ORIGINAL Bhambhani ARTICLE et al
Self-medication Practice Amongst Patients Visiting a Tertiary-care Dental Hospital in Central India Garima Bhambhania/Vrinda Saxenab/Ajay Bhambalc/Sudhanshu Saxenad/ Poonam Pandyae/Sonal Kotharif Purpose: To assess self-medication practice-related awareness for correct usage and its association with demographic factors among patients reporting to a dental college. Materials and Methods: This descriptive cross-sectional questionnaire-based study was conducted among 300 patients reporting to the People’s College of Dental Sciences and Research Centre, Bhopal, India. Only patients ≥ 18 years of age were included and consenting participants anonymously completed the questionnaire, with incomplete questionnaires being excluded from the study. The semi-structured questionnaire containing both open- and closedended questions was prepared in the local language and included demographic data, name of self-medication, frequency of self-medication, periods of illness, duration, dose, frequency of drug administration, symptoms for which drugs were used, satisfaction with healthcare facilities, source of information for self-medication, presence of chronic illness, adverse effects to self-medication seen in patients and drug interactions. The unpaired t-test and chi-square test were used for statistical analysis. p-values < 0.05 were considered statistically significant. Results: A significant association was seen between education and self-medication. It was observed that the subjects who fell ill more frequently consumed medications on their own more often. Medications were most commonly taken for cough, cold and fever. The most preferred medicine was paracetamol. Most of the subjects found the medicines effective in helping them relieve their symptoms. However, not even half of the subjects were aware of the dose, duration, side-effects or interactions of medicines. There was a significant association between knowledge about side-effects and side-effects experienced from medication. A significant association was also seen between knowledge about side-effects and frequency of self-medication. Conclusion: Self-medication and non-doctor prescribing are relatively common in Bhopal. Knowledge regarding the appropriate usage of medication is inadequate. Education to help patients decide on the appropriateness of selfmedication is required. Key words: nonprescription drugs, over the counter (OTC), prescription, prescription drugs, prescription fees, selfmedication Oral Health Prev Dent 2015;13:411-416 doi: 10.3290/j.ohpd.a33919
a
Senior Lecturer, Public Health Dentistry, People’s College of Dental Sciences and Research Centre, Bhopal, India. Idea, wrote the manuscript.
b
Professor and Head of Department, People’s Dental Academy, Bhopal, India. Contributed substantially to discussion.
c
Professor and Head of Department, People’s College of Dental Sciences and Research Centre, Bhopal, India. Collected the data.
d
Reader, Hitkarni Dental College, Jabalpur, Madhya Pradesh, India. Analysed the data.
e
Senior Lecturer, People’s College of Dental Sciences and Research Centre, Bhopal, India. Proofread the manuscript.
f
Senior Lecturer, People’s College of Dental Sciences and Research Centre, Bhopal, India. Experimental design.
Correspondence: Garima Bhambhani, Department of Public Health Dentistry, People’s College of Dental Sciences and Research Centre, Karond St, Bhopal, India 462030. Tel: +91-989-383-8594. Email: [email protected]
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Submitted for publication: 04.08.13; accepted for publication:15.10.13
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elf-medication has been defined by the World health Organization (WHO) as the selection and use of medicines by individuals to treat self-recognised illnesses or symptoms.34 The practice of selfmedication or nonprescription drug use is common in developing countries30,32 due to lack of accessible and affordable healthcare. Moreover, the ready availability of drugs/medications makes the use of nonprescription drugs an easy and convenient option for self-care.30 Furthermore, many drugs that can only be purchased with a prescription in developed countries are OTC (over the counter) in developing countries. In addition, lax medical regulation has resulted in the proliferation of counterfeit drugs that are in high demand for the treatment of highly prevalent diseases.29
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The WHO promotes the practice of self-medication for effective and quick relief of symptoms without medical consultations to reduce the burden on healthcare services, which are often understaffed and inaccessible in rural and remote areas.15 However, it emphasises that self-medication must be correctly taught and controlled.35 Although OTC drugs are meant for self-medication and are of proven efficacy and safety, their improper use due to lack of knowledge of correct dose, side-effects and interactions could have serious implications, especially in children and the elderly and special physiological conditions such as pregnancy and lactation.16 A major disadvantage of self-medication is the lack of clinical evaluation, resulting in faulty or absent diagnosis and prolonged recovery. Improper medication may lead to wasting resources and increasing antimicrobial drug resistance; it also entails health hazards such as adverse drug reactions and aggravation of chronic illness.32 Problems associated with drug therapy are more widespread in societies with less rigorous control of drug quality, availability and usage. Self-medication is very common in India and medicines can be easily provided without prescription, which increases the health-care burden and cost on the nation because this leads to an increase in complications and diseases not cured. Atlhough studies have been conducted to ascertain self-medication practice, they have largely focused on pharmacy records,33,34 and there is a paucity of community-based studies on the prevalence of self-medication in India. Hence, this study was conducted to assess self-medication practice-related awareness for correct usage and its association with demographic factors among patients reporting to a tertiary hospital.
MATERIALS AND METHODS This descriptive cross-sectional study was conducted among the patients reporting to the People’s College of Dental Sciences and Research Centre, Bhopal. The study protocol was discussed and ethical approval was granted from the Ethics Committee of the People’s University. A semi-structured questionnaire containing both open and closed-ended questions was prepared in the local language; it was designed to be completed in under 3 minutes. A pilot study was conducted to assess the validity and reliability on 20 randomly
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selected patients coming to the People’s College of Dental Sciences and Research Centre, Bhopal. The inclusion criterion for the selection of patients was age ≥ 18 years. A briefing was given about the nature of the study and the procedure of completing the questionnaire was explained to the patients. They were assured that the information given would be kept confidential. Patients were then asked verbally whether they were willing to participate or not. Consenting participants anonymously completed the questionnaire. All the information was collected based on participants’ memory of the past 6 months. About 1000 questionnaires were distributed. Incomplete questionnaires were excluded from the study, yielding a final study sample of 300 subjects. The completed questionnaires provided information on demographic data, name of self-medication, frequency of self-medication, periods of illness, duration, dose, frequency of drug administration, symptoms for which drugs were used, satisfaction with healthcare facilities, source of information for self-medication, presence of chronic illness, adverse effects to self-medication seen in patients and drug interactions. The data were collected during the month of December, 2012. For the purpose of the study, certain operational terms were defined. Self-medication was defined as the use of over-the-counter or nonprescription drugs, whether modern or traditional, for self-treatment without prior consultation with a doctor. A doctor was defined as any person who is medically qualified to prescribe medications. It included practitioners of modern scientific medicine as well as practitioners of other healthcare traditions. Medication was defined as any substance used for treatment or prevention of disease, including modern scientific medications as well as traditional or alternative medications.32 Data analysis was performed using SPSS version 17 (SPSS; Chicago, IL, USA). Descriptive statistics were generated for relevant items. The unpaired ttest and chi-square test were used for statistical analysis. p-values < 0.05 were considered statistically significant.
RESULTS A total of 300 patients participated in the study, of which 66.6% were males and 33.4% were females. The mean age was 32.71 ± 13.74. Out of 300 patients, 6.3% were illiterate and 37.5% were graduates or postgraduates. The distribution of the study
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population according to socioeconomic status is given in Table 1. When asked about the frequency of falling ill in the past year, 34.4% had fallen ill more than twice, 30.4% had fallen ill twice, 30.1% said they had fallen ill once and 5% of the patients said they had never fallen ill. When ill, 43.5% consulted a general physician nearby, 10.4% consulted a specialist, 37.8% took medicine on their own and 8.3% did not take any action. There was no association of frequency of illness with age (p = 0.473, Pearson’s chi-square = 2.511, df = 3) or gender (p = 0.802, Pearson’s chi square = 0.998, df = 3). The following reasons were given for not consulting a doctor: 41.5% knew which medicine to take, 39.8% said that distance from home too far, 6% wanted to avoid the prescription fees, 3.3% avoided it due to the time spent in travelling, 2.7% due to the time spent in consultation and 1.7% due to lack of availability of a healthcare professional. When asked about the healthcare facilities, 80.6% subjects were satisfied with the available healthcare facilities. The various symptoms for which the patients took medication on their own is shown in Table 2. It was seen that the most common ailments for which
self-medication performed were fever followed by cough, cold and pain and the most commonly used medicine was paracetamol. Regarding the source of information on self-medication, 15% had learnt from friends, 40% from doctors, 17.4% had picked up the information from drug advertisements,13.4% were told by pharmacists and 14.1% had learnt from some other source. As shown in Table 3, there was a highly significant association between frequency of falling ill and the practice of self-medication in the past one year (Pearson’s chi-square = 38.746, df =9, p = 0.0001.) A significant association was also seen between educational status and the frequency of self-medication (Table 4; Pearson’s chi square = 48.167, df = 21, p = 0.001). Self-medication was perceived as effective in 88.3% of the cases. The results showed that 62.2% had no knowledge regarding the dose, duration, side-effects or drug interactions. However, 82.3% of the subjects checked the expiration date before consuming the medicine. No association was seen between checking the date of expiration and knowledge regarding dose, duration and drug interactions (p = 0.132, Pearson’s chi-square
Table 1 Distribution of study population according to socioeconomic status (Kuppuswamy scale*)
Table 2 Distribution of study population according to symptoms of illness
Socioeconomic status
Symptoms/condition
Number (%)
Percentage
1. Upper
31 (10.4)
1.Cough and cold
33%
2. Upper middle
62 (20.7)
2. Fever
35%
3. Middle lower class
47 (15.7)
3. Bodyache
28%
4. Upper lower 5. Lower
132 ( 44.1%) 27 (9.0%)
*Kuppuswamy B. Manual of socioeconomic status scale (urban). Delhi: Manasayan, 1981.
4. Ulcer
1%
5. Weakness
1%
6. Acid reflux
1.6%
7. Vomiting
1.3%
8. Skin infection
1%
9. Fracture
0.3%
10. Boil
0.3%
Table 3 Distribution of study population according to frequency of illness and self-medication in the past year Frequency of medication Illness frequency
Never
Once
Twice
More than twice
Once
3 (3.3%)
46 (50%)
42 (46.7%)
0%
Twice
5 (5.5%)
45 (49.5%)
41 (45.1%)
0%
More than twice
2 (1.9%)
56 (54.4%)
40 (38.8%)
5 (4.9%)
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Table 4 Association between education and frequency of self-medication Frequency Education
Once
Twice
More than twice
Illiterate
3 (17.6%)
14 (82.4%)
0%
5 (41.7%)
0%
Primary school certificate
6 (50%)
Middle school certificate
23 (46%)
25 (50%)
0%
Highschool certificate
29 (42%)
38 (51.1%)
0%
Intermediate or post-highschool diploma
21 (56.8%)
11 (29.7%)
1 (2.7%)
Graduate or postgraduate
63 (56.3%)
41 (36.6%)
4 (3.6%)
Profession or honours
1 (100%)
0%
0%
7.076, df = 4). However, a significant association of knowledge regarding dose and duration was seen with side-effects experienced upon self-medication (Pearson’s chi-square = 13.508, df = 4, p = 0.009) and frequency of self-medication (Pearson’s chisquare = 18.128, df = 6, p = 0.006). On consuming self-medication, 14.1% of subjects experienced adverse effects. The various adverse effects reported were fainting (1), allergy (14), hot flushes (4) and breathlessness (1). When asked about addictions, 2.3% were addicted to some drug, 14.4% were addicted to alcohol, 18.1% were addicted to smoking and 3.3% were addicted to both alcohol and smoking. It was seen that 18.4% were aware about drug-drug interactions, 81.3% were aware of drug-alcohol interactions and 0.3% were aware about drug-smoking interactions. Chronic illnesses were seen in 13.4% subjects. The various chronic illnesses were diabetes (4.3%), hypertension (5.7%), asthma (1%), heart disease (1.1%), cervical spondylitis (0.3%), arthritis (1%), thyroid (0.3%), appendicitis (0.3%) and migraine (0.3%). There was no association between awareness about interactions and the presence of chronic illness in subjects (Pearson’s chi square = 10.533, df = 12, p = 0.569).
DISCUSSION In economically deprived communities, most episodes of illness are treated by self-medication.7,28 A study done in Great Britain4 has estimated that around £ 1.2685 billion were spent on medicines purchased privately or over the counter, which equates to one-third of the £ 4304 million spent on
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drugs prescribed by general practitioners. These studies demonstrate that in recent years, self-medication is gaining popularity globally.4 The present study demonstrated that no significant association exists between gender and selfmedication. These findings were supported by the studies done in Australia,8 Nepal30 and Malyasia.25 However, a high level of education and professional status has been mentioned as a predictive factor for self-medication.22 An educated person has the ability to read medication packages and instructions, tends to be self-confident and able to make decisions.26 This theory was supported in our study where a significant association was seen between education and frequency of self-medication. Our study revealed that self-medication was a common practice among different socioeconomic groups and education levels. The majority of respondents cited distance from home and their awareness about the treatment for illness to be the major reasons for not seeking a doctor’s advice and self-medicating instead. This differed from the studies done in Delhi, Jammu and Ethiopia, in which time and money were the major reasons for not consulting a doctor.20,32,33 However, in the study by Shankar et al,30 inaccessibility of the doctor was cited as the most common cause for non-doctor prescribing, which was only reported by 1.7% of the subjects in our study. According to Pylypa,26 self-medication ‘is encouraged by problems of accessibility to health services: the more difficult the access the more likely the patient will resort to self-medication’. Another important factor for self-medication is satisfaction with healthcare facilities.10 However, in the present study most of the subjects were satisfied with the healthcare facilities.
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Patients reported having access to drug information from various sources. These include their own past experiences, family, friends or fellow university students, doctor or nurse, and advertisements on television or radio, in newspapers, magazine or books and from pharmacy sales representatives. Drug retail shops frequently serve as the public’s first point of contact with the healthcare system.16 Drug retail outlets are reported to be the major sources of drugs used for self-medication and the availability of drugs in the informal sector contributes to the increase in the practice of self-medication.29 In Pakistan, almost every pharmacy sells drugs without a prescription, a phenomenon seen in many developing countries.14 In a study in Nepal, pharmacists were seen to be a major source of self-medication. India is a country with economic and cultural similarities to Nepal, where pharmacists and pharmacy attendants play an important role in fostering self-medication among the public.17 However, in our study, only 13.4% of subjects reported acquiring information regarding self-medication from pharmacists. The ailments for which self-administration of medicines was seen were chiefly fever, cough, cold and pain. These findings were similar to the study by Lal et al20 and Shankar et al.31 It was seen that the most commonly used drug was paracetamol. Similar findings were reported in studies done in Pokhara, South Australia and Brazil.2,31 Self-medication is more likely to be inappropriate if used by poorly informed people.19 The present study also indicated low knowledge about dose/duration, side-effects and interactions of commonly used drugs, which is in accordance with the results of previous studies.11,13 Interactions between prescribed drugs and the drugs taken for self-medication are important risk factors of which the general public must be made aware.10,23 It has been found that inappropriate self-medication results in wasting resources and generally entails serious health hazards, such as risk of drug interactions, adverse drug reactions, prolonged suffering and drug dependence.6,9,10,13,18 In a survey of US consumers, a third of all respondents admitted taking more than recommended dose of non-prescribed products because they believed that they needed to do so in order to treat their conditions effectively; 21% said that they rarely or never read the label on such products.1 Human malpractices such as inadequate dosing, incomplete courses and indiscriminate drug use have contributed to the emergence and spread of antimicrobial resistance.36 The consequence of this is the
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loss of relatively inexpensive drugs, requiring the development of new drugs which will be more expensive and will further disadvantage patients in developing countries.3 In the current study, 82.3% checked the date of expiration whereas in a study done by Kulkarni et al,19 only 4.2% subjects checked the date of expiration. The most common side-effects seen with selfmedication in the current study were allergy and hot flushes. However, in the study on urban slum dwellers in a south Indian city,19 the most commonly reported side-effects were fainting and hot flushes. There was no association between awareness about interactions and the presence of chronic illness in subjects. Although a very low percentage of participants in this study had chronic illnesses, the most common ones were diabetes and hypertension, which were also seen in the study by Hussain et al.15 Many OTC medicines, nutritional supplements and alcohol interfere with the action of prescription medicines.5,27 We found that around 38.1% of participants who self-medicated had social habits like smoking and alcohol consumption. It is known that many drug interactions occur via pharmacokinetic and pharmacodynamic mechanisms, leading to an increased risk of illness, injury or death; this is more common with alcohol consumption.21
CONCLUSION The assessment of self-medication is one important element in the study of rational drug usage. The findings of this research should form the basis for future interventional plans to maximise benefits and minimise risks. The present study revealed that self-medication and non-doctor prescribing are relatively common in Bhopal. Knowledge regarding the appropriate usage of medications is inadequate. Hence, effective public education campaigns should be carried out to improve drug use and increase awareness about the adverse effects of certain irrational practices. The rampant practice of self-medication can be discouraged by suggesting prescription at the pharmacy level and stringent rules regarding pharmaceutical advertising at the time of market authorisation. Measures should be taken to make health-care delivery much less difficult, especially at the primary health care level. As recommended by the WHO in 1995,37 governments and health authorities need to ensure that safe drugs are made available over the counter and the consumer is given adequate information about the use of drugs and when to consult a doctor.
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REFERENCES 1. Al-Motassem MY, Al-Bakri AG, Bustangi Y, Wazaify M. Selfmedication patterns patterns in Amman, Jordan. Pharma World Sci 2008;30:24–30. 2. Arrais PS, Coelho HL, Batista MC, Carvalho ML, Righi RE, Arnau JM. Profile of self-medication in Brazil. Rev Saude Publica 1997;31:71–77. 3. Awad A, Eltayeb I, Matowe L Thalib L. Self-medication with antibiotics and anti malarias in the Community of Khartoum State, Sudan. J Pharm Pharmaceut Sci 2005;8:326–331. 4. Bradley CP, Riaz A, Tobias RS, Kenkre JE, Dasu DY. Patient attitudes to over-the-counter drugs and possible professional responses to self-medication. Family Practice 1998;15:44–50. 5. Cetaruk ED, Aaron CK. Hazards of nonprescription medications. Emergency Medical Clinics of North America 1994;12:483–510. 6. Conn VS. Self-management of over-the-counter medications by older adults. Public Health Nurs 1992;9:29–36. 7. Geissler PW, Nokes K, Prince RJ, Achieng RO, AagaardHansen J, Ouma JH. Children and medicines: self-treatment of common illnesses among Luo schoolchildren in western Kenya. Soc Sci Med 2000;50:1771–1783. 8. Goh LY, Vitry AI, Semple SJ, Esterman A, Luszcz MA. Selfmedication with over-the-counter drugs and complementary medications in South Australia‘s elderly population. BMC Complement Altern Med 2009;9:1–10. 9. Gwee MC. Prevention of adverse drug reactions: role the patient (consumer). Ann Acad Med Singapore 1993;22:90–93. 10. Habeeb GE, Gearhart JG. Common patients symptoms: pattern of self-treatment and prevention. J Miss State Med Assoc 1993;34:179–181. 11. Heineck I, Schenkel EP, Vidal X. Non-prescription drugs in Brazil. Rev Panam Salud Publica 1998;3:385–391. 12. Hughes L, Whittlesea C, Luscombe D. Patients knowledge and perceptions of the side-effects of OTC medication. Clin Pharmacol Ther 2002;27:243. 13. Hughes CM, McElnay JC, Fleming GF. Benefits and risks of self-medication. Drug Safety, 2001;24:1027–1037. 14. Hunte PA, Sultana F. Health-seeking behavior and the meaning of medications in Balochistan, Pakistan. Soc Sci Med 1992;34:1385–1297. 15. Hussain S, Malik F, Ashfaq KM, Parveen G, Hameed A, Ahmad S, Riaz H. Prevalence of self-medication and health-seeking behavior in a developing country. African J Pharmacy Pharmacol 2011;5:972–978. 16. Kafle KK, Madden JM, Shrestha AD, Karkee SB, Das PL, Pradhan YM, Quick JD. Can licensed drug sellers contribute to safe motherhood? A survey of the treatment of pregnancy related anemia in Nepal. Soc Sci Med 1996;42:1577–1588. 17. Kamat VR, Nichter M. Pharmacies, self-medication and pharmaceutical marketing in Bombay, India. Soc Sci Med 1998;47:779–794. 18. Kiyingi KS, Lauwo JAK. Drug in home: danger and wastage. World Health Forum 1993;14:381–384. 19. Kulkarni PK, Khan M, Chandrasekhar A. Self-medication practices among urban slum dwellers in a South Indian City. Int J Pharm Bio Sci 2012;3:81–87.
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20. Lal V, Goswami A, Anand K. Self-medication among residents of urban resettlement colony, New Delhi. Indian J Public Health 2007; 51:249–251. 21. Mahid S, Minor S, Soto R. Smoking and inflammatory bowel diseases: a meta-analysis. Mayo Clin Proc 2006;81: 1462–1471. 22. Martins AP, Miranda AC, Mendez Z, Soares MA, Ferreira P, Nogueria A. Self-medication in a Portugese urban population: a prevalence study. Pharmacoepidemiol Drug Saf 2002;11:409–414. 23. Montastruc JL, Bagheri H, Geraud T, Lapeyre Mestre M. Pharmacovigilance of self-medication. Therapie 1997;52:105–110. 24. Neafsey PJ, Strickler Z, Shellman J, Chartier. An interactive technology approach to educate older adults about drug interactions arising from over-the-counter self-medication practices. Public Health Nursing 2002;19:255–262. 25. Parimi N, Pinto Pereira LM, Prabhakar P. The general public’s perceptions and use of antimicrobials in Trinidad and Tobago. Rev Panam Salud Publica 2002;12:11–18. 26. Pylypa J. Self-medication practices in two California Mexican communities. J Immigrant Health 2001;3:59–75. 27. Salzman C. Medication compliance in the elderly. J Clin Psychol 1995;56(suppl 1):18–22. 28. Schafer J, Slamet LS, de Visscher G. Appropriateness of self-medication: method development and testing in urban Indonesia. J Clin Pharm Ther 1997;22:261–272. 29. Shakoor O, Taylor RB, Behraus RH. Assessment of the incidence of substandard drugs in developing countries. Tropical medicine and international health 1997;2:839–885. 30. Shankar RR, Partha P, Shenoy N. Self-medication and nondoctor prescription practices in Pokhara valley, Western Nepal: a questionnaire-based study. BMC Fam Pract 2002;3:17-22. 31. Shankar, Goh LY, Vitry AI, Semple SI, Esterman E, Luszcz MA. Self-medication with over-the-counter drugs and complementary medications in South Australia‘s elderly population. BMC Complement Altern Med 2009;9:42:1–10. 32. Sharma R, Verma U, Sharma CL, Kapoor B. Self-medication among urban population of Jammu City. Ind J Pharmacol 2005;37:37–45. 33. Worku S, Mariam AG. Practice of self-medication in Jimma Town. Ethiop J Health Dev 2003;17:111–116. 34. World Health Organization/Drug Action Program (WHO/ DAP). Public education in rational drug use. Report of an informal consultation 23–26 November 1993. Geneva: WHO/DAP, 1993. 35. World Health Organization. The role of the pharmacist in self-care and self-medication. Report of the 4th WHO consultative group on the role of the pharmacist. The Hague, 1998. Available at http://www.who.int/medicines/library/ dap/whodap- 98-13/who-dap-98-13.pdf. 36. World Health Organization. Global strategy for containment of antimicrobial resistance: World Health Organization, Communicable diseases surveillance and response (CSR). WHO/ COS/CSR/DRS/2001.2001. 37. World Health Organization. Report of the WHO Expert Committee on National Drug Policies 1995. Available at http:// www.who.int/medicines/library/dap/who-dap-95-9/whodap-95.9.shtml
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Self-medication Practice Amongst Patients Visiting a Tertiary-care Dental Hospital in Central India Garima Bhambhania/Vrinda Saxenab/Ajay Bhambalc/Sudhanshu Saxenad/ Poonam Pandyae/Sonal Kotharif Purpose: To assess self-medication practice-related awareness for correct usage and its association with demographic factors among patients reporting to a dental college. Materials and Methods: This descriptive cross-sectional questionnaire-based study was conducted among 300 patients reporting to the People’s College of Dental Sciences and Research Centre, Bhopal, India. Only patients ≥ 18 years of age were included and consenting participants anonymously completed the questionnaire, with incomplete questionnaires being excluded from the study. The semi-structured questionnaire containing both open- and closedended questions was prepared in the local language and included demographic data, name of self-medication, frequency of self-medication, periods of illness, duration, dose, frequency of drug administration, symptoms for which drugs were used, satisfaction with healthcare facilities, source of information for self-medication, presence of chronic illness, adverse effects to self-medication seen in patients and drug interactions. The unpaired t-test and chi-square test were used for statistical analysis. p-values < 0.05 were considered statistically significant. Results: A significant association was seen between education and self-medication. It was observed that the subjects who fell ill more frequently consumed medications on their own more often. Medications were most commonly taken for cough, cold and fever. The most preferred medicine was paracetamol. Most of the subjects found the medicines effective in helping them relieve their symptoms. However, not even half of the subjects were aware of the dose, duration, side-effects or interactions of medicines. There was a significant association between knowledge about side-effects and side-effects experienced from medication. A significant association was also seen between knowledge about side-effects and frequency of self-medication. Conclusion: Self-medication and non-doctor prescribing are relatively common in Bhopal. Knowledge regarding the appropriate usage of medication is inadequate. Education to help patients decide on the appropriateness of selfmedication is required. Key words: nonprescription drugs, over the counter (OTC), prescription, prescription drugs, prescription fees, selfmedication Oral Health Prev Dent 2015;13:411-416 doi: 10.3290/j.ohpd.a33919
a
Senior Lecturer, Public Health Dentistry, People’s College of Dental Sciences and Research Centre, Bhopal, India. Idea, wrote the manuscript.
b
Professor and Head of Department, People’s Dental Academy, Bhopal, India. Contributed substantially to discussion.
c
Professor and Head of Department, People’s College of Dental Sciences and Research Centre, Bhopal, India. Collected the data.
d
Reader, Hitkarni Dental College, Jabalpur, Madhya Pradesh, India. Analysed the data.
e
Senior Lecturer, People’s College of Dental Sciences and Research Centre, Bhopal, India. Proofread the manuscript.
f
Senior Lecturer, People’s College of Dental Sciences and Research Centre, Bhopal, India. Experimental design.
Correspondence: Garima Bhambhani, Department of Public Health Dentistry, People’s College of Dental Sciences and Research Centre, Karond St, Bhopal, India 462030. Tel: +91-989-383-8594. Email: [email protected]
Vol 13, No 5, 2015
Submitted for publication: 04.08.13; accepted for publication:15.10.13
S
elf-medication has been defined by the World health Organization (WHO) as the selection and use of medicines by individuals to treat self-recognised illnesses or symptoms.34 The practice of selfmedication or nonprescription drug use is common in developing countries30,32 due to lack of accessible and affordable healthcare. Moreover, the ready availability of drugs/medications makes the use of nonprescription drugs an easy and convenient option for self-care.30 Furthermore, many drugs that can only be purchased with a prescription in developed countries are OTC (over the counter) in developing countries. In addition, lax medical regulation has resulted in the proliferation of counterfeit drugs that are in high demand for the treatment of highly prevalent diseases.29
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The WHO promotes the practice of self-medication for effective and quick relief of symptoms without medical consultations to reduce the burden on healthcare services, which are often understaffed and inaccessible in rural and remote areas.15 However, it emphasises that self-medication must be correctly taught and controlled.35 Although OTC drugs are meant for self-medication and are of proven efficacy and safety, their improper use due to lack of knowledge of correct dose, side-effects and interactions could have serious implications, especially in children and the elderly and special physiological conditions such as pregnancy and lactation.16 A major disadvantage of self-medication is the lack of clinical evaluation, resulting in faulty or absent diagnosis and prolonged recovery. Improper medication may lead to wasting resources and increasing antimicrobial drug resistance; it also entails health hazards such as adverse drug reactions and aggravation of chronic illness.32 Problems associated with drug therapy are more widespread in societies with less rigorous control of drug quality, availability and usage. Self-medication is very common in India and medicines can be easily provided without prescription, which increases the health-care burden and cost on the nation because this leads to an increase in complications and diseases not cured. Atlhough studies have been conducted to ascertain self-medication practice, they have largely focused on pharmacy records,33,34 and there is a paucity of community-based studies on the prevalence of self-medication in India. Hence, this study was conducted to assess self-medication practice-related awareness for correct usage and its association with demographic factors among patients reporting to a tertiary hospital.
MATERIALS AND METHODS This descriptive cross-sectional study was conducted among the patients reporting to the People’s College of Dental Sciences and Research Centre, Bhopal. The study protocol was discussed and ethical approval was granted from the Ethics Committee of the People’s University. A semi-structured questionnaire containing both open and closed-ended questions was prepared in the local language; it was designed to be completed in under 3 minutes. A pilot study was conducted to assess the validity and reliability on 20 randomly
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selected patients coming to the People’s College of Dental Sciences and Research Centre, Bhopal. The inclusion criterion for the selection of patients was age ≥ 18 years. A briefing was given about the nature of the study and the procedure of completing the questionnaire was explained to the patients. They were assured that the information given would be kept confidential. Patients were then asked verbally whether they were willing to participate or not. Consenting participants anonymously completed the questionnaire. All the information was collected based on participants’ memory of the past 6 months. About 1000 questionnaires were distributed. Incomplete questionnaires were excluded from the study, yielding a final study sample of 300 subjects. The completed questionnaires provided information on demographic data, name of self-medication, frequency of self-medication, periods of illness, duration, dose, frequency of drug administration, symptoms for which drugs were used, satisfaction with healthcare facilities, source of information for self-medication, presence of chronic illness, adverse effects to self-medication seen in patients and drug interactions. The data were collected during the month of December, 2012. For the purpose of the study, certain operational terms were defined. Self-medication was defined as the use of over-the-counter or nonprescription drugs, whether modern or traditional, for self-treatment without prior consultation with a doctor. A doctor was defined as any person who is medically qualified to prescribe medications. It included practitioners of modern scientific medicine as well as practitioners of other healthcare traditions. Medication was defined as any substance used for treatment or prevention of disease, including modern scientific medications as well as traditional or alternative medications.32 Data analysis was performed using SPSS version 17 (SPSS; Chicago, IL, USA). Descriptive statistics were generated for relevant items. The unpaired ttest and chi-square test were used for statistical analysis. p-values < 0.05 were considered statistically significant.
RESULTS A total of 300 patients participated in the study, of which 66.6% were males and 33.4% were females. The mean age was 32.71 ± 13.74. Out of 300 patients, 6.3% were illiterate and 37.5% were graduates or postgraduates. The distribution of the study
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population according to socioeconomic status is given in Table 1. When asked about the frequency of falling ill in the past year, 34.4% had fallen ill more than twice, 30.4% had fallen ill twice, 30.1% said they had fallen ill once and 5% of the patients said they had never fallen ill. When ill, 43.5% consulted a general physician nearby, 10.4% consulted a specialist, 37.8% took medicine on their own and 8.3% did not take any action. There was no association of frequency of illness with age (p = 0.473, Pearson’s chi-square = 2.511, df = 3) or gender (p = 0.802, Pearson’s chi square = 0.998, df = 3). The following reasons were given for not consulting a doctor: 41.5% knew which medicine to take, 39.8% said that distance from home too far, 6% wanted to avoid the prescription fees, 3.3% avoided it due to the time spent in travelling, 2.7% due to the time spent in consultation and 1.7% due to lack of availability of a healthcare professional. When asked about the healthcare facilities, 80.6% subjects were satisfied with the available healthcare facilities. The various symptoms for which the patients took medication on their own is shown in Table 2. It was seen that the most common ailments for which
self-medication performed were fever followed by cough, cold and pain and the most commonly used medicine was paracetamol. Regarding the source of information on self-medication, 15% had learnt from friends, 40% from doctors, 17.4% had picked up the information from drug advertisements,13.4% were told by pharmacists and 14.1% had learnt from some other source. As shown in Table 3, there was a highly significant association between frequency of falling ill and the practice of self-medication in the past one year (Pearson’s chi-square = 38.746, df =9, p = 0.0001.) A significant association was also seen between educational status and the frequency of self-medication (Table 4; Pearson’s chi square = 48.167, df = 21, p = 0.001). Self-medication was perceived as effective in 88.3% of the cases. The results showed that 62.2% had no knowledge regarding the dose, duration, side-effects or drug interactions. However, 82.3% of the subjects checked the expiration date before consuming the medicine. No association was seen between checking the date of expiration and knowledge regarding dose, duration and drug interactions (p = 0.132, Pearson’s chi-square
Table 1 Distribution of study population according to socioeconomic status (Kuppuswamy scale*)
Table 2 Distribution of study population according to symptoms of illness
Socioeconomic status
Symptoms/condition
Number (%)
Percentage
1. Upper
31 (10.4)
1.Cough and cold
33%
2. Upper middle
62 (20.7)
2. Fever
35%
3. Middle lower class
47 (15.7)
3. Bodyache
28%
4. Upper lower 5. Lower
132 ( 44.1%) 27 (9.0%)
*Kuppuswamy B. Manual of socioeconomic status scale (urban). Delhi: Manasayan, 1981.
4. Ulcer
1%
5. Weakness
1%
6. Acid reflux
1.6%
7. Vomiting
1.3%
8. Skin infection
1%
9. Fracture
0.3%
10. Boil
0.3%
Table 3 Distribution of study population according to frequency of illness and self-medication in the past year Frequency of medication Illness frequency
Never
Once
Twice
More than twice
Once
3 (3.3%)
46 (50%)
42 (46.7%)
0%
Twice
5 (5.5%)
45 (49.5%)
41 (45.1%)
0%
More than twice
2 (1.9%)
56 (54.4%)
40 (38.8%)
5 (4.9%)
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Table 4 Association between education and frequency of self-medication Frequency Education
Once
Twice
More than twice
Illiterate
3 (17.6%)
14 (82.4%)
0%
5 (41.7%)
0%
Primary school certificate
6 (50%)
Middle school certificate
23 (46%)
25 (50%)
0%
Highschool certificate
29 (42%)
38 (51.1%)
0%
Intermediate or post-highschool diploma
21 (56.8%)
11 (29.7%)
1 (2.7%)
Graduate or postgraduate
63 (56.3%)
41 (36.6%)
4 (3.6%)
Profession or honours
1 (100%)
0%
0%
7.076, df = 4). However, a significant association of knowledge regarding dose and duration was seen with side-effects experienced upon self-medication (Pearson’s chi-square = 13.508, df = 4, p = 0.009) and frequency of self-medication (Pearson’s chisquare = 18.128, df = 6, p = 0.006). On consuming self-medication, 14.1% of subjects experienced adverse effects. The various adverse effects reported were fainting (1), allergy (14), hot flushes (4) and breathlessness (1). When asked about addictions, 2.3% were addicted to some drug, 14.4% were addicted to alcohol, 18.1% were addicted to smoking and 3.3% were addicted to both alcohol and smoking. It was seen that 18.4% were aware about drug-drug interactions, 81.3% were aware of drug-alcohol interactions and 0.3% were aware about drug-smoking interactions. Chronic illnesses were seen in 13.4% subjects. The various chronic illnesses were diabetes (4.3%), hypertension (5.7%), asthma (1%), heart disease (1.1%), cervical spondylitis (0.3%), arthritis (1%), thyroid (0.3%), appendicitis (0.3%) and migraine (0.3%). There was no association between awareness about interactions and the presence of chronic illness in subjects (Pearson’s chi square = 10.533, df = 12, p = 0.569).
DISCUSSION In economically deprived communities, most episodes of illness are treated by self-medication.7,28 A study done in Great Britain4 has estimated that around £ 1.2685 billion were spent on medicines purchased privately or over the counter, which equates to one-third of the £ 4304 million spent on
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drugs prescribed by general practitioners. These studies demonstrate that in recent years, self-medication is gaining popularity globally.4 The present study demonstrated that no significant association exists between gender and selfmedication. These findings were supported by the studies done in Australia,8 Nepal30 and Malyasia.25 However, a high level of education and professional status has been mentioned as a predictive factor for self-medication.22 An educated person has the ability to read medication packages and instructions, tends to be self-confident and able to make decisions.26 This theory was supported in our study where a significant association was seen between education and frequency of self-medication. Our study revealed that self-medication was a common practice among different socioeconomic groups and education levels. The majority of respondents cited distance from home and their awareness about the treatment for illness to be the major reasons for not seeking a doctor’s advice and self-medicating instead. This differed from the studies done in Delhi, Jammu and Ethiopia, in which time and money were the major reasons for not consulting a doctor.20,32,33 However, in the study by Shankar et al,30 inaccessibility of the doctor was cited as the most common cause for non-doctor prescribing, which was only reported by 1.7% of the subjects in our study. According to Pylypa,26 self-medication ‘is encouraged by problems of accessibility to health services: the more difficult the access the more likely the patient will resort to self-medication’. Another important factor for self-medication is satisfaction with healthcare facilities.10 However, in the present study most of the subjects were satisfied with the healthcare facilities.
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Patients reported having access to drug information from various sources. These include their own past experiences, family, friends or fellow university students, doctor or nurse, and advertisements on television or radio, in newspapers, magazine or books and from pharmacy sales representatives. Drug retail shops frequently serve as the public’s first point of contact with the healthcare system.16 Drug retail outlets are reported to be the major sources of drugs used for self-medication and the availability of drugs in the informal sector contributes to the increase in the practice of self-medication.29 In Pakistan, almost every pharmacy sells drugs without a prescription, a phenomenon seen in many developing countries.14 In a study in Nepal, pharmacists were seen to be a major source of self-medication. India is a country with economic and cultural similarities to Nepal, where pharmacists and pharmacy attendants play an important role in fostering self-medication among the public.17 However, in our study, only 13.4% of subjects reported acquiring information regarding self-medication from pharmacists. The ailments for which self-administration of medicines was seen were chiefly fever, cough, cold and pain. These findings were similar to the study by Lal et al20 and Shankar et al.31 It was seen that the most commonly used drug was paracetamol. Similar findings were reported in studies done in Pokhara, South Australia and Brazil.2,31 Self-medication is more likely to be inappropriate if used by poorly informed people.19 The present study also indicated low knowledge about dose/duration, side-effects and interactions of commonly used drugs, which is in accordance with the results of previous studies.11,13 Interactions between prescribed drugs and the drugs taken for self-medication are important risk factors of which the general public must be made aware.10,23 It has been found that inappropriate self-medication results in wasting resources and generally entails serious health hazards, such as risk of drug interactions, adverse drug reactions, prolonged suffering and drug dependence.6,9,10,13,18 In a survey of US consumers, a third of all respondents admitted taking more than recommended dose of non-prescribed products because they believed that they needed to do so in order to treat their conditions effectively; 21% said that they rarely or never read the label on such products.1 Human malpractices such as inadequate dosing, incomplete courses and indiscriminate drug use have contributed to the emergence and spread of antimicrobial resistance.36 The consequence of this is the
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loss of relatively inexpensive drugs, requiring the development of new drugs which will be more expensive and will further disadvantage patients in developing countries.3 In the current study, 82.3% checked the date of expiration whereas in a study done by Kulkarni et al,19 only 4.2% subjects checked the date of expiration. The most common side-effects seen with selfmedication in the current study were allergy and hot flushes. However, in the study on urban slum dwellers in a south Indian city,19 the most commonly reported side-effects were fainting and hot flushes. There was no association between awareness about interactions and the presence of chronic illness in subjects. Although a very low percentage of participants in this study had chronic illnesses, the most common ones were diabetes and hypertension, which were also seen in the study by Hussain et al.15 Many OTC medicines, nutritional supplements and alcohol interfere with the action of prescription medicines.5,27 We found that around 38.1% of participants who self-medicated had social habits like smoking and alcohol consumption. It is known that many drug interactions occur via pharmacokinetic and pharmacodynamic mechanisms, leading to an increased risk of illness, injury or death; this is more common with alcohol consumption.21
CONCLUSION The assessment of self-medication is one important element in the study of rational drug usage. The findings of this research should form the basis for future interventional plans to maximise benefits and minimise risks. The present study revealed that self-medication and non-doctor prescribing are relatively common in Bhopal. Knowledge regarding the appropriate usage of medications is inadequate. Hence, effective public education campaigns should be carried out to improve drug use and increase awareness about the adverse effects of certain irrational practices. The rampant practice of self-medication can be discouraged by suggesting prescription at the pharmacy level and stringent rules regarding pharmaceutical advertising at the time of market authorisation. Measures should be taken to make health-care delivery much less difficult, especially at the primary health care level. As recommended by the WHO in 1995,37 governments and health authorities need to ensure that safe drugs are made available over the counter and the consumer is given adequate information about the use of drugs and when to consult a doctor.
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