Patterns of self-medication among medical and nonmedical University students in Jordan

Introduction

The US Food And Drug Administration defines over-the-counter (OTC) drugs as “drugs that are safe and effective for use by the general public without seeking treatment by a health professional”.¹ Self-medication is a global form of self-care practice and can be defined as “the taking of drugs, herbs or home remedies on one’s own initiative, or on the advice of another person, without consulting a doctor”.² Self-medication practice is highly prevalent in the developing countries and can be enhanced by the availability of medicines as OTC.³

Self-medication, when adopted correctly, can be more convenient, may relieve acute pain, and reduce treatment cost and physician interaction times.⁴ However, it can jeopardize human well-being and result in severe health-related complications when implemented inappropriately, such as in cases of self-treatment with prescription-only drugs.⁵ For instance, developing drug resistance is of great concern with the frequent and inappropriate use of antibiotics that could be available without a prescription. A survey conducted over Jordanian households reported that 39.5% of the participants had used antibiotics without prescription.⁶ Other serious consequences that might be provoked with frequent use of OTC medications include inappropriate dosing, drug duplication, drug interaction, treatment failure, masking of health problems and symptoms, and delay in prescribing the appropriate treatment.⁷

A previous study showed that the reasons behind the prevalent use of OTC medications can include the following: the desire to save money, presence of minor health problems that do not need a visit to the physician, prior experience with drug efficacy, and the long waiting time at physician’s clinic or hospitals.⁸ The common sources of self-medications may include families, friends, pharmacists, newspapers, magazines, and Internet websites.⁹

College age group represents an integral part of the community. As medical students usually try to implement their knowledge into practice, self-medication has been frequently assessed among these individuals. The prevalence of self-medication among university students ranged from 38.5% in Ethiopia¹⁰ to 98% in Palestine.¹¹ A meta-analysis of 27 studies of self-medication among physicians and medical students reported self-treatment prevalence of >50% in 76% of the studies.¹² In Jordan, studies conducted earlier on medication use were focused on medical students¹³ or public,^9,14 with special attention to the consumption of antimicrobial drugs.^6,15,16 One study assessed the attitude and behavior of antibiotic use among medical and nonmedical university students and reported high consumption rates regardless of specialty.¹⁷ As little data are available about self-medication practice among medical and nonmedical students, the goal of this study was to explore the prevalence, attitudes, determinants, and sources of self-medication among Jordanian medical and nonmedical students.

Methods

This was a descriptive cross-sectional study conducted among a convenient sample of students enrolled at medical and nonmedical schools of Jordan University of Science and Technology (JUST) located at the North of Jordan. The university students’ population is about 21,000, of 60 nationalities, distributed at 12 medical and nonmedical schools. Medical schools include pharmacy, medicine, nursing, dentistry, and applied medical sciences. Students of different academic levels (juniors and seniors) were targeted. The students were approached with the survey during their scheduled elective course classes, via taking 10 minutes out of the class time (at the end of the class). The study protocol and obtaining of informed verbal consent were approved by the institutional review board committee at King Abdullah University Hospital, JUST. An informed verbal consent was obtained from individuals after explaining the purpose of the study and that the involvement was voluntary. Students were also informed that their responses would be anonymous and confidential. Graduate students were not included in the study.

The survey included questions about respondents’ sociodemographic, clinical information, education, history and pattern of physician visits, students’ knowledge and beliefs of OTC medications and practice of the consumption of OTC and prescribed drugs (self-medication), reasons for the self-prescribed practice, sources of advice, and frequent symptoms prompting self-medication. The survey included primarily close-ended questions. Some of the questions may tolerate more than 1 answer (example: reasons for self-medication). Questions were related to the period of the previous 6 months. The questionnaire was also piloted on 50 students and tested among a group of students to receive feedback about understandability and clarity of the questions, and data of the pilot study were not included in the final analysis. The questionnaire was adjusted as per feedback from the piloted sample. The survey was developed after a comprehensive review of the related literature and consultation among the research team. It was face-validated via consultation with expert colleagues in the field and was also objectively validated for comprehensibility and clarity. Reliability was ensured via calculating Cronbach’s α, which was >0.7 for all items of the questionnaire.

Descriptive statistics such as frequency (%), mean, and SD were used to present participants, characteristics as appropriate. The study questions and characteristics were compared between medical and nonmedical students using independent Student’s t-test for continuous variables and χ² test for categorical data. The SPSS software (version 23) (IBM Corporation, Armonk, NY, USA) was used for data analysis at the level of significance of P<0.05.

Results

Demographics and clinical characteristics

This study was conducted in 504 students, of whom 248 were from medical and 256 were from nonmedical schools. Slightly more than half (55.7%) of the respondents were female, and the mean age was 21.8±1.8 years for all participants (67.5% were ≥21 years old). The majority were nonsmokers (79.6%) and lived in the city (67.7%) in places close to hospitals (<25 minutes driving). When split by study year, the majority were in the third or fourth professional year of their academic study (68%). Most of the respondents had medical insurance (83.5%) and did not have chronic diseases (96%). The following sociodemographic and clinical characteristics were significantly different between medical and nonmedical students: gender, nationality, age, the area of living, smoking status, college year, monthly income, availability of transport, and medical history. For example, 69.8% of the medical students were female vs 42.2% of the nonmedical students, P<0.001. Additionally, only 11.1% of the medical students were smokers vs 25.8% of the nonmedical students, P<0.001. Other participant characteristics are listed in Table 1.

Table 1 Demographics of study participants

Patterns of medical visits

Regarding respondents’ visits to physicians, 61.4% of the medical students reported that they had seen physicians at least 1 time in the past 6 months, which was comparable to that of the nonmedical students (68.6%), P=0.154. The major reasons for visiting physicians among participants were flu (41.5%), tooth pain (35.1%), and cold (26.4%). Nonmedical students had seen physicians for flu (48%) more than medical students (34.7%), P=0.002. Both groups of students reported that they highly adhered to doctor instructions. Data about students’ medical visits are summarized in Table 2.

Table 2 Patterns of medical visits among students Notes: aFemales only. Bold text indicates P<0.05 which is statistically significant.

Patterns of self-medication

Significant differences in the knowledge of students about prescription-only or OTC medications were observed (Table 3). Higher percentages of medical students reported that antacids, expectorants, laxatives, antibiotics, and antidiarrhea medications are prescription-only drugs compared to nonmedical. The percentages ranged from 25.4% to 55.6% and 18% to 33.2% for medical and nonmedical students, respectively. Interestingly, a lower percentage of medical students (14.5%) believed that painkillers were prescription-only drugs compared to nonmedical students (22.7%), P=0.019.

Table 3 Patterns of self-medication among students Notes: aFemales only. Bold text indicates P<0.05 which is statistically significant.

Self-medication was reported by 96.8% of the participants, and this was not different between medical (97.2%) and nonmedical students (96.5%). The most predominant medicine classes that were self-used by all students in the past 6 months were painkillers (77.6%), anti-flu decongestants (54%), sore throat drugs (25.9%), cough suppressants (24%), or antibiotics (21%). Self-medication was significantly higher in medical compared to nonmedical students with regard to the use of painkillers (82.3% vs 73%, P=0.013) and antiallergy drugs (11.3% vs 5.9%, P=0.029). However, the frequency of self-medication with anti-flu drugs was higher among nonmedical (60.2%) vs medical students (47.6%), P=0.005.

The most common indications for which students take medications on their own were headache (81.9%), cold (58.3%), flu (53%), and tooth pain (31%). Medical students showed self-medication practice for headaches and tooth pain significantly more often than nonmedical students (Table 3).

Other practices

The primary sources of advice for taking medications for all students were from physicians (55.8%), pharmacists (52.6%), Internet websites (44.2%), or family members (36.9%). A significantly higher frequency of nonmedical compared to medical students was dependent on friends (14.8% vs 7.7%, P=0.011) and own experience (7.4% vs 2.4%, P=0.01) as a source of medication use. A significantly higher proportion of medical students (57.1%) reported that they read medication instructions on the package insert (patient information leaflet) every time they bought a new pack of medication compared to nonmedical students (53.8%), P=0.016. The majority of participants (65.3%) reported that they stopped using the medicine and saw physicians whenever the drug had no effect. These data are listed in Table 4.

Table 4 Characteristics of medication use Note: Bold text indicates P<0.05 which is statistically significant.

Discussion

This study evaluated patterns and attitudes of medical and nonmedical university students toward self-medication. The study revealed that self-medication practice is very common and comparable between medical and nonmedical students. Students primarily treat themselves to relieve pain and flu symptoms, and nonmedical students are self-treated with anti-flu drugs to a level higher than that of medical students. The study also showed that students are primarily dependent on physicians or pharmacists’ advice for self-medication.

The prevalence of self-medication in our cohort sample was 96.8%. This is slightly higher than that reported among Jordanian medical and pharmacy students (78.5%),¹³ comparable with health care and non-health care students of Slovenia (92.3%)¹⁸ or Pakistan (95.5%),¹⁹ and much higher than that documented among Saudi medical students (26%)²⁰ or Egyptian medical and nonmedical students (62.9%).²¹ These differences in self-medication prevalence among students might be explained partially by the variable sample size or the level of medical knowledge and the responsible self-medication between students.

Self-medication among students was also higher compared to the Jordanian public (42.5%).⁹ This could be attributed to the higher level of medical and pharmaceutical knowledge about medications and their uses among university students; thus, it is likely that this knowledge is sufficient to practice self-treatment. The high level of self-medication observed among students of nonmedical disciplines indicates that students are becoming more familiar with medicines and their uses and that may be attributed partially to the large willingness to know and learn about medications from newspapers and Internet websites or even from the social networks. In fact, we showed that nonmedical students were more dependent on friends and own experience as a source of advice for self-medication, suggesting that they were more prone to accept recommendations from their friends compared to medical students. In Egypt, a study showed that neighbors and family, own decision, and Internet were frequent resources for self-medication among students.²¹ Another study reported that friends and family, chemist, and Internet were the primary 3 resources of self-medication among undergraduate students of Nepal.²² Other explanations for the high prevalence of self-medication in this study may include convenience, lack of time to seek physician appointment, and the fact that around 16% of the study cohort were not medically insured.

Consistent with a former study,²³ painkillers including analgesics/antipyretics were the most commonly used medications among students. For example, analgesics (55.4%) were the most frequently self-treated medications in a sample of 1,296 medical students in Serbia.²³ The nonsignificant difference in the prevalence of self-medication observed between medical and nonmedical students is in accordance with other investigations.^7,19 Nevertheless, medical and nonmedical students showed significant differences in their practice of self-medication with some group of drugs. While medical students used painkillers and antiallergy drugs more than nonmedical students, they showed lower usage of anti-flu decongestants. Perhaps, the medical knowledge gained in college might act as a driving factor for medical students to make decisions of self-medication, even with drugs that might sometimes require a prescription such as antiallergy drugs. Additionally, medical students may feel that their scientific knowledge is solid and they may no longer need medical consultation.¹³ The higher self-medication with anti-flu drugs in the nonmedical students might be related to their previous experience with the disease and such OTC medications. However, this frequent use of anti-flu decongestants may have not been effective as nonmedical students reported that they had commonly seen physicians for flu symptoms, and this was at a percentage higher than that of medical students. Although the use of antibiotics was not different between the student groups, its frequent use (21%) is of concern. As reported earlier, this inappropriate use of antibiotics may delay the prescribing of proper treatment and may increase the likelihood of bacterial resistance.^6,15

In agreement with previous studies,^7,21 we found that headache, cold, and flu were the predominant health problems that provoked self-medication practice. For instance, a study conducted among 572 students in Pakistan found that students were primarily self-medicated for symptoms of headache (72.4%), flu (65.5%), and fever (55.2%).⁷ Moreover, studies found that being a medical student was a significant risk factor for self-medication,^21,24 and this was reflected in this study as it showed that medical students self-treated for headaches and tooth pain significantly higher than nonmedical students.

The widespread use of self-medication, especially for prescription-only drugs such as antibiotics, is of concern.^6,25 Consistently, a study conducted among 731 Chinese students reported that 40.2% of the students self-treated with antibiotics purchased without a prescription from retail pharmacies and that they used this frequently for common colds.²⁶ The dispensing of antibiotics has to be restricted and regulated on different levels including legislations, physicians’ prescribing, pharmacy dispensing, and awareness of the population. Thus, implementing legal regulations should be encouraged among community pharmacies, which have to adhere to laws and policies concerning good dispensing practice to limit the misuse and irrational use of medicine. As this study was not designed to assess the appropriateness of self-medication, future investigations are required to evaluate the positive and negative impacts of self-medication on students’ health.

Although self-medication practice was high among students, they showed some awareness about the use of medications. For instance, nearly half of our participants reported that they read medication instructions every time they bought a new pack of medicine, an attitude that was unsurprisingly more prevalent with medical students. In addition, students were willing to see physicians whenever the medicine is not working for them. Nevertheless, awareness and knowledge about self-medication and its good and bad consequences have to be enhanced among university students. Medication and health awareness campaigns and educational sessions in the university campus may be appropriate.

This study is the first to comprehensively compare the pattern of self-medication between medical and nonmedical students in Jordan. However, there are some limitations. The study was conducted at 1 large university in the North of Jordan although there are other universities that include medical and nonmedical disciplines in other parts of the country. The survey was self-reported, and this may have contributed to the inconsistent understanding of questions between students. A recall bias is possible as students were asked about their experience in the past 6 months. Although the sample size may be relatively small, it is convenient and the results can reflect the pattern of self-medication among university students. Also, there were multiple demographic factors that were significantly different between the 2 groups, which may have impacted the differences in students’ patterns and practices with regard to self-medication.

Conclusion

Self-medication practice is high among medical and nonmedical university students for OTC or prescription-only medications. Although the prevalence is similar among medical and nonmedical students, some differences with respect to medical indications and the type of drugs utilized were observed between students. Health professionals have to improve students’ awareness about consumption of prescription-only drugs such as antibiotics and its health consequences. The dispensing of medicine has to be controlled by Jordanian health care authorities through developing effective preventative and interventional strategies; thus, an appropriate use of medications is achieved.

Acknowledgment

We would like to thank all participants of the study. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Disclosure

The authors report no conflicts of interest in this work.

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