The efficacy of social cognitive theory-based self-care intervention for rational antibiotic use: a randomized trial

The efficacy of social cognitive theory-based self-care intervention for rational antibiotic use:... Abstract Background Misuse of antibiotics can be described as a failure to complete treatment, skipping of the doses and reuse of leftover medicines and overuse of antibiotics. Health education interventions are expected to enhance awareness and general belief on rational antibiotics use. Therefore, the study aimed to determine the efficacy of social cognitive theory (SCT)-based self-care intervention for rational antibiotic use. Methods This randomized trial was conducted in a sample of 260 adults. The study participants were randomly assigned as the intervention (n=130) and a control (n=130) groups. The intervention group received self-care educational intervention of four sessions lasting 45–60 min augmented with the text messages and the control groups attended usual education program in health centers. The study participants were invited to complete questionnaires at the baseline and end of the intervention. The data were analyzed using SPSS version 23.0. Chi-square (X2), independent t-test and covariance analysis were used for data analysis. P<0.05 was considered statistically significant. Results After the intervention, all SCT constructs revealed significant differences in the intervention group compared with control groups (P<0.001). Awareness and general beliefs of rational antibiotic use showed a significant difference in intervention group before and after six months (P<0.001) whereas in control group no significant differences (P>0.05). Conclusion The study suggested that tailored appropriate educational programs based on SCT constructs can reflect a positive impact on appropriate antibiotics use. Therefore, a tailored health promotion intervention should be provided to enhance the awareness and general beliefs of the target groups. Introduction Inappropriate use of antibiotics among the general population has been largely outlined as a public health problem. Appropriate use of antibiotics reduced morbidity and mortality in many countries. Misuse of antibiotics can be described as a failure to complete treatment, skipping of doses, reuse of leftover medicines and overuse of antibiotics.1 Misconceptions of antibiotics use can pose the harm of inappropriate self-medication.2 The bactericide nature of antibiotics and its strong power to relieve the disease and the symptoms, the use of non-prescribed antibiotics lead to antibiotic resistance.3 Some studies revealed lack of knowledge in antibiotics worldwide.2–7 A lack of public awareness about safe and appropriate antibiotics use can lead to incorrect general beliefs and unreal demand.8,9 Unnecessary use of antibiotics reported as the main reason for antibiotics resistance which can affect excess health care costs.1 As stated in some US and European studies, the inappropriate use of antibiotics leads to antibiotics resistance and additional hospital days.10–12 Despite the massive resources and intensified interventions, the desired behavioral change was not yet attained to calm the problem of the rational use of antibiotics.12 Theories and models help to explain the process that individuals go through changes as they exchange information and as they interpret and react to different messages. Thus, this study used SCT as a conceptual framework to behavioral management and best describes human behavior through a triadic mutual causation (behavior, environment and personal factors).13–15 Furthermore, SCT used to give tailored health education and health promotion interventions focusing on knowledge and general beliefs as individual-level factors for behavior change (antibiotic use). Therefore, the aim of this study was to determine the efficacy of social cognitive theory based self-care intervention programs for rational antibiotic use. Methods Study design, populations and sample A randomized intervention trial was conducted in south health centers affiliated to Tehran University of Medical Sciences (TUMS), Tehran, Iran as of September 2016–October 2017. The study populations were adults who attended health centers to obtain routine health services. Outpatient clients of age between ≥25 years and ≤56; and lack of confirmed mental disorders were considered as inclusion criteria. Whereas, the exclusion criteria were those patients who were included in the same study in one of the health facilities but may potentially be referred to another to avoid double counting. Participants who did not attend more than two educational sessions or unable to hear and speak were excluded. A sample size of 260 participants participated in this study. We evenly distributed the samples into intervention and control groups. The included sample size was considered a minimum significance in increasing the explanation of independent variables, and a power of 80% with a 0.05 two-sided significant level. The final sample size was selected using systematic random sampling method. Randomization Randomization was carried out using a computer program by the investigators. The different health centers were alphabetically coded (A, B, C, D and so on) and a participant attached to each health center was given numerical codes (e.g. participants in health center Y were numbered Y001, Y002, Y003 and so on. Participants in the randomized trial were assigned 1:1 to the intervention and control arms under restricted randomized design after informed consent and collection of baseline data. The allocation sequence was generated and released to the interventionist on a case-by-case basis by another independent department specializes in generating research random sequence. Interventionist, data collectors, statistician were not the same persons. Interventionists also acknowledge all those contacted were in the intervention arm. But anonymous responses were entered into the database by a person unconnected with the project. Measurement and variables The investigators widely searched the literatures related to the study for the development of the questionnaires. Then, questionnaires were adapted and developed by principal investigators. A pretested, structured and translated questionnaires adapted from various studies of rational use of antibiotics based on the constructs of SCT was used as instrument for this study. The translation was made from English language into Persian language (local language) and back translated to English version by different individuals who were blind to the original version of the questionnaires. The instrument comprises four parts. Part I: socio-demographic and health-related variables (eight items), part II: the researchers-made questionnaire based on the SCT (40 items), part III: study outcome measures including awareness (five items) and part IV: general beliefs (three items) and about appropriate antibiotics use. SCT constructs questionnaires were 40 items. Various items that measure respondent’s hold belief concerning the effects of a given seriousness of condition had measured by summed score of related belief items on five-point Likert scale from Strongly Agree to Strongly Disagree. The validity was confirmed by 10 experts in pharmacology and health education and promotion fields. Reliability was tested using test–retest reliability scale which assured the sameness of results in each measure by different subjects at different times. To perform test–retest, a sample of 30 individuals attended South Health Centers affiliated to TUMS was selected. The Cronbach’s alpha was calculated for knowledge and situational perception (0.90), outcome expectations (0.79), values expectation (0.96), self-efficacy overcoming impediments (0.81), goal-setting self-control (0.87), environment (0.95), emotional coping (0.89) and perceived barriers (0.90). The total Cronbach’s alpha was 0.89. Validity and reliability of five-items awareness and three-items general belief about appropriate antibiotics use were confirmed by Nafisi et al. study.16 Participant requirement and intervention With regard to requirement, participants who were potentially eligible for the study were listed, and each individual was invited to participate in the study through oral invitation or phone call performed by investigators. An appointment was made if the person agreed to participate. Following an oral informed consent, patients who are eligible as a participant randomly were assigned as intervention and control groups. Participants in both groups were invited to complete the questionnaires at the baseline and at six months after the end of intervention. Both intervention and control groups have attended the regular health education in the health center. In addition, the intervention group received the self-care educational program based on SCT constructs in four sessions lasting 45–60 min in every two weeks for three months. Moreover, text messages were sent as a reminding and boosting after intervention that serves as a quick reference to the education. The content of educational programs included basic information and awareness and general beliefs of the threat of the antibiotic resistance and the importance of appropriate antibiotic use, overuse (means unnecessary use for viruses or colds), tips for proper storage of antibiotics, antibiotics complications and side effect. The self-care based on SCT constructs such as knowledge and situational perception, outcome expectations, values expectation, self-efficacy overcoming impediments, goal setting in self-control, environment, emotional coping and perceived barriers. Appropriate educational strategies such as lecturing, question and answer, setting achievable goals, role play and motivational interview were used to increase knowledge and general beliefs about antibiotics use based on SCT constructs. The trainers have followed an approved lesson plan to provide educational information. The trainers were health pharmacists and skilled nurses who had at least bachelor degree. The theoretical framework of the study was based on SCT to provide an opportunity to improve social and cognitive portion for participants; i.e. learning as a part of how society think and act on the appropriate antibiotics use. Moreover, cognitive portion addressed the effective contribution of thought processes regarding awareness and general beliefs about appropriate antibiotics use of participants’ motivation, attitudes and action in order to take care of general health. Control group attended only the standard health center-based education. After six months of the educational intervention, both groups filled the same questionnaire. SCT constructs, awareness and general beliefs were considered as the primary and secondary outcome measurements, respectively. Data analysis Data were analyzed using SPSS version 23.0. Descriptive statistics were calculated using mean and standard deviation for numerical variables, frequencies and percentages for categorical variables. Independent t-test and covariance analysis were used to compare independent variables and the outcomes of interest between and within groups. The significance level was considered as P < 0.05. Ethical consideration The protocol was ethically approved by TUMS educational board with application number IR.TUMS.REC.1395.553 on 4 September 2016 and registered Iranian Registry of Clinical Trials (IRCT ID: IRCT2016092412460N11). All the study participants were given detailed information about the study and written consent before participation. To ensure privacy and confidentiality, no names and identification number was written on the questionnaire. Results A total sample of 260 participants completed pre- and post-education questionnaires with a response rate of 100% (n = 260). Accordingly, the majority of participants were women [69.2% (n = 180)], and almost half of participants had education in college or more [57.3% (n = 149)]. More than half [63.4% (n = 165)] of participants were married. More than half [55% (n = 143)] of participants had moderate economic status based on their reports and 91.92% (n = 239) of participants had health insurance coverage (table 1). Table 1 Baseline characteristics of study population Variables   Intervention group   Control group   P  Number  Percent  Number  Percent  Age (yrs.)  25–35  64  49.3  76  58.4  0.636  36–45  33  25.4  28  21.5  46–56  33  25.4  26  20.0  Sex  Female  92  70.8  88  67.7  0.591  Male  38  29.2  42  32.3  Level of education  Less than high school  2  1.5  2  1.50  0.064  High school  20  15.4  17  13.1  Some college  52  40.0  38  29.2  College or more  56  43.1  73  56.2  Marital status  Single  41  31.5  54  41.5  0.094  Married  89  68.5  76  58.5  Occupation  Household  46  35.4  29  22.3  0.086  Unemployed  35  26.9  31  23.8  Non-governmental  23  17.7  33  25.4  governmental  21  16.2  32  24.6  Retired  5  3.8  5  3.8  Self-reported economic status  Not acceptable  38  29.2  48  36.9  0.246  moderate  73  56.2  70  53.8  Acceptable  19  14.6  12  9.2  Health insurance coverage  Yes  122  93.8  117  90.0  0.235  No  8  6.2  13  10.0  Variables   Intervention group   Control group   P  Number  Percent  Number  Percent  Age (yrs.)  25–35  64  49.3  76  58.4  0.636  36–45  33  25.4  28  21.5  46–56  33  25.4  26  20.0  Sex  Female  92  70.8  88  67.7  0.591  Male  38  29.2  42  32.3  Level of education  Less than high school  2  1.5  2  1.50  0.064  High school  20  15.4  17  13.1  Some college  52  40.0  38  29.2  College or more  56  43.1  73  56.2  Marital status  Single  41  31.5  54  41.5  0.094  Married  89  68.5  76  58.5  Occupation  Household  46  35.4  29  22.3  0.086  Unemployed  35  26.9  31  23.8  Non-governmental  23  17.7  33  25.4  governmental  21  16.2  32  24.6  Retired  5  3.8  5  3.8  Self-reported economic status  Not acceptable  38  29.2  48  36.9  0.246  moderate  73  56.2  70  53.8  Acceptable  19  14.6  12  9.2  Health insurance coverage  Yes  122  93.8  117  90.0  0.235  No  8  6.2  13  10.0  Table 1 Baseline characteristics of study population Variables   Intervention group   Control group   P  Number  Percent  Number  Percent  Age (yrs.)  25–35  64  49.3  76  58.4  0.636  36–45  33  25.4  28  21.5  46–56  33  25.4  26  20.0  Sex  Female  92  70.8  88  67.7  0.591  Male  38  29.2  42  32.3  Level of education  Less than high school  2  1.5  2  1.50  0.064  High school  20  15.4  17  13.1  Some college  52  40.0  38  29.2  College or more  56  43.1  73  56.2  Marital status  Single  41  31.5  54  41.5  0.094  Married  89  68.5  76  58.5  Occupation  Household  46  35.4  29  22.3  0.086  Unemployed  35  26.9  31  23.8  Non-governmental  23  17.7  33  25.4  governmental  21  16.2  32  24.6  Retired  5  3.8  5  3.8  Self-reported economic status  Not acceptable  38  29.2  48  36.9  0.246  moderate  73  56.2  70  53.8  Acceptable  19  14.6  12  9.2  Health insurance coverage  Yes  122  93.8  117  90.0  0.235  No  8  6.2  13  10.0  Variables   Intervention group   Control group   P  Number  Percent  Number  Percent  Age (yrs.)  25–35  64  49.3  76  58.4  0.636  36–45  33  25.4  28  21.5  46–56  33  25.4  26  20.0  Sex  Female  92  70.8  88  67.7  0.591  Male  38  29.2  42  32.3  Level of education  Less than high school  2  1.5  2  1.50  0.064  High school  20  15.4  17  13.1  Some college  52  40.0  38  29.2  College or more  56  43.1  73  56.2  Marital status  Single  41  31.5  54  41.5  0.094  Married  89  68.5  76  58.5  Occupation  Household  46  35.4  29  22.3  0.086  Unemployed  35  26.9  31  23.8  Non-governmental  23  17.7  33  25.4  governmental  21  16.2  32  24.6  Retired  5  3.8  5  3.8  Self-reported economic status  Not acceptable  38  29.2  48  36.9  0.246  moderate  73  56.2  70  53.8  Acceptable  19  14.6  12  9.2  Health insurance coverage  Yes  122  93.8  117  90.0  0.235  No  8  6.2  13  10.0  The randomized groups did not show any significant difference in terms of demographics, SCT constructs, awareness and general beliefs as outcome measures using chi-square test and Student’s t-test (P > 0.05) (tables 1 and 2). The SCT constructs based self-care educational intervention showed significant association after six months (P < 0.001) (table 3). There was the significant association between SCT constructs six months after. Table 4 presents covariance analysis and their significant differences in mean differences of SCT constructs and outcome measures between two groups after intervention. The normality of the data distribution was checked by Kolmogorov–Smirnov test. The educational intervention revealed that the premise of SCT was effective to improve the awareness and general beliefs about safe and appropriate antibiotics use. Based on the study findings, there were no statistical differences between demographics, socioeconomic characteristics and SCT constructs awareness and general beliefs in intervention and control groups at baseline. However, six months after intervention, the mean scores of SCT constructs, awareness and general beliefs had significantly increased in the intervention group. Table 2 SCT constructs and outcome measures before intervention SCT constructs and outcome measures  Intervention group   Control group   CI (95%)   Differences  P-value  Mean  SD  Mean  SD  Lower limit  Upper limit  Knowledge  64.8  1.96  60.9  15.5  −8.3  0.4  −4  0.072  Outcome/expectations  74.7  18.6  71.7  14.8  −7.1  1.1  −3  0.157  Values expectation  66.1  19.6  64.7  16.4  −5.8  3  1.4  0.537  Self-control  78.3  16.1  75  17.3  0.7  −7.4  −3.3  0.107  Environment  65.3  20.1  63  17.9  −2.3  7  −2.3  0.329  Emotional coping  68  18.5  63.8  20.1  0.4  −9  −4.3  0.07  Self-efficacy  75.5  17.9  71.9  17.2  −7.9  0.7  −3.6  0.101  Perceived barriers  59  24  61  20  7.4  −3.4  2  0.329  Outcomes measures  Awareness  60.9  26.6  55.8  23.1  −11.6  0.5  −5.5  0.070  General beliefs  64.7  21.9  60.4  19.4  −9.3  0.7  −4.3  0.095  SCT constructs and outcome measures  Intervention group   Control group   CI (95%)   Differences  P-value  Mean  SD  Mean  SD  Lower limit  Upper limit  Knowledge  64.8  1.96  60.9  15.5  −8.3  0.4  −4  0.072  Outcome/expectations  74.7  18.6  71.7  14.8  −7.1  1.1  −3  0.157  Values expectation  66.1  19.6  64.7  16.4  −5.8  3  1.4  0.537  Self-control  78.3  16.1  75  17.3  0.7  −7.4  −3.3  0.107  Environment  65.3  20.1  63  17.9  −2.3  7  −2.3  0.329  Emotional coping  68  18.5  63.8  20.1  0.4  −9  −4.3  0.07  Self-efficacy  75.5  17.9  71.9  17.2  −7.9  0.7  −3.6  0.101  Perceived barriers  59  24  61  20  7.4  −3.4  2  0.329  Outcomes measures  Awareness  60.9  26.6  55.8  23.1  −11.6  0.5  −5.5  0.070  General beliefs  64.7  21.9  60.4  19.4  −9.3  0.7  −4.3  0.095  Table 2 SCT constructs and outcome measures before intervention SCT constructs and outcome measures  Intervention group   Control group   CI (95%)   Differences  P-value  Mean  SD  Mean  SD  Lower limit  Upper limit  Knowledge  64.8  1.96  60.9  15.5  −8.3  0.4  −4  0.072  Outcome/expectations  74.7  18.6  71.7  14.8  −7.1  1.1  −3  0.157  Values expectation  66.1  19.6  64.7  16.4  −5.8  3  1.4  0.537  Self-control  78.3  16.1  75  17.3  0.7  −7.4  −3.3  0.107  Environment  65.3  20.1  63  17.9  −2.3  7  −2.3  0.329  Emotional coping  68  18.5  63.8  20.1  0.4  −9  −4.3  0.07  Self-efficacy  75.5  17.9  71.9  17.2  −7.9  0.7  −3.6  0.101  Perceived barriers  59  24  61  20  7.4  −3.4  2  0.329  Outcomes measures  Awareness  60.9  26.6  55.8  23.1  −11.6  0.5  −5.5  0.070  General beliefs  64.7  21.9  60.4  19.4  −9.3  0.7  −4.3  0.095  SCT constructs and outcome measures  Intervention group   Control group   CI (95%)   Differences  P-value  Mean  SD  Mean  SD  Lower limit  Upper limit  Knowledge  64.8  1.96  60.9  15.5  −8.3  0.4  −4  0.072  Outcome/expectations  74.7  18.6  71.7  14.8  −7.1  1.1  −3  0.157  Values expectation  66.1  19.6  64.7  16.4  −5.8  3  1.4  0.537  Self-control  78.3  16.1  75  17.3  0.7  −7.4  −3.3  0.107  Environment  65.3  20.1  63  17.9  −2.3  7  −2.3  0.329  Emotional coping  68  18.5  63.8  20.1  0.4  −9  −4.3  0.07  Self-efficacy  75.5  17.9  71.9  17.2  −7.9  0.7  −3.6  0.101  Perceived barriers  59  24  61  20  7.4  −3.4  2  0.329  Outcomes measures  Awareness  60.9  26.6  55.8  23.1  −11.6  0.5  −5.5  0.070  General beliefs  64.7  21.9  60.4  19.4  −9.3  0.7  −4.3  0.095  Table 3 SCT constructs and outcome measures six months after intervention SCT constructs and outcome measures   Intervention group   Control group   CI (95%)   Differences  P-value  Mean   SD   Mean   SD   Lower limit   Upper limit   Knowledge  80.7  9.4  61  15.1  −22.8  −19.6  −19.7  <0.001  Outcome expectations  84.5  10.1  72.2  14.3  −15.7  −9.5  −12.6  <0.001  Values expectation  77.4  10.1  65.8  15.5  −14.8  −8.4  −11.6  <0.001  Self-control  88.2  8.5  74.5  16.3  −16.9  −10.5  −13.7  <0.001  Environment  75.5  11.8  63.9  17  −15.6  −8.3  −12  <0.001  Emotional coping  76.5  9.4  62.5  15  −17.1  −11  −14  <0.001  Self-efficacy  82.1  10.4  71.5  17.9  −13.9  −7.3  −10.6  <0.001  Perceived barriers  74.3  12.2  61.6  19.4  −7.1  −9.3  −13.2  <0.001  Outcomes measures  Awareness  67.53  21.11  53.69  19.77  −8.89  −18.48  −13.69  <0.001  General beliefs  77.4  15  61.7  18  −19.7  −11.6  −15.6  <0.001  SCT constructs and outcome measures   Intervention group   Control group   CI (95%)   Differences  P-value  Mean   SD   Mean   SD   Lower limit   Upper limit   Knowledge  80.7  9.4  61  15.1  −22.8  −19.6  −19.7  <0.001  Outcome expectations  84.5  10.1  72.2  14.3  −15.7  −9.5  −12.6  <0.001  Values expectation  77.4  10.1  65.8  15.5  −14.8  −8.4  −11.6  <0.001  Self-control  88.2  8.5  74.5  16.3  −16.9  −10.5  −13.7  <0.001  Environment  75.5  11.8  63.9  17  −15.6  −8.3  −12  <0.001  Emotional coping  76.5  9.4  62.5  15  −17.1  −11  −14  <0.001  Self-efficacy  82.1  10.4  71.5  17.9  −13.9  −7.3  −10.6  <0.001  Perceived barriers  74.3  12.2  61.6  19.4  −7.1  −9.3  −13.2  <0.001  Outcomes measures  Awareness  67.53  21.11  53.69  19.77  −8.89  −18.48  −13.69  <0.001  General beliefs  77.4  15  61.7  18  −19.7  −11.6  −15.6  <0.001  Table 3 SCT constructs and outcome measures six months after intervention SCT constructs and outcome measures   Intervention group   Control group   CI (95%)   Differences  P-value  Mean   SD   Mean   SD   Lower limit   Upper limit   Knowledge  80.7  9.4  61  15.1  −22.8  −19.6  −19.7  <0.001  Outcome expectations  84.5  10.1  72.2  14.3  −15.7  −9.5  −12.6  <0.001  Values expectation  77.4  10.1  65.8  15.5  −14.8  −8.4  −11.6  <0.001  Self-control  88.2  8.5  74.5  16.3  −16.9  −10.5  −13.7  <0.001  Environment  75.5  11.8  63.9  17  −15.6  −8.3  −12  <0.001  Emotional coping  76.5  9.4  62.5  15  −17.1  −11  −14  <0.001  Self-efficacy  82.1  10.4  71.5  17.9  −13.9  −7.3  −10.6  <0.001  Perceived barriers  74.3  12.2  61.6  19.4  −7.1  −9.3  −13.2  <0.001  Outcomes measures  Awareness  67.53  21.11  53.69  19.77  −8.89  −18.48  −13.69  <0.001  General beliefs  77.4  15  61.7  18  −19.7  −11.6  −15.6  <0.001  SCT constructs and outcome measures   Intervention group   Control group   CI (95%)   Differences  P-value  Mean   SD   Mean   SD   Lower limit   Upper limit   Knowledge  80.7  9.4  61  15.1  −22.8  −19.6  −19.7  <0.001  Outcome expectations  84.5  10.1  72.2  14.3  −15.7  −9.5  −12.6  <0.001  Values expectation  77.4  10.1  65.8  15.5  −14.8  −8.4  −11.6  <0.001  Self-control  88.2  8.5  74.5  16.3  −16.9  −10.5  −13.7  <0.001  Environment  75.5  11.8  63.9  17  −15.6  −8.3  −12  <0.001  Emotional coping  76.5  9.4  62.5  15  −17.1  −11  −14  <0.001  Self-efficacy  82.1  10.4  71.5  17.9  −13.9  −7.3  −10.6  <0.001  Perceived barriers  74.3  12.2  61.6  19.4  −7.1  −9.3  −13.2  <0.001  Outcomes measures  Awareness  67.53  21.11  53.69  19.77  −8.89  −18.48  −13.69  <0.001  General beliefs  77.4  15  61.7  18  −19.7  −11.6  −15.6  <0.001  Table 4 SCT constructs and outcome measures differences six months after intervention SCT constructs/ outcome measures  Intervention group   Control group   CI (95%)   Difference  P-value  Difference  Mean  SD  Mean  SD  Lower limit  Upper limit  Knowledge  15.9  20.7  0.2  6.4  −19.5  −12  −15.7  <0.001  0.78<0.001  Outcome expectations  9.8  21.2  0.2  4.3  −13.4  −5.9  −9.7  <0.001  0.61<0.001  Values expectation  11.3  22  1.1  5.9  −14.2  −6.3  −10.2  <0.001  0.4<0.001  Goal-setting self-control  7.2  11.1  −0.5  5.7  −4.3  −11.1  −7.7  <0.001  0.35<0.001  Environment  10.1  23.5  0.5  5  −5.5  −13.8  −9.7  <0.001  0.29<0.001  Emotional coping  −1.58  19.9  −1.3  12.9  −5.7  −13.9  −9.8  <0.001  0.26<0.001  Self-efficacy  6.6  21.5  −0.4  1.4  −3.2  −10.8  −7  <0.001  0.28<0.001  Perceived barriers  15.3  25.9  0.2  4.9  −10.6  −19.7  −15.2  <0.001  0.72<0.001  Outcomes measures  Awareness  2  32.06  −7.6  14.81  −18.48  −8.89  −13.6  <0.001  0.68<0.001  G. beliefs  12.7  27.9  1.3  10.3  −16.5  −6.2  −11.3  <0.001  0.3<0.001  SCT constructs/ outcome measures  Intervention group   Control group   CI (95%)   Difference  P-value  Difference  Mean  SD  Mean  SD  Lower limit  Upper limit  Knowledge  15.9  20.7  0.2  6.4  −19.5  −12  −15.7  <0.001  0.78<0.001  Outcome expectations  9.8  21.2  0.2  4.3  −13.4  −5.9  −9.7  <0.001  0.61<0.001  Values expectation  11.3  22  1.1  5.9  −14.2  −6.3  −10.2  <0.001  0.4<0.001  Goal-setting self-control  7.2  11.1  −0.5  5.7  −4.3  −11.1  −7.7  <0.001  0.35<0.001  Environment  10.1  23.5  0.5  5  −5.5  −13.8  −9.7  <0.001  0.29<0.001  Emotional coping  −1.58  19.9  −1.3  12.9  −5.7  −13.9  −9.8  <0.001  0.26<0.001  Self-efficacy  6.6  21.5  −0.4  1.4  −3.2  −10.8  −7  <0.001  0.28<0.001  Perceived barriers  15.3  25.9  0.2  4.9  −10.6  −19.7  −15.2  <0.001  0.72<0.001  Outcomes measures  Awareness  2  32.06  −7.6  14.81  −18.48  −8.89  −13.6  <0.001  0.68<0.001  G. beliefs  12.7  27.9  1.3  10.3  −16.5  −6.2  −11.3  <0.001  0.3<0.001  G. beliefs = General beliefs. Table 4 SCT constructs and outcome measures differences six months after intervention SCT constructs/ outcome measures  Intervention group   Control group   CI (95%)   Difference  P-value  Difference  Mean  SD  Mean  SD  Lower limit  Upper limit  Knowledge  15.9  20.7  0.2  6.4  −19.5  −12  −15.7  <0.001  0.78<0.001  Outcome expectations  9.8  21.2  0.2  4.3  −13.4  −5.9  −9.7  <0.001  0.61<0.001  Values expectation  11.3  22  1.1  5.9  −14.2  −6.3  −10.2  <0.001  0.4<0.001  Goal-setting self-control  7.2  11.1  −0.5  5.7  −4.3  −11.1  −7.7  <0.001  0.35<0.001  Environment  10.1  23.5  0.5  5  −5.5  −13.8  −9.7  <0.001  0.29<0.001  Emotional coping  −1.58  19.9  −1.3  12.9  −5.7  −13.9  −9.8  <0.001  0.26<0.001  Self-efficacy  6.6  21.5  −0.4  1.4  −3.2  −10.8  −7  <0.001  0.28<0.001  Perceived barriers  15.3  25.9  0.2  4.9  −10.6  −19.7  −15.2  <0.001  0.72<0.001  Outcomes measures  Awareness  2  32.06  −7.6  14.81  −18.48  −8.89  −13.6  <0.001  0.68<0.001  G. beliefs  12.7  27.9  1.3  10.3  −16.5  −6.2  −11.3  <0.001  0.3<0.001  SCT constructs/ outcome measures  Intervention group   Control group   CI (95%)   Difference  P-value  Difference  Mean  SD  Mean  SD  Lower limit  Upper limit  Knowledge  15.9  20.7  0.2  6.4  −19.5  −12  −15.7  <0.001  0.78<0.001  Outcome expectations  9.8  21.2  0.2  4.3  −13.4  −5.9  −9.7  <0.001  0.61<0.001  Values expectation  11.3  22  1.1  5.9  −14.2  −6.3  −10.2  <0.001  0.4<0.001  Goal-setting self-control  7.2  11.1  −0.5  5.7  −4.3  −11.1  −7.7  <0.001  0.35<0.001  Environment  10.1  23.5  0.5  5  −5.5  −13.8  −9.7  <0.001  0.29<0.001  Emotional coping  −1.58  19.9  −1.3  12.9  −5.7  −13.9  −9.8  <0.001  0.26<0.001  Self-efficacy  6.6  21.5  −0.4  1.4  −3.2  −10.8  −7  <0.001  0.28<0.001  Perceived barriers  15.3  25.9  0.2  4.9  −10.6  −19.7  −15.2  <0.001  0.72<0.001  Outcomes measures  Awareness  2  32.06  −7.6  14.81  −18.48  −8.89  −13.6  <0.001  0.68<0.001  G. beliefs  12.7  27.9  1.3  10.3  −16.5  −6.2  −11.3  <0.001  0.3<0.001  G. beliefs = General beliefs. Discussion According to SCT, someone perceiving that he/she has a good self-efficacy of ill health condition gets the force to engage in healthy behavior but think over the best path to be healthier by choosing best action; i.e. weight of balance between expectancy and self-control for goal setting under basic assumption that people are motivated for their health due to environmental and personal factors.12,13 In this study, the results on improving awareness about appropriate antibiotics use were significantly associated with outcome variables which in line with Solhi et al. study (2013) which indicated promoting preventive behaviors were effective in irrational antibiotics use.17 Also, based on literature from developed countries, insurance coverage led to inappropriate antibiotic usage due to patient unreal demand which can be related to inadequate awareness about the inappropriate use and antibiotics resistance.18 Widayati et al. study (2012) lay people understand antibiotic use can be applied for every kind of infection aside its origin without any side effects.2 The misunderstanding might be the obstacle to tackle incorrect beliefs regarding rational antibiotics use. Based on some studies, the relationships between awareness and beliefs suggested that the more you know about the use of the antibiotics, the more you use appropriately and the correct belief revealed the same.2,3,19 SCT based self-care intervention in antibiotics use had shown a significant effect in different constructs. This is not similar to the study conducted by Milos et al. (2013), theory-based intervention programs which run among general practitioners (GPs) to reduce antibiotics against upper respiratory tract infections (URTIs) in primary care center did not show a significant effect. This might be the previous study was conducted in relation with GPs not patient themselves. In this study, the result revealed that behavioral interventions resulted in decreasing inappropriate antibiotic use. This is similar to the study conducted Meeker et al. (2016) showed behavioral interventions resulted in decreasing inappropriate antibiotic use in primary care practices.20 This finding might lead the health system decision makers to apply some kind of effective and applicable intervention in the preventive setting. In our study, after six months of intervention, knowledge and perception construct had significantly increased in the intervention group. This is similar to the study conducted by Amini Moridani et al. (2015) which was a family-based SCT—intervention on diabetic elders.21 Another study by Ghasemi et al. (2017) on cardiovascular risk factors using SCT showed a significant effect in the outcome and value expectations related to the application of SCT on preventive behaviors among high school students.22 Jalily et al. (2015) study revealed predictive determinants of SCT based intervention on nutritional behaviors was similar to our study.23 There is a possibility of the importance of the issue, nature of subject and intervention processing might have different results. Back to values expectation constructs, our result was in accordance with Beiranvandpour et al. study (2014) which was about effective factors on fast food in women.24 We assumed that the similarity of the outcome of the two studies was in general health. Self-efficacy overcoming impediment is another construct of SCT which was improved after intervention in the intervention group. Sullivan et al. study (2008) results about physical activity were in line with this study.25 Another study conducted by Bruening et al. (2010) was similar to our study results, which revealed that there was a positive and significant relation between self-efficacy and vegetable consumption.26 The study findings on goal setting for self-control construct were in line with Jalily et al. (2015).23 It seems that improvement of goal-setting self-control needs raising awareness, skills and resources allocation. Based on this issue, the results revealed that improving the mentioned construct led to appropriate and safe antibiotics use. Ahmad et al. study (2014) revealed that perceived barrier was significant in self-medication prevention which was congruent with our study.27 As strength, this study is used randomization to ensure similarity between the study groups in terms of demographic variables and the SCT constructs. As limitations, this study lacks the designed intervention based on SCT theory for comparison purpose. Lack of available literatures in the same topic leads us to discuss with other topics which utilized SCT. The other limitation is the bias made on self-reporting of the participants during the data collection. In conclusion, the findings of this study comprehensively summed up to the following conclusions and recommendations to encourage rational use of antibiotics for better understanding. The study evidences the possibility of increasing public population awareness and general beliefs about the appropriate antibiotic use. The study findings informed about the benefits of SCT interventional program. It seems that public health strategies including educational and motivational programs should be developed to reach the at-risk populations. The other recommendation is raising public awareness and general beliefs about proper use and informing for the government to take part in proper regulations and prescription policies. Acknowledgements The authors enthusiastically thank all the staffs of South Health Networks affiliated to TUMS for their cooperation. We would also like to thank educational and research chancellor of TUMS for partially funding as a part of MSPH thesis with Project number: 33537. Funding This research is partly funded by educational and research chancellor of Tehran University of Medical Sciences. Conflicts of interest: None declared. Key points To see the efficacy of the health education model based interventions. To give insight into the rational use of antibiotics. To provide the professional contribution in the field of health education and promotion. References 1 Shehadeh MB, Suaifan G, Hammad EA. Active educational intervention as a tool to improve safe and appropriate use of antibiotics. Saudi Pharm J  2016; 24: 611– 5. Google Scholar CrossRef Search ADS PubMed  2 Widayati A, Suryawati S, De Crespigny C, Hiller JE. Knowledge and beliefs about antibiotics among people in Yogyakarta City Indonesia: a cross sectional population-based survey. Antimicrob Resist Infect Control  2012; 1: 38. Google Scholar CrossRef Search ADS PubMed  3 Mc Cullough AR, Parekh S, Rathbone J, et al.   A systematic review of the public’s knowledge and beliefs about antibiotic resistance. J Antimicrob Chemother  2016; 71: 27– 33. Google Scholar CrossRef Search ADS PubMed  4 Andre M, Vernby A, Berg J, Lundborg CS. A survey of public knowledge and awareness related to antibiotic use and resistance in Sweden. J Antimicrob Chemother  2010; 65: 1292– 6. Google Scholar CrossRef Search ADS PubMed  5 Scicluna EA, Borg MA, Gur D, et al.   Self-medication with antibiotics in the ambulatory care setting within the Euro-Mediterranean region; results from the ARMed project. J Infect Public Health  2009; 2: 189– 97. Google Scholar CrossRef Search ADS PubMed  6 You JH, Yau B, Choi KC, et al.   Public knowledge, attitudes and behavior on antibiotic use: a telephone survey in Hong Kong. Infection  2008; 36: 153– 7. Google Scholar CrossRef Search ADS PubMed  7 Larson E, Ferng YH, Wong J, et al.   Knowledge and misconceptions regarding upper respiratory infections and influenza among urban Hispanic households: need for targeted messaging. J Immigr Minor Health  2009; 11: 71– 82. Google Scholar CrossRef Search ADS PubMed  8 Shorr AF, Micek ST, Welch EC, et al.   Inappropriate antibiotic therapy in Gram negative sepsis increases hospital length of stay. Crit Care Med  2011; 39: 46– 51. Google Scholar CrossRef Search ADS PubMed  9 Ozgenc O, Genc VE, Ari AA, et al.   Evaluation of the therapeutic use of antibiotics in Aegean Region hospitals of Turkey: a multi centric study. Indian J Med Microbiol  2011; 29: 124– 9. Google Scholar CrossRef Search ADS PubMed  10 Center for Disease Control and Prevention. World Health Day: Media Fact Sheet. Available at: http://www.cdc.gov/media/releases/2011/f0407_antimicro-bialresistance.pdf (20 December 2013, date last accessed). 11 Center for Disease Control and Prevention. Antibiotic Resistance Threats in the United States, 2013. Available at: http://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf (19 March 2014, date last accessed). 12 European Medicine Agency. The Bacterial Challenge: Time to React. A Call to Narrow the Gap between Multidrug-Resistant Bacteria in the EU and the Development of New Antibacterial Agents. Available at: http://www.ema.europa.eu/docs/en_GB/document_library/Report/2009/11/WC500008770.pdf (20 December 2013, date last accessed). 13 Stajkovic AD, Luthans F. Social cognitive theory and self-efficacy: going beyond traditional motivational and behavioral approaches. Organ Dyn  1998; 26: 62– 74. Google Scholar CrossRef Search ADS   14 Sharma M, Romas JA. Theoretical Foundations of Health Education and Health Promotion . Burlington, Massachusetts: Jones and Bartlett Publishers, Inc, 2008: 163– 82 15 World Health Organization (WHO). The Evolving Threat of Antimicrobial Resistance: Options for Action, 2012. Available at: http://www.who.int/patientsafety/implementation/amr/publication/en/ (5 March 2013, date last accessed). 16 Nafisi M, Omrani M, Torkamannejad SH, Farsar AR. Knowledge and general belief related to self-care in pharmaceutical. J Razi  2015; 26: 20– 31. 17 Nilsadat N, Solhi M, Shijaezadeh D, Gohari M. Investigating the effect of education based on health belief model on improving the preventive behaviors of self-medication in the women under the supervision of health institutions of zone 3 of Tehran. RJMS  2013; 20: 48– 59. 18 Kuzujanakis M, Kleinman K, Rifas-Shiman S, Finkelstein JA. Correlates of parental antibiotic knowledge, demand, and reported use. Ambul Pediatr  2003; 3: 203– 10. Google Scholar CrossRef Search ADS PubMed  19 Vukovic DS, Ljudmila M, Nagorni-Obradovic LM. Knowledge and awareness of tuberculosis among Roma population in Belgrade: a qualitative study. BMC Infect Dis  2011; 11: 284. Google Scholar CrossRef Search ADS PubMed  20 Meeker D, Linder JA, Fox CR, et al.   Effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices. A randomized clinical trial. JAMA  2016; 315: 562– 70. 21 Amini Moridani MR, Tol A, Sadeghi R, et al.   Assessing the effect of family-based intervention education program on perceived social support among older adults with type 2 diabetes: application of Social Cognitive Theory. JNE  2015; 4: 30– 40. 22 Ghasemi S, Mohebbi B, Sadeghi R, et al.   The effect of educational intervention on prevention of cardiovascular risk factors among girl students of secondary course in high school: application of Social Cognitive Theory. JNE  2017; 6: 26– 37. 23 Jalily M, Barati M, Bashirian S. Using social cognitive theory to determine factors predicting nutritional behaviors in pregnant women visiting health centers in Tabriz, Iran. JECH  2014; 1: 11– 21. Google Scholar CrossRef Search ADS   24 Beiranvandpour N, Karimi-Shahanjarini A, Rezapur-Shahkolai F, Moghimbeigi A. Factors affecting the consumption of fast foods among women based on the social cognitive theory. JECH  2014; 1: 19– 26. Google Scholar CrossRef Search ADS   25 Sullivan KA, White KM, Young RM, et al.   Predictors of intention to reduce stroke risk among people at risk of stroke: an application of an extended health belief model. Rehabil Psychol  2008; 53: 505– 12. Google Scholar CrossRef Search ADS   26 Bruening M, Kubik MY, Kenyon D, et al.   Perceived barriers mediate the association between self-efficacy and fruit and vegetable consumption among students attending alternative high schools. J Am Diet Assoc  2010; 110: 1542– 6. Google Scholar CrossRef Search ADS PubMed  27 Ahmad A, Patel I, Mohanta G, Balkrishnan R. Evaluation of self medication Practices in rural area of town Sahaswan at Northern India. Annals of Medical and Health Sciences Research  2014; 4:73–8. © The Author(s) 2018. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The European Journal of Public Health Oxford University Press

The efficacy of social cognitive theory-based self-care intervention for rational antibiotic use: a randomized trial

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
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1101-1262
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1464-360X
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10.1093/eurpub/cky082
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Abstract

Abstract Background Misuse of antibiotics can be described as a failure to complete treatment, skipping of the doses and reuse of leftover medicines and overuse of antibiotics. Health education interventions are expected to enhance awareness and general belief on rational antibiotics use. Therefore, the study aimed to determine the efficacy of social cognitive theory (SCT)-based self-care intervention for rational antibiotic use. Methods This randomized trial was conducted in a sample of 260 adults. The study participants were randomly assigned as the intervention (n=130) and a control (n=130) groups. The intervention group received self-care educational intervention of four sessions lasting 45–60 min augmented with the text messages and the control groups attended usual education program in health centers. The study participants were invited to complete questionnaires at the baseline and end of the intervention. The data were analyzed using SPSS version 23.0. Chi-square (X2), independent t-test and covariance analysis were used for data analysis. P<0.05 was considered statistically significant. Results After the intervention, all SCT constructs revealed significant differences in the intervention group compared with control groups (P<0.001). Awareness and general beliefs of rational antibiotic use showed a significant difference in intervention group before and after six months (P<0.001) whereas in control group no significant differences (P>0.05). Conclusion The study suggested that tailored appropriate educational programs based on SCT constructs can reflect a positive impact on appropriate antibiotics use. Therefore, a tailored health promotion intervention should be provided to enhance the awareness and general beliefs of the target groups. Introduction Inappropriate use of antibiotics among the general population has been largely outlined as a public health problem. Appropriate use of antibiotics reduced morbidity and mortality in many countries. Misuse of antibiotics can be described as a failure to complete treatment, skipping of doses, reuse of leftover medicines and overuse of antibiotics.1 Misconceptions of antibiotics use can pose the harm of inappropriate self-medication.2 The bactericide nature of antibiotics and its strong power to relieve the disease and the symptoms, the use of non-prescribed antibiotics lead to antibiotic resistance.3 Some studies revealed lack of knowledge in antibiotics worldwide.2–7 A lack of public awareness about safe and appropriate antibiotics use can lead to incorrect general beliefs and unreal demand.8,9 Unnecessary use of antibiotics reported as the main reason for antibiotics resistance which can affect excess health care costs.1 As stated in some US and European studies, the inappropriate use of antibiotics leads to antibiotics resistance and additional hospital days.10–12 Despite the massive resources and intensified interventions, the desired behavioral change was not yet attained to calm the problem of the rational use of antibiotics.12 Theories and models help to explain the process that individuals go through changes as they exchange information and as they interpret and react to different messages. Thus, this study used SCT as a conceptual framework to behavioral management and best describes human behavior through a triadic mutual causation (behavior, environment and personal factors).13–15 Furthermore, SCT used to give tailored health education and health promotion interventions focusing on knowledge and general beliefs as individual-level factors for behavior change (antibiotic use). Therefore, the aim of this study was to determine the efficacy of social cognitive theory based self-care intervention programs for rational antibiotic use. Methods Study design, populations and sample A randomized intervention trial was conducted in south health centers affiliated to Tehran University of Medical Sciences (TUMS), Tehran, Iran as of September 2016–October 2017. The study populations were adults who attended health centers to obtain routine health services. Outpatient clients of age between ≥25 years and ≤56; and lack of confirmed mental disorders were considered as inclusion criteria. Whereas, the exclusion criteria were those patients who were included in the same study in one of the health facilities but may potentially be referred to another to avoid double counting. Participants who did not attend more than two educational sessions or unable to hear and speak were excluded. A sample size of 260 participants participated in this study. We evenly distributed the samples into intervention and control groups. The included sample size was considered a minimum significance in increasing the explanation of independent variables, and a power of 80% with a 0.05 two-sided significant level. The final sample size was selected using systematic random sampling method. Randomization Randomization was carried out using a computer program by the investigators. The different health centers were alphabetically coded (A, B, C, D and so on) and a participant attached to each health center was given numerical codes (e.g. participants in health center Y were numbered Y001, Y002, Y003 and so on. Participants in the randomized trial were assigned 1:1 to the intervention and control arms under restricted randomized design after informed consent and collection of baseline data. The allocation sequence was generated and released to the interventionist on a case-by-case basis by another independent department specializes in generating research random sequence. Interventionist, data collectors, statistician were not the same persons. Interventionists also acknowledge all those contacted were in the intervention arm. But anonymous responses were entered into the database by a person unconnected with the project. Measurement and variables The investigators widely searched the literatures related to the study for the development of the questionnaires. Then, questionnaires were adapted and developed by principal investigators. A pretested, structured and translated questionnaires adapted from various studies of rational use of antibiotics based on the constructs of SCT was used as instrument for this study. The translation was made from English language into Persian language (local language) and back translated to English version by different individuals who were blind to the original version of the questionnaires. The instrument comprises four parts. Part I: socio-demographic and health-related variables (eight items), part II: the researchers-made questionnaire based on the SCT (40 items), part III: study outcome measures including awareness (five items) and part IV: general beliefs (three items) and about appropriate antibiotics use. SCT constructs questionnaires were 40 items. Various items that measure respondent’s hold belief concerning the effects of a given seriousness of condition had measured by summed score of related belief items on five-point Likert scale from Strongly Agree to Strongly Disagree. The validity was confirmed by 10 experts in pharmacology and health education and promotion fields. Reliability was tested using test–retest reliability scale which assured the sameness of results in each measure by different subjects at different times. To perform test–retest, a sample of 30 individuals attended South Health Centers affiliated to TUMS was selected. The Cronbach’s alpha was calculated for knowledge and situational perception (0.90), outcome expectations (0.79), values expectation (0.96), self-efficacy overcoming impediments (0.81), goal-setting self-control (0.87), environment (0.95), emotional coping (0.89) and perceived barriers (0.90). The total Cronbach’s alpha was 0.89. Validity and reliability of five-items awareness and three-items general belief about appropriate antibiotics use were confirmed by Nafisi et al. study.16 Participant requirement and intervention With regard to requirement, participants who were potentially eligible for the study were listed, and each individual was invited to participate in the study through oral invitation or phone call performed by investigators. An appointment was made if the person agreed to participate. Following an oral informed consent, patients who are eligible as a participant randomly were assigned as intervention and control groups. Participants in both groups were invited to complete the questionnaires at the baseline and at six months after the end of intervention. Both intervention and control groups have attended the regular health education in the health center. In addition, the intervention group received the self-care educational program based on SCT constructs in four sessions lasting 45–60 min in every two weeks for three months. Moreover, text messages were sent as a reminding and boosting after intervention that serves as a quick reference to the education. The content of educational programs included basic information and awareness and general beliefs of the threat of the antibiotic resistance and the importance of appropriate antibiotic use, overuse (means unnecessary use for viruses or colds), tips for proper storage of antibiotics, antibiotics complications and side effect. The self-care based on SCT constructs such as knowledge and situational perception, outcome expectations, values expectation, self-efficacy overcoming impediments, goal setting in self-control, environment, emotional coping and perceived barriers. Appropriate educational strategies such as lecturing, question and answer, setting achievable goals, role play and motivational interview were used to increase knowledge and general beliefs about antibiotics use based on SCT constructs. The trainers have followed an approved lesson plan to provide educational information. The trainers were health pharmacists and skilled nurses who had at least bachelor degree. The theoretical framework of the study was based on SCT to provide an opportunity to improve social and cognitive portion for participants; i.e. learning as a part of how society think and act on the appropriate antibiotics use. Moreover, cognitive portion addressed the effective contribution of thought processes regarding awareness and general beliefs about appropriate antibiotics use of participants’ motivation, attitudes and action in order to take care of general health. Control group attended only the standard health center-based education. After six months of the educational intervention, both groups filled the same questionnaire. SCT constructs, awareness and general beliefs were considered as the primary and secondary outcome measurements, respectively. Data analysis Data were analyzed using SPSS version 23.0. Descriptive statistics were calculated using mean and standard deviation for numerical variables, frequencies and percentages for categorical variables. Independent t-test and covariance analysis were used to compare independent variables and the outcomes of interest between and within groups. The significance level was considered as P < 0.05. Ethical consideration The protocol was ethically approved by TUMS educational board with application number IR.TUMS.REC.1395.553 on 4 September 2016 and registered Iranian Registry of Clinical Trials (IRCT ID: IRCT2016092412460N11). All the study participants were given detailed information about the study and written consent before participation. To ensure privacy and confidentiality, no names and identification number was written on the questionnaire. Results A total sample of 260 participants completed pre- and post-education questionnaires with a response rate of 100% (n = 260). Accordingly, the majority of participants were women [69.2% (n = 180)], and almost half of participants had education in college or more [57.3% (n = 149)]. More than half [63.4% (n = 165)] of participants were married. More than half [55% (n = 143)] of participants had moderate economic status based on their reports and 91.92% (n = 239) of participants had health insurance coverage (table 1). Table 1 Baseline characteristics of study population Variables   Intervention group   Control group   P  Number  Percent  Number  Percent  Age (yrs.)  25–35  64  49.3  76  58.4  0.636  36–45  33  25.4  28  21.5  46–56  33  25.4  26  20.0  Sex  Female  92  70.8  88  67.7  0.591  Male  38  29.2  42  32.3  Level of education  Less than high school  2  1.5  2  1.50  0.064  High school  20  15.4  17  13.1  Some college  52  40.0  38  29.2  College or more  56  43.1  73  56.2  Marital status  Single  41  31.5  54  41.5  0.094  Married  89  68.5  76  58.5  Occupation  Household  46  35.4  29  22.3  0.086  Unemployed  35  26.9  31  23.8  Non-governmental  23  17.7  33  25.4  governmental  21  16.2  32  24.6  Retired  5  3.8  5  3.8  Self-reported economic status  Not acceptable  38  29.2  48  36.9  0.246  moderate  73  56.2  70  53.8  Acceptable  19  14.6  12  9.2  Health insurance coverage  Yes  122  93.8  117  90.0  0.235  No  8  6.2  13  10.0  Variables   Intervention group   Control group   P  Number  Percent  Number  Percent  Age (yrs.)  25–35  64  49.3  76  58.4  0.636  36–45  33  25.4  28  21.5  46–56  33  25.4  26  20.0  Sex  Female  92  70.8  88  67.7  0.591  Male  38  29.2  42  32.3  Level of education  Less than high school  2  1.5  2  1.50  0.064  High school  20  15.4  17  13.1  Some college  52  40.0  38  29.2  College or more  56  43.1  73  56.2  Marital status  Single  41  31.5  54  41.5  0.094  Married  89  68.5  76  58.5  Occupation  Household  46  35.4  29  22.3  0.086  Unemployed  35  26.9  31  23.8  Non-governmental  23  17.7  33  25.4  governmental  21  16.2  32  24.6  Retired  5  3.8  5  3.8  Self-reported economic status  Not acceptable  38  29.2  48  36.9  0.246  moderate  73  56.2  70  53.8  Acceptable  19  14.6  12  9.2  Health insurance coverage  Yes  122  93.8  117  90.0  0.235  No  8  6.2  13  10.0  Table 1 Baseline characteristics of study population Variables   Intervention group   Control group   P  Number  Percent  Number  Percent  Age (yrs.)  25–35  64  49.3  76  58.4  0.636  36–45  33  25.4  28  21.5  46–56  33  25.4  26  20.0  Sex  Female  92  70.8  88  67.7  0.591  Male  38  29.2  42  32.3  Level of education  Less than high school  2  1.5  2  1.50  0.064  High school  20  15.4  17  13.1  Some college  52  40.0  38  29.2  College or more  56  43.1  73  56.2  Marital status  Single  41  31.5  54  41.5  0.094  Married  89  68.5  76  58.5  Occupation  Household  46  35.4  29  22.3  0.086  Unemployed  35  26.9  31  23.8  Non-governmental  23  17.7  33  25.4  governmental  21  16.2  32  24.6  Retired  5  3.8  5  3.8  Self-reported economic status  Not acceptable  38  29.2  48  36.9  0.246  moderate  73  56.2  70  53.8  Acceptable  19  14.6  12  9.2  Health insurance coverage  Yes  122  93.8  117  90.0  0.235  No  8  6.2  13  10.0  Variables   Intervention group   Control group   P  Number  Percent  Number  Percent  Age (yrs.)  25–35  64  49.3  76  58.4  0.636  36–45  33  25.4  28  21.5  46–56  33  25.4  26  20.0  Sex  Female  92  70.8  88  67.7  0.591  Male  38  29.2  42  32.3  Level of education  Less than high school  2  1.5  2  1.50  0.064  High school  20  15.4  17  13.1  Some college  52  40.0  38  29.2  College or more  56  43.1  73  56.2  Marital status  Single  41  31.5  54  41.5  0.094  Married  89  68.5  76  58.5  Occupation  Household  46  35.4  29  22.3  0.086  Unemployed  35  26.9  31  23.8  Non-governmental  23  17.7  33  25.4  governmental  21  16.2  32  24.6  Retired  5  3.8  5  3.8  Self-reported economic status  Not acceptable  38  29.2  48  36.9  0.246  moderate  73  56.2  70  53.8  Acceptable  19  14.6  12  9.2  Health insurance coverage  Yes  122  93.8  117  90.0  0.235  No  8  6.2  13  10.0  The randomized groups did not show any significant difference in terms of demographics, SCT constructs, awareness and general beliefs as outcome measures using chi-square test and Student’s t-test (P > 0.05) (tables 1 and 2). The SCT constructs based self-care educational intervention showed significant association after six months (P < 0.001) (table 3). There was the significant association between SCT constructs six months after. Table 4 presents covariance analysis and their significant differences in mean differences of SCT constructs and outcome measures between two groups after intervention. The normality of the data distribution was checked by Kolmogorov–Smirnov test. The educational intervention revealed that the premise of SCT was effective to improve the awareness and general beliefs about safe and appropriate antibiotics use. Based on the study findings, there were no statistical differences between demographics, socioeconomic characteristics and SCT constructs awareness and general beliefs in intervention and control groups at baseline. However, six months after intervention, the mean scores of SCT constructs, awareness and general beliefs had significantly increased in the intervention group. Table 2 SCT constructs and outcome measures before intervention SCT constructs and outcome measures  Intervention group   Control group   CI (95%)   Differences  P-value  Mean  SD  Mean  SD  Lower limit  Upper limit  Knowledge  64.8  1.96  60.9  15.5  −8.3  0.4  −4  0.072  Outcome/expectations  74.7  18.6  71.7  14.8  −7.1  1.1  −3  0.157  Values expectation  66.1  19.6  64.7  16.4  −5.8  3  1.4  0.537  Self-control  78.3  16.1  75  17.3  0.7  −7.4  −3.3  0.107  Environment  65.3  20.1  63  17.9  −2.3  7  −2.3  0.329  Emotional coping  68  18.5  63.8  20.1  0.4  −9  −4.3  0.07  Self-efficacy  75.5  17.9  71.9  17.2  −7.9  0.7  −3.6  0.101  Perceived barriers  59  24  61  20  7.4  −3.4  2  0.329  Outcomes measures  Awareness  60.9  26.6  55.8  23.1  −11.6  0.5  −5.5  0.070  General beliefs  64.7  21.9  60.4  19.4  −9.3  0.7  −4.3  0.095  SCT constructs and outcome measures  Intervention group   Control group   CI (95%)   Differences  P-value  Mean  SD  Mean  SD  Lower limit  Upper limit  Knowledge  64.8  1.96  60.9  15.5  −8.3  0.4  −4  0.072  Outcome/expectations  74.7  18.6  71.7  14.8  −7.1  1.1  −3  0.157  Values expectation  66.1  19.6  64.7  16.4  −5.8  3  1.4  0.537  Self-control  78.3  16.1  75  17.3  0.7  −7.4  −3.3  0.107  Environment  65.3  20.1  63  17.9  −2.3  7  −2.3  0.329  Emotional coping  68  18.5  63.8  20.1  0.4  −9  −4.3  0.07  Self-efficacy  75.5  17.9  71.9  17.2  −7.9  0.7  −3.6  0.101  Perceived barriers  59  24  61  20  7.4  −3.4  2  0.329  Outcomes measures  Awareness  60.9  26.6  55.8  23.1  −11.6  0.5  −5.5  0.070  General beliefs  64.7  21.9  60.4  19.4  −9.3  0.7  −4.3  0.095  Table 2 SCT constructs and outcome measures before intervention SCT constructs and outcome measures  Intervention group   Control group   CI (95%)   Differences  P-value  Mean  SD  Mean  SD  Lower limit  Upper limit  Knowledge  64.8  1.96  60.9  15.5  −8.3  0.4  −4  0.072  Outcome/expectations  74.7  18.6  71.7  14.8  −7.1  1.1  −3  0.157  Values expectation  66.1  19.6  64.7  16.4  −5.8  3  1.4  0.537  Self-control  78.3  16.1  75  17.3  0.7  −7.4  −3.3  0.107  Environment  65.3  20.1  63  17.9  −2.3  7  −2.3  0.329  Emotional coping  68  18.5  63.8  20.1  0.4  −9  −4.3  0.07  Self-efficacy  75.5  17.9  71.9  17.2  −7.9  0.7  −3.6  0.101  Perceived barriers  59  24  61  20  7.4  −3.4  2  0.329  Outcomes measures  Awareness  60.9  26.6  55.8  23.1  −11.6  0.5  −5.5  0.070  General beliefs  64.7  21.9  60.4  19.4  −9.3  0.7  −4.3  0.095  SCT constructs and outcome measures  Intervention group   Control group   CI (95%)   Differences  P-value  Mean  SD  Mean  SD  Lower limit  Upper limit  Knowledge  64.8  1.96  60.9  15.5  −8.3  0.4  −4  0.072  Outcome/expectations  74.7  18.6  71.7  14.8  −7.1  1.1  −3  0.157  Values expectation  66.1  19.6  64.7  16.4  −5.8  3  1.4  0.537  Self-control  78.3  16.1  75  17.3  0.7  −7.4  −3.3  0.107  Environment  65.3  20.1  63  17.9  −2.3  7  −2.3  0.329  Emotional coping  68  18.5  63.8  20.1  0.4  −9  −4.3  0.07  Self-efficacy  75.5  17.9  71.9  17.2  −7.9  0.7  −3.6  0.101  Perceived barriers  59  24  61  20  7.4  −3.4  2  0.329  Outcomes measures  Awareness  60.9  26.6  55.8  23.1  −11.6  0.5  −5.5  0.070  General beliefs  64.7  21.9  60.4  19.4  −9.3  0.7  −4.3  0.095  Table 3 SCT constructs and outcome measures six months after intervention SCT constructs and outcome measures   Intervention group   Control group   CI (95%)   Differences  P-value  Mean   SD   Mean   SD   Lower limit   Upper limit   Knowledge  80.7  9.4  61  15.1  −22.8  −19.6  −19.7  <0.001  Outcome expectations  84.5  10.1  72.2  14.3  −15.7  −9.5  −12.6  <0.001  Values expectation  77.4  10.1  65.8  15.5  −14.8  −8.4  −11.6  <0.001  Self-control  88.2  8.5  74.5  16.3  −16.9  −10.5  −13.7  <0.001  Environment  75.5  11.8  63.9  17  −15.6  −8.3  −12  <0.001  Emotional coping  76.5  9.4  62.5  15  −17.1  −11  −14  <0.001  Self-efficacy  82.1  10.4  71.5  17.9  −13.9  −7.3  −10.6  <0.001  Perceived barriers  74.3  12.2  61.6  19.4  −7.1  −9.3  −13.2  <0.001  Outcomes measures  Awareness  67.53  21.11  53.69  19.77  −8.89  −18.48  −13.69  <0.001  General beliefs  77.4  15  61.7  18  −19.7  −11.6  −15.6  <0.001  SCT constructs and outcome measures   Intervention group   Control group   CI (95%)   Differences  P-value  Mean   SD   Mean   SD   Lower limit   Upper limit   Knowledge  80.7  9.4  61  15.1  −22.8  −19.6  −19.7  <0.001  Outcome expectations  84.5  10.1  72.2  14.3  −15.7  −9.5  −12.6  <0.001  Values expectation  77.4  10.1  65.8  15.5  −14.8  −8.4  −11.6  <0.001  Self-control  88.2  8.5  74.5  16.3  −16.9  −10.5  −13.7  <0.001  Environment  75.5  11.8  63.9  17  −15.6  −8.3  −12  <0.001  Emotional coping  76.5  9.4  62.5  15  −17.1  −11  −14  <0.001  Self-efficacy  82.1  10.4  71.5  17.9  −13.9  −7.3  −10.6  <0.001  Perceived barriers  74.3  12.2  61.6  19.4  −7.1  −9.3  −13.2  <0.001  Outcomes measures  Awareness  67.53  21.11  53.69  19.77  −8.89  −18.48  −13.69  <0.001  General beliefs  77.4  15  61.7  18  −19.7  −11.6  −15.6  <0.001  Table 3 SCT constructs and outcome measures six months after intervention SCT constructs and outcome measures   Intervention group   Control group   CI (95%)   Differences  P-value  Mean   SD   Mean   SD   Lower limit   Upper limit   Knowledge  80.7  9.4  61  15.1  −22.8  −19.6  −19.7  <0.001  Outcome expectations  84.5  10.1  72.2  14.3  −15.7  −9.5  −12.6  <0.001  Values expectation  77.4  10.1  65.8  15.5  −14.8  −8.4  −11.6  <0.001  Self-control  88.2  8.5  74.5  16.3  −16.9  −10.5  −13.7  <0.001  Environment  75.5  11.8  63.9  17  −15.6  −8.3  −12  <0.001  Emotional coping  76.5  9.4  62.5  15  −17.1  −11  −14  <0.001  Self-efficacy  82.1  10.4  71.5  17.9  −13.9  −7.3  −10.6  <0.001  Perceived barriers  74.3  12.2  61.6  19.4  −7.1  −9.3  −13.2  <0.001  Outcomes measures  Awareness  67.53  21.11  53.69  19.77  −8.89  −18.48  −13.69  <0.001  General beliefs  77.4  15  61.7  18  −19.7  −11.6  −15.6  <0.001  SCT constructs and outcome measures   Intervention group   Control group   CI (95%)   Differences  P-value  Mean   SD   Mean   SD   Lower limit   Upper limit   Knowledge  80.7  9.4  61  15.1  −22.8  −19.6  −19.7  <0.001  Outcome expectations  84.5  10.1  72.2  14.3  −15.7  −9.5  −12.6  <0.001  Values expectation  77.4  10.1  65.8  15.5  −14.8  −8.4  −11.6  <0.001  Self-control  88.2  8.5  74.5  16.3  −16.9  −10.5  −13.7  <0.001  Environment  75.5  11.8  63.9  17  −15.6  −8.3  −12  <0.001  Emotional coping  76.5  9.4  62.5  15  −17.1  −11  −14  <0.001  Self-efficacy  82.1  10.4  71.5  17.9  −13.9  −7.3  −10.6  <0.001  Perceived barriers  74.3  12.2  61.6  19.4  −7.1  −9.3  −13.2  <0.001  Outcomes measures  Awareness  67.53  21.11  53.69  19.77  −8.89  −18.48  −13.69  <0.001  General beliefs  77.4  15  61.7  18  −19.7  −11.6  −15.6  <0.001  Table 4 SCT constructs and outcome measures differences six months after intervention SCT constructs/ outcome measures  Intervention group   Control group   CI (95%)   Difference  P-value  Difference  Mean  SD  Mean  SD  Lower limit  Upper limit  Knowledge  15.9  20.7  0.2  6.4  −19.5  −12  −15.7  <0.001  0.78<0.001  Outcome expectations  9.8  21.2  0.2  4.3  −13.4  −5.9  −9.7  <0.001  0.61<0.001  Values expectation  11.3  22  1.1  5.9  −14.2  −6.3  −10.2  <0.001  0.4<0.001  Goal-setting self-control  7.2  11.1  −0.5  5.7  −4.3  −11.1  −7.7  <0.001  0.35<0.001  Environment  10.1  23.5  0.5  5  −5.5  −13.8  −9.7  <0.001  0.29<0.001  Emotional coping  −1.58  19.9  −1.3  12.9  −5.7  −13.9  −9.8  <0.001  0.26<0.001  Self-efficacy  6.6  21.5  −0.4  1.4  −3.2  −10.8  −7  <0.001  0.28<0.001  Perceived barriers  15.3  25.9  0.2  4.9  −10.6  −19.7  −15.2  <0.001  0.72<0.001  Outcomes measures  Awareness  2  32.06  −7.6  14.81  −18.48  −8.89  −13.6  <0.001  0.68<0.001  G. beliefs  12.7  27.9  1.3  10.3  −16.5  −6.2  −11.3  <0.001  0.3<0.001  SCT constructs/ outcome measures  Intervention group   Control group   CI (95%)   Difference  P-value  Difference  Mean  SD  Mean  SD  Lower limit  Upper limit  Knowledge  15.9  20.7  0.2  6.4  −19.5  −12  −15.7  <0.001  0.78<0.001  Outcome expectations  9.8  21.2  0.2  4.3  −13.4  −5.9  −9.7  <0.001  0.61<0.001  Values expectation  11.3  22  1.1  5.9  −14.2  −6.3  −10.2  <0.001  0.4<0.001  Goal-setting self-control  7.2  11.1  −0.5  5.7  −4.3  −11.1  −7.7  <0.001  0.35<0.001  Environment  10.1  23.5  0.5  5  −5.5  −13.8  −9.7  <0.001  0.29<0.001  Emotional coping  −1.58  19.9  −1.3  12.9  −5.7  −13.9  −9.8  <0.001  0.26<0.001  Self-efficacy  6.6  21.5  −0.4  1.4  −3.2  −10.8  −7  <0.001  0.28<0.001  Perceived barriers  15.3  25.9  0.2  4.9  −10.6  −19.7  −15.2  <0.001  0.72<0.001  Outcomes measures  Awareness  2  32.06  −7.6  14.81  −18.48  −8.89  −13.6  <0.001  0.68<0.001  G. beliefs  12.7  27.9  1.3  10.3  −16.5  −6.2  −11.3  <0.001  0.3<0.001  G. beliefs = General beliefs. Table 4 SCT constructs and outcome measures differences six months after intervention SCT constructs/ outcome measures  Intervention group   Control group   CI (95%)   Difference  P-value  Difference  Mean  SD  Mean  SD  Lower limit  Upper limit  Knowledge  15.9  20.7  0.2  6.4  −19.5  −12  −15.7  <0.001  0.78<0.001  Outcome expectations  9.8  21.2  0.2  4.3  −13.4  −5.9  −9.7  <0.001  0.61<0.001  Values expectation  11.3  22  1.1  5.9  −14.2  −6.3  −10.2  <0.001  0.4<0.001  Goal-setting self-control  7.2  11.1  −0.5  5.7  −4.3  −11.1  −7.7  <0.001  0.35<0.001  Environment  10.1  23.5  0.5  5  −5.5  −13.8  −9.7  <0.001  0.29<0.001  Emotional coping  −1.58  19.9  −1.3  12.9  −5.7  −13.9  −9.8  <0.001  0.26<0.001  Self-efficacy  6.6  21.5  −0.4  1.4  −3.2  −10.8  −7  <0.001  0.28<0.001  Perceived barriers  15.3  25.9  0.2  4.9  −10.6  −19.7  −15.2  <0.001  0.72<0.001  Outcomes measures  Awareness  2  32.06  −7.6  14.81  −18.48  −8.89  −13.6  <0.001  0.68<0.001  G. beliefs  12.7  27.9  1.3  10.3  −16.5  −6.2  −11.3  <0.001  0.3<0.001  SCT constructs/ outcome measures  Intervention group   Control group   CI (95%)   Difference  P-value  Difference  Mean  SD  Mean  SD  Lower limit  Upper limit  Knowledge  15.9  20.7  0.2  6.4  −19.5  −12  −15.7  <0.001  0.78<0.001  Outcome expectations  9.8  21.2  0.2  4.3  −13.4  −5.9  −9.7  <0.001  0.61<0.001  Values expectation  11.3  22  1.1  5.9  −14.2  −6.3  −10.2  <0.001  0.4<0.001  Goal-setting self-control  7.2  11.1  −0.5  5.7  −4.3  −11.1  −7.7  <0.001  0.35<0.001  Environment  10.1  23.5  0.5  5  −5.5  −13.8  −9.7  <0.001  0.29<0.001  Emotional coping  −1.58  19.9  −1.3  12.9  −5.7  −13.9  −9.8  <0.001  0.26<0.001  Self-efficacy  6.6  21.5  −0.4  1.4  −3.2  −10.8  −7  <0.001  0.28<0.001  Perceived barriers  15.3  25.9  0.2  4.9  −10.6  −19.7  −15.2  <0.001  0.72<0.001  Outcomes measures  Awareness  2  32.06  −7.6  14.81  −18.48  −8.89  −13.6  <0.001  0.68<0.001  G. beliefs  12.7  27.9  1.3  10.3  −16.5  −6.2  −11.3  <0.001  0.3<0.001  G. beliefs = General beliefs. Discussion According to SCT, someone perceiving that he/she has a good self-efficacy of ill health condition gets the force to engage in healthy behavior but think over the best path to be healthier by choosing best action; i.e. weight of balance between expectancy and self-control for goal setting under basic assumption that people are motivated for their health due to environmental and personal factors.12,13 In this study, the results on improving awareness about appropriate antibiotics use were significantly associated with outcome variables which in line with Solhi et al. study (2013) which indicated promoting preventive behaviors were effective in irrational antibiotics use.17 Also, based on literature from developed countries, insurance coverage led to inappropriate antibiotic usage due to patient unreal demand which can be related to inadequate awareness about the inappropriate use and antibiotics resistance.18 Widayati et al. study (2012) lay people understand antibiotic use can be applied for every kind of infection aside its origin without any side effects.2 The misunderstanding might be the obstacle to tackle incorrect beliefs regarding rational antibiotics use. Based on some studies, the relationships between awareness and beliefs suggested that the more you know about the use of the antibiotics, the more you use appropriately and the correct belief revealed the same.2,3,19 SCT based self-care intervention in antibiotics use had shown a significant effect in different constructs. This is not similar to the study conducted by Milos et al. (2013), theory-based intervention programs which run among general practitioners (GPs) to reduce antibiotics against upper respiratory tract infections (URTIs) in primary care center did not show a significant effect. This might be the previous study was conducted in relation with GPs not patient themselves. In this study, the result revealed that behavioral interventions resulted in decreasing inappropriate antibiotic use. This is similar to the study conducted Meeker et al. (2016) showed behavioral interventions resulted in decreasing inappropriate antibiotic use in primary care practices.20 This finding might lead the health system decision makers to apply some kind of effective and applicable intervention in the preventive setting. In our study, after six months of intervention, knowledge and perception construct had significantly increased in the intervention group. This is similar to the study conducted by Amini Moridani et al. (2015) which was a family-based SCT—intervention on diabetic elders.21 Another study by Ghasemi et al. (2017) on cardiovascular risk factors using SCT showed a significant effect in the outcome and value expectations related to the application of SCT on preventive behaviors among high school students.22 Jalily et al. (2015) study revealed predictive determinants of SCT based intervention on nutritional behaviors was similar to our study.23 There is a possibility of the importance of the issue, nature of subject and intervention processing might have different results. Back to values expectation constructs, our result was in accordance with Beiranvandpour et al. study (2014) which was about effective factors on fast food in women.24 We assumed that the similarity of the outcome of the two studies was in general health. Self-efficacy overcoming impediment is another construct of SCT which was improved after intervention in the intervention group. Sullivan et al. study (2008) results about physical activity were in line with this study.25 Another study conducted by Bruening et al. (2010) was similar to our study results, which revealed that there was a positive and significant relation between self-efficacy and vegetable consumption.26 The study findings on goal setting for self-control construct were in line with Jalily et al. (2015).23 It seems that improvement of goal-setting self-control needs raising awareness, skills and resources allocation. Based on this issue, the results revealed that improving the mentioned construct led to appropriate and safe antibiotics use. Ahmad et al. study (2014) revealed that perceived barrier was significant in self-medication prevention which was congruent with our study.27 As strength, this study is used randomization to ensure similarity between the study groups in terms of demographic variables and the SCT constructs. As limitations, this study lacks the designed intervention based on SCT theory for comparison purpose. Lack of available literatures in the same topic leads us to discuss with other topics which utilized SCT. The other limitation is the bias made on self-reporting of the participants during the data collection. In conclusion, the findings of this study comprehensively summed up to the following conclusions and recommendations to encourage rational use of antibiotics for better understanding. The study evidences the possibility of increasing public population awareness and general beliefs about the appropriate antibiotic use. The study findings informed about the benefits of SCT interventional program. It seems that public health strategies including educational and motivational programs should be developed to reach the at-risk populations. The other recommendation is raising public awareness and general beliefs about proper use and informing for the government to take part in proper regulations and prescription policies. Acknowledgements The authors enthusiastically thank all the staffs of South Health Networks affiliated to TUMS for their cooperation. We would also like to thank educational and research chancellor of TUMS for partially funding as a part of MSPH thesis with Project number: 33537. Funding This research is partly funded by educational and research chancellor of Tehran University of Medical Sciences. Conflicts of interest: None declared. Key points To see the efficacy of the health education model based interventions. To give insight into the rational use of antibiotics. To provide the professional contribution in the field of health education and promotion. References 1 Shehadeh MB, Suaifan G, Hammad EA. Active educational intervention as a tool to improve safe and appropriate use of antibiotics. Saudi Pharm J  2016; 24: 611– 5. Google Scholar CrossRef Search ADS PubMed  2 Widayati A, Suryawati S, De Crespigny C, Hiller JE. Knowledge and beliefs about antibiotics among people in Yogyakarta City Indonesia: a cross sectional population-based survey. Antimicrob Resist Infect Control  2012; 1: 38. Google Scholar CrossRef Search ADS PubMed  3 Mc Cullough AR, Parekh S, Rathbone J, et al.   A systematic review of the public’s knowledge and beliefs about antibiotic resistance. J Antimicrob Chemother  2016; 71: 27– 33. Google Scholar CrossRef Search ADS PubMed  4 Andre M, Vernby A, Berg J, Lundborg CS. A survey of public knowledge and awareness related to antibiotic use and resistance in Sweden. J Antimicrob Chemother  2010; 65: 1292– 6. Google Scholar CrossRef Search ADS PubMed  5 Scicluna EA, Borg MA, Gur D, et al.   Self-medication with antibiotics in the ambulatory care setting within the Euro-Mediterranean region; results from the ARMed project. J Infect Public Health  2009; 2: 189– 97. Google Scholar CrossRef Search ADS PubMed  6 You JH, Yau B, Choi KC, et al.   Public knowledge, attitudes and behavior on antibiotic use: a telephone survey in Hong Kong. Infection  2008; 36: 153– 7. Google Scholar CrossRef Search ADS PubMed  7 Larson E, Ferng YH, Wong J, et al.   Knowledge and misconceptions regarding upper respiratory infections and influenza among urban Hispanic households: need for targeted messaging. J Immigr Minor Health  2009; 11: 71– 82. Google Scholar CrossRef Search ADS PubMed  8 Shorr AF, Micek ST, Welch EC, et al.   Inappropriate antibiotic therapy in Gram negative sepsis increases hospital length of stay. Crit Care Med  2011; 39: 46– 51. Google Scholar CrossRef Search ADS PubMed  9 Ozgenc O, Genc VE, Ari AA, et al.   Evaluation of the therapeutic use of antibiotics in Aegean Region hospitals of Turkey: a multi centric study. Indian J Med Microbiol  2011; 29: 124– 9. Google Scholar CrossRef Search ADS PubMed  10 Center for Disease Control and Prevention. World Health Day: Media Fact Sheet. Available at: http://www.cdc.gov/media/releases/2011/f0407_antimicro-bialresistance.pdf (20 December 2013, date last accessed). 11 Center for Disease Control and Prevention. Antibiotic Resistance Threats in the United States, 2013. Available at: http://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf (19 March 2014, date last accessed). 12 European Medicine Agency. The Bacterial Challenge: Time to React. A Call to Narrow the Gap between Multidrug-Resistant Bacteria in the EU and the Development of New Antibacterial Agents. Available at: http://www.ema.europa.eu/docs/en_GB/document_library/Report/2009/11/WC500008770.pdf (20 December 2013, date last accessed). 13 Stajkovic AD, Luthans F. Social cognitive theory and self-efficacy: going beyond traditional motivational and behavioral approaches. Organ Dyn  1998; 26: 62– 74. Google Scholar CrossRef Search ADS   14 Sharma M, Romas JA. Theoretical Foundations of Health Education and Health Promotion . Burlington, Massachusetts: Jones and Bartlett Publishers, Inc, 2008: 163– 82 15 World Health Organization (WHO). The Evolving Threat of Antimicrobial Resistance: Options for Action, 2012. Available at: http://www.who.int/patientsafety/implementation/amr/publication/en/ (5 March 2013, date last accessed). 16 Nafisi M, Omrani M, Torkamannejad SH, Farsar AR. Knowledge and general belief related to self-care in pharmaceutical. J Razi  2015; 26: 20– 31. 17 Nilsadat N, Solhi M, Shijaezadeh D, Gohari M. Investigating the effect of education based on health belief model on improving the preventive behaviors of self-medication in the women under the supervision of health institutions of zone 3 of Tehran. RJMS  2013; 20: 48– 59. 18 Kuzujanakis M, Kleinman K, Rifas-Shiman S, Finkelstein JA. Correlates of parental antibiotic knowledge, demand, and reported use. Ambul Pediatr  2003; 3: 203– 10. Google Scholar CrossRef Search ADS PubMed  19 Vukovic DS, Ljudmila M, Nagorni-Obradovic LM. Knowledge and awareness of tuberculosis among Roma population in Belgrade: a qualitative study. BMC Infect Dis  2011; 11: 284. Google Scholar CrossRef Search ADS PubMed  20 Meeker D, Linder JA, Fox CR, et al.   Effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices. A randomized clinical trial. JAMA  2016; 315: 562– 70. 21 Amini Moridani MR, Tol A, Sadeghi R, et al.   Assessing the effect of family-based intervention education program on perceived social support among older adults with type 2 diabetes: application of Social Cognitive Theory. JNE  2015; 4: 30– 40. 22 Ghasemi S, Mohebbi B, Sadeghi R, et al.   The effect of educational intervention on prevention of cardiovascular risk factors among girl students of secondary course in high school: application of Social Cognitive Theory. JNE  2017; 6: 26– 37. 23 Jalily M, Barati M, Bashirian S. Using social cognitive theory to determine factors predicting nutritional behaviors in pregnant women visiting health centers in Tabriz, Iran. JECH  2014; 1: 11– 21. Google Scholar CrossRef Search ADS   24 Beiranvandpour N, Karimi-Shahanjarini A, Rezapur-Shahkolai F, Moghimbeigi A. Factors affecting the consumption of fast foods among women based on the social cognitive theory. JECH  2014; 1: 19– 26. Google Scholar CrossRef Search ADS   25 Sullivan KA, White KM, Young RM, et al.   Predictors of intention to reduce stroke risk among people at risk of stroke: an application of an extended health belief model. Rehabil Psychol  2008; 53: 505– 12. Google Scholar CrossRef Search ADS   26 Bruening M, Kubik MY, Kenyon D, et al.   Perceived barriers mediate the association between self-efficacy and fruit and vegetable consumption among students attending alternative high schools. J Am Diet Assoc  2010; 110: 1542– 6. Google Scholar CrossRef Search ADS PubMed  27 Ahmad A, Patel I, Mohanta G, Balkrishnan R. Evaluation of self medication Practices in rural area of town Sahaswan at Northern India. Annals of Medical and Health Sciences Research  2014; 4:73–8. © The Author(s) 2018. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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The European Journal of Public HealthOxford University Press

Published: May 19, 2018

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