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Prevalence, knowledge and perception of self-medication practice among undergraduate healthcare students

• Wuraola Akande-Sholabi   ORCID: orcid.org/0000-0003-0869-1726 1 ,
• Amen. T. Ajamu 1 &
• Rasaq Adisa 1  

Journal of Pharmaceutical Policy and Practice volume  14 , Article number:  49 ( 2021 ) Cite this article

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Globally, self-medication is a common practice, and an increasingly perceived necessity to relieve burdens on health services. However, inappropriate self-medication may result to reduced health outcomes, increased antimicrobial resistance and economic waste. Healthcare students are the future health professionals who will be consistently responsible for educating the public on rational use of medication. This study therefore aimed to assess the prevalence, knowledge and perception of self-medication practices among healthcare students.

A cross-sectional study was carried out among 866 healthcare students in a Nigerian University, comprising medical, nursing and pharmacy students. Information was garnered from respondents using a self-administered questionnaire. Data were summarized with descriptive statistics, while Chi-square and logistic regression tests were used for categorical variables at p  < 0.05.

Mean age was 21 ± 2.8 years, and female respondents were 447 (51.6%). Prevalence of self-medication among respondents was 473 (54.6%). A total of 288 (55.3%) demonstrated good knowledge of self-medication practices, comprising 250 (52.2%) among those who have previously self-medicated and 229 (47.8%) among those who had not. Reasons for engaging in self-medication practices were mentioned to include treatment of minor ailments (357; 32.4%), while 248 (22.5%) believed they had the medical knowledge of what to use. Analgesic (353; 30.1%), antimalarial (352; 30.0%), and antibiotics (182; 15.5%) were the commonest classes of medication used for self-medication. Headache (363; 18.4%), malaria (334; 16.9%), and cough (184; 9.3%) were the most frequently treated conditions. More than half (281; 59.4%) of the respondents’ purchased their self-medicated drugs from the community pharmacy. Gender and respondents’ disciplines were found to be the independent predictors for good knowledge of self-medication practice.

Prevalence of self-medication among the studied healthcare students is moderately high, while approximately half demonstrates good knowledge and perception of self-medication practices. Stimulation for self-medication practice largely arise from the perception of treating minor ailments. This underscores a need for advocacy on responsible self-medication practice during the formal training of these future health professionals, in order to avert its imminent/widespread negative consequences.

Introduction

Globally, self-medication is increasingly being considered as a component of self-care [ 1 ]. World Health Organization (WHO) defines self-care as what people do by themselves to keep their health, prevent and treat illness [ 2 ], while International Pharmaceutical Federation [ 3 ], supported by World Health Organization [ 4 ] defines self-medication (SM) as the self-administration of a medication in the absence of a current prescription and/or without consulting a healthcare professional. Self-medication (SM) with either over-the-counter medications or prescribed medications including antibiotics is a common practice in many developing countries, and partly in some developed countries [ 5 ]. The reason(s) for engaging in self-medication practice in developing countries have been reported to include lack of medical insurance, expensive hospitals visits/consultation fees, easy public access to the prescribed medications [ 5 ], suggestions of friends, inexpensiveness of the practice and previous experience [ 6 , 7 , 8 , 9 ]. Generally, SM is regularly used for minor ailments such as headache, fever, sore throat, gastrointestinal tract problems, respiratory problems, skin disorders, ear symptoms among others [ 10 , 11 , 12 , 13 , 14 , 15 ], and WHO recognizes SM as a viable tool for achieving universal health coverage [ 16 , 17 ].

Self-medication could offer several advantages to patients including quick access to treatment, self-independence in alleviating symptoms, reduction in the cost of accessing healthcare and frequency of visits to health centers; and also, to the community, its advantages include saving medical resources, decreasing absence from work, declining pressure on medical services and providing more time for critical conditions [ 18 ]. Notwithstanding its various advantages, self-medication, especially if unguided could results into possible risks at the individual level such as incorrect diagnosis, serious adverse effects, increased antimicrobial resistance, dangerous food and drug interactions, as well as drug misuse and abuse. Also, at the community level, unguided self-medication may lead to increased drug induced disease and public expenses [ 18 , 19 ]. The negative consequences of SM can be largely felt in many developing countries with limited resources, low literacy level and healthcare amenities, as well as the huge populace who neither have access to information nor satisfactory knowledge regarding therapy, dosage and duration of use or side effect [ 18 , 19 , 20 ]. In Nigeria for instance, the sales of both over-the-counter (OTC) and prescription-only medicine by roadside hawkers, and various unregistered and registered proprietary and patent medicine vendors is common [ 21 ], largely because of weak enforcement of drug regulations [ 22 ]. The unregulated sales of these products, may incessantly trigger self-medication practice among the general populace. However, a responsible/guided self-medication may still be envisaged, whereby the patient treat his illness or symptom with medicine which are approved and available without prescription, but which are safe and effective when used as directed [ 4 ].

Previous studies have documented that, influencing the prescribing conduct as well as knowledge of the healthcare professionals can encourage responsible self-medication [ 6 , 7 , 13 , 14 ]. Thus, creating awareness frequently and providing extensive formal training on the concept of responsible self-medication for healthcare students who are the future health professionals may potentially be an efficient approach to circumvent the unwarranted consequences of self-medication. However, to partly achieve this, there may be a need to probe into the knowledge and extent of involvement of healthcare students in self-medication practices.

Most of the previous studies on self-medication in Nigeria focused on general populations [ 8 , 9 , 10 , 21 , 23 , 24 , 25 ], with a paucity of information on healthcare students. Thus, this study aims to assess the prevalence, knowledge and perception of self-medication practices among healthcare students, while the possible reasons for engaging in such practice were also explored.

Study design and setting

This study was a university-based cross-sectional study using a self-administered questionnaire. It was conducted among undergraduate students at the University of Ibadan, in the Faculty of Pharmacy, Departments of Medicine and Surgery, as well as Nursing, between August and November 2019. Presently in Nigeria, the Bachelor of Pharmacy and Bachelor of Nursing degrees are a 5-year program, while the Bachelor of Medicine and Surgery degree is a 6-year program.

Data collection instrument

The questionnaire used for this study was designed by the researchers after a thorough review of similar studies [ 10 , 26 , 27 , 28 ], as well as utilizing researchers’ proficiency. The questionnaire comprised three sections. Section A evaluated socio-demographic characteristics of the students such as age, gender, level of study and course of study. Section B consisted of questions on students’ level of knowledge and perception on self-medication, while Section C consisted of questions on the participants’ practice of self-medication. The questions were evaluated on a 5-point Likert rating scale from strongly agree (5) to strongly disagree (1) to explore and evaluate students’ knowledge and perception of self-medication practice. The overall score for the knowledge and perception questions were categorized into ‘good’ and ‘poor’ depending on respondents’ score in each domain. For the 8-item statements on knowledge with 5-point Likert scale response, a total score of at least 32 (≥ 80%) out of the maximum obtainable score of 40 was categorized as ‘good’ knowledge, while a knowledge score < 32 (< 80%) was categorized as ‘poor’ knowledge. For the 3-item statements on perception with 5-point Likert scale response, a total score of at least 12 (≥ 80%) out of the maximum obtainable score of 15 was categorized as ‘good’ perception, while a score < 12 was categorized as ‘poor’ perception. The binary categorization of knowledge and perception scores was adapted from Bloom’s cut-off criteria and other similar studies [ 29 , 30 , 31 ].

Inclusion and exclusion criteria

Eligible participants were registered undergraduate students of Medicine and Surgery, Pharmacy and Nursing, for the 2018/2019 academic session. Participants must have also given voluntary informed consent to partake in the study. Students who were absent in the classes during the period of questionnaire administration, as well as the non-consenting individuals were excluded.

Sample size determination

Based on the population of 1521 registered students for the 2018/2019 academic session, comprising Pharmacy (360), Medicine and Surgery (881), and Nursing (280) at 95% confidence level and 5% alpha error, a sample size of 316 was obtained using Yamane’s formula [ 32 ]. Additionally, to cater for the possibility of a low response rate, which is not uncommon among students, an attrition rate close to 200% was allowed.

Sampling and data collection procedure

Students were approached after a major lecture identified across the levels in each faculty/departments, purpose and objectives of the study were explained to the students immediately at the end of the identified major classes. Each questionnaire, which took about 12–15 min to be completed was subsequently administered only to the consented individuals. This was done in the period allocated for questionnaire administration for each Faculty or Department. The questionnaires were retrieved after completion and inspected for completeness and correctness. Study participation was voluntary and the students were informed of the possibility of withdrawing from the study anytime. Response anonymity and confidentiality were reiterated to the respondents. Measures were put in place to prevent multiple filling of the questionnaire by the respondents. This was achieved by coding each questionnaire administered to the students from each department to avoid duplication.

Pretest and content validation

Content validity was established by three scholars with expertise in the subject area, to ascertain the inclusiveness of question-items in line with the objectives of the study. Thereafter, pretest was carried out by administering the questionnaire to thirty students randomly selected from the Pharmacy, Nursing, and Medical and Surgery departments. These students were exempted from the main study. Feedback from these students on clarity of the questions or statements in the questionnaire led to some modifications in the questionnaire, such as significant reduction in the number of open-ended questions.

Statistical analysis

Data were coded, cleaned, and analyzed using the IBM Statistical Package for Social Sciences (version 23). Descriptive statistics such as frequency, percentages, mean, and standard deviation were used to summarize the data. The internal consistency/reliability of the 11-items self-medication knowledge and perception questions was determined using Cronbach alpha test, with a value of 0.68. Association between demographic variables and respondents’ engagement in self-medication practice or not was evaluated with Chi-square, while binary logistic regression was used to ascertain the predictors of good or poor knowledge and perception on self-medication practice. The level of significance was set at p  < 0.05.

Demographic characteristics of respondents

Of the 960 copies of questionnaires distributed among the respondents, 866 were completed and included in the analysis given a response rate of 90.2%. This comprised, Medicine and Surgery (436; 50.3%), Pharmacy (275; 31.8%) and Nursing (155; 17.9%) students. Mean age was 21 ± 2.8 years, and 447 (51.6%) were females. The prevalence of self-medication practice was highest among females (261; 58.4%) and students aged > 20 years (259; 56.2%). Also, self-medication practice among the healthcare students was in the order of Medicine and Surgery (259; 59.4%) > Nursing (78; 50.3%) > Pharmacy (136; 49.5%), p  = 0.017. Year 5 and Year 6 students constituted those who had largely engaged in self-medication, 116 (63.0%) and 44 (81.5%), respectively ( p  = 0.000). In all, the prevalence of self-medication practice among the respondents was 473 (54.6%) (Table 1 ).

Knowledge and perception about self-medication practice among respondents

Table 2 shows the assessment of respondents’ knowledge and perception on the practice of self-medication. A total of 479 (55.3%) had score ≥ 80% indicating ‘good’ knowledge; comprising 250 (52.2%) among those who had self-medicated and 229 (47.8%) among those who had not. Over half (223; 57.6%) of the respondents who had self-medicated constituted those with ‘poor’ knowledge compared to those who had not (164; 42.4%). Moreover, a total of 584 (67.4%) had score ≥ 80% indicating ‘good’ perception. There was no statistically significant difference among respondents who had either self-mediated or not in respect of knowledge ( χ 2  = 2.547; p  = 0.111) and perception ( χ 2 = 0.020; p  = 0.887).

Determinants of knowledge and perception on self-medication practice among the respondents

Gender and respondents’ disciplines were found to be independent predictors of good knowledge. Females were 1.4 times more knowledgeable about self-medication (AOR: 1.43 [CI: 1.059–1.953], p  = 0.02) than males. However, students of Pharmacy had lower odds for knowledge (AOR: 0.621 [CI: 0.401–0.961], p  = 0.03), and perception (AOR: 0.577 [CI: 0.365–0.913], p  = 0.019) on self-medication practice than the students of Nursing and Medicine and Surgery. Details are in Table 3 .

Reasons for engaging in self-medication practice by respondents

The arrays of reasons for engaging in self-medication practice are presented in Table 4 . The majority, 357 (32.4%) engaged in the practice for treatment of minor ailments, while 248 (22.5%) believed they had the medical knowledge of what to use and 122 (11.1%) did not want to waste time at the clinic. Other reasons cited included previous experience from old prescriptions (81; 7.3%), inability to afford laboratory investigation costs (66; 6.0%), as well as left-over medications (61; 5.5%) (Table 4 ).

Medications used for self-medication practice and the conditions treated

Analgesic, 353 (30.1%) was the most commonly used class of medication, followed by antimalarial (352; 30.0%), antibiotics (182; 15.5%) and multivitamins, 142 (12.1%). The most frequently treated conditions by self-medication among respondents were headache (363; 18.4%), malaria (334; 16.9%), cough (184; 9.3%), menstrual pain (170; 8.6%) and cold and flu (158; 8.0%). Details are in Table 5 .

Source of medications and information on drug dosage regimen for self-medication practice

More than half (281; 59.4%) of the respondents’ purchased their medications from the community pharmacy, followed by proprietary and patent medicine vendor (116; 24.5%), and friends/family (48; 10.1%). Twenty-eight (5.9%) reported to have their medications from the hospital, perhaps representing those who reuse medication from left over of previously prescribed medications. Patient information leaflet (251; 32.3%) was the commonest source of information about dosage and duration of medications, followed by family and friends (172; 22.1%) and classroom/lectures 143 (18.4%) (Table 6 ).

In this study, we investigated the prevalence of self-medication as well as the knowledge and perception towards self-medication practice among healthcare students in a Nigerian University. This was done to better understand the extent of this practice among the cohort, while exploring the reasons that drives or encourages such practice. Our findings reveal a moderately high prevalence (54.6%) of self-medication practice across the three major disciplines of healthcare students studied. The moderately high rate of self-medication practice is consistent with previous studies across different countries, which focus largely on university students and the general population [ 6 , 7 , 8 , 9 , 11 , 12 , 13 , 14 , 15 , 21 , 23 , 24 , 26 , 27 , 33 , 34 ]. The variation in self-medication practice among countries might be attributed to the differences in demographic characteristics and socioeconomic factors of respondents [ 6 , 7 , 8 , 9 , 11 , 12 , 13 , 14 , 15 , 21 , 23 , 24 , 26 , 27 , 33 , 34 ].

Of note, the self-medication practice was highest among female healthcare students compared to their male counterparts, which perhaps correlate with previous studies [ 10 , 11 , 12 , 13 ]. The gender difference in self-medication practice among the respondents might possibly be linked to the propensity of the females to engage in self-recommendation of analgesic group of medications to relieve pains and symptoms during their monthly menstrual cycle. Analgesics are the most commonly recommended medicines for the relief of menstrual pain in women, and as reflected in this study, menstrual pain is one of the top five conditions treated by self-medication.

In addition, 5th year Nursing and Pharmacy students, as well as Medicine and Surgery students constitute respondents who mostly engaged in self-medication practice. Generally, in the curriculum for the healthcare students at the 5th year, students are expected to have gained substantial knowledge in disease management, while they would have also been involved in direct patient care and management at one point or the other during their mandatory clinical rotations and exposure. Perhaps, this could have accounted for the perceived confidence in managing minor ailments by the respondents, as well as believe that they have acquired the requisite medical knowledge of what to use for a particular condition treated. Even though, ‘learning by doing’ is an encouraging concept that is consistently advocated in the training of healthcare students. However, for this approach to achieve the intended goal, it should be done responsibly, especially under the tutelage and guidance of senior and qualified clinical instructors/tutors in their respective disciplines. Otherwise, the act may lead to avoidable risk that self-medication could pose to future healthcare professionals. Previous studies have also documented that healthcare students tend to self-medicate probably owing to believe that they have the knowledge of what to use [ 6 , 7 , 12 , 14 ].

In the present study, it is observed that pharmacy students engaged least in self-medication, compared to their counterparts in Nursing and Medicine, this variation in the engagement of self-medication could be as a result of pharmacy student knowing more about the risks of self-medication. Furthermore, female respondents, as well as nursing and medical students had higher odds of knowledge of self-medication practice than their other counterparts. Similarly, nursing and medical students had higher odds of perception of self-medication than the pharmacy students. Typically, one who have expected pharmacy students to have higher odds of knowledge and perception of self-medication than their nursing and medical students’ counterparts, mainly because they are largely going to be the future custodian of medicines, thus they should possess more knowledge of self-medication. This gap perhaps suggests a need to further look into the training curriculum of the healthcare students in general, and the pharmacy students in particular. This is in a bid to consider incorporation of relevant components of self-medication concept that will prepare the students for the future roles and responsibilities as a medicine expert.

Noteworthy to mention that the main source for purchasing medications for self-medication practices by respondents is the community pharmacies, followed by patent medicine vendors, while the left-over medicines at home, from friends and families were also mentioned. Hence, the need for appropriate government authorities specifically National Agency for Food Drug Administration and Control (NAFDAC) and the Pharmacists Council of Nigeria (PCN), to take necessary steps in ensuring consistent enforcement of medicine regulation as well as public enlightenment of responsible self-medication. On the other hand, community pharmacists especially should consistently uphold the ethics of the pharmacy profession by ensuring that only the clients who genuinely need a medicine obtain the product with proper guidance/instruction on rational usage. Our study is perhaps the first study in Nigeria to comprehensively evaluate self-medication practice among the healthcare students, while concurrently attempting to clarify the likely motivating reasons driving these practices, hence a major strength of the study.

Aside from analgesics as the most prevalent medication category used for self-medication, antimalarial and antibiotics were also part of the topmost medications used to self-medicate by respondents. This is not surprising, and can be supported by the fact that headache, malaria, cough, menstrual pain, cold and flu were the most frequently treated conditions by the respondents. Findings from previous studies also reported that analgesics and antipyretic are the most prevalent medication categories used for self-medication [ 7 , 12 , 15 , 28 , 35 ], Ideally, antibiotics and antimalarial should not be sold without a prescription from a qualified medical practitioner/physician as practiced in most developed countries and some developing countries. However, this is contrary to the situation in Nigeria, where most antimalarial and antibiotics may be purchased over-the-counter from medicine vendors without a prescription, and some community pharmacies are also inclusive. The weak enforcement of medicine regulations, as well as public easy accessibility to prescription-only medicine needs to be addressed by the appropriate authorities in order to prevent potential harm(s). Previous studies have reported that between 52.2% and 55% of Nigerian population obtained their medicines for self-medication practice from the patent medicine stores [ 23 , 24 ], where they do not have the opportunity of accessing relevant and appropriate counselling services to guide medication usage [ 36 , 37 ].

Our study also reveals that patient information leaflet is topmost of the common sources of information on dosage regimen for medicines used for self-medication practice. This may be expected since most of the respondents are more likely to be aware that patient information leaflet or the manufacturer’s literature insert serves as a quick and most readily available source of information for pharmaceutical products, though sometimes, manufacturer’s bias may distort/affect the reliability of information from such package insert.

Limitation of the study

This study is limited by the possibility of recall bias, which is most inherent in self-report study of this nature. Also, the likelihood of respondents discussing among themselves while filling the questionnaire may not be totally excluded, being a self-administered questionnaire. In addition, future study may still need to consider other possible indicators aside from knowledge and perception as well as factors that may influence future healthcare professional especially pharmacy students in engaging in responsible self-medication practice. The above-mentioned gaps may therefore need to be considered in order to ensure a far-reaching conclusion, while caution should be exercised in generalizing the study findings to the entire population of healthcare students in the region.

Prevalence of self-medication among the studied healthcare students is moderately high, while approximately half demonstrates good knowledge and perception of self-medication practices. Gender and respondents’ discipline were the notable independent predictors of good knowledge of self-medication, while stimulation for self-medication practice largely arise from the perception of treating minor ailments. This generally underscores a need for relevant advocacy and incorporation of aspects of responsible self-medication practice during the formal training of these future healthcare professionals. In addition, national guideline on medicine access should be re-enforced, with strong measures put in place to implement the policy, this may become necessary in order to avert the widespread negative consequences of self-medication practice among the populace generally.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

National Agency for Food and Drug Administration and Control

Over the counter

Pharmacist Council of Nigeria

World Health Organization

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Acknowledgements

We would like to express our appreciation to the students who accepted to participate and dedicated their time to fill the questionnaire.

No specific Grant from any funding agency in the public, commercial or not-for-profit sector was received in carrying out this study.

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Wuraola Akande-Sholabi, Amen. T. Ajamu & Rasaq Adisa

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We declare that this work was done by the author(s) named in this article. Wuraola Akande-Sholabi (WAS) conceived the idea, WAS and Amen T Ajamu (ATA) designed the study, contributed in data acquisition, performed data analysis and interpretation. WAS drafted the manuscript. RA revised the manuscript. All authors contributed to the preparation of the manuscript, read and approved the final version.

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Correspondence to Wuraola Akande-Sholabi .

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Ethics approval for the study was obtained from the joint University of Ibadan/University College Hospital Institution Review Board with approval number UI/EC/19/0403. Verbal informed consent in accordance with the approved study protocol by the Ethics committee was obtained from individual student after explaining the objectives and procedure of the study to participant individually. Verbal informed consent was deemed appropriate for our study being a questionnaire-based survey with questions carefully designed without infringement on participants’ privacy. Only the consented participants within the study period were enrolled.

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Akande-Sholabi, W., Ajamu, A.T. & Adisa, R. Prevalence, knowledge and perception of self-medication practice among undergraduate healthcare students. J of Pharm Policy and Pract 14 , 49 (2021). https://doi.org/10.1186/s40545-021-00331-w

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DOI : https://doi.org/10.1186/s40545-021-00331-w

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• Self-medication practice
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ORIGINAL RESEARCH article

Self-medication practices in medical students during the covid-19 pandemic: a cross-sectional analysis.

• 1 Department of Internal Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
• 2 Department of Internal Medicine, Dow University of Health Sciences–Ojha Campus, Karachi, Pakistan
• 3 Department of Nephrology, Dow University of Health Sciences–Ojha Campus, Karachi, Pakistan
• 4 Department of Internal Medicine, Aga Khan University Hospital, Karachi, Pakistan

Background and Objectives: During the pandemic, the growing influence of social media, accessibility of over-the-counter medications, and fear of contracting the virus may have led to self-medication practices among the general public. Medical students are prone to such practices due to relevant background knowledge, and access to drugs. This study was carried out to determine and analyze the prevalence of self-medication practices among medical students in Pakistan.

Materials and Methods: This descriptive, cross-sectional study was conducted online in which the participants were asked about the general demographics, their self-medication practices and the reasons to use. All participants were currently enrolled in a medical college pursuing medical or pharmacy degree. Non-probability sampling technique was used to recruit participants.

Results: A total of 489 respondents were included in the final analysis. The response rate was 61%. Majority of the respondents were females and 18–20 years of age. Self-medication was quite prevalent in our study population with 406 out of 489 individuals (83.0%) were using any of the drugs since the start of pandemic. The most commonly utilized medications were Paracetamol (65.2%) and multivitamins (56.0%). The reasons reported for usage of these medications included cold/flu, or preventive measures for COVID-19. The common symptoms reported for self-medication included fever (67.9%), muscle pain (54.0%), fatigue (51.7%), sore throat (46.6%), and cough (44.4%). Paracetamol was the most commonly used drug for all symptoms. Female gender, being in 3rd year of medical studies, and individuals with good self-reported health were found more frequent users of self-medication practices.

Conclusion: Our study revealed common self-medication practices among medical and pharmacy students. It is a significant health issue especially during the pandemic times, with high consumption reported as a prevention or treating symptoms of COVID-19.

Introduction

The Coronavirus 2019 (COVID-19) was declared a pandemic by the World Health Organization on January 30th, 2020 ( 1 ). As of October 22nd, 2021, the global crisis has affected 242 million individuals and claimed over 4.9 million lives ( 2 ).

With clinical trials of multiple drugs in the pipeline, there are no definitive treatments with confirmed evidence against the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2). Anti-malarial drugs, hydroxychloroquine, and chloroquine received emergency approval to treat prophylaxis in COVID-19 when a small non-randomized trial was initially promising ( 3 ). It was soon labeled controversial as randomized studies depicted an increased risk-to-benefit ratio ( 4 ). However, rapid medical research has developed, and massively rolled out COVID-19 vaccines prevented the adverse effects from symptoms of the disease in affected individuals ( 5 ). It is envisaged that vaccine advent and procurement by developed countries will soon create global inequity as middle-to-low income nations struggle to vaccinate healthcare workers and the older population ( 6 ). Economic recession in developing countries, like Pakistan has only managed to fully vaccinate less than half of its population ( 7 ).

The third wave of coronavirus had peaked, yet Pakistan's overburdened healthcare system reached a 90% occupancy of ventilators and hospital beds ( 8 ). Travel restrictions, oxygen shortage, and the risk of contracting the virus from crowded clinics and hospitals have inculcated fear in the public, allowing a nation prone to self-medication to rely more heavily on self-diagnosis ( 9 , 10 ). Self-medication is the administering of medicines to treat self-recognized symptoms, psychological ailments, and first aid based on prior knowledge, without consulting a physician ( 11 ). The growing influence of social media has let individuals explore COVID-related symptoms, pain keywords, and treatments worldwide, as well as in Pakistan, as revealed by an infodemiological study on Google trends ( 12 ). Adding to this is the availability of over the counter (OTC) drugs in pharmacies across Pakistan which has been the highest contributor to a self-medicating prevalence of 81% in the populous Karachi. Easily accessible drugs in pharmacies across Pakistan range from analgesics, antibiotics, anti-diarrheal agents, antihistamines, antipyretics, cough-suppressants, vitamins to herbal medicines and homeopathy ( 10 , 13 ). Though the primary reason was affordability, the greatest driver (47.8%) of self-medication was the belief that the illness was insignificant. This stems from poor health literacy amongst the general public which is easily influenced by the media ( 10 ). It is also well noted that preference for self-medication is cultural practice in Pakistan. The positive and negative effects of self-medication of Sanna Makki, a herbal laxative, which was widely used as a COVID-19 cure after mass-circulation on WhatsApp was a well-publicized example ( 14 ). The risks attached to self-medicated drugs include incorrect and improper dosage, and antibiotic abuse leading to drug resistance ( 15 ).

A trending worldwide practice of self-medication does not have enough literature on an ongoing pandemic, except studies conducted in Peru and Saudi Arabia ( 16 , 17 ). However, no study reports the prevalence of self-medication in the highly affected medical student population in Pakistan—the future of the healthcare system. It is important to assess self-medication practices among medical students, because they have relevant knowledge, and are more likely to access to prescription as well as OTC drugs. Low tendency to consult health professionals, reliance on the internet for information on background medical knowledge, and treating self-diagnosed illnesses could be factors that promotes self-medication practice among medical students.

The primary objective was to determine and analyze the prevalence of self-medication practices among medical students for respiratory symptoms, from the onset of first COVID-19 symptom or in case of being positively tested for COVID-19. We further assessed the self-medicated drugs used for respiratory problems during the pandemic. A secondary aim was to evaluate the factors associated with self-medication of various drugs among medical students during the COVID-19 pandemic in Pakistan. This will allow the health ministries and educational administrations alike to undertake measures and address the gap of health negligence that can result from self-medication practices.

Materials and Methods

Study design.

This descriptive, cross-sectional study was conducted online from January 25th to February 20th, 2021. The design of the study and sample size was modified according to the pilot study carried out from December 11th to December 15th, 2020, under the expertise of professors and doctors. The questionnaire was developed in English, on Google survey, and distributed through social media platforms. The online survey questions were obtained after a thorough literature search and assessing the validity and reliability ( 16 , 17 ). The responses were made anonymous to maintain confidentiality and reliability. Each participant received an email of their response to avoid duplication of data. Clarification of the contents and the purpose of the study were explained at the start of the survey followed by an informed consent. Data was anonymized and only the lead investigator had access to the responses.

Development of Survey Questionnaire and Operationalization of Variables

The questionnaire included a total of 11 questions. Seven questions were dedicated to the general demographics including the city of residence, gender, age, marital status, level of education/medical, and comorbid conditions. The next 4 questions were based on self-medication of drugs for prevention and treatment of respiratory symptoms: drug selection, reasoning for self-medication, symptoms they were looking to improve, and if any of the drugs improved those symptoms. The participants were asked if they consulted any physician before starting these medications, were they been using these medications before COVID-19 pandemic, and do they have any comorbid conditions that warrant the use of these medications. All these questions if answered as a No have been considered as self-medication during the pandemic. The drugs listed in the survey included acetaminophen, ibuprofen, azithromycin, hydroxychloroquine, ivermectin, doxycycline, antivirals (lopinavir, ritonavir, remdesivir, and others), cetirizine, multivitamin compounds or any other drug (open question) for respiratory symptoms. All drugs were classified according to the Anatomical Therapeutic Chemical (ATC) ( 18 ). This selection of drugs was based on the existing literature, and reports from the local media. COVID-19 can present with a range of symptoms. Frequently reported symptoms were obtained from CDC's guidelines ( 19 ). The list of symptoms included fever, fatigue, cough, muscle ache, nasal congestion, sore throat, headache, breathing difficulty, no symptom, and other symptom (open question). Anosmia was omitted as being controversial at the time of inception of this study ( 16 ). To assess the reason for drug use, participants had seven options listed as cold/flu, no symptoms, COVID-19 prevention, had COVID-19 symptoms, COVID-19 positive, consume the drug regularly, other reason (open question). The following 5-point Likert scale was used to identify and list the improvement in symptoms if any: improved all symptoms, improved most of the symptoms, improved a few of the symptoms, improved only one symptom, did not alleviate any of the symptoms.

Sample Size/Sampling Technique

The sample size of the survey was obtained from the pilot study determined using the power analysis. The minimum sample size was 385, with a statistical power of 80% and a confidence interval of 95%. We hypothesized that at least 50% of the participants would practice self-medication, with a 5% margin of error. The formula for sample size estimation was n = N ×/((N-1) E2 + x), where N is the population size and n is sample size estimation. A non-probability sampling technique was used to recruit participants from social media platforms, including WhatsApp, Facebook, and Messenger.

Inclusion/Exclusion Criteria

Inclusion criteria included completed responses, and the respondent i.e., male or a female medical student pursuing MBBS or Pharm D degree from a medical college in Pakistan, having the ability to understand English, and being technologically adept and have access to Internet. While exclusion criteria included respondents from other than the medical field.

Ethical Approval

The study received ethical approval from the Institution's Ethics Committee of the Dow University Ojha Hospital. Each participant had the right to withdraw from the study at any time. The possible risks and the purpose of the survey were thoroughly explained. Participants had to provide consent before filling out the questionnaire.

Data Analysis

Microsoft Excel 2016 was used for data collection and assembled in to Statistical Package for Social Sciences (SPSS) version 25.0 for data analysis. A multivariate analysis estimated the preference of self-medication for the surveyed drugs using the baseline demographics i.e., sex, age, marital status, educational status, region, presence of comorbid conditions, and self-reported health as control variables. Categorical variables were assessed using frequencies and percentages, through univariate analysis. Analytical statistics were performed with 95% confidence intervals (CI) and odds ratios (OR), which were obtained using logistic regression.

A total of 374 medical and 115 pharmacy students were included in the final analysis. The response rate was 61%. Majority of the respondents were of 18–20 years of age (58.5%). More than three-fourths were females. 34.0% of medical students were in first year, 20.6% in second year, 20.3% in third year, 13.9% in fourth year, and 11.2% were in final year of their medical education. Most respondents were from province Sindh and Punjab (combined 85.7%). Only 4.5% reported previous comorbid conditions, while majority (60.5%) were in good state of self-reported health. While reporting the risk of acquiring COVID-19 infection, 43.8% were unbothered. Another 38.0% admitted mild risk while only 2.9% reported severe risk. 15.3% of participants were already infected with the virus. The socio-demographic characteristics of the participants are described in Table 1 .

Table 1 . Sociodemographic characteristic of medical students during the COVID-19 lockdown ( n = 489).

Self-medication was prevalent in our study population with 316 out of 374 medical students (84.5%) and 90 out of 115 pharmacy students (78.3%) were using any of the drugs since the start of pandemic. The most commonly utilized medications were Paracetamol (65.2%), multivitamins (56.0%), Ibuprofen (29.0%), Cetirizine (27.8%), and Azithromycin (25.6%) among others. The reasons reported for usage of these medications included cold/flu (71.4%), as preventive measures for COVID-19 (43.3%), or a self-medication for COVID-19 symptoms (34.1%). However, 35.2% reported taking these medications without any reason or symptoms, while another 40.1% consumed them regularly for other reasons. The symptoms reported for self-medication included fever (67.9%), fatigue (51.7%), cough (44.4%), sneezing (40.7%), muscle pain/body aches (54.0%), nasal congestion (42.1%), sore throat (46.6%) anosmia (23.1%), and breathing difficulty (24.5%) as shown in Table 1 . Paracetamol was the most commonly used drug for all symptoms including fever, fatigue, cough, sneezing, myalgia, nasal congestion, sore throat, anosmia, and shortness of breath. Figure 1 demonstrates the relative proportions of drug use for each specific symptomatology.

Figure 1 . Relative proportions of drug use on specific symptomatology.

Paracetamol use was common in individuals >21 years, final year medical students, those already infected with COVID-19, and having flu, fever, and fatigue. 45.4% shown all or most symptoms resolved with its use as shown in Table 2 . Azithromycin use was common in age >21 years, 5th year medical students, inhabitants of Khyber Pakhtunkhwa/Balochistan, as well as those already infected with COVID-19. Cetirizine use was frequent among pharmacy students, final year medical students and those with self-reported risk of COVID-19 infection. Use of antivirals was prevalent among males of above 21 years of age. Use of multivitamins was also common in individuals >21 years, females, residents of Khyber Pakhtunkhwa/Balochistan and those either already infected with COVID-19 or reported mild to severe risk of acquiring infection. Individuals from province Punjab were more likely to use ivermectin and less likely to use cetirizine as self-medication. Doxycycline use was found prevalent in males. Use of ivermectin was not shown to improve any of the self -reported symptoms. Other medications were more common among those having comorbid conditions and self-reported as fair/poor. All these factors showed significant association when conducted on a logistic regression model with reported odds ratios and p -values as shown in Table 3 .

Table 2 . Factors associated with self-medication of various drugs among medical students during the COVID-19 lockdown ( n = 489).

Table 3 . Bivariate analysis of the factors associated with the self-medication of various drugs during the COVID-19 lockdown among medical students ( n = 489).

The following variables were significantly associated with self-medication practice in logistic regression ( Supplementary Figure 1 ; Table 4 ): female sex ( p < 0.001), third-year medical students ( p = 0.022), self-reported health as good ( p = 0.029), and those previously infected with COVID-19 ( p = 0.050). In multivariate analysis, female gender (<0.001), those in third year of medical studies ( p = 0.031) and those students who perceived their self-reported health as “good” were more likely to adopt self-medication practices ( p = 0.032).

Table 4 . Multivariate analysis of the factors associated with the self-medication practice during the COVID-19 lockdown among medical students ( n = 489).

Self-medication is often considered as an ambiguous phenomenon and the practice is commonplace in developed and developing countries alike. However, it has not been extensively qualitatively or quantitatively studied, especially in Pakistan ( 20 ). Self-medication with antibiotics rates were generally low in middle income countries, according to a 2020 review, however, among affected countries, Pakistan had one of the highest prevalence of 81.23%, with only 7.3% in Indonesia and 26.9% in Bangladesh ( 21 ). A study conducted by the Aga Khan University, Karachi in 2008 revealed 76% self-medication rates among the medical and non-medical university students surveyed ( 22 ), while another survey from pre-COVID times, consisting of a small segment of medical students in Pakistan found 99% of them to be engaged in practicing self-medication ( 23 ). To the best of our knowledge, our study is the first of its kind within the current pool of literature available, that has evaluated self-medication among medical students in the context of COVID-19, encompassing most provinces of Pakistan.

The incidence of self-medication revealed in our results is around 83%, a finding that is comparable to self-medication occurrence rates during COVID-19 reported in studies conducted abroad. Among the nursing undergraduates in Saudi Arabia, self-medication practice with antibiotics and analgesics was found to be 87% ( 5 ) while In Kenya, health care self-medication prevalence was 60.4% among healthcare workers, indicating an increase from pre pandemic results ( 24 ). Another study assessing self-medication prevalence in the Nigerian population during the pandemic reported a finding of 41% ( 25 ). In Togo, 34.1 % of the participants that belonged to healthcare, air transport, police, road transport and informal sectors reported to self-medicate and healthcare division had the highest of 51.9% against all sectors ( 26 ). Conversely, in Peru, the number of responders not engaging in self-medication was higher than those that did, for all drugs including Acetaminophen, Ibuprofen, Azithromycin, Hydroxychloroquine, Penicillin, Antiretrovirals, which were evaluated ( 16 ). Multivariate logistic regression model showed that being female gender, medical school year 3rd, having been already infected with COVID-19 or having already infected with COVID-19 were factors that were associated respondents expected to self-medicate the most.

Paracetamol was the highest used drug in our study, respondents 21–25 years and above, 5th year medical students, those already infected with COVID-19, and stating symptoms of cold/flu, fever and fatigue showed significant use. High use of Paracetamol aligns with results from the nursing undergraduates in Saudi Arabia ( 17 ) and from the Peru adult population ( 16 ) where it was also the most consumed drug. As a widely used first line pharmacotherapy analgesic for tackling pain disorders and different pyrexia, Paracetamol use is widely reported in studies comprising of medical students. Health science major students in Nigeria commonly used it as a pain reliever ( 25 ), while medical students in Iran were also frequent users of this drug ( 27 ). An Indian study found medical students to be more likely to self-medicate than paramedical students and for this purpose, Paracetamol was consumed mostly ( 28 ). Paracetamol has been known to have negligible anti-inflammatory action ( 28 ) and guidelines issued during the initial months of the pandemic state that it can be used for treating mild COVID-19 symptoms when managing patients at home ( 29 ) or for self-medication, especially for fever or headache ( 30 ). This is consistent with our results corresponding to Paracetamol use as it was greatly used to treat “fever” in our study population, and its use also showed improvement in all or most of the symptoms experienced by the responders who employed Paracetamol. However, some instances report the drug to be exacerbating COVID-19 symptoms, likely due to activation of prothrombotic mechanisms which is known as one of the leading pathogenic causes of COVID-19 ( 29 ). Single or repeated high Paracetamol dose, or chronic ingestion above therapeutic doses can result in hepatotoxicity ( 17 ). Hepatotoxicity from intentional or non-intentional Paracetamol overdose is the most common cause of drug-induced liver injury and is a global issue ( 17 ). The medicine's toxic dosage effects must be known to students utilizing it.

Multivitamins were the second highest consumed drug in our study, which have also been the drug of choice as divulged in a population-based survey during COVID-19 in Nigeria with 51.8% reporting to use this group of medicine ( 25 ). In Togo, 27.6% used Vitamin C when self-medicating ( 26 ), while in Egypt, 27% used vitamin C and 17.7% used vitamin D ( 31 ). A study from 2015 involving healthcare and non-healthcare university students from South India found multivitamins to be among the most commonly self-medicated drugs ( 32 ). Multivitamins include multiple vitamins and minerals, trace elements all of which possess antioxidant properties and have a crucial role in regulating immune function and can reduce risk of respiratory infection ( 33 ). A large observational study conducted in US, UK, and Sweden during first waves of COVID-19 demonstrated a modest protective effect among those taking multivitamin supplements with a reduced risk for testing positive for SARS-CoV-2 ( 33 ). Hence, these might explain the significant use of multivitamins by females and participants 21–25 years and above. Additionally, individuals with COVID-19 can experience weight loss; having adequate amounts of vitamins and minerals can prevent this unintended reduction in weight ( 34 ). Moreover, a deficiency in certain micronutrients such as Vitamin A, Vitamin D, Zinc can be deleterious during viral infections ( 33 ). These factors might elucidate why those infected with COVID-19 in our research resorted to a significantly high rate of multivitamin use.

Ibuprofen was the third highest self-medicated drug in our population. Previously, it has been reported to be the most preferred NSAID for analgesic purposes among nursing undergraduates in Saudi Arabia (20%) ( 17 ). As a non-steroidal anti-inflammatory drug (NSAID), it is well tolerated and effective during pain and inflammation and has minor side effects ( 17 ). Alongside Paracetamol, it is one of the most extensively used antipyretic ( 35 ). Since the start of the pandemic, Ibuprofen use has been subject to debate ( 36 ). Initially discouraged for use as it was suspected to aggravate infections ( 37 ), such claims were later rejected. A study analyzing data from ISARIC Clinical Characterization Protocol UK cohort found NSAIDS use not disposing to any poor COVID-19 outcome ( 38 ). A 2021 systematic review and meta-analysis reiterated similar findings and revealed no negative association between use of NSAIDS, including Ibuprofen, with SARS-CoV-2 infection or its outcomes ( 39 ). Ibuprofen has been known to have a better analgesic response in men while higher threshold and greater tolerance for electrically induced pain, responded significantly to ibuprofen in contrast to women ( 40 ). Nevertheless, the high use of this drug during COVID-19 can be linked to its efficacy in relieving fever, infection ( 35 ). However, users must be wary that disproportionate use of the drug can cause adverse drug reactions (ADRs) ( 17 ).

Hydroxychloroquine and ivermectin, the sales of which escalated globally in wake of COVID-19 were found to be consumed in low amounts in our study ( 41 ). Other frequently used drugs were Cetirizine and Azithromycin. Azithromycin has been popular amongst antibiotics that have been used for self-medication in Pakistan ( 21 ) and has also been an alternative for self-medication in other countries such as Saudi Arabia ( 17 ) and Peru ( 16 ). Using antibiotics during self-medication is the leading cause of antimicrobial resistance ( 42 ) thus its intake must be regulated, its appropriate use and disposal ensured especially by medical students.

The most common reason for use of the respective drug was “cold/flu”, consistent with results from studies of including medical students from Iran ( 29 , 43 ) and Brazil ( 44 ). “Fever”, one of the most common COVID-19 symptom ( 19 ), followed by “Muscle Pain” were the highest symptomologies reported for medicine use. Analgesic use for muscular pain at any site was also highly common among undergraduate medical and paramedical students in India ( 28 ). Studies evaluating medical students' attitudes toward self-medication delineate sufficient knowledge, familiarity with disease, and time constraints which can also be cited as motives for self-medication among our participants in this pandemic scenario ( 17 ). In the early days of SARS-CoV-2 outbreak, when the disease was a source of fear and stigma, knowledge and access to prescription-only medicines while trying to keep one's health status, especially if infected with COVID-19, could be accounted for self-medication rates among the medical students' community ( 26 ). Furthermore, practicing self-medication allowed the students to exercise freedom in managing their health and wellbeing instilling a sense of independence ( 24 ). The overall high self-medication rate throughout all year groups can be ascribed to the extensive educational load upon these students and stressful circumstances which results in distress and compels them to seek OTC drugs ( 45 ). Another study conducted in Poland highlighted such behaviors increased during lockdown ( 46 ). According to a study from Jordan, factors such as female gender, working in the medical field, and history of COVID-19 infection were reportedly associated with self-medication similar to our findings ( 47 ).

While the high self-medication percentage suggests medical students' confidence while self-prescribing, the possibility that students' knowledge about drug pharmacology, cultural prevalence, and limited experience at the current student level can make them susceptible to unfavorable outcomes, must not be undermined ( 28 ). Drug addiction and drug dependence ( 29 ) can also be induced by repeated self-medication, which students must be aware of. Lockdown and isolation guidelines have prevented the population from visiting hospitals and clinics and have altered health-seeking behavior. As different SARS-CoV-2 variants keep emerging, people are likely to self-medicate ( 48 ). Medical students are also probable to keep self-medicating, which could be helpful in obtaining benefits of self-care, and alleviating burden on the healthcare system of the country by reducing number of physician visits ( 49 ). By practicing self-medication wisely themselves, staying mindful of the pharmacological and taxological risks of improper drug use ( 25 ), they could facilitate the lay population to treat themselves for minor ailments which could further relieve pressure on health care setups.

The study is important as questions specific to the drug trends in the local population were incorporated, and responses from all parts of the country were received. However, as online platforms were used for disseminating the questionnaire, students in remote areas with no access to the internet could not be a part of the survey. Other limitation included non-random sampling method and generalizability of study results. Besides, due to recall bias, some responders might have answered incorrectly.

Our study revealed common self-medication practices among medical and pharmacy students. It is a significant health issue especially during the pandemic times, with high consumption reported as a prevention or treating symptoms of COVID-19. Further measures are needed to improve healthcare policies regarding awareness and sensitization about the risks of self-medication. Future studies should also assess students' attitude toward self-medication, their knowledge regarding drug dosage and potential side effects, and the role of medical colleges to better ascertain their approach toward self-medication.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics Statement

The studies involving human participants were reviewed and approved by Ethics Approval was taken in this study from Institutional Review Board of Dow University Ojha Hospital (Approval No. IRB (DUH)-2020/174/021), and content to participate was obtained from all the individuals through online platform. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

FY: conceptualization. UN, HNaj, HNau, and AK: data curation. MSA: formal analysis. FY and MNA: funding acquisition. FY, UN, and HNaj: investigation. MSA and AK: methodology. FY, UN, and AK: project administration. UN, HNaj, and HNau: resources. MSA and HNau: software. MSA, HNau, and AK: validation. HNaj and HNau: visualization. UN and HNau: writing—original draft. FY, MSA, MNA, and AK: writing—review and editing. All authors approved the final version of the manuscript.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpubh.2022.803937/full#supplementary-material

Supplementary Figure 1. Crude and Adjusted level analysis of factors associated with self-medication among medical students.

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Keywords: self-medication, medical students, COVID-19, pandemic, public health, Pakistan

Citation: Yasmin F, Asghar MS, Naeem U, Najeeb H, Nauman H, Ahsan MN and Khattak AK (2022) Self-Medication Practices in Medical Students During the COVID-19 Pandemic: A Cross-Sectional Analysis. Front. Public Health 10:803937. doi: 10.3389/fpubh.2022.803937

Received: 28 October 2021; Accepted: 07 February 2022; Published: 09 March 2022.

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Copyright © 2022 Yasmin, Asghar, Naeem, Najeeb, Nauman, Ahsan and Khattak. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Muhammad Sohaib Asghar, sohaib_asghar123@yahoo.com

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Prevalence and associated risk factors of self-medication among patients attending El-Mahsama family practice center, Ismailia, Egypt

• Wael Zeid 1 ,
• Madeha Hamed 1 ,
• Nadia Mansour 1 &
• Rokaya Diab   ORCID: orcid.org/0000-0002-2470-5297 1  

Bulletin of the National Research Centre volume  44 , Article number:  92 ( 2020 ) Cite this article

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Self-medication is defined as taking medications without the physician’s prescription. It is a worldwide public health problem, especially in countries with limited resources. Although self-medication can reduce waiting time and save money, it may carry some potential risks, e.g., antibiotic resistance or inappropriate management with subsequent complication. A limited number of self-medication studies have been conducted in Egypt.

To determine the prevalence of self-medication practices and to identify the factors associated with self-medication

A cross-sectional study was conducted on 160 patients. The sample was randomly selected from those who attended the El-Mahsama family practice center, Ismailia, Egypt, from November 2018 to February 2019. The center is affiliated to the Suez Canal University and provides preventive and curative services to a rural community. The participants were interviewed using a semi-structured questionnaire including sociodemographic scale and self-medication knowledge and behavior. Data was analyzed using descriptive and analytic statistical methods.

Frequency of self-medication among the study sample has reached 96%. More than half of the participants (53.6%) reported that the first reason behind using self-medication was cost saving. Meanwhile, the most prevalent conditions that make them use these medications by themselves were headaches (17%), aches and pain (other than headache) (39.2%), and fevers (11.8%). The most frequent self-administered drugs were analgesics (59.5%) and antibiotics (23.5%).

Prevalence of self-medication is high among all socioeconomic levels of patients attending the El-Mahsama family practice center, which serves a rural community in Ismailia governorate, Egypt.

Introduction

Self-medication is defined as the use of medicines to treat self-diagnosed disorders without any medical consultation (Sarahroodi et al. 2012 ). It may involve over-the-counter (OTC) medications, prescription-only medicines (POM), or the use of complementary and alternative medicine (Torres et al. 2019 ). Methods of self-medication may include buying drugs by reutilizing a previous prescription, taking medicines on advice of relative or others, or consuming leftover medicines already available at home (Helal and Abou-ElWafa 2017 ). Self-medication is a global phenomenon and potential contributor to human pathogen resistance to antibiotics (Bennadi 2013 ). However, its patterns vary between countries depending on various features, e.g., socioeconomic factors, medical knowledge, satisfaction and people’s perception of disease, ready access to drugs, the increased potential to manage certain illnesses through self-care, and greater availability of medicinal products (Abay and Amelo 2010 ; Klemenc-Ketiš et al. 2011 ).

Although self-medication can reduce the load on medical services and save cost, it is far from being a completely safe practice (WHO 2005 ). Potential risks may include incorrect self-diagnosis, delays in seeking medical advice when needed, severe adverse reactions, dangerous drug interactions especially for older people with multi-morbidity, incorrect manner of administration, incorrect dosage, incorrect choice of therapy, masking of a severe disease, and development of microbial resistance (Ruiz 2010 ).

Antibiotics resistance, one of the biggest threats to global health, may result from self-medication of antibiotics (Rather et al. 2017 ). The acceleration of antibiotic resistance and the decline in the development of new antibiotics to combat the problem have created significant public health challenges to health policymakers, health care workers, and the population around the world (Gebeyehu et al. 2015 ). In many developing countries including Egypt, antibiotics are unregulated and available over the counter without a prescription (Ventola 2015 ).

Despite the potential risks of self-medication, and to the best of our knowledge, few epidemiological data is available about the prevalence of self-medication among patients in our community.

Data management

Data was analyzed using the Statistical Package for the Social Sciences (SPSS), version 22 (IBM Corp., Chicago, IL, USA). Descriptive data was presented as numbers and percentages. Fisher’s exact test and Pearson’s chi-squared test were used for statistical analysis of categorical variables. For all tests, a probability value of less than 0.05 was considered.

The participants’ mean age was 37.3 ± 12.2 years, and the majority (89.4%) of them came from rural areas. About half of the families (48.8%) had less than five members. Less than half of them (42.5%) depend on free governmental health services as a usual source of health care. The skilled manual workers/farmers represent 23.8% among men, while about the two thirds (63.7%) of the women were unemployed/housewives. About 57.5% of the families have only one earning person. Regarding the crowding index, about 55% of the participants had more than one person in each room. Families who can just meet their routine expenses represent 44.4% of the overall families. The majority (80.6%) of the participants’ families receive governmental support. Regarding the level of socioeconomic status (SES), 56% and 42% had moderate and low levels respectively.

Figure 1 showed that 96% of the participants have used medications without any medical consultations or supervision, mainly to alleviate pain and fever. As shown in Table 1 , about half of them owed that to save money; however, two thirds of them (62.7%) perceive self-medication as an unacceptable practice. Furthermore, information sources include recommendation by community pharmacists (23.5%), previous doctor’s prescriptions (20.9%), or the patient’s own experience (18.3%). The most frequent self-administered drugs were analgesics (59.5%) and antibiotics (23.5%). Table 2 showed no statistically significant association between the socioeconomic status of the participants and usage of self-medications ( P = 0.56).

Frequency of self-medication in the study sample ( N = 160)

The present study revealed a very high prevalence of self-medication (96%), compared to the previously reported prevalence in other Egyptian studies. A recent systematic review included some Egyptian studies conducted in different cities from 1995 to 2014 (Kasim and Hassan 2018 ). The review demonstrated that the prevalence of medication abuse among the Egyptian population before twenty-first century ranged from 21.1 to 72%. However, according to the more recent studies conducted in Egypt, the reported prevalence has significantly increased to range from 81.1 to 86.4% (Sallam et al. 2009 ; El-Nimr et al. 2015 ). As for other countries, the reported prevalence varied widely from 45.4% in China (Lei et al. 2018 ), 42.5% in Jordan (Yousef et al. 2008 ), 53.5% in Mexico (Balbuena et al. 2009 ), 65.1% in Brazil (Bertoldi et al. 2014 ), 75% in Chile (Fuentes Albarran and Villa Zapata 2008 ), and 79.9% among university students in Serbia (Lukovic et al. 2014 ). The variations in the reported prevalence can be explained by the difference in populations, sample size, and study design. But more importantly, the recall period in these studies was only a few weeks or months, whereas in our study, self-medication use was assessed during the past whole year. This long recall period could explain the very high prevalence reported in our study.

In the present study, the most commonly used drugs were analgesics and antibiotics. This is consistent with the findings of previous studies which reported that analgesics and anti-inflammatories were highly used in self-medication (Jerez-Roig et al. 2014 ; Domingues et al. 2017 ). In fact, Domingues et al. ( 2017 ) explained this by the strong association between self-medication and the presence of minor diseases and conditions. Similarly, El-Nimr et al. (2015) reported that the most commonly used drugs were analgesics, followed by cough and common cold preparations and vitamins and minerals. They also reported that over half of the participants used antibiotics without a prescription. The same findings were reported in the systematic review by Kasim and Hassan ( 2018 ).

The socioeconomic score of the participants was not significantly associated with frequency of self-use of medications, diseases for which medicines were self-prescribed, drugs commonly used, sources of information, reason for not consulting a doctor, or patients’ opinion about self-medication practice. Additionally, self-medication was not associated with participants’ economic and household characteristics, in terms of their occupation, the number of earning members of the family, their income, crowding index, and whether they use governmental support. However, and contrary to our findings, Chang and Trivedi ( 2003 ) suggested that economic factors such as family size, income, and availability of health insurance may influence the self-medication practice. Also, a large Mexican study found that those who practiced self-medication usually had lower income (Pagan et al. 2006 ). Meanwhile, medical insurance has been proposed as a key determinant for self-medication (Hoai and Dang 2017 ). Some even suggested that broadening health insurance to cover over-the-counter drugs may lead to a significant reduction in self-medication practice (Lei et al. 2018 ). With medical insurance come some obstacles that hinder the full utilization of such insurance and therefore direct some insured patients towards self-medication. For example, patients have to wait for quite long times to see a doctor. Also, some drugs might be unavailable sometimes, and thus, patients quite often end up buying the medications themselves. Moreover, regular, non-emergency health services are only available during usual working hours/days, which force the employee to ask for sick leave and this may not be easily granted (Yousef et al. 2008 ).

Limitations of the present study

The present study had some limitations. First, the recall bias may have affected our analysis, and although the long recall period may add strength to our study, yet, it might also have caused confusion to the participants. Second, the study was a regional study conducted at a single health unit. Therefore, our results cannot be generalized and are not representing self-medication practice in Egypt. Third, since this was a cross-sectional study, each variable was measured only once and exposure and outcome are simultaneously assessed, so evidence of any associations should be closely interpreted before a causal relationship could be established.

Frequency of self-medication among the study sample has reached 96%. There was no statistically significant association between the socioeconomic status of the participants and usage of self-medications.

Availability of data and materials

The datasets generated during this study are available from the corresponding author on reasonable request.

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This work was carried out in collaboration between all authors. MH was responsible for choosing the tool of the study. RD and WZ designed the study, wrote the manuscript, and were involved in the subject selections and data collection. NM was responsible for the statistical analysis and revised the final manuscript. All authors read and approved the final manuscript.

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Zeid, W., Hamed, M., Mansour, N. et al. Prevalence and associated risk factors of self-medication among patients attending El-Mahsama family practice center, Ismailia, Egypt. Bull Natl Res Cent 44 , 92 (2020). https://doi.org/10.1186/s42269-020-00351-7

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Assessment of Self-Medication Practices Among Medical, Pharmacy, and Health Science Students in Gondar University, Ethiopia

Department of Pharmacy, Jimma University, Jimma, Ethiopia

1 Department of Pharmacology, Faculty of Medicine, Addis Ababa University, Ethiopia

The study was aimed at assessing the magnitude and factors of self-medication among medical, pharmacy, and health science students of GCMHS (Gondar College of Medicine and Health Sciences). A cross-sectional study with two-month illness recall was conducted. A Questionnaire consisting of demographic questions and questions on illnesses in the last two months prior to the interview and treatment strategies was prepared and administered to the 414 students, selected as the sample population, from the GCMHS students. Of a total of 414 students, 213 (51.5%) reported at least one episode of an illness, and 82 (38.5%) of them practiced self-medication. Most drugs for self-medication were obtained from the pharmacy or drug shops; and the most commonly used drugs were Paracetamol and NSAIDs (Non-steroidal anti-inflammatory drugs). Common reported illnesses were fever and headache (24.8%) followed by cough and common cold (23.9%). Prior experience and the non-seriousness of the illness were the top two reported factors for self-medication. Reading materials were the top reported source of information. In conclusion, self-medication was practiced with a range of drugs from the conventional anti-pains to antibiotics. Although the practice of self-medication is inevitable; drug authorities and health professionals need to educate students about the pros and cons of self-medication.

INTRODUCTION

In economically deprived countries most episodes of illness are treated by self-medication.[ 1 ] In a number of developing countries many drugs are dispensed over the counter without medical supervision. In this case, self-medication provides a lower cost-alternative for people who cannot afford the cost of clinical service.[ 2 ]

Studies revealed that the increase in self-medication was due to a number of factors. These included socioeconomic factors, lifestyle, ready access to drugs, the increased potential to manage certain illnesses through self-care, and greater availability of medicinal products.[ 3 ]

A study conducted in the southern part of Ethiopia showed that 15% of the persons with perceived illnesses practiced self-medication.[ 4 ] In another study conducted in Addis Ababa and central Ethiopia, the magnitude of self-medication was as high as 50%.[ 5 ] The study carried out in North West Ethiopia showed 27.2% self-medication prevalence in the study areas (i.e., Gondar, Dabark, and Kola-Diba).[ 6 ] The previous study, included households in Gondar, did not consider Medical, Pharmacy, and Health Science students, who differed from the general population of Gondar. They were exposed to knowledge about diseases and drugs, so they might be expected to behave differently. To our knowledge, there is no published data with regard to self-medication practice and the factors that affect the practice in GCMHS students. The objective of our study was, therefore, to assess the self-medication practice, assess common types of illnesses, and identify frequently used drugs and determinants of self-medication.

METHODOLOGY

Study site: Study was carried out in GCMS, North West Ethiopia. It is the oldest health professional training institute in Ethiopia. It was established in 1954, as a Public Health College and training center. The college is a pioneer in training Health Officers, Community Nurses, Medical Laboratory Technicians, and Sanitarians. Since then, the college is expanding its scope of activities and currently it is training students in Human Medicine, Pharmacy, Nursing, Midwifery, Environmental Health, Physiotherapy, Medical Laboratory Technology, Optometry, Anesthesia and Occupational Health and Safety. The students get healthcare services mainly from the Gondar University Hospital and also from different private and governmental healthcare settings providing this service.[ 7 ]

Study population: TThe cross-sectional study was conducted on 414 students taken as a sample from 2485 students in GCMHS. The stratified sampling method was used to choose the respective number of students from each department and each study year during data collection. The sample size was determined according to the following assumption. As there was no previous study conducted in the study area of the college Medical and Health Science a 50% expected prevalence of self-medication and 2% of sample population was added to compensate for the loss.

Data collection and analysis: The pre-tested, semi-structured questionnaire was prepared. Data was collected from April 20 to May 15, 2007. The study subjects were informed that the information collected would be anonymous; and participation would be totally voluntary. The age, sex, and year of study were noted. The information regarding the type of medication, illness for which the medication was used and the reason for not consulting a doctor was collected. The pattern of drug use over a two-month period preceding the study was noted. Their attitude toward self-medication and source of information for those who practiced self-medication were also recorded. Data were analyzed using EPI Info version 6 and Microsoft Excel and the results were presented using absolute figures and percentages. Analysis was done by using the Chi-square test of significance, to identify the associations among variables.

Ethical issues: To obtain the consent of students prior to data collection, a detailed explanation on the aim and objectives of the study was given; and confidentiality was ensured.

Operational definition

• Self-medication is the selection and use of medicines by individuals to treat self-recognized illnesses or symptoms.

Four hundred and fourteen students were covered during the study period and 213 (51.4%) of them had faced health-related problems within the last two months prior to the study. Age distribution of those who had episodes of illness in the specified period is shown in Table 1 . One hundred and twenty one (56.8%) of 213 were aged between 18 and 20 years, 84 (39.4%) students were aged between 20 and 24 years, and the rest were < 18 years and > 24 years of age, one (0.5%) and seven (3.3%), respectively. One hundred and seventy five (82%) were males and eighty-two (18%) were females. The respective number of students from each year of study is also given in Table 1 . Seventy-five (35.2%) were first year students (included first year Medicine, Pharmacy, and Health Science Students), 67 (31.4%) were second year students, 46 (21.6%) were third year students, and 17 (8%) and eight (3.8%) were fourth and fifth year students, respectively. Among the self-medicators 54 (25.4%) were from the School of Medicine, 42 (19.7%) were from the School of Pharmacy, and the remaining 28 (13.1%) and 89 (41.8%) were from the School of Community Health and Health Science, respectively.

Demographic characteristics of students who reported illness in the last two months in GCMHS, in 2007; N = 213

Fever and headache were the most frequently reported causes of morbidity; respiratory and gastrointestinal tract diseases were the second and third most common causes of morbidity, with a frequency of 55 (24.8%), 51 (23.9%), and 28 (13.2%), respectively. Other episodes of illness included diarrhea 19 (8.9%), malaria 13 (6.1%), pneumonia 13 (6.1%), constipation 12 (5.6%), and eye disease 8 (3.8%) [ Table 2 ].

Frequency of reported symptoms / disease

Eighty-two of the 213 students (38.5%) had practiced self-medication during the two months period preceding the study. As shown in Table 3 among 82 students who practiced self-medication, 59 (72%) obtained drugs from the pharmacy or drug shop without prescription, 13 (5.9%); from their friends, 3 (3.6%); from drugs left over from prior use, and the remaining 7 (8.5%) from plant (traditional medicines). Majority of the students 92 (43.2%) obtained drugs by visiting the physician and with prescription; and 39 (18.3%) accounted for students who suffered episodes of illness and did not take any action

Measures taken by students who reported an illness (n = 213)

Drugs or drug groups commonly used for self-medication among 82 students is shown in Table 4 . The most common drug used in self-care was Paracetamol, that is, 38 (46.3%) of 82 respondents used Paracetamol for self-medication in the preceding two months. Others were analgesics constituting 20 (24.4%), followed by antacids 10 (12.2%), anti-helminthes 9 (10.9%), antibiotics 4 (4.8%), and anti-malarials 3 (3.7%).

Drugs or drug groups used by the students for self-medication, (n = 82)

Among the reasons given for self-medication, 29 (35.4%) respondents felt that they had previous experience of treating a similar illness. Twenty-five (30.5%) respondents felt that the illness was mild and did not require the service of a physician. Eight respondents (9.8%) reported that cost-effectiveness was their major reason to practice self-medication, and 13 (15.8%) stated emergency use [ Table 5 ].

Factors for self-medication (n = 82)

Information sources to practice self-medication were also analyzed and are shown in Table 6 . Respondents who practiced self-medication because of advice given by the physician / nurse, but without prescription covered 13.4% of those who practiced self-medication, and the percentage of those who practiced self-medication because of advice from a pharmacist was 25.6%. Respondents who practiced self-medication within the last two months prior to study because of advice from their friends constituted 19.5% (16 students); and a majority of self-medicators who reported that they did it following information obtained from reading material, traditional healers, and others, constituted 30.5, 3.7, and 7.3%, respectively.

Information source for those who practiced self-medication (n = 82)

Data regarding attitude toward self-medication was collected from 414 students, including those who did not face any health-related problem within two months prior to study [ Table 7 ]; 270 students (55.5%) agreed on the practice of self-medication. On the other hand, 172 (41.5%) students disagreed with this practice.

Attitude of GCMHS students toward selfmedication practice (n = 414)

There was no significant difference between the self-medication practices of medical and non-medical students ( P = 0.57), males and females ( P = 0.36) or in the school ( P = 0.46). There was, however, an association between the year of study and self-medication practice ( P < 0.05).

Self-medication refers to using drugs that have not been prescribed, recommended or controlled by a licensed healthcare specialist.[ 8 ] In developing countries people are not only using non-prescription drugs but also prescription drugs, as self-medication products, without supervision.[ 2 ] From a previous study in North West Ethiopia, the most common reported factors for self-medication were low severity of symptoms and financial inaccessibility.[ 6 ]

Fever and headache were the most commonly reported symptoms in the two-month period prior to the study that led to self-medication, followed by cough and common cold. However, the most prevalent symptoms reported in the previous study in North West Ethiopia were cough and cold followed by fever and headache.[ 6 ] As compared with the study result in North West Ethiopia, a higher percent for fever and headache were reported in the present study and an equal percent for cough and cold report (23.9% from both studies).

Of the respondents, 38.5% had taken some form of self-medication during the specified period. In the previous study the prevalence of self-medication varied from 15 to 50% (in Southern Ethiopia and Addis Ababa, respectively).[ 4 , 5 ] The percentage of persons who did not take any action against their illness was relatively lower in this study (18.3%) than in the previous one (27.9%). This difference clearly shows the degree to which people perceive their health-related problems and knowledge about where to go to get relief. Seventy-two percent of the individuals who practiced self-medication reported that they obtained drugs from a pharmacy or drug shops. This indicated that most of the self-medicated persons (72%) had obtained drug-related information (at least when to take, and what should never be taken with the drug) from the dispensers.

Paracetamol and NSAIDs were the most commonly used class of drugs. Antimicrobials were not commonly used for self-medication and were obtained mostly by prescription, and it was relatively low as compared to the prevalence of antibiotics used in Nepal.[ 9 ]

Prior experience and non-seriousness of the illness were the two major reasons of self-medication in this study. The low severity of symptoms of illness is frequently reported in literature and different surveys.[ 6 , 10 ] What makes this study different is that the majority of respondents who practiced self-medication reported that they practiced self-medication because of their prior experience.

The major information source for most of those who practiced self-medication was reading material. The result of the present study supported the impact of medical education and knowledge on self-medication practice.

Among the total respondents, 55.5% agreed on self-medication practice and 44.5% disagreed on the practice. The report from the present study, with a mix of medical, pharmacy, and health science students, is relatively low as compared to the report from the medical students of Bahrain, wherein, the majority (76.9%) of the respondents had a positive attitude favoring self-medication.[ 11 ]

CONCLUSIONS

Students in GCMHS, 38.5%, practiced self-medication. Paracetamol and NSAIDs were the drugs most commonly used. Prescription drugs such as antibiotics were involved in self-medication practice. Prior experience and non-seriousness of the illness were the most common reasons for self-medication. Although the self-medication practice is inevitable; drug authorities and health professionals need to educate students about the pros and cons of self medication.

Source of Support: Nil

Conflict of Interest: None declared.

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The Self-Medication Hypothesis: A Review of the Two Major Theories and the Research Evidence

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• Published: 16 January 2020

Self-medication and knowledge among pregnant women attending primary healthcare services in Malang, Indonesia: a cross-sectional study

• Rizka Novia Atmadani 1 , 2 ,
• Owen Nkoka 2 ,
• Sendi Lia Yunita 1 , 2 &
• Yi-Hua Chen 2  

BMC Pregnancy and Childbirth volume  20 , Article number:  42 ( 2020 ) Cite this article

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Metrics details

Self-medication with over-the-counter (OTC) drugs is an important public health concern, especially in the vulnerable population of pregnant women due to potential risks to both the mother and fetus. Few studies have studied how factors, such as knowledge, affect self-medication. This study investigated self-medication and its associated factors among pregnant women attending healthcare services in Malang, Indonesia.

A cross-sectional study was conducted from July to September 2018 in five healthcare services. A self-administered questionnaire was used and the data were analyzed using multiple regression models.

Of 333 female participants, 39 (11.7%) used OTC medication. Women with a higher level of knowledge of OTC medication were more likely to self-medicate—adjusted odds ratio (aOR) = 2.15, 95% confidence interval (CI) = 1.03–4.46. Compared with those with less knowledge, pregnant women with more correct knowledge of the possible risk of self-medication were less likely to self-medicate—aOR = 0.29; 95% CI = 0.14–0.60. The effect of a higher level of knowledge of OTC medication was significant among women who had middle school and lower education—aOR = 8.18; 95% CI = 1.70–39.35. The effect of correct knowledge on the possible risks of self-medication was significant only among women with high school and higher education—aOR = 0.17; 95% CI = 0.07–0.42.

Imparting specific knowledge of the potential risks of using non-prescribed medication during pregnancy may help pregnant women navigate and more safely manage their OTC use. We also suggest further collecting data from more healthcare services, such as hospitals, to obtain more findings generalizable to the Indonesian community.

Peer Review reports

The use of medication during pregnancy is a public health concern. Globally, almost 50% of pregnant women use medication in the early weeks of gestation [ 1 ]. Using a web-based multinational study, Lupattelli et al. discovered that 81.2% of pregnant women used at least one type of medication, either prescribed or over-the-counter (OTC) [ 2 ]; over 65% self-medicated with OTC medication.

Self-medication, particularly with OTC medication, is considered a potential for harm for pregnant women [ 3 , 4 , 5 ]. The United States Food and Drug Administration’s (FDA’s) 1979 regulations categorized drugs by pregnancy risk. There are five categories, each marked by a letter: A, B, C, D, or X [ 6 ]. Only a few OTC medications or prescription drugs are of category A or B (indicating no evidence of risk to the fetus), whereas many drugs are of category C (indicating evidence of potential benefits outweighing potential fetal risks), or of categories D or X (indicating evidence of fetal risk) [ 7 ].

Indeed, medication use during pregnancy is a dilemma because the vulnerable population (i.e., pregnant women and children) is not included in clinical drug trials [ 8 , 9 ]. Therefore, there is not enough data of the effects from such medicine on the vulnerable groups. One such study discovered an association between a pregnant woman’s use of aspirin and intracranial hemorrhage in her newborn baby [ 10 ]. Another study discovered an association between a pregnant woman’s use of valproic acid and the risk of neural tube defects in her fetus [ 11 ]. In general, studies on the fetal effects of self-medication are limited because of the complexity of the examination [ 12 ].

Despite the dilemma, prenatal self-medication is reportedly frequent. Studies on self-medication have reported its varying prevalence due to different study populations, design, and socio-cultural contexts. For instance, self-medication was reported among 12.5% of pregnant women in a study conducted in Netherlands [ 13 ], whereas a higher rate of 40% during pregnancy was reported by another study conducted in the United Arab Emirates [ 14 ]. In addition, there were inconsistent findings of the effect of different factors on self-medication during pregnancy from other studies [ 12 , 15 ]. Studies concluded that factors such as one’s knowledge, beliefs, and socio-demographic background are associated with self-medication during pregnancy [ 16 , 17 , 18 , 19 , 20 , 21 ]. For instance, in studies conducted in Ethiopia and Italy, pregnant women with more knowledge of the risks of self-medication were less likely to self-medicate, compared with those with less knowledge [ 19 , 22 ]. However, studies investigating about the knowledge of potential risk effects of those medications on the fetus are scarce.

In Indonesia, OTC medicines are readily available in drug stores, retail stores, or kiosks [ 23 ]. Previous studies have investigated self-medication in the Indonesian population, but they did not focus on prenatal usage [ 24 ]. Moreover, there is scant information in the literature on how a pregnant woman’s knowledge of OTC medication and her beliefs on the use of medication affects their practice of self-medication.

Due to self-medication’s potential for harm to both the mother and fetus, it is therefore imperative to study the prevalence of self-medication and factors associated with self-medication during pregnancy. In addition, such a study ought to focus on the factors of a pregnant woman’s knowledge of OTC medication and beliefs on the use of medication. Findings from such studies will help public health practitioners appraise the importance of a woman’s knowledge of the use of OTC medication. An appraisal will help in the formulation of health education programs to assist women in realizing how to safely manage their OTC use during pregnancy. For Indonesia in particular, although self-medication use for the general population has been investigated, the examination of the use during critical periods of women’s pregnancy has been lacking. Findings from those studies would be vital for tailor-made interventions to promote the safe use of medication during pregnancy for maternal and fetal health. Furthermore, it is important to examine effect modifiers between the relationship of knowledge of OTC medication with the practice of self-medication. Some examinations are helpful in the identification of high-risk groups with regard to self-medication during pregnancy.

Therefore, this study aims to examine (1) the proportion of pregnant women who self-medicated in this convenience sample in Malang, Indonesia; (2) the factors associated with the practice of self-medication during pregnancy; and (3) the moderating effects of socio-demographic characteristics on the relationship between knowledge of OTC medication and the practice of self-medication during pregnancy.

This study was conducted in Malang City and Malang Regency, Java, Indonesia. Malang Regency is the largest regency in East Java province. In 2017, its population was approximately 2,576,596 [ 25 ] and the population of Malang City was approximately 861,414 [ 26 ].

Samples and data collection

This cross-sectional study was conducted from July to September 2018 at five primary healthcare services ( Puskesmas , also called public health center) in Malang. Three healthcare services are located in the southeast area of Malang Regency, and two are located in the center of Malang City. A convenience sampling method was adopted. All pregnant women coming to the Puskesmas and queuing to see a healthcare provider (either a midwife or doctor) were eligible for inclusion in this study. Pregnant women who were unable to read or speak the language of Bahasa Indonesia were excluded from the survey as the data collection instrument was administered in this local language. Approximately 80 % of pregnant women agreed to participate in this survey among those who accessed care at that time. The questionnaires were self-administered in the waiting room at each of the healthcare service. They were collected on-site immediately after the questionnaires were completed. Upon completion, the interviewer checked the questionnaire and asked the respondent to review their responses if there were missing items.

The formula by Kish and Leslie (1965) was used for sample size calculation. With the use of previous data that 25% of pregnant women used OTC medication [ 27 ] and a 5% margin of error was expected, the sample size required for this study was 321 participants.

Questionnaire development

A structured self-reported questionnaire was developed to assess pregnant women’s (1) health and pregnancy condition (pregnancy status, health condition, and health behavior), (2) knowledge of OTC medication during pregnancy, (3) beliefs about medication use during pregnancy, and (4) socio-demographic characteristics. The questionnaire was originally developed in English (Additional file  1 ) and translated into Bahasa Indonesia. For the evaluation of the content, semantics, and conceptual equivalence of the instruments in both the source and target languages, translation, back-translation, expert review and a pilot study was recommended by Guillemin et al. (1993) as guidelines for cross-cultural adaptation of health-related measures. The questionnaire utilized in this study was developed based upon these guidelines [ 28 ].

To translate the English instrument into Bahasa Indonesia version, we performed a forward and backward translation. First, a bilingual expert who was fluent in both English and Bahasa Indonesia translated the English version to Bahasa Indonesia. Another expert from a language center in Indonesia then back translated to English to ensure consistency of meaning. Then, two additional experts independently compared the original English instrument and the version translated back from Bahasa Indonesia to certify the equivalence and cultural relevance. An overall agreement was achieved. In addition, the instrument utilized was edited and modified based upon expert review. Four experts in pharmacy, public health, and epidemiology fields comprehensively reviewed the scope of this study and examined the content validity of the questionnaire in April, 2018. A pilot study was then conducted among 20 pregnant women [ 29 ] in May 2018 to assess practicability and face validity. This pilot study certified women’s understanding and feasibility of implementation. Minor modifications of the wording of the questions were further performed to ensure easier comprehension based upon experts’ evaluation.

Outcome variable

The outcome measure was “self-medication” (specifically, of OTC medication) assessed by asking whether the pregnant women had used at least one type of OTC medication in their current pregnancy. They answered either yes or no.

Independent variable

A pregnant woman’s knowledge of OTC medication, the main independent factor of this study, was evaluated relative to items generated from a literature review, yielding a total of 12 knowledge statements that was validly used previously [ 22 , 30 ]. In our study, content validity index (CVI) calculated from expert review was utilized to quantify content validity. Based upon expert opinions along with CVI values over 0.8, all 12 questions were retained. Questions were further edited based upon the experts’ opinions. The Cronbach’s alphas for the questions on knowledge of OTC medication during pregnancy were 0.88 and 0.85 in the pilot study and in the final enrolled sample, respectively, indicating appropriate internal consistency.

Assessments of pregnant women’s knowledge of OTC medication involved statements such as “There are possible risks from the use of OTC medication during pregnancy” and “There is a need to consult a healthcare provider before taking OTC medication.” Each statement was accompanied by three possible responses: “yes,” “no,” and “do not know.” Items answered correctly were coded as “1” and items answered incorrectly (including those having the response “do not know”) are coded as “0.” These were summed into a knowledge score. As there were 12 statements, the knowledge scores ranged from 0 to 12. We used these total knowledge scores to estimate the change in the likelihood of self-medication per unit of change in knowledge.

In addition, we investigated whether women having knowledge above a certain level behaved differently in terms of OTC medication. We thus used the third quartile as a cut-off point to categorize knowledge scores into two (“high level of knowledge” and “low level of knowledge”) subcategories [ 31 ]. We also separately analyzed the two important questions/statements in the knowledge section of “Knowledge about the need to consult any healthcare provider” and “Knowledge about possible risk from taking OTC medication during pregnancy” to emphasize on the crucial and specific medication understanding of consultation with healthcare provider and possible risks during pregnancy.

Other covariates

A pregnant woman’s beliefs regarding medication during pregnancy was measured using nine questions (six for medication and three for natural remedies usage) adopted from previously validated surveys in Norway [ 32 ], Saudi Arabia [ 33 ] and Belgium [ 34 ]. In our study, all nine questions were retained based upon experts’ evaluation and CVI values larger than 0.8, with minor editing performed corresponding with experts’ opinions. The Cronbach’s alphas were 0.82 and 0.7 in the pilot study and in the final enrolled sample, respectively, to indicate acceptable internal consistency. For the assessment of woman’s beliefs regarding medication during pregnancy in the first six questions, each question had a five-point Likert scale ranging from “strongly disagree” to “strongly agree.” The sum of the scores ranged from 6 to 30. This sum measured the level of a pregnant woman’s belief toward taking medication during pregnancy, with lower scores indicating a more positive belief. The first quartile was used as a cut-off point to categorize belief scores into two (“positive” and “negative”) subcategories.

Data on socio-demographic characteristics were also gathered. Two- and three-level variables were used. Two-level variables included gestational age (first vs. second and third trimesters), age (16–27 vs. 28–45 years), parity (0 vs. 1 or more children), education level (middle school and lower vs. high school and higher), number of antenatal care (ANC) visits (fewer than 4 vs. 4 or more), household income (fewer than 1.5 million Rupiah vs. 1.5 million Rupiah or more), and residence (urban vs. rural). Three-level variables included occupation (student, homemaker, and employed) and health behavior with regard to reading a drug’s accompanying leaflet (always, sometimes, and never).

Statistical analysis

Data were entered and analyzed using SPSS version 18 (SPSS, Chicago, IL, USA). We used the chi-square tests and Fisher’s exact tests to analyze differences in socio-demographics (e.g., age, education), pregnancy related variables (e.g., number of ANC visits), health related variables (e.g., self-perceived heath status, checking drug leaflet), and knowledge on OTC medication in relation to self-medication. The variables that had been reported previously to potentially confound the association examined or were possibly related to main independent and outcome variables using simple logistic regression models ( p  ≤ 0.25) were considered for multivariable regression models selection [ 22 , 35 ]. Logistic regression using the “enter method” with all potential covariates simultaneously included for consideration was performed for final model selection. All factors were reported with their crude and adjusted odds ratios (aORs) and their 95% confidence intervals (CIs). A p value of < 0.05 was considered statistically significant.

We also examined the interaction between knowledge and socio-demographic characteristics with the likelihood of self-medication. An interaction p value of < 0.1 [ 36 ] was used to indicate potential moderation effects and the warranting of further subgroup analyses.

Ethical considerations

The Commission of Research Ethics of the University of Muhammadiyah Malang (E.5.a/226a/KEPK-UMM/VII/2018) provided ethical approval. Informed consent was sought from each respondent about the details of the study’s background, objectives, and providing information on the protection of the participant’s data. All respondents signed a written informed consent.

Socio-demographic characteristics

In total, 340 respondents were enrolled for participation. After excluding those with missing or incomplete information on main variables, a valid sample of 333 women was included for analyses. Most participants were aged 16–27 years (54.4%), had attended high school or institutes of higher education (70.3%), had adequate ANC visits (68.5%), and were homemakers (72.1%) (Table  1 ).

Self-medication during pregnancy

In total, 39 (11.7%) women self-medicated at least once during pregnancy. During pregnancy, the OTC medications used included antiemetic medicines (33%), cold and flu remedies (29%), anti-fever medication (15%), pain killers (13%), and others (10%). Among those who self-medicated during pregnancy, approximately 10.3% did so in their first trimester. No significant difference was observed in socio-demographic characteristics between those who self-medicated and those who did not (Table 1 ).

Knowledge of OTC medication

Of the 12 statements measuring knowledge of OTC medication, 6 were answered correctly by over 60% of participants. The statement having the highest proportion (86.2%) of correct responses is “You need to consult with healthcare provider before or when taking OTC medication during pregnancy,” and the statement having the lowest proportion (28.8%) of correct responses is “Antibiotics is one of OTC medication” (Table  2 ). Table 2 lists the proportion of different knowledge responses segmented by self-medication. Women who took at least one OTC medication during pregnancy were more likely to correctly answer the statements “Vitamin is one of OTC medication” (79.5%) and “OTC medication can be in the dosage form of oral medication” (92.3%). By contrast, these women were more likely to incorrectly answer the statement “While taking OTC medication there is possible risk that OTC drugs can affect the baby” (59.0%).

Beliefs about taking medication during pregnancy

Respondents’ beliefs about taking medication during pregnancy are presented in Table  3 . They generally expressed negative belief toward medication use during pregnancy. A majority of respondents agreed with the following statements. “Pregnant women have a higher threshold for using medicine when pregnant than when not pregnant.” (84.1%). “It is better for the fetus that pregnant women refrain from using medicines during pregnancy, even when they were not pregnant and have an illness, they would have taken medicines.” (61.3%). “It is better for the fetus if the mother takes medicines and get well than having untreated illness during pregnancy.” (63.1%). By contrast, 56.5% of the sampled women disagreed with the statement “All medicines can be harmful to the fetus.”

Factors associated with self-medication

Table  4 reports the results from the multiple logistic regression analysis. Model 1 displays the crude odds ratio. Models 2 to 4 display the effects of knowledge, including the total knowledge score, binary knowledge outcome, and binary outcome of the two aforementioned important pieces of knowledge on self-medication during pregnancy, after adjusting for socio-demographics. Specifically, Model 2 indicates that the total knowledge score is significantly associated with self-medication—adjusted odds ratio (aOR) = 1.16, 95% CI = 1.02–1.33. Including overall knowledge with a binary outcome in Model 3, we observe that women with a higher level of knowledge of OTC medication were more likely to self-medicate compared with women with lower knowledge—aOR = 2.15, 95% CI = 1.03–4.46. Results from Model 4 indicate that compared with those who had a lower level of knowledge about the need to consult a healthcare provider before taking OTC medication during pregnancy, pregnant women who had high levels of such knowledge were more likely to self-medicate—aOR = 5.07, 95% CI = 1.11–23.2. However, pregnant women who had high levels of knowledge about the possible risks of OTC medication in the fetus were significantly less likely to self-medicate—aOR = 0.29, 95% CI = 0.14–0.60. Additionally, age remains significant in all adjusted models. This indicates that older pregnant women (28–45 years) were significantly more likely to self-medicate—aOR = 2.14, 95% CI = 1.01–4.50 (Model 4).

Finally, as both knowledge and belief are important factors, we further estimate the effects of knowledge on self-medication, after considering the effects of belief. The results were fairly consistent. Specifically, knowledge of OTC medication remains significant—aOR = 2.14, 95% CI = 1.03–4.46 after controlling for belief and other covariates. Meanwhile, no association was observed between belief and self-medication.

Subgroup analysis for the effects of knowledge on self-medication by socio-demographics

The interaction terms of binary knowledge with education and binary knowledge with occupation had significant effects on self-medication (both p  < 0.1). Subgroup analyses were then performed. Specifically, the effect of a higher level of knowledge on self-medication was significant among women with middle school or lower education—aOR = 8.18, 95% CI = 1.70–39.35—but not among women with high school or higher education (Table  5 ). Furthermore, the effect of knowledge of the possible risks of taking OTC medication during pregnancy on self-medication was significant only among women with high school or higher education—aOR = 0.17, 95% CI = 0.07–0.42 (Table 5 ). The moderation effects of occupation on the association between knowledge of possible risks and self-medication were not significant.

This study aimed to investigate first, the proportion of pregnant women self-medicated in this collected sample and factors associated with self-medication and second, the potential moderation effects of socio-demographic characteristics. This study focused on pregnant women attending primary healthcare services in Malang, Indonesia. A higher level of knowledge was associated with a higher likelihood of self-medication during pregnancy. However, if women had knowledge of the risks from OTC medication, they were less likely to self-medicate. The effects of a higher level of knowledge on higher self-medication were significant among women with middle school or lower education, whereas the correct knowledge of potential risk effects was associated with a lower likelihood of self-medication among women with high school or higher education.

The proportion of self-medication during pregnancy in our sample was observed to be low (11.7%). Our findings were similar to those of studies conducted in the Netherlands (12.5%) [ 13 ], Nigeria (22.3%) [ 37 ], and Saudi Arabia (13.2%) [ 33 ]. The proportion in this study is however lower than that (40%) observed by a study conducted in the United Arab Emirates [ 14 ]. A US study reported that self-medication is common [ 12 ]. It is likely that pregnant women in Malang have more knowledge of the risks of taking OTC medication during pregnancy. This is evident in the high proportion of correct response for the statement such as “While taking OTC medication there is possible risk that OTC drugs can affect the baby” (63.4%). These findings are consistent with those of a study conducted in Saudi Arabia: 60% of pregnant women were able to name some medications to be avoided during pregnancy. This indicates relatively high levels of knowledge of the risk of using medication during pregnancy [ 33 ]. A lower proportion of self-medication in this current study population may also be partially explained by the relatively healthier group to investigate. Pregnant women in Malang who live in rural areas could rely more on herbal or traditional remedies than modern medicine.

Women with high levels of knowledge of OTC medication in our study were more likely to self-medicate during pregnancy. Because they knew more about the OTC medication, these women may be more likely to manage self-medication responsibly. This result is consistent with those of studies conducted in China [ 38 ], Nigeria [ 18 ], and India [ 39 ]. To propose some possible reasons explaining this phenomenon, first, a higher level of knowledge from prior experiences of self-medication to manage ill symptoms may increase the chance or competence for later practice of self-medication during pregnancy. Second, the faster alleviation of symptoms may also be associated with the use of alternative medication [ 18 ]. However, our findings are inconsistent with those of a study conducted in Delta State, Nigeria [ 37 ]. Examining the specific use of non-steroidal anti-inflammatory drugs (NSAIDs) as their main dependent factor might explain this inconsistency [ 40 ].

Two important knowledge statements were separately examined. Consistent with results from a study conducted in Italy [ 22 ], pregnant women were observed to be more likely to consult a medical professional before taking OTC medication. Such behavior is healthy and allows medical professionals to impart sound information on the use of medication during pregnancy. Another important observation was of pregnant women being less likely to self-medicate if they knew there were possible risks of taking medication during pregnancy. Imparting specific and crucial information about OTC medication may be more effective to help pregnant women safely manage their practice towards OTC medication.

Previous studies have reported socio-demographic characteristics, such as one’s education [ 18 , 41 , 42 , 43 ], occupation [ 22 , 41 , 42 , 43 ], health status [ 44 ], and household income [ 41 ] to be important factors on the likelihood of self-medication. Similarly, we observed that older pregnant women were significantly more likely to self-medicate, after including other covariates in the logistic regression. Nevertheless, this current study did not observe the significant effects of other socio-demographic characteristics on self-medication. Instead, the moderating effects of socio-demographic characteristics on the association between knowledge and self-medication were observed. The effects of a higher level of knowledge on taking at least one type of OTC medication were particularly significant among pregnant women with middle school or lower education ( p  < 0.05). Highly educated pregnant women with high levels of knowledge of the risks of taking OTC medication during pregnancy were less likely to self-medicate.

Our findings have important implications. Imparting specific knowledge of the potential risks of using non-prescribed medication during pregnancy may help pregnant women more safely manage their OTC use. The significant effects of a higher level of knowledge on self-medication among women with lower income and education levels may indicate a level of their competence that is a strength upon which a provider could build. This study was conducted in primary healthcare services ( Puskesmas ), a very basic type of healthcare service in Indonesia. Here, knowledge and experiences using OTC medication can be easily shared and spread. Most patients also come from low to middle-income families, especially in the rural area that is Malang Regency. Expanding the role of healthcare providers together with the provision of evidence-based information in prenatal health education is crucial to promote pregnant women’s safe management of OTC medication.

Our study is the first to examine self-medication during pregnancy in Indonesia. We identified factors associated with self-medication in the Malang population. To identify vulnerable segments of pregnant women for possible unsafe use of self-medication, we further performed subgroup analyses to examine moderation effects. These women should be targeted in the design and implementation of future health programs.

There are some limitations to this study. First, this study used a convenient sample drawn from the population in Malang area. As the areas selected for investigation may not be representative, the study’s results may not be generalized to all pregnant women in Indonesia. Second, the proportion of self-medication in this sample may have been underestimated. This study included women in all trimesters when administering the questionnaire. Thus, the subsequent medication use among women in their early trimester was not recorded in this study. Third, the study’s cross-sectional design inhibited causal inference.

This study observed 11.7% of women in this convenience sample self-medicated during pregnancy. Knowledge and age were observed to be associated with self-medication during pregnancy. Our results demonstrated that knowledge of OTC medication in general, and knowledge of the possible risks of taking OTC medication during pregnancy in particular, were strongly associated with the use of self-medication among pregnant women in Malang.

This study can be improved by future studies using either larger cohorts or a case-control method to examine the effects of self-medication on the mother and child’s health during pregnancy and postpartum. Based on our findings, we also suggest collecting more data from more healthcare services, such as hospitals, to obtain more findings generalizable to the Indonesian community.

Availability of data and materials

The data used/or analyzed during the current study is available from the corresponding author on a reasonable request.

Abbreviations

Antenatal care

adjusted odd ratio

Confidence interval

Food and Drug Administration

Neural tube defects

Over-the-counter

Pusat kesehatan masyarakat

Statistical Packages for Social Sciences

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Acknowledgements

The authors would like to thank the pharmacists who helped with the data collection process in Malang, Indonesia. We would also like to thank all the pregnant women that participated in this study.

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Rizka Novia Atmadani & Sendi Lia Yunita

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RNA carried out data collection, data analysis, data interpretation, and drafted the manuscript. ON provided suggestions for manuscript preparation and critically revised the draft of the manuscript. SLY assisted in the data collection process. YHC conceived and designed this study and supervised all critical data analysis and manuscript preparation. All authors read and approved the final manuscript.

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Questionnaire – Self-medication Questionnaire.

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Atmadani, R.N., Nkoka, O., Yunita, S.L. et al. Self-medication and knowledge among pregnant women attending primary healthcare services in Malang, Indonesia: a cross-sectional study. BMC Pregnancy Childbirth 20 , 42 (2020). https://doi.org/10.1186/s12884-020-2736-2

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Received : 04 July 2019

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DOI : https://doi.org/10.1186/s12884-020-2736-2

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