A Survey of Community Perceptions and Knowledge Toward Antibiotic Resistance: Case Study in Magelang, Indonesia

. One of the main causes of antibiotic resistance is the unprescription dispensing of antibiotics, which can result in the improper use of antibiotics. The purpose of a self-administered questionnaire-based study was to gauge participants' understanding and opinions regarding antibiotic resistance. In October 2019, a cross-sectional descriptive survey was self-administered to individuals. For this survey, Total of 455 respondents were used. Respondents who were residing in Magelang, spoke Indonesian, and were older than eighteen were the inclusion criteria. Six sections made up the questionnaire: demographic information; five questions about general antibiotic resistance information; five questions about the advantages of antibiotics; three questions about prescription antibiotics; four questions about using antibiotics personally; and five questions about antibiotic knowledge. Data analysis were used SPSS version 21, research data is treated as a descriptive analysis. The results show that majority of respondents have the perception that antibiotics are the best choice for treating fever (26.5%), 72.3% of participants are aware of antibiotic resistance. Furthermore, 53.8% of respondents said they completely trusted medical experts' advice. Health professionals have a greater responsibility to alert the public about antibiotic use and resistance. In conclusion, it is important to increase knowledge about antibiotic resistance because it concerns the general public's opinion regarding antibiotic resistance and their level of awareness of the risks associated with it. Ultimately, this can change people's attitudes and actions to use antibiotics wisely. Kkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkk


Introduction
Antibiotic resistance is one of the biggest health threats in the world, especially in developing countries including Indonesia [1].The negative effects of antibiotic resistance are the increasing mortality rates, requiring longer time for therapy, decreasing functionality and the need for post-acute care [2].Approximately 0.7 million deaths/year are caused by antibiotic problems and it is expected to exceed 10 million by 2050.This report shows the alarming spread of antibiotic resistance worldwide [3].A research conducted in Indonesia showed that of 781 patients in the hospital, 81% of them had resistance with ampicillin, 73% resistance with cotrimoxazole and 56% resist against Escherichia coli [4].This study was supported by research conducted by Huda in 2016, it was confirmed that Escherichia coli was the most resistant to Sulfamethoxazole (100%), Ampicillin (93.3%) and  Corresponding email: prasojopribadi@unimma.ac.idCefadroxil (90.9%) [5] and another study conducted by Kibret in 2011 at northeast Ethiopia found that high levels of resistance to erythromycin (89.4%), amoxicillin (86.0%) [6].
Factors influencing antibiotic resistance are improper use of antibiotics, a low level of patient knowledge in the use of antibiotics such as using antibiotics for handling viruses like colds, cold coughs, and fevers.Patients with high income usually ask to be given antibiotic therapy at a high price, new and without a doctor's prescription even though it is not necessarily used, whereas patients with low income are often unable to continue the therapy with antibiotics.Massive sales and commercial promotions from pharmaceutical companies supported by the influence of globalization, would facilitate the exchange of goods and the number of antibiotics circulating in the wider community so it is easy to get antibiotics.The use of monotherapy is easier to cause resistance compared to the use of combination therapy.Based on research conducted by Bish et al (2009), it is stated that research in the discovery of new antibiotics is still small, the supervision carried out by the government in the distribution of antibiotic use is weak, and there is a lack of commitment from related agencies to improve drug quality and infection control [7].
Several studies in Europe showed that the increasing antibiotic resistance is related to high use in the community.It is caused by irrational use of drugs and lack of education about antibiotics for patients [8,9], while several studies in developing countries showed The high use of antibiotics without a prescription.Widayati on her research, stated that 324 respondents, namely 58.00%, out of 559 respondents do not consult with doctors and use antibiotics to treat symptoms of the disease and using antibiotics without a prescription for the past one month, they are about 7.30% [10,11].The global action plan outlines five strategic goals, including raising public awareness and understanding of antimicrobial resistance, strengthening knowledge via research and surveillance, lowering infection rates, maximizing the use of antimicrobial agents, and guaranteeing ongoing funding for the fight against antimicrobial resistance [12].Moreover, the National Action Plan Antimicrobial Resistance (AMR NAP) Indonesia was created with five strategic goals in mind: raising awareness and comprehension of AMR through efficient communication, instruction, and training; fortifying the body of knowledge and evidence via research and supervision; decreasing the frequency of infections related to sanitation, hygiene, and preventive infections; optimizing the use of antimicrobial drugs in human and animal health; and creating business cases for sustainable investment and boosting spending on novel medications, medical equipment, immunizations, and other interventions [13].
Based on research conducted by Carter in the United State, it was found that people were aware of antibiotic abuse associated with antibiotic resistance.However, many people do not consider it is as an important issue [14].Several studies related to the knowledge of antibiotics have been conducted in Putra Jaya, Malaysia.It showed a low level of knowledge of the community in the area of antibiotics [15].Another study done in Malaysia showed that 43% respondents have good knowledge [16].Similar research is limited in Indonesia.Research conducted by Khoirunnisa stated that the knowledge, perceptions and beliefs of the Indonesian people on antibiotics were still very low.Some efforts should be made to increase their knowledge and understanding of antibiotics [1].There are many studies conducted in Indonesia investigating knowledge of antibiotic use, only a few of those links it with antibiotic resistance.Knowledge about how to use antibiotics is not enough if it is not balanced with awareness of the dangers of antibiotic resistance.Knowledge of antibiotic resistance can foster awareness to change people's behavior in using antibiotics properly.Therefore, this study aims to examine people's perceptions and knowledge about antibiotic resistance in Central Java, Indonesia.

METHOD
This study was carried out in October 2019 using a cross-sectional survey methodology.Descriptive analysis was employed in the research design to evaluate Central Javans' perceptions and level of knowledge regarding antibiotic resistance.In this study, 455 respondents were used.Respondents who were at least eighteen years old, spoke Indonesian, and lived in Central Java met the inclusion requirements.Data collection was done using questionnaire which consists of six parts.The first section contains demographic data including gender, age, education level and occupation.The second part contains five questions regarding general information about resistance.The third part contains five questions regarding the benefits of antibiotics.The fourth part contains three questions regarding antibiotic prescription.The fifth section deals with the personal use of antibiotics.The sixth part contains five questions related to antibiotic knowledge.The questionnaire was adapted from Carter [14].The respondents were asked to rate on a 4-point Likert scale from 1 (fully disagree) to 4 (fully agree) the degree.A pilot study was conducted on 10 respondents to find out the simplicity and clarity of the questionnaire.Furthermore, it is done with the aim to detect the ambiguous language and the level of understanding of respondents.Research data is processed in the form of analysis descriptive using SPSS version 21 software.

RESULTS
Table 1 shows the demographic profile of the respondents.A total of 455 respondents' data was processed in this study.The majority of respondents in this study were women (69.9%), while male respondents were 30.1%.Respondents aged 18-29 years dominate in this study with a percentage of 91%.The most educational level of respondents were senior high school students (62.9%).The majority of respondents have an income level of less than 1,500,000 Indonesian Rupiah (IDR) with a percentage of 65.1%.The knowledge about symptoms that can be relieved by antibiotic and knowledge of antibiotic resistance are shown in Table 2.More than 10% of respondents believed that antibiotics are the best choice to treat fatigue (5.5%), cough (8.8%) fever (26.5%) and runny nose and sore throat (25.5%).In the source section of the information obtained by respondents regarding antibiotic resistance including medical professionals are the most common source of information (38.24%).Furthermore, to hearing that information from medical professionals, there are several other sources that are often used is the internet (20.88%) and others (14.95%).The results of the study on the assessment of people's knowledge and perceptions in Central Java are shown in Figure 1.It was found that a total of 256 (56.30%) of respondents acknowledged that inappropriate use of antibiotics could encounter the development of antibiotic resistance.The most of respondents agreed that antibiotic resistance was a problem in the hospital (43.1%).The majority of respondents agreed if resistant bacteria could infect them or their family members (37.1%).Most of respondents strongly agreed that antibiotic resistance was a significant problem (47%).A total of 33% of respondents agreed that the use of fewer antibiotics would reduce antibiotic resistance.
Similar with previous studies which stated that resistance to antibiotics can be prevented by stopping antibiotics as soon as they feel healed [17].Moreover, a total of 36% respondents agreed that the use of antibiotics for livestock caused resistant bacteria in meat that could make people sick.However, 10.1% respondents strongly disagreed.Shown in Figure 2 most of the respondents (53.8%) in this study trusted their doctors or nurses advice about the need for antibiotics to be consumed or not.This was reinforced by the community's assumptions in the next statement, there were 41.3% respondents who assumed that doctors or nurses have adequate knowledge about antibiotic resistance.Figure 3 Shown in 44.5% of the respondents agreed that antibiotics can kill bacteria.This is supported by finding that 45.9% respondents agree if antibiotics can kill bacteria where they normally live on the skin and in the intestine.The majority of respondents (51.9%) agreed if they had to take antibiotics which had been prescribed.Total of 40.9% respondents disagreed if there was no relationship between taking antibiotics and developing bacterial resistance.Most respondents (47.3%) disagree if there is no problem on how long antibiotics are taken.

Fig. 4. Knowledge of Antibiotics (n=455)
The results of this study showed that 44.55% of respondents agreed with the statement that antibiotics can kill bacteria.In addition, 38.9% of respondents agreed that antibiotics can kill viruses (Figure 4).

DISCUSSION
Most of the respondents believed that several symptoms can be relieved by antibiotics.Only about 10% of respondents believed that antibiotics are the best choice to treat fatigue (5.5%), cough (8.8%), fever (26.5%), runny nose and sore throat (25.5%).The same results were mentioned in previous research conducted by Dadari which found that as many as 25.27% of respondents believed that antibiotics are used to treat fevers, colds, bacterial and viral infections [18].Meanwhile, antibiotics are used to kill bacteria or prevent bacterial proliferation [19,20].Therefore, it can be seen that public knowledge about the use of antibiotics is sufficient.Public knowledge should be increased because inadequate knowledge can lead to misunderstandings and inappropriate use of antibiotics.This may contribute to antibiotic resistance [18].The result show, there are 72.3% of respondents who know the term antibiotic resistance.Moreover, 43.7% of respondents said that they had never heard of the term before.The similar study conducted in Jordan stated that 70% of respondents were unaware of the term "antimicrobial resistance" [21].In this study, most of respondents chose medical professionals as a source of information about antibiotic resistance.These results are supported by WHO, which reported that doctors or nurses are a great source of information on antibiotic resistance for respondents [22].
The assessment of people's knowledge and perceptions found that 56.30% of respondents BIO Web of Conferences 75, 05002 (2023) https://doi.org/10.1051/bioconf/20237505002BioMIC 2023 acknowledged that inappropriate use of antibiotics could encourage the development of antibiotic resistance, whereas there were 5.1% of respondents stated disagree with the statement.One of the factors causing improper use of antibiotics is dispensing antibiotics without a prescription.According to Canton, the improper and excessive use of antimicrobials contributes to the persistence of resistant bacteria [23].Approximately, 196 (43.1%) of our respondents also agreed that antibiotic resistance was a problem in the hospital and 19 (4.2%) our respondents disagreed about this.In previous studies there were also 69% of respondents considered it a problem in their hospital [24].Out of 455 respondents, 35 (7.7%) respondents disagreed if resistant bacteria could infect them or their family members, however 169 (37.1%) respondents agreed with the statement.A total of 215 of our respondents strongly agreed that antibiotic resistance was a significant problem while as many as 13 (2.9%)respondents disagreed if antibiotic resistance was considered a significant problem.These findings are similar to survey reported in India which stated that 25% (125/500) of patients knew about the development of bacterial resistance to antibiotics & which could be fatal to themselves and even their family members and 47% (235/500) the patient is not aware about it [25].
This research found that 33% of respondents agreed that limiting antibiotic use could reduce antibiotic resistance and there were still 9.9% of respondents who disagreed that reducing antibiotic use could minimize antibiotic resistance.Similar with previous studies which stated that resistance to antibiotics can be prevented by stopping antibiotics as soon as they feel healed [17].A total of 36% of the respondents agreed that the use of antibiotics for livestock caused resistant bacteria in meat that could make people sick.Referring to Hadi's research the spread of resistant bacteria comes from fisheries, hospitals, livestock and household waste [26].According to Thapa (2014) and Usui (2014) reported that in the Indonesian traditional market found 16% of samples of chicken meat infected with listeria monocytogenes and most of these isolates showed multi-drug resistance especially against penicillin, ampicillin, and erythromycin [27,28].
Most of respondents in this study trusted their doctors or nurses about the need for antibiotics to be consumed by them (53.8%).This was reinforced by the community's assumptions in the next statement, there were 41.3% respondents assumed that doctors or nurses have adequate knowledge about antibiotic resistance.The consistent finding was also conveyed by Chan's study, were found 84% of respondents agreed to take antibiotics on time according to doctor's instructions.This shows that adequate knowledge from health workers can lead to confidence for patients to be obedient in taking antibiotics [29].The community considers that the knowledge and competence possessed by health workers can explain the rational use of antibiotics, because health workers are able to provide knowledge about side effects, pharmacological effects, drug interactions, and how to use them.In addition, information from doctors and pharmacists is also needed to support patient compliance in rational antibiotic use [30].
The majority of respondents (51.9%) agreed if they had to take antibiotics that had been prescribed.A total of 40.9% of the respondents disagreed and 9.9% agreed if there was no relationship between taking antibiotics and developing bacterial resistance.Most of respondents (47.3%) disagree if there is no problem how many days antibiotics are taken.These results are in accordance with previous studies, which stated that most of respondents from 5 hospital districts in Indonesia correctly answer that taking antibiotics should be regular.General guidelines to take antibiotics is every day until they run out; If the patient condition has improved, the dose of antibiotics taken should remain the same until all antibiotic tablets are used up [17].
The results in this study, there are 44.5% of respondents agreed with the statement about antibiotics can kill bacteria, and 38.9% of respondents agreed that antibiotics can kill viruses.Similar results were mentioned in a study conducted by Robert, there are 66% of patients answered correctly to the statement: "Antibiotics can be used to treat bacterial infections" and 31% of patients also believed antibiotics to be effective against viruses.Overall, 44% of patients knew that antibiotics were effective against bacteria and ineffective against viruses [31].The antibiotics could kill viruses is a false statement because antibiotics are not effective against viruses [32].A survey in Europe shows that 57% of Europeans and 35% of French people think that antibiotics are effective against viruses and they don't know if antibiotics are not effective against viral infections [33].The limitation of this study lies in the small number of samples, data obtained from one region, therefore this result cannot generalized.

CONCLUSION
This research shows that the majority of respondents have the perception that antibiotics are the best choice for treating fever (26.5%).As many as 72.3% of respondents understood the term antibiotic resistance.The majority of respondents also understand that inappropriate use of antibiotics can encourage the development of antibiotic resistance (56.39%) and 53.8% of respondents trusted doctors or nurses to handle the need for antibiotics to be consumed.In addition, a total 44.5% of the respondents agreed that antibiotics can kill bacteria.

Table 2 .
Knowledge about Symptoms can be Relieved by Antibiotic, Knowledge of Antibiotic Resistence, and Fig. 1.Knowledge and Perception about Antibiotic Resistance and Preservation of Antibiotic Efficacy (n=455)