International Journal of

Environmental Research
and Public Health

Article
Assessment of Knowledge, Attitude, and Practice of
Antibiotic Use among the Population of Boyolali,
Indonesia: A Cross-Sectional Study
Hidayah Karuniawati 1,2, * , Mohamed Azmi Ahmad Hassali 1,† , Sri Suryawati 3 , Wan Ismahanisa Ismail 4 ,
Taufik Taufik 5 and Md. Sanower Hossain 6,7

1 Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains
Malaysia, Gelugor 11800, Pulau Pinang, Malaysia; azmihassali@usm.my
2 Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Muhammadiyah
Surakarta, Surakarta 57102, Indonesia
3 Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta 55281, Indonesia;
suryawati@ugm.ac.id
4 Faculty of Health Science, Universiti Teknology MARA, Cawangan Pulau Pinang Kampus Bertam,
Kepala Batas 13200, Pulau Pinang, Malaysia; ismahanisa@uitm.edu.my
5 Faculty of Psychology, Universitas Muhammadiyah Surakarta, Surakarta 57102, Indonesia; taufik@ums.ac.id
6 Department of Biomedical Science, Kulliyyah of Allied Health Sciences, International Islamic University
Malaysia, Kuantan 25200, Pahang, Malaysia; mshossainbge@gmail.com
7 Faculty of Science, Sristy College of Tangail, Tangail 1900, Bangladesh
* Correspondence: hk170@ums.ac.id; Tel.: +62-856-4215-8302



† Deceased during the communication of this manuscript.



Citation: Karuniawati, H.; Hassali, Abstract: Misuse and overuse of antibiotics are potential causes of the increasing prevalence of
M.A.A.; Suryawati, S.; Ismail, W.I.; antibiotic resistance (ABR). Having information about the knowledge, attitude, and practices con-
Taufik, T.; Hossain, M.S. Assessment cerning antibiotics use by the public might help control ABR growth. Therefore, this cross-sectional
of Knowledge, Attitude, and Practice
study aimed to investigate the levels and associated factors of knowledge, attitude, and practice
of Antibiotic Use among the
(KAP) of antibiotics use among the public. A questionnaire was designed and validated, which
Population of Boyolali, Indonesia:
consisted of a total of 51 questions with four sections: demographics (6), knowledge (20), attitude (12),
A Cross-Sectional Study. Int. J.
and practice (13) to measure KAP. Univariate analysis (using Mann–Whitney U and Kruskal–Wallis
Environ. Res. Public Health 2021, 18,
8258. https://doi.org/10.3390/
analysis) was applied to assess the differences in the mean scores of KAP. Linear regression analysis
ijerph18168258 was performed to identify factors associated with KAP. Finally, using Spearman analysis we have
examined the correlation between responses to the KAP. The sample size of this study was 575,
Academic Editor: Tara Zolnikov with a 99.96% response rate. Regarding knowledge, 73.12% of respondents stated that antibiotics
could be used to treat viral infections, and 63.35% of respondents answered that antibiotics could
Received: 23 June 2021 reduce fever. Concerning attitude, 50% of respondents had considered stopping taking antibiotics as
Accepted: 27 July 2021 soon as symptoms had disappeared. In analyzing practice, we found 40% of respondents obtained
Published: 4 August 2021 antibiotics from a pharmacy without a prescription from a physician, a nurse, or a midwife. Statistical
analysis revealed that KAP about antibiotic use was significantly associated with gender, area of
Publisher’s Note: MDPI stays neutral
residence, level of education, and monthly income (p < 0.05). Our findings concluded that men,
with regard to jurisdictional claims in
respondents with low income, those with low-level education, and those living in rural areas are
published maps and institutional affil-
more prone to excessive use of antibiotics without knowing the adverse effects of improper use and
iations.
how it can contribute to high ABR. So it is urgently necessary to strengthen policies on antibiotics
use, including drug provision, distribution, and sales. In addition, people with low KAP should be a
priority consideration in education outreach initiatives.

Copyright: © 2021 by the authors.

Keywords: antibiotics misuse; antibiotics resistance; knowledge; attitude; practice
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
1. Introduction
creativecommons.org/licenses/by/ Antibiotic resistance (ABR) is a global threat that leads to treatment failure, increases
4.0/). in length of hospital stay, cost of care, morbidity, and mortality [1–4]. Additionally, ABR

Int. J. Environ. Res. Public Health 2021, 18, 8258. https://doi.org/10.3390/ijerph18168258 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2021, 18, 8258 2 of 16

threatens human healthcare progress, agricultural production, and, ultimately, life ex-
pectancy. Among the causes of ABR, misuse and overuse of antibiotics directly affect
ABR development [3,5,6], which occurs due to a lack of knowledge, careless attitudes, and
incorrect beliefs of the public about antibiotics [6,7]. Patients’ belief in the remarkable
effectiveness of antibiotics and their being universally efficacious against all ailments has
resulted in overuse, which is one of the significant factors of the exponential growth of
ABR [8–10]. For example, patients’ believed that antibiotics would help them in overcoming
viral respiratory illnesses, such as the common cold [7,11–13]. Recently, the high preva-
lence of COVID-19 associated mucormycosis (CAM) has been witnessed by India, caused
by resistant mucormycetes. Mucormycosis is a relatively rare type of fungal infection,
but its prevalence has increased significantly due to the irrational use of broad-spectrum
antibiotics in treating COVID-19 patients [14,15].
Respiratory and gastrointestinal diseases are common but are also commonly incor-
rectly managed by using antibiotics, and physicians needlessly write antibiotic prescrip-
tions, increasing the chances of ABR prevalence [2,7,11,16]. A recent systematic review
and meta-analysis has reported that antibiotics are used inappropriately by the general
population, as seen in behaviours such as purchasing antibiotics from pharmacies without
a prescription, demanding antibiotics from physicians, not following prescribed antibi-
otics, and using antibiotics as prophylaxis for non-indicated diseases [17]. An incomplete
course of antibiotics—not completing the entire course of antibiotics prescribed by the
physician—educates microbes to become resistant, probably leading to a higher rate of ABR
development [18,19]. Another study conducted in the Philippines has reported that 78%
of respondents (N = 218 with 69% having graduated high school) shared their antibiotics
with others [20]. A dominant cause of the high prevalence of ABR is the availability of
antibiotics over the counter, particularly in developing countries where the sale of antibi-
otics is not well documented and regulated. Therefore, the prevalence of self-medication
with antibiotics is high for treating common symptoms, which do not require antibiotics. A
review found that one third (33.7%) of the population practiced self-medication [21]. Barber
et al. [10] reported that most patients do not necessarily require antibiotics for treatment.
Patient pressure and the motivation of greater profit from selling more antibiotics further
enhance the irrational use of antibiotics [22,23].
Several studies related to knowledge, attitude, and practice about antibiotics in the
general population have been undertaken in a range of different countries [24–29]. These
studies have shown that 57–79% of respondents said that antibiotics are good for treating
infections caused by viruses [25,26,28,29], and 50% believed that antibiotics might shorten
an upper respiratory tract infection [25]. Self-medication with antibiotics used as prophy-
laxis against infection was reported by more than 50% of respondents, and almost 42% of
respondents discontinued antibiotics on the alleviation of symptoms [21,27,28].
Indonesia is overpopulated and is one of the top five most populous countries in
the world and also experiences the misuse and overuse of antibiotics due to widespread
inadequate knowledge and incorrect attitude [7,30–32]. Purchasing antibiotics without
prescription and self-medication are highly prevalent in Indonesia. More than 50% of
people have inaccurate knowledge about antibiotics, and believe that antibiotics cure
viral infection and prevent the worsening of illness [31]. Self-medication as a tendency
to try to relieve disease symptoms like those a patient has experienced already is high
(48.5%). Respondents reported remembering which antibiotics had been suggested by
their physician before and have purchased them again over the counter without getting a
new prescription. Some respondents have reported that they have even followed relatives’
recommendations for prescriptions or their general medical advice (51.9%) to treat similar
symptoms. They have justified this by saying that they can get rid of the disease and
simultaneously save money. A few other Indonesian studies showed that respondents
have usually self-medicated using the same antibiotics prescribed before for similar clinical
symptoms to save time and money [32–34].
 their physician before and have purchased them again over the counter without getting
a new prescription. Some respondents have reported that they have even followed rela-
tives’ recommendations for prescriptions or their general medical advice (51.9%) to treat
similar symptoms. They have justified this by saying that they can get rid of the disease
Int. J. Environ. Res. Public Health 2021,and simultaneously save money. A few other Indonesian studies showed that respond-
18, 8258 3 of 16
ents have usually self-medicated using the same antibiotics prescribed before for similar
clinical symptoms to save time and money [32–34].
Antibiotic-resistant germs arise because of the irrational use of antibiotics that fails
Antibiotic-resistant germs arise because of the irrational use of antibiotics that fails to
to meet the General Guidelines for the Use of Antibiotics. A study in Indonesia showed
meet the General Guidelines for the Use of Antibiotics. A study in Indonesia showed that
that 43% of Escherichia coli collected from community samples were resistant to the anti-
43% of Escherichia coli collected from community samples were resistant to the antibiotics
biotics ampicillin (34%), cotrimoxazole (29%), and chloramphenicol (25%) [35]. There-
ampicillin (34%), cotrimoxazole (29%), and chloramphenicol (25%) [35]. Therefore, the
fore, the Indonesian government has implemented ABR control programs in 2015, such
Indonesian government has implemented ABR control programs in 2015, such as Gerakan
as Gerakan Masyarakat Cerdas Menggunakan Obat (GEMA CERMAT), to halt the mis-
Masyarakat Cerdas Menggunakan Obat (GEMA CERMAT), to halt the misuse and overuse
use and overuse of antibiotics and improve the community’s rational use of antibiotics
of antibiotics and improve the community’s rational use of antibiotics in hospitals and
in hospitals and the community nationwide. One of the primary purposes of this pro-
the community nationwide. One of the primary purposes of this program is to offer a
gram
series isof to offer a to
activities series ofantibiotics
create activities to create antibiotics
awareness, awareness,
understanding, understanding,
and good practice. Asand
the
good practice. As the government has implemented awareness
government has implemented awareness programs nationwide, evaluating peoples’ programs nationwide,
current
evaluating
knowledge,peoples’
attitude,current knowledge,
and practice attitude,antibiotics
(KAP) towards and practiceuse (KAP) towards
is essential. antibiotics
Therefore, this
use is essential. Therefore, this study has assessed and evaluated the
study has assessed and evaluated the KAP of antibiotics use among the local community.KAP of antibiotics
use
The among
findingstheof local community.
this study Thethe
might help findings of this to
government study might
redesign help and
policy the government
evaluate the
to redesign policy and evaluate
implementation of ABR control programs.the implementation of ABR control programs.

2. Materials
Materials and
and Methods
Methods
Study Site
2.1. Study Site
Indonesia isisthe
Indonesia thelargest and
largest andmost populous
most populous country in Southeast
country Asia. ItAsia.
in Southeast has 271.34
It hasmillion
271.34
people and
million 34 provinces
people with 416with
and 34 provinces regencies. The study
416 regencies. area
The is located
study area isatlocated
Boyolali, Boyolali
at Boyolali,
Regency,Regency,
Boyolali Central Java,
CentralIndonesia. It is in central
Java, Indonesia. Java,
It is in Indonesia,
central surrounded
Java, Indonesia, by the Grobo-
surrounded by
ganGrobogan
the and Semarang Regency to
and Semarang the north,
Regency Karanganyar,
to the Sragen, and
north, Karanganyar, Sukoharjo
Sragen, Regency
and Sukoharjo
to the east,
Regency to Klaten and
the east, Yogyakarta
Klaten to the south,
and Yogyakarta to and Magelang
the south, andand Semarang
Magelang andRegency
Semarangto
the west (Figure 1). Boyolali includes 19 subdistricts with 1.06 million
Regency to the west (Figure 1). Boyolali includes 19 subdistricts with 1.06 million popu- populations. The
averageThe
lations. literacy of this
average regionofisthis
literacy 87.52%
region[36,37].
is 87.52% [36,37].

Figure 1. Data collection site of the cross-sectional study. Boyolali, Boyolali Regency, Central Java, Indonesia.

2.2. Study Design

The sample was chosen using the cluster sampling method following World Health
Organization (WHO) guidelines [38,39]. Boyolali comprises 19 subdistricts, of which five
subdistricts have been selected. One selection was made using judgmental sampling that
comprised two subdistricts and another selection was made using random sampling that
accounted for three subdistricts. A total of 20 clusters were identified from the selected
subdistricts. The smallest administrative unit, the “village”, was considered a cluster.
Int. J. Environ. Res. Public Health 2021, 18, 8258 4 of 16

Judgmentally selected subdistricts cover the highest-income subdistrict (the capital city
area), and the lowest-income subdistrict (rural areas) [38]. In each selected subdistrict, four
villages were selected randomly, and 27–29 respondents in each village were involved. The
first house visited in each cluster was randomly selected using existing lists of household
names. After the first household visit, the second household was visited based on what
was nearest to the first. The nearest household has been defined as the household which
could be reached starting from the previously visited household in the shortest walking
time. This cluster similarly included 29 respondents [39]. The same held for other clusters.
In this study, to select variables we used the theory of Health Belief Model (HBM).
HBM suggests that a person’s health behavior is influenced by modifying factors (age,
gender, ethnicity, level of education, socioeconomic status, and knowledge) and individual
beliefs [40].

2.3. Sample Size

The sample size was determined using the Raosoft sample size calculator [41]. For
a population of 1 million (Boyolali regency, Indonesia as per Department of Statistics,
Indonesia) with a 95% confidence interval and 5% margin of error, the minimum number
of estimated samples was 384. The sample size was increased by about 50% to minimize
the weakness of cluster sampling and increase the representative sample [42]. The r2 was
used to evaluate the effect size [43].

2.4. Data Instrument and Collection

A closed-ended cross-sectional quantitative survey was conducted in the Boyolali
Regency, Indonesia, from January 2020 to March 2020. A validated self-administered
questionnaire was used in this study [44]. The questionnaire was developed based on the
literature reported [28,29,45–47], early individual interviews, and input from nine experts,
including one clinical pharmacologist, two pharmacists, one community medicine special-
ist, two physicians, one clinical psychologist, one expert methodologist, and one expert
epidemiologist. The validation phase consisted of face, content, and construct validity.
Content validity ratio (CVR) and content validity index (CVI) were used to analyse content
validity. Items which had CVR ≥ 0.78 and CVI > 80% were retained [48,49]. Construct
validity was measured using exploratory factor analysis (EFA) and confirmatory factor
analysis (CFA) [50–52]. Item analysis was employed for knowledge evaluation [48]. Re-
liability was evaluated with internal consistency reliability [53] and test–retest reliability
in a two-week interval [54]. Validity and reliability were assessed using 407 respondents.
Items’ difficulty and discrimination index in the knowledge section was found to be accept-
able, with the Cronbach’s α and test–retest reliability being 0.827 and 0.713, respectively.
Four factor-solutions emerged for the attitude and practice section with a cumulative
contribution of 59.79% and 58.99%, respectively. The CFA result indicated acceptable fit
indices for the proposed model (χ2 /df ≤ 5, GFI > 0.90, RMSEA < 0.08); incremental fit
(TLI > 0.90, CFI > 0.90); and parsimonious (PNFI 0.60–0.90) [55]. Every single factor in both
the attitude and practice section had an acceptable range in internal consistency reliability,
and test–retest reliability ranged from 0.717 to 0.898. Items that were found not to be valid
and reliable were removed or revised [44]. The finalised questionnaire that had met the
validity and reliability criteria was used to collect and measure data of KAP.
This questionnaire has included 20 questions relating to knowledge, 12 questions
about attitudes, and 13 questions about practice. Based on the exploratory factor analysis
(EFA), the knowledge section was divided into six domains, including “identification of
antibiotics” (Q1–Q3), “role of antibiotics” (Q4–Q7), “antibiotics access” (Q8–Q11), “an-
tibiotics misuse effect” (Q12–Q15), “side effect of antibiotics” (Q16–Q17), and “antibiotics
use” (Q18–Q20). The attitude questions, based on the EFA result, were divided into four
domains: “antibiotics resources” (Q1–Q5), “leftover” (Q6–Q8), “antibiotics use” (Q9–Q10),
and “hopes about antibiotics” (Q11–Q12). The questions about practices were divided into
Int. J. Environ. Res. Public Health 2021, 18, 8258 5 of 16

four domains; “antibiotics resources” (Q1–Q7), “antibiotics recommendations” (Q8–Q9),

“antibiotics use” (Q10–Q11), and “intention towards antibiotics use” (Q12–Q13).
Each correct response to a statement on knowledge of antibiotics was given a score
of 1, whereas incorrect or “don’t know” responses were given a score of 0. The maximum
possible score in the knowledge domain was 20. A five-point Likert scale ranging from 1 to
5 was used for scoring the attitude and practice questions. Score “1” was given for the least
appropriate answer and “5” was given for the most appropriate response. Some of the
questions were unfavorable questions, and the scores were inverted. The minimum and
maximum possible scores for the attitude section were 12 and 60, respectively. The lowest
possible score was 13, and the highest possible score was 65 for the practice section. The
scores then were transformed to a scale ranging from 0 (worst possible score) to 100 (best
possible score) with the formula (Equation (1)) [54,56]. The total score of <50%, 50-70%,
and >70% were categorized as low, moderate, and high knowledge, attitude, and practice,
respectively [28].

Obtained score − least possible score

Total Score (%) = × 100 (1)
Maximum score − least possible score

Data collection was carried out by a team of researchers supported by two assistants.
Before starting the data collection, the people conducting the survey had received adequate
briefing and training. They were informed that they were not allowed to be present while
the respondents filled in the questionnaire. However, they have guided the respondents on
how to fill in the questionnaire. The survey was conducted all day. The questionnaire was
distributed and collected after it had been filled in, usually on the same day. The preferred
respondents in this study were the heads of households. If the head of the household was
absent at the time of the visit, the questionnaire was left at the home and then collected at
the time agreed with the respondent or the oldest member of the household (above 17 years
old), who filled in the questionnaire in the case of possible prolonged absence of the head
of the household. If multiple families lived together with shared cooking and sleeping
quarters, they were considered a single household and given one questionnaire [39]. The
inclusion criteria were the general community having writing and communicating ability,
having ever used antibiotics, and being willing to participate. Having health-related
educational or occupational backgrounds was an exclusion criterion.

2.5. Ethical Issues

The study protocol received approval from the Medical and Health Research Ethics
Committee of the Faculty of Medicine of Universitas Muhammadiyah Surakarta before the
study was conducted (Reference No. 2063/B.1/KEPK-FKUMS/III/2019). The respondents
were informed verbally about the nature of this study, and they were asked to sign an
informed consent form as proof of participation in this study.

2.6. Data Analysis

Paper-based questionnaires were collected, and data were entered and analyzed
using Statistical Package for the Social Sciences (SPSS) version 21 (International Business
Machines Corporation, New York, United States). Descriptive statistics, univariate, and
multivariate linear regression statistics have been used for data analysis.
Demographic characteristic variables and responses to the knowledge, attitude, and
practice questions were analysed for descriptive statistics. Demographic data were reported
as a percentage and mean ± SD (Standard Deviation). Responses from respondents
in the form of “yes”, “no”, and “don’t know” on knowledge about antibiotics domain
were assessed descriptively by calculating the percentage of each response. To simplify
the description of attitudes towards antibiotics, the responses were combined into three
categories, namely “disagree”, “doubtful”, and “agree”. Participants’ responses about
the practice domain were assessed using the 5-Likert scale including “never”, “seldom”,
“sometimes”, “often”, and “always”.
Int. J. Environ. Res. Public Health 2021, 18, 8258 6 of 16

Because of non-normal distribution, the Mann–Whitney U test and Kruskal–Wallis

test were run to assess differences in mean scores of KAP. Mann–Whitney U test was used
for the independent variable with two groups (example: gender). Kruskal–Wallis was run
for independent variables with more than two groups (example: level of education). Linear
regression statistical analysis was used to determine the relationship between demographic
characteristics of respondents and knowledge, attitude, and practice of antibiotics usage.
Gender and area of residence were coded as a dichotomous indicator (‘female and living
in an urban area’ were set as the reference); age was coded as a continuous indicator;
marital status, educational level, and monthly income were coded as an interval scale.
The Spearman correlation coefficient correlation test was administered to determine the
correlation between knowledge and attitude, knowledge and practice, and attitude and
practice. A statistically significant difference between groups was determined at the 95%
confidence level (p-value < 0.05).

3. Results
A total of 575 questionnaires was distributed in the study area, of which 573 partici-
pants returned completed surveys. The recorded response rate was 99.6%. Respondents
were male (50.6%), female (49.4%), those from a rural area (59.7%), married (77.7%), and
ranged in age from 17 to 77 years (average: 37 ± 13). The highest percentage of respon-
dents (42.4%) were senior high school graduates, and the lowest percentage of participants
(1%) were post-graduates. A total of 77.3% of respondents had a monthly income below
the regional minimum wage. So, most people belong to poor economic conditions. The
demographic characteristics of respondents are described in Table 1.

Table 1. Demographic characteristics of respondents.

Variables Number (573) Percentage (%)

Sex
Male 290 50.6
Female 283 49.4
Age
<20 39 6.8
20–39 286 49.9
40–59 208 36.3
≥60 40 7.0
Marital status
Married 445 77.7
Single 105 18.3
Widow/widower/divorced 23 4
Level of education
No formal education to
148 25.8
elementary school
Junior high school 126 22.0
Senior high school 243 42.4
Diploma-graduate 50 8.8
Postgraduate 6 1.0
Area residence
Urban 231 40.3
Rural 342 59.7
Monthly income (IDR)
<1,600,000 443 77.3
1,600,000–3,000,000 90 15.7
>3,000,000 40 7.0
IDR = Indonesian Rupiah.

3.1. Knowledge
Most respondents (46.9%) had moderate knowledge about antibiotics (Table 2). More
than 50% of respondents answered correctly in three out of six domains: “identification of
Int. J. Environ. Res. Public Health 2021, 18, 8258 7 of 16

antibiotics” (Q1–Q3), “knowledge of antibiotics misuse effects” (Q12–Q15), and “knowl-

edge about the side effects of antibiotics” (Q16–Q17). In the domain of “Knowledge of
the role of antibiotics”, 73.12% of respondents answered that antibiotics could be used
to treat infections due to viruses and 63.35% of respondents responded that antibiotics
could reduce fever. In “antibiotics access”, more than 40% of respondents did not correctly
answer the questions “antibiotics can be bought online” and “amoxicillin can be purchased
at a pharmacy without a doctor’s prescription”. In the domain of knowledge of antibiotics
use, more than 50% of respondents incorrectly answered the questions “antibiotics need to
be stored in case of illness in the future” and “antibiotics should be stopped if the illness
has improved” (Table 3).

Table 2. The number of questions, range, score, and level of knowledge, attitude, and practice.

Level (%), N = 573

Number of Range of Total Score (%)
Variables Low Moderate High
Questions Score (Mean ± SD)
(<50%) (50–70%) (>70%)
Knowledge 20 0–100 52.98 ± 18.06 38.9 46.9 14.2
Attitude 12 0–100 57.03 ± 15.43 31.6 47.8 20.6
Practice 13 0–100 65.84 ± 17.23 16.6 45.0 38.4

Table 3. Responses to the questionnaire on antibiotic knowledge (N = 573).

Respondents’ Answer N (%)

Domain Statements Expected Ideal
Correct Incorrect Don’t know
Response
Q1. Amoxicillin is antibiotic Yes 404 (70.51) 93 (16.23) 76 (13.26)
Identification of
Q2. Supertetra is antibiotic Yes 341 (59.51) 145 (25.31) 87 (15.18)
antibiotics
Q3. Paracetamol is antibiotic No 236 (41.19) 246 (42.93) 91 (15.88)
Q4. Antibiotics can kill bacteria Yes 523 (91.27) 15 (2.62) 35 (6.11)
Q5. Antibiotics can be used to treat
No 74 (12.91) 419 (73.12) 80 (13.96)
Knowledge on the role infections due to viruses
of antibiotics Q6. Colds and flu can be cured
Yes 413 (72.08) 113 (19.72) 47 (8.20)
without antibiotics
Q7. Antibiotics can reduce fever No 136 (23.73) 363 (63.35) 74 (12.91)
Q8. Antibiotics can be bought online No 199 (34.73) 248 (43.28) 126 (21.99)
Q9. Antibiotics from other people
No 379 (66.14) 110 (19.20) 84 (14.66)
may be taken
Knowledge on Q10. Amoxicillin can be purchased at
antibiotics access a pharmacy without a doctor’s No 194 (33.86) 305 (53.23) 74 (12.91)
prescription
Q11. Antibiotics can be purchased at
No 342 (59.69) 162 (28.27) 69 (12.04)
the grocery shop
Q12. Inappropriate use of antibiotics
Yes 388 (67.71) 89 (15.53) 96 (16.75)
will cause antibiotic resistance
Q13. Inappropriate use of antibiotics
Knowledge on will cause these antibiotics not to be Yes 314 (54.80) 115 (20.07) 144 (25.13)
antibiotics usable later
misuse effect Q14. Inappropriate use of antibiotics
Yes 370 (64.57) 103 (17.98) 100 (17.45)
can cause more severe illness
Q15. Inappropriate use of antibiotics
Yes 295 (51.48) 175 (30.54) 103 (17.98)
increases costs
Int. J. Environ. Res. Public Health 2021, 18, 8258 8 of 16

Table 3. Cont.

Respondents’ Answer N (%)

Domain Statements Expected Ideal
Correct Incorrect Don’t know
Response
Q16. Antibiotics can cause allergic
Knowledge on side Yes 391 (68.24) 86 (15.01) 96 (16.75)
reactions, such as redness of the skin
effect of antibiotics Q17. Antibiotics can kill good
Yes 294 (51.31) 119 (20.77) 160 (27.92)
bacteria in the intestines
Q18.Antibiotics need to be stored in
No 208 (36.30) 309 (53.93) 56 (9.77)
case of illness in the future
Knowledge on Q19. Leftover Antibiotics can be used
antibiotics use No 353 (61.61) 163 (28.45) 57 (9.95)
again if sick
Q20. Antibiotics can be stopped if the
No 212 (37.00) 306 (53.40) 55 (9.60)
illness has improved

The mean ± SD of knowledge was 52.98 ± 18.06% (Table 2). This score was signifi-
cantly (p < 0.05) lower in men (51.47 ± 17.82%) than women (54.52 ± 18.21%) (Table 4).
Respondents with no formal education–elementary school (49.86 ± 14.23%) and respon-
dents with junior high school education (51.79 ± 15.97%) had lower knowledge scores
than those with higher background education. In addition, the knowledge score was
significantly (p < 0.001) lower among respondents who lived in rural (50.13 ± 14.54%) and
respondents who had a monthly income <1,600,000 (51.37 ± 16.08%) (Table 4). Linear
regression results showed that gender, age, area resident, educational level, and monthly
income were significantly associated with antibiotics knowledge (Table 5).

Table 4. Association of demographic characteristics and knowledge, attitude, and practice based on univariate analysis.

Variables N Knowledge (%) Attitude (%) Practice (%)

Mean ± SD p-Value Mean ± SD p-Value Mean ± SD p-Value
Gender *
Men 290 51.47 ± 17.82 0.040 55.56 ± 14.96 0.009 64.19 ± 16.89 0.012
Women 283 54.52 ± 18.21 58.53 ± 15.77 67.53 ± 17.43
Age (year) **
<20 39 53.59 ± 18.85 0.067 59.26 ± 14.18 0.133 67.56 ± 16.92 0.016
20–29 132 50.19 ± 17.74 58.12 ± 14.88 67.33 ± 17.94
30–39 154 53.25 ± 18.50 56.89 ± 13.95 65.58 ± 15.28
40–49 126 55.32 ± 19.27 58.66 ± 16.03 68.44 ± 16.42
50–60 82 55.55 ± 17.21 53.82 ± 17.18 62.39 ±18.62
≥60 40 47.88 ± 12.19 53.20 ± 17.17 59.15 ± 19.70
Area Residence *
Rural 342 50.13 ± 14.54 <0.001 54.67 ± 14.02 <0.001 63.01 ± 16.87 <0.001
Urban 231 57.19 ± 21.64 60.52 ± 16.72 70.04 ± 16.93
Marital status **
Married 437 53.00 ± 17.89 0.910 56.72 ± 15.65 0.211 65.32 ± 17.01 0.019
Single 113 53.32 ± 19.20 58.99 ± 13.63 69.26 ± 16.93
Widow/Widower 23 50.87 ± 16.21 53.22 ± 18.69 59.00 ± 20.18
Educational Level **
No formal–elementary
148 49.86 ± 14.23 0.003 52.19 ± 14.95 <0.001 60.25 ± 16.36 <0.001
school
Junior 126 51.79 ± 15.97 56.24 ± 13.40 66.64 ± 14.97
Senior 243 53.68 ± 19.38 58.37 ± 15.48 66.73 ± 17.98
Diploma-graduate 50 59.20 ± 23.35 64.78 ± 16.08 73.92 ± 16.18
Post-graduate 6 74.17 ± 14.30 74.00 ±17.14 83.67 ± 16.06
Monthly income **
<1,600,000 443 51.37 ± 16.08 <0.001 55.02 ± 14.19 <0.001 64.06 ± 16.63 <0.001
1,600,000–3,000,000 90 57.44 ± 22.50 62.47 ± 17.59 70.61 ± 18.10
>3,000,000 40 60.75 ± 23.74 66.95 ± 16.96 74.88 ± 17.23
* Mann–Whitney; ** Kruskal–Wallis test.
Int. J. Environ. Res. Public Health 2021, 18, 8258 9 of 16

Table 5. Linear regression models for knowledge, attitude, and practice domain (N = 573).

Variables Knowledge Attitude Practices

Regression Standard Regression Standard Regression Standard
p-Value p-Value p-Value
Coefficient Error Coefficient Error Coefficient Error
Intercept 39.163 3.338 <0.001 49.661 2.793 <0.001 59.430 3.147 <0.001
Gender 4.272 1.492 0.004 3.594 1.249 0.004 3.799 1.407 0.007
Age 0.137 0.063 0.030 −0.015 0.053 0.781 −0.049 0.060 0.409
Area residence 5.803 1.537 <0.001 4.006 1.286 0.002 5.471 1.449 <0.001
Marital status −0.241 1.437 0.867 −0.631 1.202 0.600 −0.758 1.355 0.576
Education level 2.392 0.836 0.004 2.423 0.699 0.001 2.413 0.788 0.002
Monthly income 3.199 1.341 0.017 4.668 1.122 <0.001 3.709 1.264 0.003

3.2. Attitude
Among the most important results on attitude (Figure 2), more than 45% of respon-
dents considered taking antibiotics to speed up recovery from a cold, and respondents
hoped the doctor would give them antibiotics. In a complementary way, 29% of respon-
dents stated that they were disappointed if the doctor did not give them antibiotics, and
35% of respondents considered buying antibiotics at the pharmacy without a doctor’s
prescription
Int. J. Environ. Res. Public Health 2021, 18, when they did not get antibiotics from the doctor. Additionally, 50% of respon-
10 of 17
dents considered stopping taking antibiotics as soon as symptoms disappeared, and 25%
of respondents stated they would keep leftover antibiotics for future treatment.

Figure
Figure 2.
2. Responses
Responses patterns
patterns to
to questions
questions about
about the
the attitude
attitude towards
towards antibiotics.
antibiotics. Data
Data presented
presented here
here is
is question-specific
question-specific
and not compared with any demographic characteristic.
and not compared with any demographic characteristic.

Scoring data(0–100)
Scoring the data (0–100)showed
showedthatthat
thethe average
average attitude
attitude score
score waswas
57.0357.03 ± 15.43%,
± 15.43%, and
and 47.8% of respondents had a moderate attitude toward antibiotics (Table
47.8% of respondents had a moderate attitude toward antibiotics (Table 2). The score was 2). The
score was significantly
significantly (p < 0.05)
(p < 0.05) lower in menlower in ±
(55.56 men (55.56than
14.96%) ± 14.96%) than(58.53
in women in women (58.53Re-
± 15.77%). ±
15.77%).
spondentsRespondents
who lived in who lived (54.67
rural areas ± 14.02%),
in rural areas (54.67 ± 14.02%),
respondents with respondents with no
no formal–elementary
formal–elementary school education (52.19 ± 14.95%) and junior high school education
(56.24 ± 13.40%), respondents with a monthly income <1,600,000 (51.37 ± 16.08%) also
had significantly (p < 0.001) lower attitude score. Statistical analysis with linear regres-
sion revealed that antibiotics attitudes were significantly associated with gender, area of
residence, level of education, and monthly income (Tables 4 and 5).
Int. J. Environ. Res. Public Health 2021, 18, 8258 10 of 16

school education (52.19 ± 14.95%) and junior high school education (56.24 ± 13.40%), re-
spondents with a monthly income <1,600,000 (51.37 ± 16.08%) also had significantly
(p < 0.001) lower attitude score. Statistical analysis with linear regression revealed that
antibiotics attitudes were significantly associated with gender, area of residence, level of
education, and monthly income (Tables 4 and 5).

3.3. Practice
Based on the questions about the practices of respondents in obtaining antibiotics,
more than 50% of respondents never bought antibiotics from the grocery store or online
and never obtained antibiotics from others. Nevertheless, 41% of respondents sometimes
bought antibiotics from a pharmacy without a prescription, 43% of respondents obtained
antibiotics from nurses, and 51% got antibiotics from midwives (Figure 3). Furthermore,
as many as 31% of respondents occasionally took leftover antibiotics when experiencing
sickness with the same symptoms. However, 35% of respondents sometimes recommended
their family members should buy antibiotics when sick, 43% of respondents took antibiotics
Int. J. Environ. Res. Public Health 2021, 18, 11 of 17
to speed up recovery from a cold, and 47% of respondents stopped taking antibiotics if
their condition improved (Figure 3).

3. The response profile

Figure 3. profile of
of antibiotics
antibiotics practices
practices among
among the
the people.
people. Data presented here is question-specific and not
compared with
compared with any
any demographic
demographic characteristic.
characteristic.

The
The data
data were
weretransformed
transformedand
andput
putonona scale (0–100)
a scale to to
(0–100) seesee
thethe
respondents’ general
respondents’ gen-
and the average practice was 65.84 ±
eral practices, and the average practice was 65.84 ± 17.23%. Practice scores were noted to
practices, 17.23%. Practice scores were noted to
be worse among men (64.19 ± 16.89%); people 50–60 years old (62.39 ± 18.62%); peo-
be worse among men (64.19 ± 16.89%); people 50–60 years old (62.39 ± 18.62%); people
ple ≥60 years old (59.15 ± 19.70%); rural people (63.01 ± 16.87%); widows/widowers
≥60 years
(59.00 old (59.15
± 20.18%); ± 19.70%);
people rural
with no people
formal (63.01 ± 16.87%); widows/widowers
education–elementary (59.00 ±
school (60.25 ± 16.36%);
20.18%); people
and people withwith no formal
a monthly education–elementary
income <1,600,000 (64.06 ± school
16.63%).(60.25 ± 16.36%);
Respondent and peo-
practices on
ple with a monthly income <1,600,000 (64.06 ± 16.63%). Respondent practices on antibiot-
ics use were significantly associated with gender, area residence, level of education, and
monthly income (p < 0.05). Females, urban people, people with higher levels of educa-
tion, and people with higher monthly incomes had better practices in antibiotics use (Ta-
Int. J. Environ. Res. Public Health 2021, 18, 8258 11 of 16

antibiotics use were significantly associated with gender, area residence, level of education,
and monthly income (p < 0.05). Females, urban people, people with higher levels of ed-
ucation, and people with higher monthly incomes had better practices in antibiotics use
(Table 4 and 5).

3.4. Correlation between Knowledge, Attitude, and Practices of Respondents towards Antibiotics
Based on the results of the graphic scatterplot, the relationship between each variable
of knowledge, attitude, and practices is linear so that the Spearman test could be continued.
Furthermore, the results of correlation analysis using the Spearman correlation coefficient
show a significantly (p = 0.001) positive correlation between each aspect of knowledge to
attitude (0.488), attitude to practice (0.638), and knowledge to practices (0.442).

4. Discussion
This study has been intended to assess the KAP regarding antibiotics use among the
general population of a regency in Indonesia using a validated questionnaire and following
WHO guidelines. The findings have shown that each aspect of knowledge, attitude, and
practice positively correlates. Our findings are consistent with previous studies [24,28]. It
implies that the better one’s knowledge, the better the attitude, and the better the practice
of antibiotics will be. Knowledge itself is not sufficient to change behavior but knowledge
plays an important role in shaping beliefs and attitudes towards certain behaviors. There is
always a correlation between knowledge, attitude, and practice concerning a particular
subject. Inadequate knowledge about antibiotics also increases the overuse or misuse of
antibiotics. We expected that the awareness program would have greater influence on
antibiotic use among the public. However, this was not shown as happening, and our
findings align with previous study results showing that respondents used antibiotics as
self-medication to treat cold, fever, flu, cough, sore throat, and pain [7,28].
Although the average literacy rate in the study area is 87.52%, almost half (45.0–47.8%)
of the respondents belong to the medium level of KAP about antibiotics. This is prob-
ably due to inadequate antibiotics information gained during schooling. For example,
respondents had not learned in detail about the role of antibiotics, access to antibiotics, and
how to use antibiotics rationally. Furthermore, the GEMA CERMAT method is carried out
continuously but not on the same respondents because of the limited number of health
workers (pharmacists). Even though a respondent might have received material about the
prudent use of antibiotics, they might have forgotten this information due to dissemination
not being carried out continuously.
A total of 46.9% of respondents to this study had a moderate level of antibiotics knowl-
edge. Of the six domains, three domains regarding the respondents’ antibiotics knowledge
showed respondents had retained information inaccurately. These areas of information
cover the function of antibiotics, how to get antibiotics, and the correct use of antibiotics.
These domains should be addressed as the focus of health education initiatives for the
general community in the future. More than 63% of respondents assume that antibiotics
can be used to treat virus infections and reduce fever. This is in line with the previous
studies in China and the United States which revealed that 79% (675/854) of respondents in
China and 57% (288/505) of respondents in the United States thought that antibiotics could
cure viral infection [25,26]. In this study, respondents thought antibiotics could be bought
online or purchased at a pharmacy without a doctor’s prescription. They also believed
that antibiotics could be stopped if illness improved and stored for future use if needed.
Another study also reported that more than 40% of respondents stopped antibiotics upon
the alleviation of symptoms [27]. In line with a previous study [25], many respondents
to our survey (45%) reported that they take antibiotics to speed up recovery from a cold
and hope doctors will give them antibiotics. This belief indicates the respondents’ inad-
equate knowledge about the action of antibiotics and when antibiotics are prescribed by
a physician. Unfortunately, sometimes physicians needlessly prescribed antibiotics [22].
Antimicrobial Stewardship Programs (ASPs) have been promoted and implemented by the
Int. J. Environ. Res. Public Health 2021, 18, 8258 12 of 16

Global Alliance for Infection in Surgery to minimize irrational antibiotic use and optimize
antimicrobial usage by applying protocol pre-prophylaxis and recommending protocols
for antimicrobial treatment of surgical infection. The interventions are both persuasive
and obligatory, including audit and feedback, expert approval, compulsory order forms,
educational materials, and outreach [57].
Insufficient knowledge of who is entitled to suggest antibiotics and where the antibi-
otics must be obtained (from a pharmacy with a doctor’s prescription) might promote
self-medication. A previous study of the Indonesian population showed that most patients
or consumers do not know that antibiotics should be obtained from the pharmacy with
a prescription. Worryingly, more than 80% of community pharmacists sold antibiotics
without a prescription [58], which is not expected as pharmacists know about antibiotics. In
another study of the population of Saudi Arabia and Kuwait, 70% and 30% of respondents
were taking self-prescribed antibiotics, respectively [27]. The same study also reported
that more than 40% of respondents obtained antibiotics from the pharmacy without a
doctor’s prescription. Surprisingly, more than 50% of respondents obtained antibiotics
from midwives and nurses. According to Indonesian regulations, antibiotics can only be
obtained in pharmacies with a doctor’s prescription [35].
Here, knowledge is not the central factor in the overuse of antibiotics; instead, attitude
and practice are significant factors as pharmacists, nurses, and midwives are aware of
antibiotics. Therefore, the government should implement strict regulations, and monitor
self-medication, and control the sale of medicines not intended to be available over the
counter. However, the reality is that our survey shows practices are not following the
laws and regulations in Indonesia. Furthermore, as health workers, physicians, nurses,
and midwives must provide education and health services within their competencies,
further research is required regarding the factors that affect pharmacies’ administration of
antibiotics without a doctor’s prescription, or a note from a nurse or midwife.
We have reported that people of high socioeconomic status, those with higher educa-
tion levels, those living in urban areas, those with higher incomes, and those who are female
are likely to have better knowledge, attitude, and practice of antibiotics use. A previous
study has discovered that females, older respondents, those who were college-educated
or had higher education, and those with a healthcare-related occupation or education
were likely to have better knowledge, more appropriate attitudes, and better practice of
antibiotics usage [24,59]. In contrast, inappropriate antibiotics were associated with males,
younger respondents, and those who were married [25]. In addition, those who live in
urban areas tended to be more health aware due to having better access to information and
better exposure to community health-awareness programs [27].
The findings of this study would be helpful as the baseline for the future develop-
ment of more effective public-education initiatives to improve knowledge, attitudes, and
practices regarding antibiotic use among the general public. These findings could be an
excellent platform for researchers to identify which areas need to be prioritized, create
appropriate material for education, and choose the most suitable education methods so
that the interventions given will be more focused, more on target, and more effective.
The respondents’ knowledge, attitude, and practice show gaps regarding antibiotics role,
antibiotics access, antibiotics use, and intention or reason for antibiotics use. Therefore,
these areas should be made priority considerations in further educational programs. Males,
those with low educational levels, living in rural areas, and having low income are more
prone to overuse or misuse of antibiotics and should be the main target in subsequent
educational programs.
Campaigns and education initiatives on the prudent use of antibiotics should always
be carried out for the general population and health workers, including doctors, phar-
macists, nurses, and midwives. There have been frequent seminars for pharmacists and
doctors on the importance of the rational use of antibiotics. Meanwhile, there have not
been many similar seminars for nurses and midwives, so it is necessary to conduct sem-
inars on the prudent use of antibiotics for nurses and midwives. Moreover, controlling
Int. J. Environ. Res. Public Health 2021, 18, 8258 13 of 16

the distribution of antibiotics and applying drug regulation strictly for health workers
requiring them to work within their competence and enforcing statutory regulations need
to be more encouraged.
To the best of our knowledge, this is the first study in Indonesia that investigated the
KAP towards antibiotics among the general population after the implementation of the
national awareness program (GEMA CERMAT) intended for reducing ABR. This study has
assessed and identified the levels and associated factors of KAP of antibiotics use among
the public. The findings of this study might help the government to redesign policy and
evaluate the implementation of Indonesian ABR control programs.

5. Strengths and Limitations of this Study

Respondents in this study included respondents who live in urban and rural areas
with various ages, levels of income, and levels of education so that this study’s results
could be seen as able to represent the whole population. Furthermore, the sampling of
this study was conducted by visiting households one by one and talking face-to-face with
the respondents. So, the response rate obtained was high (99.96%). Collecting face-to-face
questionnaires allows researchers to double-check if the questionnaire has been completely
filled in by respondents and to cross-check the questionnaire answers to minimize missing
data. On the other hand, when filling out the questionnaire, some respondents were not
taking antibiotics. So, they had to remember when they used antibiotics last, which may
open a recall bias.
Furthermore, some respondents were not familiar with the word “antibiotics” but
were more familiar with amoxicillin. Therefore, terminology might cause bias and make
the score of the “identification of antibiotics” domain higher because when recruiting
and identifying whether respondents met the inclusion criteria (ever used antibiotics),
we changed the word “antibiotics” to “amoxicillin”. Hence, respondents answered the
question quickly that “amoxicillin is antibiotics”.
Furthermore, because the self-administered questionnaire was conducted and the data
were taken in the same household, there is a possibility that respondents who answered
questions together caused each other to give similar responses. In addition, this study
was only administered in one regency. These results may not be generalized to the whole
Indonesian population because Indonesia consists of many islands/regencies with different
ethnicities and cultures. Further study is suggested on this subject, looking at the different
islands/regencies of Indonesia with the same/different demographic characteristics.

6. Conclusions
This survey has laid a foundation to better understand the knowledge, attitude,
and practice of antibiotics after the implementation of the Gerakan Masyarakat Cerdas
Menggunakan Obat (GEMA CERMAT) program by the Indonesian Government in 2015. To
the best of our knowledge, this is the first survey conducted after an antibiotics’ awareness
program was implemented nationwide. Still, we found that most respondents did not
understand the correct function of antibiotics, antibiotics access, and the use of antibiotics.
The findings of this study are essential as they provide valuable information to develop an
intervention in public-health promotion to improve knowledge, attitudes, and practices
towards antibiotics among the general public and will help policymakers tailor and design
effective multifaceted interventions to improve prudent use of antibiotics in future.
Here, we suggest some interventions that could be immediately implemented na-
tionwide to achieve the goal of sustainable healthcare and halt the spread of the ABR
directly or indirectly. These are: (i) auditing the prescription of antibiotics; (ii) continu-
ing public-education programs with the aim of not only increasing knowledge but also
improving attitudes and practices in the use of antibiotics; (iii) targeting healthcare profes-
sionals (pharmacists, nurses, and midwives) in prohibiting the dispensation of antibiotics
beyond allowed areas of authority; (iv) highlighting the role of healthcare professionals
(pharmacists, nurses, and midwives) in health education and the promotion of appropriate
Int. J. Environ. Res. Public Health 2021, 18, 8258 14 of 16

antibiotics use by the public; and (v) controlling antibiotics distribution by applying strict
antibiotics regulations.

Supplementary Materials: The following materials are available online at https://www.mdpi.com/

article/10.3390/ijerph18168258/s1, Table S1. Knowledge, attitude, and practices towards antibiotics
questionnaire (KAPAQ).
Author Contributions: Conceptualization, H.K., M.A.A.H. and S.S.; Data curation, H.K. and W.I.I.;
Formal analysis, H.K. and W.I.I.; Funding acquisition, M.A.A.H. and T.T.; Investigation, H.K. and
W.I.I.; Methodology, H.K., M.A.A.H. and S.S.; Project administration, W.I.I. and T.T.; Resources, S.S.
and T.T.; Supervision, M.A.A.H., S.S. and T.T.; Visualization, H.K. and M.S.H.; Validation, M.A.A.H.;
Writing—original draft, H.K., W.I.I. and M.S.H.; Writing—review and editing, H.K., M.S.H., M.A.A.H.,
S.S. and T.T. All authors have read and agreed to the published version of the manuscript.
Funding: This study funded by the Universitas Muhammadiyah Surakarta (Reference No. 565/A.3-
II/BPSDM/VII/2018).
Institutional Review Board Statement: The study protocol received approval from the Medical and
Health Research Ethics Committee of Faculty Medicine of Universitas Muhammadiyah Surakarta
before conducting the study (Reference No. 2063/B.1/KEPK-FKUMS/III/2019).
Informed Consent Statement: The respondents were informed verbally about the nature of this
study, and they were asked to sign the informed consent form as proof of participation in this study.
Data Availability Statement: Data is contained within the article or Supplementary Material.
Acknowledgments: The authors would like to thank all participants who responded to this study.
Conflicts of Interest: All authors declare no conflict of interest.

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