland explains that patients' beliefs are shaped through several perceptions, such as perceived severity, perceived susceptibility, perceived benefit, and perceived barriers and cues to action, which in turn affect patients decision making on treatment. 8nterview results with 32 female and 14 male showed six types of patients' behavioral patterns in the community, including use of antibiotics in accordance with prescriptions, not taking drugs due to being busy at work, taking care of children or social activities, forgetting to take antibiotics, stopping the antibiotic intake when feeling better, reducing the use of antibiotics because they can damage the body, and stopping the consumption of antibiotics immediately to be stored for reuse, thereby eliminating the need to go to a doctor or a hospital. 8This study aimed to determine the correlation of patients' knowledge and beliefs in adherence to using antibiotics at a Private Hospital in Sidoarjo, East Java.

Method
This cross-sectional study used a purposive sampling technique in which respondents who met the inclusion criteria were chosen by chance.This study was conducted at Sidoarjo Private Hospital from November 2017 to February 2018.The population consisted of patients who use anti biotics and the inclusion criteria were patients aged 18 -60 years and did not work in the healthcare field.Exclusion criteria were patients with jobs as healthcare workers.Respondents who were willing to participate in the study signed an informed consent form.
A questionnaire was distributed to patients in the private hospital.Data collection conducted over threemonth period from November 2017 to February 2018.][11][12][13][14][15] The independent variable in this study are knowledge and belief, and the dependent variable is adherence.The knowledge questionnaire used a Guttman scale and consisted of the following items: provision of drug information by health workers (two questions), antibiotic resistance prevention (three questions), guidelines on antibiotic use (four questions) and explanation for antibiotic resistance (one question).Correct answers were given a score of 1 and wrong answers were given a score of 0. The beliefs questionnaire was based on HBM using a Likert scale from disagree (1 -3) and agree (4 -5).Items in the beliefs questionnaire consisted of perceived barrier (eight questions), perceived benefit (eight questions), perceived threat (nine questions), and perceived self-efficacy (eight questions). 16,17efore data analysis, knowledge and beliefs were divided into three categories (low, moderate, and high) by calculating the mean of the respondents' total scores.Knowledge low score was below 4, moderate score ranged from 4 to 8, and high score was 8. Belief low score was below 93, moderate score was between 93 and 112, and high score was above 112.Patients' adherence to antibiotic use was divided into three categories, name-ly high (the respondent completed the course of antibiotics prescribed), moderate (the respondent missed one tablet / capsule of antibiotics), and low (the respondent missed more than one tablet / capsule of antibiotics).
Processing the collected data was conducted and explained to provide a description of the frequency distribution of demographic characteristics, categories of respondents' knowledge, and beliefs and adherence to using antibiotics.The statistical test used were independent sample t-test for sex groups and one-way Anova for age, education, employment, and marital status groups to determine differences in knowledge and beliefs in each demographic group with a confidence level of 95%.If the value of p-value < 0.05, a difference exists in the score of knowledge and belief in the demographic group.
Bivariable analysis was performed to determine the relationship between knowledge and beliefs (perceived benefit, perceived barrier, perceived benefit threat, and self-efficacy) with adherence to using antibiotics (p-value < 0.05) using Pearson's correlation analysis.Multivariate analysis was used to determine the knowledge and belief that contributed most to patients' adherence with antibio tics.The statistical test used was logistic regression by entering all the independent variables, namely know ledge and beliefs consisting of perceived benefits was one's belief in the effectiveness of various measures available in reducing the threat of disease, or the benefits felt in taking these health efforts, perceived barrier is a barrier that is felt to change, or if an individual faced an obstacle in taking the action, the perceived threat was a feeling about the seriousness of an illness, including evaluating clinical and medical consequences (for example, death, disability, and illness) and social consequences that may occur (such as effects on work, family life, and social relations), and self-efficacy is a person's belief in his/her ability to produce something that is desired.The dependent variable, which is adherence, had a confidence level of 95%.This study fulfilled ethical approval No. 025/S/KEPK/V/2017.

Results
The knowledge validity test was conducted on 30 patients using the "biserial point correlation coefficient" on 10 questions with a score of 0 and 1.The belief validity test was carried out on 32 questions with a 1 -4 Likert scale using the "corrected item-total correlation" validity test.The results of the validity test of knowledge and belief show that the calculated r value is greater than r table ranging from 0.399 to 0.902 with r table 0.361 such that the questionnaire is valid.
Test of reliability of knowledge and belief used the Cronbach's alpha formula provided that a question has reliability if the Cronbach's alpha value is equal to or greater than 0.7.The reliability test showed that the value of Cronbach's alpha obtained for knowledge of antibiotic use was 0.704 and the belief in antibiotic use was 0.713 so that the instrument was declared reliable.
Based on data collected from patients who had antibiotic prescriptions in the hospital, 109 respondents met the inclusion criteria and were willing to participate in the study.Table 1 shows that 52% of the respondents are female, 42.2% are in the 32 -45 age group, 57.8% have a higher secondary education level, 45% work as employees, and 90% are married.
Based on Table 2, knowledge and beliefs in using antibiotics are divided into three categories, namely high, moderate, and low based on mean.Most respondents have moderate levels of knowledge of antibiotics (69.7 %) and majority of the respondents' beliefs about antibiotics are in the moderate category (67.9%).Respondents' adherence to using antibiotics is in the high category (72%).
Bivariable analysis shows that knowledge has a significant relationship to compliance using antibiotics with a correlation coefficient of 0.289 (p-value < 0.05).Table 4 shows that the more obstacles for patients taking antibiotics, the lower is the adherence to antibiotic use with a correlation coefficient of −0.030.
Table 5 shows the results of the logistic regression between knowledge and belief (perceived barrier, perceived benefit, and self-efficacy) with adherence to using antibio tics.The results indicated that knowledge, perceived barrier, perceived benefit, and self-efficacy did not have a significant relation to respondents' adherence to antibiotic use (p-value > 0.05).The variable that was significantly related to respondents' adherence to using antibiotics was perceived threat (p-value = 0.014).The higher the perceived threat felt by the respondents, the greater was their commitment to using antibiotics (β = 0.129, OR = 1.138, 95% CI = 1.026 -1.262).

Discussion
Antibiotics must be used rationally because using them in a manner that is not in accordance with the guidelines can cause antibiotic resistance.Evaluating the use of antibiotics in the community is useful to provide information that can help optimize the use of antibiotics in the community.As reported by Gasson, et al., 18  In term of knowledge, the majority of the respondents did not understand antibiotic resistance.Study conducted in Kuwait shows that public knowledge about antibiotic resistance was still relatively low.In this case, 51% (95% CI = 47.2 -54.8) of respondents agreed that terminating the use of antibiotics leads to resistance.Knowledge of this antibiotic resistance in the study was still low at 52.5% (95% CI = 48.7 -56.3). 15A survey in the United Kingdom on the adult population showed that a lack of awareness of antibiotic resistance was strongly associated with self-medication antibiotics for influenza disease. 19nowledge of antibiotics is influenced by various factors.A study conducted in Norway on adult subjects showed that the level of knowledge of patients using antibiotics was influenced by information provided by health workers, education levels, and a positive view on the value of medications in general. 20n terms of belief, patients' beliefs in this study consisted of perceived benefit, perceived barrier, perceived threat, and perceived self-efficacy. 5The results of this study are in accordance with Jose J' study, 21 which showed no significant differences between demographic groups and patients' beliefs in using antibiotics.Study conducted on the adult population in the United Kingdom showed that belief in antibiotics for influenzalike illnesses and low awareness of antimicrobial resistance (AMR) significantly affected the use of antibiotics.In the study, 39% of groups with low AMR awareness would often ask doctors about antibiotics compared with groups with high AMR awareness (p-value < 0.001). 19dherence of patients in using antibiotics was in the high category in which patients completed the course of antibiotics prescribed by doctors at Sidoarjo's Private Hospital.This study's results are consistent with Omani's study in Hong Kong that measured adherence with antibiotics using pill count method; the study found that adherence to using antibiotics did not differ among groups based on age, sex, and education level. 16,22Other studies that used questionnaires as an instrument to measure pa-tients' adherence to using antibiotics gene rated similar results in which no significant differences were found between groups based on age, sex, education level, income, and marital status on adherence with anti biotics. 21,22his study is in accordance with research conducted in the Saudi Arabia and Oman where knowledge of antibiotics was correlated with demographic characteristics such as sex, age, occupation, education level, and marital status. 18,21,23However, previous research suggests that different age groups had significant differences in the knowledge of antibiotics used.The older the respondents, the lower the level of knowledge with regard to using antibiotics. 21Different levels of education also showed significant differences in the knowledge of antibiotics in which respondents with higher education level had better knowledge about antibiotics. 21atients' adherence may be influenced by age, sex, edu cation level, knowledge, and beliefs in antibiotics. 6,15,24,25Unwise use of antibiotics and incompliance with prescriptions could result in antibiotic resistance. 9Antibiotic resistance then increases mortality rates, length of hospital stay, and costs of antibiotic therapy and health services. 2egression analysis and HBM showed that perceived threats correlated significantly with patient compliance with antibiotic use. 5 In this study, no significant correlation was found between knowledge and adherence to using antibiotics, but previous study suggests that knowledge had a significant correlation with adherence to antibiotic use. 16,17,22Thus, to improve patients' adherence to the use of antibiotics at the hospital, intervention is necessary with regard to patients' knowledge of antibiotics.The HBM showed significant differences between knowledge, perceived benefit, perceived barrier, and perceived threat in the two intervention groups: before and after being provided with education (p-value (0.001) < 0.05).However, the control group that was not provided with education showed no significant differences among the variables examined (p-value > 0.05). 26n addition to patients who must understand the antibiotics used, doctors and pharmacists play an important role in increasing knowledge of antibiotics.Doctors and pharmacists should be good models to increase rational use of antibiotics in society and improve antibiotic use behavior.In addition, all health education institutions must pay close attention to providing rational antibiotic therapy knowledge and effective patient consultation skills. 24,27he strength of this study is that limited research has been conducted on knowledge, beliefs, and adherence to using antibiotics in the Sidoarjo, East Java Province.Hence, the results of this study can be used as a basis for policy making in hospitals in Sidoarjo or East Java.The limitation of the study is that most of the respondents used the Javanese language.Further study is needed to illustrate the use of antibiotics, so that steps can be taken to reduce antibiotic resistance in Indonesia.

Conclusion
The respondents' knowledge and beliefs about the anti biotics used in this study are in the moderate category, while adherence levels in antibiotic use are in the high category.No significant difference is observed in knowledge and beliefs in adherence to using antibiotics among groups based on sex, age, education, income, occupation, and marital status.Respondents' adherence to using antibiotics is not influenced by knowledge of antibiotics but by perceived threat of antibiotic use.Respondents' adherence to the use of antibiotics can be improved through education about any threat to antibiotic use.This study improves patient compliance in using antibiotics, namely, by increasing the knowledge of patients.In addition to doctors and pharmacists who play an important role in providing information to patients, health institutions must also provide knowledge of rational antibiotic therapy.

Competing Interest
Author declares that there are no significant competing financial, professional, or personal interests that might have affected the performance or presentation of the work described in this manuscript.

Kesmas:
Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal).2020; 15 (2): 99-104 Wattiheluw et al, Correlation of Knowledge and Belief to Adherence with Antibiotic Use in Adult Patients at a Private Hospital in Siduarjo

Table 1 . Demographic of Respondents
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