Prevalence of using non prescribed medications in economically deprived rural population of Pakistan

Self medication is described as an act of procurement and consumption of medical drugs without the advice of medical physician for diagnosis, prescription and surveillance of treatment [1]. The definition is further applicable with regards to treatment of family members, specifically children and elderly. The practice is considered as a major element of self care and primary public health resource in health care system of Pakistan. The epidemiological data has revealed high prevalence all over the world; up to 59 % in Nepal [2] and other developing countries [2], 92 % in adolescents of Kuwait [3], 31 % in India [4] and in European countries (Sweden, Finland, Netherlands) ranged from 17–67 %, depending on the underlying recall period [5]. However, few studies that were conducted in Pakistan have revealed the prevalence of 51 % [6] among children. Moreover, studies conducted in Karachi have confirmed the frequency of self medication among university students to be as high as 80.4 % [7]. Particularly, usage frequency among non-medical students was 83.3 % while for those in medical school, it was estimated to be 77.7 % [7].

Recently, there has been a considerable increased concern among public and professional health associations regarding irrational usage of drugs [8]. Studies have deduced that behaviors towards self medication are more common among women specially those who live alone, people facing chronic health issues, psychiatric conditions and those who are of younger age and are students [9]. Furthermore, lack of access to healthcare, availability of medicines as over the counter medicines, poor regulatory practices and long delay in medical care from hospitals has contributed significantly to rising trends in modern societies [10]. It is also claimed that self medication current trends are economic driven, where the person who is not able to pay for the cost of medicines practices self medication because he finds it feasible [11].

It is believed that public awareness along with enforcing and implementing laws about prescribed medications can immensely reduce the rate of self medication [12]. In Pakistan, it is a common practice that the prescription drug is sold in pharmacy without prescription; which is strictly prohibited according to local law. Pharmacist dispensing these prescribed drugs have no information of patients allergies and as a result antibiotics and habit forming medicines are easily accessible without prescription.. Furthermore, there is a paucity of literature with regards to self medication among rural dwellers of Pakistan and no initiatives have been taken to resolve this issue. Therefore, the study aimed to evaluate frequency, practice and prevalence of self medication among economically deprived rural population of Karachi (South Pakistan).

A remarkably high response rate of 100 % was obtained, due to proper explanation of research proposal and assurance of maintaining full confidentiality of the data they provided. Three fifty participants (50 %) were recruited from each hospital. The mean age of the subjects was 48.5 ± 6.3, consisting of 441 (63 %) males and 259 (37 %) females. Besides, 217 (31) participants were matriculated (grade 10),182 (26) had secondary school degree (intermediate), 77 (11 %) participants were graduated,49 (7 %) had qualification of post graduation and 175 (25 %) OPD patients had no formal education. Regarding occupation, 329 (47 %) were employed,77 (11 %) were retired, 161 (23 %) were un-employed and 133 (19 %) were students. When questioned about monthly income, 147 (21 %) earned <5000 PKR, 210 (30 %) responded in the range of 5000–10,000PKR, 182 (26 %) subjects responded 10,000–20,000 PKR, 95 (13.5 %) responded 20,000–50,000PKR, 66 (9.5 %) responded for >50,000PKR. Further,429 (61.3 %) participants were married, 122 (17.5 %) were single,56 (8.0 %) were widow and 92 (13.2 %) were divorced. For the subdivision of chronic illness, 365 (52.2 %) were not having any chronic disease where as 77 (11 %) responded diabetes and 133 (19.0) claimed cardiovascular diseases.

According to the survey, 595 (85 %) subjects practiced self medication. The most common reason evaluated for self medication was cost of consultation (90.3 %), availability of transport (81.0 %), advice from friend/family (78.0 %), convenience (62.0 %) and previous experience (67.0). The prevalent symptoms that led rural dwellers to indulge in self medication were headaches (81.0 %), flu/cough (79.0 %), fever (68.0 %) and pain elsewhere in body (63.0 %). As a result paracetamol as a painkiller (93.0 %), acetylsalicylic acid as an anti pyretic (69.0 %), anti biotic (52.0 %) and anti allergic (51.0 %) were the commonest drug used without prescription of a health care physician. Besides, 90 % (535) never read the instructions that are placed with medicine and only 9 % (54) read about side effects and contraindications. Moreover, 35 % (208) of the subjects practicing self medication adjusted dosage of medicine consulting pharmacist and 22 % (131) adjusted according to previous experiences.

Furthermore, for the most prevalent self medicated drug, paracetamol (pain killers) were used with the frequency of every few months by 216 (39 %) subjects, 172 (42 %) subjects also used acetylsalicylic acid (anti pyretic) within every few months. However, anti allergics were used by 136 (45 %) participants with with the frequency of 2–3 times in a year whereas same frequency was recorded for usage of antibiotics by 151 (49 %) participants. Alarmingly, only 196 (33 %) self medicated OPD patients were aware of the fact that their practice can lead to harmful effects and only 150 (25.2 %) subjects among them appreciated that they should consult a medical physician before starting a new medicine.

Further analysis was performed to assess the significant difference associated with demographical features with regards to prevalence of self medication. There was no significant difference between self medication practiced by male and females (p = 0.32; 41 % vs 44 %) and subjects having a chronic disease with participants having no disease (p = 0.48; 42 % vs 43 %). However, a significant difference was obtained between participants earning less than 50,000 PKR and greater than this amount (p = 0.029; 61 % vs 24 %) and for the self medicated patients having education less than graduation with the participants having education of graduation or above it (p = 0.03; 63 % vs 22 %) (Tables 1, 2, 3 and 4).

The current study highlights that about 85 % population of rural dwellers of Karachi self medicate. To the best of our knowledge this is the first study of its kind and there is no such data available on rural dwellers of other cities, as a result there is no study available for comparison on national level. However, a study conducted on Pakistani mothers reported a prevalence of 51 % for giving medicines to their children without consulting medical doctor in a district of Karachi [6]. Coversely, a study indicated that 76 % of university students of Karachi self medicate [13]. The results of our study are in line with the situation of Croatia [14] and Hong Kong [15] where percentage population found to be self medicating were 88 % and 94 % respectively from results of 2001. However our results are inconsistent with the work of Deshpande SG et al., who has reported the prevalence of self medication of 31 % in general population of India [4]. This suggests that prevalence calculated in our study is quite high and serious actions must be taken by health care authorities to tackle the situation.

It is also worthy to consider the fact that self medication can help to cure minor sickness that do not require advice of medical doctor and it also reduces the burden on country’s health department specifically in the developing and underdeveloped countries having limited health care resources [14]. However, the ease of accessibility of more complex drugs such as antibiotics without prescription has become a source of growing concern [16]. The increase usage of non prescribed drugs has many adverse effects and can lead to global health concerns like emergence of Multi-Drug resistant pathogenisis [19], drug dependence and addiction [20], masking of malignant and lethal diseases [17, 18], danger of misdiagnosis [21], problems relating to over and under dosaging [19], drug interactions with other compounds in body [22] and problems relating to the side effect profile of particular drugs [23].

Among rural dwellers of Karachi, the most popular reasons behind self medication were cost of consulting a medical doctor (90 %), lack of facility of transport (81 %) and advice from friend/relative (78 %) . This is due to the fact that owing to low socioeconomic status and lack of infrastructure, rural dwellers are inaccessible to medical facilities available in nearby cities. However, results are contradictory with the other study conducted on university students of Pakistan [13] where the most prevalent response was ‘previous experience with similar symptoms’ (50.3 %) and the ‘problem seeming to be too trivial’ (48.3 %). Another study conducted in Saudi Arab; Majmaah city also reported previous experience with similar symptoms to be the most commonest answer for self medication [24].

Furthermore, results also revealed that medicines were directly bought from pharmacies and alarmingly, usage of stock of medicines present at home was the most popular option among rural dwellers for the availability of drugs to self medicate. The latter induces the higher risk of exposure to expired medicines, medicines brought for someone else at home or drugs that have been advised for different health issues; as a result this practice could lead to fatal side effects [14]. The former factor is valid due to the fact that all kinds of drugs including prescribed medicines are easily available from pharmacies and medical stores without prescription which is a common practice in Pakistan. Strict vigilance must be imposed on selling of medicines that are not categorized as over-the-counter drug by government bodies in order to stop this practice. On the other hand, various studies have revealed that easy access to pharmaceuticals have become an important determinant of self medication in our societies [8]. This draws our attention to increase marketing and advertisements carried out by pharmaceutical companies through print and electronic media. Researchers have indicated that advertisements lead to individuals decision to self medicate [25]. As a result strict monitoring policies must be introduced to resolve the issue. Marketing and advertisements by pharmaceutical companies should be restricted to over-the-counter drugs only.

Our results also demonstrated that the most common drugs used to self medicate were anti pyretic, anti allergic, pain killer and anti biotic to treat fever, pain, flu, headache and allergies respectively. The outcome is similar with the study conducted in Majmaah [24]. The results are alarming as 52 % of those who self medicated used anti biotic with half of the consumers used at a frequency of 2–3 times a year . The numbers are higher than the study conducted in Pakistan on university students [13]. The results are comparable to a study conducted in Southern Spain where significant number of people employed anti biotic without proper clinical evaluation [26]. The serious health issue linked with this indiscriminate use is development of anti biotic resistance in Pakistan [17]. The results derived from this study can help to provide a framework for educational programs that will create knowledge about the risk of self-prescribed antibiotics in Pakistan.

Strikingly, 90 % of those who self medicated never red medications instructions and quite a few of people adjusted dosage of medicine according to drug instructions. The results could be attributed to the low educational qualification of rural dwellers. Therefore, vigorous media campaigns must be initiated by government and private bodies to emphasize people regarding importance of reading medication instructions and adverse effects associated with ill adjustment of dosage of medicine.

There were few limitations to the study. Firstly, it was only conducted on rural dwellers of Karachi, therefore results could not be generalized to entire population of Pakistan. Secondly, it was a cross sectional survey, therefore it might have excluded causal relationships between the dependent and independent variable . Thirdly, it was a self administered questionnaire for most of the participants, therefore they might have over reported socially acceptable behaviors and under reported socially undesirable responses. There were no methods to employ in order to evaluate the honesty of participants’ answers to the question in survey. The absence of identifying data on the survey sheets and confidentiality would have helped to eliminate such bias. Moreover, it has to be considered that only those rural dwellers were recruited who visited hospital for an acute or chronic disorder, and compared with the general rural population they are likely to have used more self medication during the last 6 months. Lastly, questionnaires were filled in outpatient department and it is a possibility that subjects might have red recommended guidelines and thus acquired knowledge prior to survey. As a result we might have overestimated knowledge for few participants. Despite of the limitations discussed above, our results extended previous works and has comprehensively evaluated the self medication prevalence and attitudes among rural dwellers of Karachi.

The self medication among rural dwellers of Karachi is high. As a result, urgent steps must be taken to initiate the awareness and educational programs regarding potential risk factors of self medication. Secondly, strict measures like cancellation of pharmacy permits must be implemented to stop supply of prescription drugs from pharmacies selling these medicines without prescription. Thirdly, provision of cost effective treatment from public sector hospitals to rural population can help to reduce self medication among rural population of Pakistan.