Background
SM is an activity practiced by ordinary people with the aim of dealing with their health problems without consulting healthcare practitioners [
1]. In other words, SM refers to the use of over-the-counter drugs to treat a whole host of ailments without medical supervision [
2]. Medication overuse in particular and SM in general are two major social, health, and economic problems in many countries, including Iran [
3]. Research findings have indicated that a large percentage of Iranian patients practiced SM before seeking for care at public service [
4‐
7].
SM may involve the use of herbal [
8] or chemical drugs [
9], access to over-the-counter drugs, consumption of the previously prescribed drugs in similar cases, shared use of the prescribed drugs for one person by family members and partners, consumption of excess drugs at home, drug misuse on friends’ and peers’ advice, and previous experience with medicine [
10‐
14].
SM has led to the expansion of adverse effects, such as antibiotic and drug resistance [
10], inefficient and prolonged treatment [
15], harmful toxicity and implications [
16], and drug dependence [
15]. Despite the few positive effects of SM on improvement of health conditions [
17], the patient is exposed to more adverse effects and greater drug resistance. This also results in disruption in the pharmaceutical market, waste of money, and increased per capita of drug use [
18,
19].
Healthcare system in Iran consists of public and private sectors. The public sector plays important roles in primary, secondary, and tertiary health services. The private sector, on the other hand, provides secondary and tertiary healthcare services [
20]. In Iran, pharmacies in public and private settings are allowed to sell drugs in accordance with physicians’ prescriptions or without prescription as over-the-counter drugs [
21]. However, selling drugs by other stores is considered to be illegal [
21].
Many Iranian researchers have thus far focused on the issue of SM. A quantitative study by Jafari et al. [
22] revealed an 83% prevalence of SM among elderly individuals in Iran. A study on Iranian university students by Sararoudi et al. [
23] also showed that 76.6% of the students had a history of SM with analgesic drugs. Similarly, the meta-analysis performed by Azami Aghdash et al. [
3] was indicative of a 53% prevalence of SM in Iran. In spite of focusing on the issue of SM, none of these research works adopted a qualitative approach to SM.
Given the fact that SM is a multi-dimensional process and potentially has different implications in different cultures and societies, it is necessary to identify the influential factors on this process according to the social context and cultural aspects and values to find a solution by means of appropriate and realistic planning. A primary step, to begin with, is to collect a set of qualitative in-depth information from the SM practitioners themselves. Due to the mentioned research gap, the present qualitative study aims to explain the process of SM among Iranian people.
Methods
In methodological terms, this qualitative study was conducted based on Strauss and Corbin’s version of GT (1998). The study aimed at investigating the SM process during 2014–2018. The main question of the study was “how is SM practiced by Iranians”. To this end, the qualitative research method based on the GT approach was taken into account as the most effective approach to the question under consideration [
24]. GT is a methodological approach for qualitative researches that allows researchers to interpret a process and its components based on the data derived from the participants’ experiences [
25].
The participants in this study were first selected from the individuals with a history of SM through purposive sampling. Theoretical sampling was applied after the development of classes to establish the relationships. The inclusion criteria of the study were having a recent experience of SM and being willing to share the experience. Initially, 11 participants (with a history of SM) were selected through purposive sampling. After the development of the classes, six other participants were interviewed to establish the interclass relationships and to extract the final theory. Apart from the participants with a history of SM, three pharmacists and six general practitioners and specialists were enrolled in the process of theoretical sampling to develop and establish the model themes and interclass relationships. The process continued to the point of data and theoretical saturation.
The data were collected via semi-structured face-to-face and online interviews. The location and time of the interviews were determined and then agreed by the participants. Every 25-40-min interview started with a general question, “
How do you describe your SM experience?”. This was followed by a series of exploratory questions according to the participants’ responses to gain a full understanding of the SM process. Some of these questions were as follows: “could you please explain more about your decision?” and “could you please mention the basis of your decision for SM?” (see Additional file
1). These questions included an examination of facilitators, inhibitors, and theme-based factors affecting the process. In online interviews, the participants were asked to provide a detailed answer to a certain set of questions and, if necessary, more questions were added later. The face-to-face interviews were recorded with the participants’ written informed consent. Afterwards, the online and face-to-face interviews were all transcribed. In addition to the interviews, some reminders were used to collect information and complete the process and interclass relationships. These reminders revealed a primary analysis after the interviews with the participants and helped generate the final process of the study.
The constant comparative method based on Strauss and Corbin’s version of GT (1998) was employed in order to analyze the data extracted from the interviews. In doing so, the records were transcribed immediately after each interview. After reviewing, they were analyzed manually through open, axial, and selective coding to reach the point of theoretical saturation. In open coding, the interview scripts were read for several times and then, the main theme-based sentences were extracted and coded. These codes were divided into certain classes based on similarity. In axial coding, the classes were related to their subclasses and consequently, they were arranged around a common axis. Finally, the central theme was extracted in selective coding. Another method for collecting and analyzing the data was the use of reminders at all stages of data analysis to relate the classes and themes and develop a conceptual framework [
25].
This study was approved by Fasa University of Medical Sciences (grant No. 93093). Indeed, the researchers observed all ethical considerations for a qualitative study, including explaining the study purpose and methodology, obtaining written informed consents, offering the possibility of resigning voluntarily at any time, and ensuring the participants’ right for privacy.
The criteria suggested by Lincoln and Guba were used to enhance the accuracy of the study results [
25]. Long-term involvement of the researcher with the study process as well as continuous data examination aimed to increase data credibility. The process of data validation was conducted through reviews by both participants and supervisors. Other subjects who had a history of SM but did not participate in the study were provided with the results and were asked to compare them to their own experiences. Other approaches adopted in the study to enhance the accuracy of the results were the inclusion of participants of different ages and genders, application of different data collection methods, and close examination of the study process from data coding and analysis up to the final theory development by a group of three professors experienced in qualitative researches. The study findings were reported based on the consolidated criteria for reporting qualitative research (COREQ) checklist.
Discussion
This GT study aimed to explain the process of SM occurring among Iranian people. The study results indicated that the main stimulant of the SM process was people’s willingness to deal as simply and quickly as possible with illnesses/symptoms. Not only this process occurred based on people’s attitudes towards their illnesses and physicians, but it was also affected by economic and social problems. The process also involved strategies, such as seeking for information and consulting others about their related experiences, which contributed to the prevalence of SM. Moreover, the consequences of SM ranged from satisfaction to dissatisfaction, in which the resulting temporary satisfaction and relief from illnesses/symptoms was the dominant dimension. Furthermore, “To avoid being trapped in the vortex of illness” was the central category in this study, thereby connecting all the other categories. The components of this conceptual model are going to be discussed in details in the following paragraphs.
According to the study results, the patients’ attitudes toward illnesses and physicians influenced their practice of SM. The individuals who practiced SM justified their behavior by not taking their illnesses seriously and believing that it was both minor and transient. In this regard, Loyola Filho et al. [
13] suggested that the above-mentioned approach played a central role in SM. Beza et al. [
12] and Jafari et al. [
22] also highlighted the same issue as one of the factors affecting the SM behavior. Not taking the illness seriously by SM attempters can cause many problems, such as progression of the disease, occurrence of complications, need for long-term hospitalization, and increases in health services costs [
17‐
19,
26]. In the same line, the meta-analysis conducted by Azami-Aghdash et al. [
3] indicated that mild symptoms accounted for the largest impact (63.7%) among the effective factors in SM. Thus, it is necessary to provide opportunities for education in this respect in order to reduce the conditions leading to SM.
The deep mistrust in the medical profession and the rare honesty among physicians was another underlying factor in SM. These results were consistent with those of the studies by Mortazavi et al. [
27], Azami-Aghdash et al. [
3], and Jafari et al. [
22]. Generally, the process of building trust bears on treatment acceptability among patients. This necessitates paying special attention by healthcare policymakers with the aim of eliminating the factors resulting in the above-mentioned mistrust through the development of public knowledge about physicians’ duties and treatment processes.
Moreover, individual and social problems reportedly encouraged SM. According to the participants, socioeconomic problems stimulated SM. The findings of the studies performed by Azami-Aghdash et al. [
3], Beza et al. [
12], Mortazavi et al. [
27], and Wen et al. [
10] also revealed that SM practitioners avoided consulting physicians due to their socioeconomic problems, such as financial and time constraints. Similarly, Jafari et al. [
22] found that 82 and 45.5% of the participants practiced SM due to time and cost savings, respectively. Hence, healthcare policymakers and administrators have to adopt appropriate measures in order to improve the underlying conditions facilitating SM and to reduce patients’ waiting times and financial burdens in medical centers.
The main concern among SM practitioners was to deal with their illnesses/symptoms both simply and quickly. The study results showed that the people tended towards SM so as to cope with their health problems as simply and quickly as possible. Consistently, Wen et al. [
10], Le et al. [
11], and Mortazavi et al. [
27] mentioned simplicity and time-efficiency as two major factors that encouraged SM and discouraged medical treatment. Furthermore, Albusalih et al. [
14] stated that the most common reasons for SM were mild problems and previous experience with medicine. The outlined concern requires attraction of public’s attention to the consequences and complications of SM, so that people would choose whether or not to practice SM in an informed manner.
The present study findings showed that people employed different methods to decide on SM. According to their desire to seek for rapid relief from illnesses/symptoms, the participants had self-reportedly employed different methods, such as searching the Internet and sharing their SM experiences. The practitioners’ efforts to address their main concern were summarized as “to avoid being trapped in the vortex of illness”. Other research findings have also indicated few agents for SM, including family members [
12,
28], friends and neighbors [
13,
28], peers [
10], and non-medical staff like pharmacists [
2,
28]. These findings were consistent with those of the present study, thus emphasizing the influence of others on the decision to practice SM. The meta-analysis performed by Azami-Aghdash et al. [
3] also revealed a 35.9% share for unprofessional advice in SM cases. Jafari et al. [
22], too, showed that 64.6% of the patients acted according to such advice (friends, neighbors, and family members). In the same line, the findings of the studies by Le et al. [
11], Loyola Filho et al. [
13], Mortazavi et al. [
27], and Wen et al. [
10] demonstrated that having suffered from similar illnesses in the past and having a history of using similar medications facilitated the decision on SM. According to Jafari et al. [
22] and Azami-Aghdash et al. [
3], the previous experience with the same illness and the same medications accounted for 73 and 51.4% of the cases of SM, respectively. The strategies for inhibiting the growing phenomenon of SM may include changing the public attitudes towards SM and raising awareness about the different conditions facing different patients.
The implications of SM were manifested through a range of satisfaction levels. Most of the participants mentioned a temporary sense of satisfaction as the result of SM with few components, including time-efficiency, cost-effectiveness, and transient relief. Consistently, Beza et al. [
12], Wen et al. [
10], and Jafari et al. [
22] reported that the cost-effectiveness of SM was a strong promoter compared to the financial burdens imposed by physicians and medical procedures. The cost-effectiveness reportedly embraces both time and cost savings, which are possible to achieve by avoiding physicians or medical centers [
29,
30]. Since the resultant satisfaction is often temporary, it is necessary to raise awareness about the consequences of avoiding physicians and medical treatments so that people would make a well-informed decision. Quite apart from this temporary sense of satisfaction, SM led nowhere but to long-term dissatisfaction in some cases where the high cost of delayed medical procedures and prolonged treatments by SM were self-reportedly found to be the components of dissatisfaction.
The present study population included a group of Iranian people with a history of SM in two southern provinces. Despite the detailed data analysis and the careful development of categories from the process of SM, it requires a cautious approach to generalize the study results to other populations. A major advantage of this study was interviewing general practitioners, specialists, and pharmacists through theoretical sampling to complete the process and relate the categories as perfectly as possible.
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