Demographic, socio-economic and other associated risk factors for self-medication behaviour among university students of Sri Lanka: a cross sectional study

An analytical cross-sectional survey was conducted from February to April 2019.A total of700 randomly selected undergraduates of three state universities in Sri Lanka, namely University of Moratuwa, University of Kelaniya and Wayamba University of Sri Lanka, were recruited as the study population by following Krejcie and Morgan [39]. During the calculation of sample size, it was assumed that the marginal error is 3.5%, population proportion is 0.5, while the actual population size of the whole undergraduate community per year is 30, 000. During the fieldwork, the sample size was increased to reach 700 undergraduates. Any student who refused to participate in the study due to one or more reasons such as religious beliefs or an opinion that it is not worth participating, were not considered for the survey. New members were recruited, randomly to cater for such exclusions. The selection of students was done in such a way to ensure effective representation of different streams of study and levels of undergraduates.

The socio-economic, Knowledge, Attitudes and Practices (KAPs) of the selected undergraduates on self-medication behavior were collected using an interviewer-administered questionnaire prepared in three local languages (Sinhala, English and Tamil). The selected undergraduates were interviewed by a group of 5 trained interviewers.

The questionnaire covered the following areas: 1.Socio-demographic information (age, gender, nature of the residence locality, field of study and the level of study of the undergraduates); 2.Self-medication and associated practices (practicing of SM, frequency of SM, maximum number of medications used at once, symptoms for which SM is practiced); 3.Knowledgeon SM (knowledge on Over the Counter Drugs (OTC) and the possible risks of SM); 4 Attitudes towards SM (Reasons for SM, factors considered during selection of medication, Preferred sources of information and medication purchase). Prepared questionnaire was pre-tested and validated by using a preliminary sample of 30 undergraduates.

All collected data were double-checked and verified on the same day for completeness and consistency, prior entering into Microsoft Access® data sheets (Version, 2013). Quality controlling procedures were followed throughout the process by trained personnel. Meanwhile the accuracy of data were routinely checked by cross tabulations and logical checks. Discrepant data were checked against original data forms and any mistakes were promptly corrected. The binary logistic regression approach was used to calculate the Odds Ratio (OR) and the 95% Confidence Intervals (CI) of the OR for socio-demographic risk factors on SM. All statistical analysis were done using the SPSS package 23.

Among the 700 respondents, majority (55.1%) were males, while the age group of 24 to 26 years dominated accounting for 54.9% of the study population. In case of locality, a relatively higher portion of respondents (41.5%) were residing in semi-urban areas followed by urban (32.1%) and rural (26.4%) areas. All the respondents had diverse fields of study, where majority studied agriculture and food sciences (30.3%), followed by biological sciences (16.3%) and technology stream (15.1%). Meanwhile, fourth year undergraduates dominated within the study population (29.1%), while first year undergraduates denoted the least frequency of 20.6% (Table 1).

Of the respondents, 62.3% were not aware of the classification of OTC medications, which can be purchased without any prescription. Meanwhile 86.0% were knowing what antibiotics are. Surprisingly, only 54.9% of the study population correctly mentioned that antibiotics are used against bacterial infections, while a considerable fraction of undergraduates had a limited knowledge on this (45.1%). Relatively higher percentage of undergraduates were well aware that humans can become resistant to antibiotics (65.9%) and the possible side effects of strong medications (76.4%). Around 77% of the respondents knew that prior knowledge on the mechanism of drugs is necessary before initiating SM practices. However, a notable fraction was not aware of the facts such as higher doses not always result fast recovery (35%), low doses can’t always prevent less adverse conditions (22%) and medication can’t be stopped when basic symptoms fade away (21%).

Limited knowledge in medicine (64.0%), risk of having adverse reactions/effects (60.4%), risk of misdiagnosing (53.7%) and misuse of drugs/medications (49.6%) were recognized as the major risks associated with SM. The proportion of respondents aware of possible risks such as the development of drug/medication dependence and administration of medications wrongly (wrong doses and inappropriate methods etc.) were relatively low (24.3 and 27.1%, respectively). Even though, only a limited faction of study population (9.1%) was knowing the chemical composition of drugs used by them, approximately quarter of the respondents (26.3%) were capable of fully understanding the instructions that comes with medication. Meanwhile, 54.7% of respondents were proficient in partially understanding the instructions (Table 2).

Of the entire study population, 546 undergraduates (78.0%) practiced SM. Majority (47.1%) of the undergraduates were practicing SM more than 5 times per year, followed by once in every two three months (31.1%). Only, 2.3% of the respondents were frequently indicating SM practices at a weekly interval (Table 3). Approximately 52.9% of the respondents were using a single drug at a time, while the proportion of undergraduates that used multiple drugs were least (18.9%). Among the respondents, only 63.3% were occasionally changing the administrated dose of SM. Interestingly, 21.3% were never changing the initial dosage. On the other hand, 15.4% were always changing the administrated dosage of medication. Unsatisfaction of the administering dosage to cure the disease (36.7%), worsening of the existing condition (23.9%) and improving of the existing condition (21.1%) were the major reasons for changing the dosage during SM.

Fever, was the major cause for practicing SM (61.3%) followed by cough, gastritis and stomachache (56.7, 46.4 and 42.4%, respectively). Interestingly, complications in eyes (0.6%) and ears (2%) were the least contributing causes for SM within the study population. Antipyretics for fever (73.6%), drugs for cough/runny nose (73.6%), pain killers (53.1%) and Cetrazine (47.4%) were the most consumed medications used for Self-Medication by the undergraduates (Table 3). On the contrary, other medications such as traditional medicines, Ayurvedic products, primary wound care medication (0.6%) and sleeping pills (2%) were the least used medications by the respondents.

Checking the package (69.3%) and consulting a pharmacist (60%) were the most practiced methods of dose determination during SM. Among them, only 12.7% undergraduates were consulting a medical officer for accurate instructions. Interestingly, 29.3% of the respondents were always checking the instructions of the medicines that they consume, while 44.0% were checking the instructions occasionally. Meanwhile, a notably high fraction (26.7%) were never inspecting the safety instructions for drug usage. A total of 483 undergraduates (69%) of the study population were keeping the left overs of previously used medications at home, which could be a contributing factor for SM (Table 3). Approximately 29.3% of the respondents accepted that they might have taken the same medication with different brand names at the same time. Meanwhile 40.1% stated that they have faced adverse impacts of SM. Consulting the pharmacy staff (45.4%) and family member/friend (39.1%) were the mostly practiced response for such adverse reactions (Table 3).

Previous experience (76.0%), trivial nature of issues (73.0%)and necessity of avoiding embarrassing moments (52.6%) were the major contributing factors that encouraged the respondents for SM. Meanwhile, time, urgency and economic constraints were having limited influences (23.0, 22.7 and 17.4%, respectively) on SM behaviour. A higher proportion of the study population (40.7%) were satisfied with any medication provided by the pharmacist. Interestingly, a notable percentage of respondents were paying attention to the possible side effects (32.1%), brand name (31.7%) and price (25.7%), when purchasing drugs or medication. Community pharmacies (86.9%) and left over from previous prescriptions (51%) were the most preferred sources of obtaining medications. On the contrary, friends (21.1%) and neighbours (4.1%) were the least preferred sources (Table 4).

Own previous experience (77.9%) was the most preferred source of advice for selection of medications, followed by a previous prescription of a doctor (68.6%), pharmacist advice (47.9%) and opinion of a family member (45.4%). It was interesting to note that internet and social media accounted for around 36.7% preference among the undergraduates as a source of information. A majority of respondents believed that they have not consumed any counterfeit drugs (79.6%). At the same time, higher percentage of respondents (53.7%) were not sure whether common disease conditions can be cured by SM. On the contrary, only 46.7% believed that common diseases can be successfully treated via SM. Interestingly, a notable fraction of undergraduates (43.6%) were willing to recommend medicines for their friends or family members, which could promote SM (Table 4).

As suggested by the results of binary logistic regression, all the basic demographic and socio-economic factors (except for gender) were having a significant association with the practicing of SM by the studied population (Table 5). Even though, males were having a relatively higher preference for SM (P = 0.08; OR = 1.65; CI = 0.92–2.01) than the females, the association of gender and SM behavior was non-significant. The highest prevalence of SM was observed among the students belonging to the age group of 24–26 years (81.3%; OR = 1.23), followed by 20–23 (77.9%; OR = 1). Students from urban (92.4%; OR = 10.18; CI = 8.20–10.75) and semi-urban (81.7%; OR = 3.72; CI = 2.60–4.13) areas had significantly higher tendency (P = 0.004) for SM behaviour, than those from rural localities (54.6%). Interestingly, undergraduates from Biological Sciences (94.7%; OR = 2.08; CI = 1.46–3.02) showed a significantly higher prevalence of SM, followed by undergraduates from Agriculture & Food Sciences (89.6%; OR = 1). In case of academic year of study, the final (fourth) year undergraduates denoted the highest prevalence of SM (97.1%; OR = 23.57; CI = 20.88–24.45), followed by third year undergraduates (85.7%; OR = 4.29; CI = 3.05–4.82). The tendency for practicing SM significantly increased with the academic year (P < 0.001) as shown in Table 5.

SM is an important aspect, which should be rigorously monitored by the health authorities (especially in developing countries) to ensure safe and responsible usage of drugs by patients. This requires effort to aware the patients with adequate information regarding the usage of pharmaceuticals and instances to consult a qualified medical officer, when needed [24, 40, 41]. The undergraduate population in the current study reported a 78% prevalence of SM at higher SM frequencies such as 2–3 times per month or more (52.9%). Several studies conducted in Oman (94%), Palestine (98%), India (87%), Pakistan (76%)also have reported similarly high levels of SM among undergraduates [18, 23, 42‐44]. On the contrary, Buke et al. [37] has reported only a 45% prevalence of SM among university students in Turkey. Meanwhile a Brazilian study conducted with university healthcare and non-healthcare students has shown 57.7% prevalence of SM [45]. Findings of the current study stands in line with few similar studies conducted with university students in Pakistan [22], Slovenia [46] and Palestine [18].

Ear and eye related issues were the least dealt issues through SM, mostly due to the higher sensitivity of those systems. Antipyretics (such as Panadol, Paracetamol), drugs for cough/runny nose (cough syrups, piriton, cetirizine) and pain killers (Paracetamol, Panadine, Aspirin and Brufen) were the mostly used medication that denoted a usage by more than 50% of the studied population. Several recent studies have reported similar findings, where painkillers, flu/cough remedies have emerged as most commonly used medication in SM [2, 5, 8, 17, 32, 45]. Especially, few studies that focused on the SM behaviours of undergraduate populations in Bangladesh [21] and Jordan [24] have also reported a similar observation in the region. Even though, a higher usage level of antibiotics have been reported in many previous studies [12, 17], only 38.8% of the entire study population administrated antibiotics during SM. A similar rate of antibiotic usage has been found among medical and non-medical students in Jordan [24].

Despite the high rates of SM, only approximately one third of the entire study population (37.7%) was familiar with the classification of OTC drugs. This suggested that SM is practiced with limited knowledge. Further, only 53.3% of the study population were truly aware of the fact that antibiotics are used against bacterial infections, among 86% who claimed to have knowledge on antibiotics. A notable fraction of the study population carried misconceptions on antibiotics such as higher doses always result fast recovery (35%), low doses can always result less adverse conditions (22%) and administration of antibiotics can be stopped immediately when basic symptoms fade away (21%). A recent study conducted by Grigoryan et al. has also reported that people in Southern and Eastern European countries tend to possess a less accurate knowledge on antibiotics, especially regarding the effectiveness of antibiotics against bacterial and viral infections [38]. However, majority (65.9%) of the respondents were aware of antibiotic resistance and the ability of SM causing ill effects (76.4%). This level of understanding within undergraduates of Sri Lanka remains higher than in Europe (48%), while lies closer (73%) to the awareness level in United States [38, 47]. A recent study conducted in Turkey has also reported that a high proportion of undergraduates tend to engage in SM, since they only know that SM is wrong and is capable of causing ill effects [37]. Regardless of this primary understanding, more awareness on the devastating ill effects of SM should be communicated to the undergraduates to promote responsible SM within Sri Lanka. Few recent studies that have focused on the undergraduate communities in several regional countries have also recommended such measures to enhance the responsible SM [7, 21, 24, 26].

High SM prevalence within the studied university population, despite the reasonable knowledge on the risks of SM such as risk of using wrong drugs (49.6%), lack of knowledge about medicines (64%), risk of having adverse effects (60.4%) and risk of misdiagnosis (53.7%), agrees with the findings of previous studies [4, 24, 48]. This has been described as a phenomenon, whereby the practitioners of SM tend to outweigh the potential risks of side-effects with potential benefits, due to their belief that only safe medicines are permitted to be sold as OTC [17, 48]. Further, the limited understanding on the classification of OTC and malpractices of pharmacists (who sell non-OTC medication without proper prescriptions) could also be prominent risk factors for SM prevalence [12, 23, 24].

The risk of SM behavior among the studied Sri Lankan university population further increased since the preferred methods to determine the administration dosage of medication were checking the package, consulting a pharmacist or based on previous experience. Therefore, administration of appropriate doses remains questionable as majority of the respondents claimed that they are capable of understanding the instructions that comes with the package, partially (54.7%) or very poorly (19%). A recent study in China has also reported a similar low level of understanding the instructions that comes with medication among the university students [17]. Majority of students changed the administration dosage occasionally (63.3%) or never changed the dosage (21.3%), which could result severe side effects in case of misdiagnosis or due to over use [2, 12]. Irrational use of antibiotics arising due to inappropriate antibiotic prescribing, selection of wrong drug, dosage and inappropriate period of use could lead to serious health concerns and antibiotic resistance [12, 49, 50].

More than one third of the study population have faced side effects of SM previously and stop taking the drug (76%) or consulting a pharmacist (45.4%) has remained as their preferred option. Meanwhile only a limited number of respondents tend to consult a physician in such occasions. This behavior could also worsen the risk of SM on the well-being of the community, due to poor treatment seeking behavior [12, 24]. Previous experience, trivial nature of the problem, need for avoiding the embarrassing moments and quick relief have been the major reasons for SM among the studied university student population. These findings agree with many previous studies on SM conducted among different populations [2, 20‐26, 51]. Even though, majority of the respondents were accepting any medication provided by the pharmacist, a notable fraction were considering the potential side effects and the brand name they preferred in purchasing medication. A study conducted in Saudi Arabia has reported that majority (84.1%) pay attention to the effectiveness of medications, followed by the brand [51].

Community pharmacies (86.9%) was the most preferred source of medication purchase for SM followed by left over from previous prescriptions and family members. Community pharmacies often remain as the most preferred source of medication and other therapeutic drugs in many studies conducted all over the world [12, 20, 24, 40, 52, 53]. Availability of left-over medication or home pharmacies could provide free access and easy visualization of medication, which in turn act as promoters of SM [2, 20, 54]. As emphasized by Reynolds and McKee left over medication from previous prescriptions suggest that either doctors over-prescribe and/or the patients not complying with the prescription [55].

Own previous experience (77.9%), previous prescriptions of a doctor (68.6%), pharmacist advice (47.9%) and opinions of family members (45.4%) were used for the decision making in SM in the current study. Several previous studies have also reported similar findings [2, 18, 20‐24, 44, 56]. Both family members and the pharmacists often tend have inadequate knowledge about antibiotics [2, 40, 56]. Further, previous prescriptions may not be ideal for the current scenario, elevating the risk for unintended side effects due to SM. Continuous use of the same medicines (based on previous prescriptions) could lead to development of drug resistance, addition and concealing of malicious and potentially fatal diseases [17, 57‐59]. In addition, following of an advice of a family member in selecting medication would evidence for culturally inherited acceptance of self-medication [40, 55, 56], which remain as a critical risk factor.

Majority of respondents believed that common diseases could be successfully treated through SM, which remains as a crucial factor to be considered by the health authorities in the country [7, 8, 24]. Further, nearly half of the respondents (43.6%), accepted that they are recommending drugs for their friends and other family members, which is a serious concern. On the contrary, a recent study conducted in Brazil and Saudi Arabia have reported that a notable fraction of university students tend to discourage SM practices among their friends and relatives [2, 20].

Even though males were having a higher tendency for SM (OR = 1.65) in comparison to female undergraduates, the effect of gender on SM behavior was found to be insignificant. This finding agrees with several previous studies conducted in India [7], Lithuania [12] and western China [40], while an opposite trend has been reported from Brazil [2].Few recent studies conducted in Bangladesh [21] and Saudi Arabia [25] also reported that the effect of gender on SM remained insignificant among undergraduates. Age was also a significant risk factor, where younger students showed a higher prevalence rate of SM, which agrees with several other studies [2, 17, 38]. Students from urban and semi-urban localities denoted significantly higher prevalence rates of SM, suggesting that locality is a critical risk factor. Undergraduates from such areas have more exposure to medical services and media, which directly encourage them for SM [18, 23]. Further, the availability of community pharmacies is also high in such areas, unlike in rural areas, which could have resulted the above observation [23]. On the contrary, an opposite trend has been reported in Lithuania, where rural people have shown the high prevalence of SM behaviour [12].

Undergraduates from science background (biological sciences and agriculture & food sciences) denoted higher SM bahaviours than undergraduates from art or commerce fields. Undergraduates with a science background may have a better knowledge on medication, leading to elevated SM rates than undergraduates from non-science backgrounds [24, 26]. Academic year of study also emerged as a significant risk factor, where final year students (third year and fourth year) had higher prevalence rates of SM. However, a previous study conducted in Sri Lanka has reported a similar positive trend among the academic year of students and the SM behaviour of undergraduates in the University of Peradeniya, which was not statically significant [32]. Few regional studies conducted in Pakistan [19] and Saudi Arabia [26] have evidenced that SM practices have increased with the academic year in undergraduate populations. An opposite trend has been reported in Brazil, where final year students have shown lesser SM preference, which has also remained non-significant [2]. Similar reluctance in SM has been shown by a cohort of pharmacy and medicine undergraduates in Saudi Arabia with the progression in educational career [20]. However, the influence of friends, more exposure to media and advertisements, availability of left-over medication may be the influencing factors for the higher SM practice among final year students in the current study. Several studies conducted in the region have evidenced that both medical websites and advertisements play a key role in inducing the SM behaviour within undergraduates [20, 21, 24‐26].

The current study has evaluated the SM behaviour of undergraduates belonging to three major state universities of Sri Lanka, out of 15 government universities in Sri Lanka, which remains as a limitation. However, a satisfactory proportion of undergraduate community has been recruited from three major universities representing all the academic fields to compensate for this limitation. Further, a recall bias could occur as the SM practices were reported by the students, which remains a general limitation in this type of studies [40]. In addition, the chronic diseases, which are often associated with SM, were not assessed within the study. However, this also has been mentioned as a limitation in similar studies [2].

Findings of the current study suggest a higher prevalence of SM among the undergraduate community in Sri Lanka, which should be considered as a critical factor in health care management. Despite strict national regulations that prohibits issue of medication without proper prescriptions, findings of this study suggests easy access to medications and therapeutic drugs in Sri Lanka from community pharmacies and other sources without supervision of a physician. Numerous countries have reported similar situations [8, 12, 24, 52], emphasizing the need for more effective supervision system and tools to regulate selling of antibiotics and other medication [24]. As highlighted by the WHO, responsible SM could reduce costs and economic burden of healthcare systems and individual citizens [60]. This requires proper knowledge and transparent regulatory system to ensure responsible use of medication and therapeutic drugs via SM [20, 24]. Therefore, properly planned health education programmes, effective tools and regulations are recommended to be implemented within Sri Lanka, to empower Sri Lankans to make well informed decisions regarding SM. Especially, such educational programmes should be combined into the general curricular of the university system of Sri Lanka, to promote responsible SM within the community.