The Association Between Knowledge About Gout Arthritis with NSAID and Allopurinol Consumption in Rumah Susun Penjaringan

Background: The Health Ministry in Indonesia needs high funding for various programs every year. It is used for national health initiatives, starting from the availability of health infrastructure to the availability of essential medicines in primary health care and hospitals. In Indonesia, there is a myth that joint pain is gout arthritis. In Indonesia, 71% of people who have joint pain buy pain killers without getting an examination by a doctor first. Accordingly, research is needed concerning the relationship between knowledge about gout arthritis and NSAID and allopurinol consumption in Rumah Susun Penjaringan. Objective: To identify any associations between knowledge about gout arthritis and NSAID and allopurinol consumption. Methods: This research was a cross-sectional study involving 68 people in Rumah Susun Penjaringan. Result: Chi-squared analysis found no significant relationship between knowledge about gout arthritis with NSAID ( p = 0.234) and allopurinol ( p = 0.666) consumption in Rumah Susun Penjaringan. Conclusion: It was concluded that there is no relationship between knowledge about gout arthritis with NSAID and allopurinol consumption in Rumah Susun Penjaringan.


BACKGROUND
Health equalization is one of the goals that the Indonesian Government aims to reach. Based on Anggaran Pendapatan Belanja Nasional (APBN)/National Income Budget data, there is always increasing requirements in the health equalization budget every year 1 . On top of that, the Indonesian Ministry of Health requires the most expensive funding 2 . This funding is used for many aspects of national health initiatives, including the availability of equipment and essential medicines in primary health care and hospital.
Based on Keputusan Menteri Kesehatan Indonesia No HK.01.07/Menkes/395/2017 about National Essential Medicine List/Daftar Obat Esensial Nasional (DOEN), allopurinol and non-steroidal anti-inflammatory drugs (NSAID) such as ibuprofen, ketoprofen, and diclofenac sodium were included 3 . There is an increasing in the incidence and prevalence of gout arthritis every year worldwide. It makes many health professionals concerned about gout arthritis. Allopurinol is one of the gout arthritis medicines which are available in many stores, can be purchased without doctors' prescriptions and are not expensive.
Hyperuricemia can lead to gout arthritis. Gout arthritis has higher incidence in men (30 -40 years old) and women Brigita Naomi Santoso et al. │ The Association Between Knowledge About Gout Arthritis with NSAID... │ Research Article (55 -70 years old, after menopause) and the prevalence of gout arthritis increases as people get older. In Indonesia, the prevalence of hyperuricemia is about 15%. Based on the projections of the Ministry of National Development Planning of the Republic of Indonesia, the Indonesian population will increase.
In 2045, it is estimated there will be an increase in the geriatric population in Indonesia, from 18 million to 60.2 million people 4 . This will present new challenges for Indonesia to increase health services quality, infrastructure and health facilities availability, and ensure population health in Indonesia. The trend means Indonesia has to increase national health funding. There is myth that says if you have joint pain it means you have gout arthritis. As well-know, joint pain is not always gout arthritis. Diagnosing gout arthritis needs a laboratory examination.
Based on the World Health Organization (WHO), many people who have joint injury buy painkillers without consulting a doctor first. It is known that and allopurinol and NSAID have many side effects. It can increase allopurinol and NSAID consumption and this makes the government have to spend more money for the availability of gout arthritis medicine and NSAID. Also, the reason that people consume painkillers without a doctor's prescription can be because they believe that myth so they take their medication not based on indications. This mistake can cause other health issues and increase the health burdens in Indonesia. In 2014, generic medicine consumption in Indonesia reached 60-70% and always increases every year. Annual data showed that the Jaminan Kesehatan Nasional (JKN) program and Indonesian Government spend Rp 1.3 trillion for generic medicine availability in primary health care 5 .
Therefore, the researcher aimed to identify any associations between knowledge about gout arthritis in Indonesia with allopurinol and NSAID consumption. If there is association between them, it can assist the public and national government so these health problems can be better resolved. This research was conducted in Rumah Susun Penjaringan because it was accessible for the researcher which enabled more and variated data so the accuracy was increased.

RESEARCH METHODS
The research was a cross-sectional study. The data were collected by interviewing people in Rumah Susun Penjaringan by using a validated questionnaire. The questionnaire contains an informed consent form, 24 closed-ended questions to measure knowledge about gout arthritis (13 questions based on etiology, predisposition factors, complication, and diagnosis; 7 questions based on diet; and 4 questions based on sign and symptoms), and 4 closed-ended questions about NSAID and allopurinol consumption.
The samples in this research were 75 samples (68 samples and 7 samples for 10% drop out) with 90% confidence interval (CI) in Rumah Susun Penjaringan who are ³ 50 years old and agreed to participate in this research by signing an informed consent form in the questionnaire after the researcher gave the explanation about this research. Samples were collected by using simple random sampling.
The researchers processed data by editing, coding, and cleaning, and then analyzed the data with the SPSS program using chi-squared methods. This research was approved by the Department of Ethic, Faculty of Medicine and Health Science Atma Jaya Catholic University of Indonesia.

RESULTS
The data results included demography (gender, age, marital status, occupation, and education level), knowledge about gout, NSAID and allopurinol consumption, association between knowledge about gout arthritis and allopurinol consumption, and association between knowledge about gout arthritis and NSAID consumption. The following tables present the research data results. Further analysis was conducted by using chi-squared methods (90% CI). The analysis result showed p value 0.234 (p > 0.05). This result means there was no association between knowledge about gout arthritis and NSAID consumption history.

. Association between Knowledge about Gout Arthritis and Allopurinol Consumption History
Further analysis was conducted by using chi-squared methods (90% CI). The analysis result showed p value 0.666 (p > 0.05). This result means there was no association between knowledge about gout arthritis and allopurinol consumption history.

Public Knowledge About Gout Arthritis
Based on the data results, the majority of respondents in Rumah Susun Penjaringan / Penjaringan Flat House do not have sufficient knowledge about gout arthritis, mainly based on etiology, predisposing factors, diagnosis, complication, and diet.
Based on a research conducted in United States (US) in 2019, less than 25% of respondents have sufficient knowledge about gout arthritis based on diet 6 . This study also found the same result which showed 50% of respondents have insufficient knowledge about gout arthritis based on diet. Based on a research conducted in China, only 22.5% of respondents have sufficient knowledge about gout arthritis based on diet 7 .
Based on a research conducted in New Zealand, many people did not know about gout arthritis before they were diagnosed gout arthritis by health professionals. So, health professionals are important to give education to the public about gout arthritis 8  Based on those research results, it can be concluded that many people have insufficient knowledge about gout arthritis not only in Indonesia, but also in some developed countries like the US, New Zealand, and China. Education about gout arthritis needs to be given by health professionals to the public so people will have sufficient knowledge about gout arthritis.

The Association Between Knowledge About Gout
Arthritis with NSAID and Allopurinol Consumption.
This is the first research conducted in Indonesia about the association between knowledge about gout arthritis with NSAID and allopurinol consumption. Hypothesis (Ha) of this research was: There is associations between knowledge about gout arthritis with NSAID and allopurinol consumption. Researcher hypothesized that people who have insufficient knowledge about gout arthritis will consume NSAID and allopurinol without doctors' prescriptions. Also people, who have sufficient knowledge about gout arthritis will consume NSAID and allopurinol based on doctors' prescriptions.
Based on Tables 2.3  Based on the analysis result, there is no association between knowledge about gout arthritis with NSAID and allopurinol consumption. Accordingly, the hypothesis from this research cannot be proved. From a research conducted in Australia which included respondents who are cystic fibrosis patients, the results showed from three kinds of medication (dornase alpha, multivitamin, and hypertonic saline solution), patients' knowledge about gout arthritis only affected their adherence to one kind of medication (hypertonic saline solution) 11 .
A research in Taiwan also showed the same results. That research aimed to identify any association between patients' knowledge about type 2 diabetes mellitus (T2DM) with their adherence to T2DM management and the result found no association between their knowledge about T2DM with their adherence to T2DM management mainly relating with chronic disease management 12 .
A research about the association between knowledge about T2DM with patients' adherence to medication was also conducted in Pakistan. The conclusion from that study found patients who have sufficient knowledge about their diseases did not guarantee patients' adherence to their scheduled medication 13 .
Those studies all show the same result that patients' knowledge about their disease did not guarantee their adherence to having their medications from doctors. Beside developing new medications, increasing patients' adherence to their medication is an important rule and has positive impacts to patients' health conditions 14 . However, patients' adherence to medication (chronic disease medication) is one of main issues in public health discussions. In developed countries, patients' adherence to medication is also a challenging issue as well. Many patients have low adherence to medication. Low adherence to medication not only relates to health conditions, but also to healthcare costs.
It is estimated that patients' low adherence to medications contributes to 75% of failures in medication 15 . It is also estimated that nonadherence contributes significantly to avoidable healthcare costs every year. In the US, nonadherence to medication contributes to 125,000 deaths and costs $ USD 100 billion every year. But, Indonesia is currently lacking the data about patients' adherence to medication.
Presently, several methods or strategies were developed to increase adherence to medication which have positive impacts in the future 16 . One of the positive impacts from increasing patients' adherence to medication is less health care costs. Other than that, further analysis needs to be conducted about other factors which contribute to medication consumption besides knowledge about a disease so people can consume medication based on its indications.
This research has some limitations which include it was conducted only in one location (Rumah Susun Penjaringan) and the data were collected from a small sample of people in Rumah Susun Penjaringan which limits the generalizability of the findings.

CONCLUSIONS
This study concluded that the majority of respondents have insufficient knowledge about gout arthritis, there are more respondents who are consuming NSAID than consuming allopurinol, and there is no association between knowledge about gout arthritis with NSAID and allopurinol consumption. The recommendations for this study are:

For Researchers
Future studies should collect more data in several places so the results can be generalized. Also, more assessment and research are needed about how health professionals give prescriptions to patients so the prescriptions are based on a working diagnosis.

For Health Professionals
Health professionals need to give more education about gout arthritis so the public has sufficient knowledge about gout arthritis.

For the Government
There should be more data about public obedience to scheduled medication. The data about public obedience to medication can help the government make interventions if the public's adherence is low.