1. Identifying key beliefs of self medication with antibiotics in Yogyakarta City Indonesia (by applying the Theory of Planned Behavior) Aris Widayati 1,3,4, Sri Suryawati 2, Charlotte de Crespigny 3, Janet E. Hiller 4,5 1 Faculty of Pharmacy Sanata Dharma University Yogyakarta Indonesia 2 Faculty of Medicine Gadjah Mada University Yogyakarta Indonesia 3 School of Nursing, 4 School of Population Health and Clinical practice University of Adelaide Australia 5 Faculty of Health Sciences Australian Catholic University Australia Presented at the 3 rd ICIUM 2011 (International Conference for Improving Use of Medicines), Antalya Turkey, 14 – 18 November, 2011

2. Background Slide 1 Self medication with antibiotics (SMA) antibiotic resistance (WHO, 2001) Indonesia: Antibiotics are prescription– only medicines People may purchase antibiotics without prescription (Hadi, 2008) Strategies to improve the use of antibiotics health practitioners (Norris, 2007). Investigation about individual’s behaviour related to SMA is required

3. Theoretical framework: Theory of Planned Behavior (Ajzen, 1991) Slide 2 Intention to SMA Behavioral beliefs (BB) X Outcome evaluation (OE)= Attitude Normative beliefs (NB) X Motivation to comply (MC)= Subjective norm Control beliefs (CB) X Power of control beliefs (P) = Perceived Behavioral Control (PBC) SMA Behavior Figure: TPB framework

4. Objectives and methods Slide 3 Exploring beliefs about SMA:  Behavioural  advantages  disadvantages  Normative  approval  disapproval  control  facilitator  barrier Identifying beliefs affecting intent to SMA Mixed methods  TPB questionnaire  Cluster random sampling  Analysis (n=283):  descriptive statistics  logistic regression  In-depth interview: 25 respondents  Thematic -content analysis  to develop TPB questionnaire Adults (over 18 years) Phase 1 Phase 2

5. Beliefs regarding SMA reported by respondents (Findings of the interviews – Phase 1) Slide 4 Behavioural beliefs Advantages of SMA:  Saving time  Saving money  Avoiding over- prescription Disadvantages: Concerns about:  side/adverse effects,  antimicrobial resistance,  misdiagnosing,  inappropriate antibiotics selection Normative beliefs Approval for SMA practice:  families + friends, particularly with health education / industry background,  pharmacy staff Disapproval:  doctors (GPs). Control beliefs Factors that facilitate SMA:  availability of antibiotics over-the- counter;  sucessful experience in using antibiotics;  perception about similar antibiotics prescribed by doctors;  respondents’ knowledge about antibiotics Barriers of SMA:  medication for children

6. Overall results of the survey (Phase 2 )  Attitude: respondents negatively evaluated SMA practice  Subjective norm: respondents expressed no social pressure to practice SMA  Perceived behavioural control: respondents reflected a negative control of doing SMA -  SMA is quite tricky Slide 5

7. Beliefs that affect intent to SMA  Respondents are more likely to intend to SMA if: they have successful experience in using antibiotics; OR=0.32 (0.16 – 0.66) They purchase antibiotics without prescription from outlets other than kiosks ; OR=0.15 (0.03 – 0.81). Slide 6

8. Implications Policy: Enhancing public awareness regarding the risks of SMA Strengthening regulations regarding antibiotics supply and distribution Improving prescribing policies Practice:  Health messages to public should focus on disadvantages of SMA  Health practitioners should improve the provision of information about the safe use of antibiotics Slide 7

9. Lessons learnt The Theory of Planned Behavior framework + mixed methods are useful to explore individual factors regarding SMA behavior.  Developing the TPB questionnaire is time consuming.  Potential biases should be considered in future research, such as:  Self-report responses,  Inclusion criteria of sample. Slide 8

10. Specific studies for future research agenda  In-depth interview with a group of the surveyed population:  to explore underlying factors of SMA practice  Focus group discussion with stake holders and policy makers:  to formulate strategies regarding policy and practice for improving the safe use of antibiotics. Slide 9

11. References 1.WHO, WHO global strategy for containment of antimicrobial resistance, 2001, Switzerland: WHO. 2.Hadi U, et al: Survey of antibiotic use of individuals visiting public healthcare facilities in Indonesia. International Journal of Infectious Diseases, 2008, 12:622-629. 3.Norris, P., Intervention to improve antimicrobial use: evidence from ICIUM 2004, 2007, Switzerland: WHO Press. 4.Ajzen, I., The Theory of Planned Behavior. Organizational Behavior and Human Decision Process, 1991. 50: p. 179- 211. 5.Tashakkori, A. and C. Teddlie, Eds. (2003). Handbook of Mixed Methods in Social and Behavioral Research. California, Sage Publications Inc. Slide 10

12. Acknowledgements and funding  This is a component of the first’s author PhD thesis in the School of Population Health and Clinical Practice University of Adelaide Australia.  Research funding: the Ministry of Education, Indonesia (DIKTI Scholarship).  Travel funds: the WHO-SEARO.  Acknowledges:  Colleagues at the Centre of Clinical Pharmacology and Drug Policy Study Yogyakarta;  Writing Group at the Faculty of Pharmacy Sanata Dharma University Yogyakarta Indonesia;  The Public Health Thesis Writing Group at the University of Adelaide.  Findings of the phase 1 had been presented at the 4 th Asia- Pacific ISPOR at Thailand; travel funds: The University of Adelaide Australia.