Public Knowledge, Attitudes, and Practices Regarding the Use of Over-The-Counter (OTC) Analgesics in Indonesia: A Cross-Sectional Study

Introduction

Analgesics, commonly known as pain relievers, are crucial role in alleviating pain and discomfort worldwide.¹ Optimizing pain management is essential for improving patients’ quality of life and overall wellbeing.² Analgesics, including nonsteroidal antiinflammatory drugs (NSAIDs), opioids, and acetaminophen, offer relief for various acute and chronic pain conditions.^1,3 However, individuals’ understanding of proper analgesic use can vary considerably, resulting in different attitudes and practices toward their consumption.^4,5

A comprehensive understanding of the general population’s knowledge about analgesics is crucial for identifying knowledge gaps and specific areas requiring targeted educational interventions.⁶ Evaluating knowledge regarding potential adverse effects, appropriate dosages, contraindications, and potential drug interactions associated with analgesic use is of utmost importance.^7,8 The use of analgesics is also influenced by attitudes toward pain management and the tendency toward self-medication as an alternative to seeking medical advice.^4,6–8

Pain reporting tends to be more common among women, older individuals, and those with lower socioeconomic status. The prevalence of chronic pain among adults in Asian countries varies widely, ranging from 7.1% to 90.8%, depending on the measurement methods used.^9,10 However, despite the growing importance of understanding pain in Indonesia, there is a lack of comprehensive large-scale studies addressing the prevalence and quality of pain across all types. Moreover, Indonesia lacks practical parameters to evaluate pain, assess patient comfort levels, and measure the impact of pain on the overall quality of life of its population.¹¹

The use of analgesics spans a broad spectrum of practices, ranging from responsible and ethical use to the potential risks of misuse or excessive use.^12,13 Various determinants, including cultural values, individual encounters, and economic circumstances, can influence an individual’s perspectives and actions concerning analgesic medications.^6,7,13 By gaining a deeper understanding of these influences, healthcare professionals can implement tailored approaches that address the unique needs and circumstances of individuals, fostering optimal pain relief while minimizing the risks associated with inappropriate analgesic use.

This study aims to analyze the knowledge, attitudes, and behaviors of the general public toward using over-the-counter (OTC) analgesic medications comprehensively. The study’s findings will contribute to the existing literature on pain management and provide valuable insights to healthcare professionals, policymakers, and educators, guiding potential interventions and improvement strategies.

Materials and Methods

Study Design and Setting

This cross-sectional study aimed to assess the level of knowledge, attitudes, and practice regarding the use of over-the-counter analgesics in Indonesia. The study was conducted from December 2019 to June 2020. Initially, paper questionnaires were distributed directly to respondents. However, due to the implementation of large-scale social restrictions caused by COVID-19, the questionnaires were later administered online through email and WhatsApp, using our community engagement group.

Sample Size and Respondents

The study used a consecutive sampling technique, with a standard type 1 error rate of 5% based on the conventional normal variation. The expected percentage of individuals participating in the study was 50%, with a margin of error of 5%. The sample size calculation indicated that a minimum of 384 respondents were needed. However, we managed to recruit up to 582 respondents. Eligible respondents for this study were aged 18 years or older who were not employed in the healthcare sector, had access to electronic communication devices and the Internet, and provided voluntary consent to participate in the research.

Data Collection

Data collection for the study was performed by five research assistants. Initially, respondents were recruited in public areas using the paper form. During the recruitment process, respondents were provided with comprehensive information about the study and were required to sign an informed consent form. However, due to the implementation of large-scale social restrictions, questionnaire administration shifted to online platforms, such as email or WhatsApp. Questionnaire responses were securely stored in an online database, which was exclusively accessible and downloadable by the authors.

Study Instruments

The questionnaire used in this research was adapted from a study conducted by Saengcharoen et al,¹⁴ and was professionally translated into Bahasa Indonesia. The adapted questionnaire comprised four sections: respondent background information, a knowledge assessment that included eight items on paracetamol and eight items on NSAIDs, an attitude assessment comprising four items, and a practice assessment consisting of three items. Responses to knowledge and practice questions were scored as 1 for correct responses and 0 for incorrect ones. In contrast, those about attitude were assessed using a five-point Likert scale encompassing the following choices: strongly disagree (scored 4), disagree (scored 3), undecided (scored 0), agree (scored 2), and strongly agree (scored 1). Cronbach’s alpha coefficients for knowledge about paracetamol, knowledge about NSAIDs, attitude, and practice were 0.73, 0.75, 0.76, and 0.71, respectively.

Statistical Analysis

The socioeconomic backgrounds of the respondents were presented using descriptive statistics. We used a t-test to explore differences in knowledge, attitudes, and practices related to all predictors except for educational attainment, which was analyzed using ANOVA. A linear multiple regression analysis was conducted to identify variables influencing successful practice attainment. The Durbin-Watson coefficient of 1.925 confirmed the lack of autocorrelation. The multicollinearity was evaluated by examining the tolerance levels and variation inflation factor (VIF) thresholds, set at 0.50–0.99 and 1.01–1.96, respectively. A regression analysis was conducted, and the resulting statistical significance level, as indicated by the p-value, was 0.002. The residual standard deviation mean was determined to be zero, and the range was less than three, suggesting the lack of any outliers. All statistical analyses were conducted using SPSS 27 software (SPSS Inc., Chicago, IL, United States).

Results

Table 1 presents the data collected from the questionnaire, indicating that 582 respondents completed it. The gender distribution shows that approximately 68.2% of the respondents were male, while 31.8% were female. Further analysis revealed that among males, 67.0% were below 22 years old, while 33.0% were above 22 years old. Among females, the percentages were 55.7% and 44.3% for below and above 22 years old, respectively. Most respondents were undergraduate students, accounting for 56.0% of the total. Many respondents had no chronic diseases (94.5%) and were not using herbal medicine (95.9%) at the time of the survey. Approximately 79% of the respondents resided near primary healthcare facilities.

Table 1 Characteristics of Respondents (N = 582)

Regarding knowledge scores, the mean score for paracetamol was 4.56 ± 1.84, while for NSAIDs, it was 2.88 ± 2.40. In addition, the mean scores for attitude and practice using analgesics were 6.80 ± 3.74 and 2.71 ± 0.448, respectively.

The majority of respondents were aware that paracetamol effectively reduces fever (94.5%) and can be taken up to three times a day (81.3%). However, up to 74% of the respondents were unaware that the maximum daily dosage of paracetamol should not exceed 4 grams or 8 tablets. In contrast, nearly 27% of respondents knew that paracetamol could be taken with or without food, and 70% believed it would not cause any allergies (Table 2).

Table 2 Participants’ Responses to Questions About Analgesic Knowledge

Concerning the use of NSAIDs, approximately 50% of respondents knew that these medications are used to treat inflammation. However, a significant number of respondents (72.0%) mistakenly thought that NSAIDs could be taken every three hours, and a majority (63.1%) believed they could be consumed without meals. Nearly half of the respondents were unaware that NSAIDs could irritate the stomach and cause ulcers. Furthermore, most respondents had limited knowledge about the potential harm of using multiple NSAIDs (87.5%) and the risk of allergies (79.4%).

Table 3 provides an overview of the respondents’ attitudes toward analgesic usage. Approximately 25% of the respondents believe that taking certain types of analgesics can quickly alleviate pain, while 30% think that using high-dose analgesics can provide immediate pain relief. Only 30.3% of respondents agree that analgesics prescribed by a doctor are unlikely to cause allergies. In comparison, 35.5% believe that analgesics are entirely safe without additional warnings from healthcare professionals, such as doctors or pharmacists.

Table 3 Participants’ Responses to Questions About Attitudes Regarding Analgesic Use

Most respondents (97.4%) reported using analgesics less than five times per month. However, it is concerning that approximately 1% of respondents tended to exceed the recommended dosage of analgesics daily. In addition, approximately 70% of respondents acquire analgesics from community pharmacies (Table 4).

Table 4 Participants’ Responses to Questions About Practices Regarding Analgesic Usage

Table 5 illustrates the analysis of knowledge, attitude, and practice among respondents across various characteristics. The findings revealed notable disparities in knowledge regarding paracetamol and NSAIDs based on respondents’ gender, educational level, and employment status. However, concerning the attitude toward analgesic usage, only the level of education exhibited a significant difference (p < 0.001). Similarly, regarding using analgesics, only gender showed a significant difference (p = 0.023).

Table 5 Comparison of Participants’ Characteristics and Mean Scores of Knowledge, Attitude, and Practice

The correlation analysis revealed a significant association (p < 0.05) between the knowledge, attitude, and practice of using analgesics. Furthermore, Table 6 presents a moderate positive correlation between knowledge regarding using paracetamol and NSAIDs (r = 0.681), and attitude and practice in using analgesics (r = 0.578).

Table 6 Correlation Between Knowledge, Attitude, and Practice of Using Analgesics

This study employed linear multiple regression analysis to determine the variables correlated with good practices in using analgesics. Ten variables, including age, gender, education, employment status, chronic disease, herbal medicine consumption, availability of primary health care (PHC), knowledge of paracetamol and NSAIDs, and attitude, were examined. The findings, presented in Table 7, revealed that gender (p = 0.021, β = −0.104), availability of PHC near residency (p = 0.041, β = 0.100), and knowledge about NSAIDs (p = 0.009, β = 0.030) were factors associated with good practices using analgesics. These factors collectively accounted for 3.3% of the variance in outcomes (F = 2.670, p-value < 0.05).

Table 7 Factors Associated with Good Practices Using Analgesics

Discussion

The current study examined the understanding of paracetamol and NSAIDs separately. The data regarding paracetamol revealed a score of 4.56 (76.0%), whereas the mean score for knowledge about NSAIDS was 2.88 (48%). The findings of our investigation indicate that a significant proportion of the subjects exhibit a satisfactory comprehension level related to paracetamol as opposed to NSAIDs (p<0.001). Paracetamol is a nonprescription medication that is commonly accessible in many countries. The fact that it can be obtained without a prescription from pharmacies, grocery stores, and convenience stores enhances its accessibility to individuals. The accessibility and convenience of paracetamol usage enhance the level of public familiarity and comprehension of this medication compared to NSAIDs, which may have limited accessibility. Paracetamol is a frequently used medication to reduce fever and alleviate mild-to-moderate pain, both of which are prevalent afflictions encountered by individuals.¹⁵ A significant number of individuals possess personal familiarity with or have observed the administration of paracetamol in such circumstances, either for their benefit or that of their family members.

While a significant number of respondents in the study exhibited familiarity with the indications of paracetamol, the overall population lacked an understanding of the proper administration of paracetamol and NSAIDs. Paracetamol may be consumed with or without food, whereas NSAIDs should not be consumed on an empty stomach as it may lead to gastric irritation and ulceration.¹⁶ The data suggest that the respondents demonstrated a high level of awareness regarding the potential consequences of the overconsumption of paracetamol and NSAIDs. According to a systematic review conducted by Roberts et al,¹⁷ the risk of hospitalizations for upper gastrointestinal adverse events (AEs) significantly increased when higher doses of analgesics were used, or paracetamol and NSAIDs were combined. Therefore, ensuring the appropriate dosage is imperative to prevent possible liver damage associated with excessive paracetamol consumption and gastrointestinal complications correlated with excessive NSAID usage.

The data reveal an essential concern about improper analgesic use among respondents concerning their attitude. It is alarming that a notable portion of respondents admitted to using different analgesics simultaneously or exceeding recommended dosages. This behavior raises concerns about their understanding of the proper administration of analgesic medications and suggests a potential disregard for recommended dosing guidelines. Moreover, the respondents lacked awareness of the potential risks of developing allergies to these medications and experiencing adverse drug reactions. Therefore, individuals need to know about potential interactions to minimize adverse effects and maximize the overall effectiveness of their treatment plans.

Moreover, the small proportion of respondents who believe that physician-recommended analgesics are unlikely to trigger allergies suggests that insufficient knowledge regarding the plausible allergic responses is linked with these drugs. The discovery that 33% of respondents perceive analgesics as entirely safe without supplementary cautionary advice from healthcare practitioners underscores a reasonable misapprehension among the respondents. This perception may result in improper analgesic use without adequate guidance, thereby elevating the likelihood of unfavorable outcomes or medication interferences.^18,19

The results of this study underscore the significance of enhancing patient education regarding the use of analgesics. Healthcare practitioners must assume an active role in providing patients with clarity and encompassing details regarding the correct dosage, potential adverse reactions, and the significance of adhering to the prescribed directives. Furthermore, it is imperative to address misunderstandings and encourage careful use of analgesics, specifically concerning the concomitant use of medications and exceeding prescribed dosages. Improving patient education and comprehension can help healthcare professionals to mitigate the risks associated with improper analgesic use and facilitate the implementation of safer and more efficacious pain management strategies.

The data present intriguing trends in the use of analgesics among the subjects. It can be determined from the responses provided by the respondents that the use of analgesics is not a common practice, as most respondents reported a frequency of fewer than five times per month. The findings indicate that most respondents demonstrated a responsible approach toward using analgesics, as infrequent use corresponds to using medication only when necessary. Nonetheless, it is alarming that a minor proportion of subjects (around 1%) tended to exceed the prescribed analgesic dosage daily. The aforementioned conduct implies an apparent mishandling or misinterpretation of appropriate dosage protocols, thereby increasing the likelihood of unfavorable outcomes or health hazards.

Consistent with the finding that nearly 80% of the respondents reside near primary healthcare facilities, this study reveals that approximately 70% of respondents obtain analgesics from community pharmacies, emphasizing the convenience and accessibility of these medications. Community pharmacies are pivotal in delivering over-the-counter analgesics, as they offer a convenient avenue for individuals seeking pain relief.⁸ The data highlights the significant contribution of community pharmacies in providing patient education and counseling on the proper use of analgesics. Previous study by Murphy et al,²⁰ stated that pharmacists must engage and guide patients actively, offering essential information on appropriate dosages, potential side effects, and necessary precautions when obtaining analgesics. This active involvement of pharmacists is essential in ensuring safe and informed analgesic medication use.

Hence, considering the aforementioned findings, ongoing educational programs and awareness campaigns specifically focusing on promoting responsible analgesic use and mainly emphasizing adherence to prescribed dosages are needed. Addressing the subset of individuals exceeding recommended dosages is crucial by providing accessible and accurate information through community pharmacies, and this ensures safe and appropriate analgesic use.

The investigation revealed that gender, resided close to PHC, and knowledge on NSAIDs were significant predictors of the respondents’ good practice in using analgesics appropriately. The findings regarding gender as a predictor are consistent with previous studies,^21,22 which have consistently shown that females demonstrate a higher level of understanding regarding analgesic medications. This phenomenon can be because women are more likely to rely on analgesics regularly to manage menstrual discomfort and related symptoms.

The heightened awareness and knowledge exhibited by females in understanding analgesics can be attributed to their personal experiences and the necessity of finding effective pain relief options for menstrual pain. It is plausible that the repeated use of analgesics during menstrual cycles has contributed to their comprehensive understanding of these medications, including their proper usage, potential side effects, and appropriate dosages. The implications of this finding underscore the importance of recognizing the unique needs and experiences of females regarding analgesic use.

Research has consistently demonstrated that individuals with easy access to healthcare facilities are more inclined to seek appropriate medical advice and comply with prescribed treatment regimens. Previous studies revealed that individuals residing in regions with enhanced healthcare accessibility exhibited increased levels of medication adherence for chronic ailments.^23,24 The present study contributes to the existing literature by emphasizing the correlation between proximity to primary healthcare facilities and responsible analgesic use.

Furthermore, our research highlights the significance of knowledge in shaping appropriate analgesic use, specifically regarding NSAIDs. The aforementioned discovery is corroborated by prior scholarly investigations that have illustrated the influence of health literacy and patient education on medication adherence and medical condition self-management. Green et al²⁵ conducted a study that found that individuals with greater knowledge of NSAIDs were more inclined to comply with recommended dosages and precautions. This finding highlights the significance of furnishing patients with comprehensive, easily accessible information to supplement their understanding of analgesic use.

Notably, although our research provides insight into these variables, their collective explanatory capacity is relatively limited, accounting for only 3.3% of the variance. This implies that supplementary variables that may are not be accounted for in our analysis that could potentially influence effective analgesic use. Subsequent investigations should delve into the aforementioned variables, namely socioeconomic status, cultural beliefs, and healthcare provider-patient communication, to attain a more all-encompassing understanding of medication adherence and judicious analgesic use.

While the current study offers significant insights into the factors related to proper analgesic usage, it is crucial to recognize the inherent limitations of this research. The data were collected through self-reported questionnaires, prone to recall and reporting biases. In addition, the research was conducted among a specific demographic, primarily undergraduate students, which may limit the generalizability of the findings to other contexts or populations. Future investigations should validate these findings in larger and more diverse cohorts, employing objective measures of medication adherence and exploring additional factors that could influence appropriate analgesic use.

Conclusion

The population demonstrates a better understanding of paracetamol and exhibits good practices in analgesic use. However, their understanding of NSAIDs and attitudes toward these medications is low. These findings emphasize the importance of implementing tailored interventions and educational initiatives targeting the identified population to enhance their understanding and promote the safe usage of analgesics.