1. Introduction
The behaviors of patients toward different medical conditions vary considerably, from immediately seeking medical advice, relying on self-medication (SM), or neglecting the condition [
1]. The World Health Organization (WHO) described self-medication (SM) as the use of medicinal products or herbs to manage self-diagnosed disorders or symptoms; moreover, SM also comprises repeated or continued use of a prescribed drug for chronic, recurrent diseases or symptoms. This generally occurs through obtaining medicines without a prescription, sharing medicines, or using leftover medicines stored at home [
2].
Even though SM might have some positive outcomes when used properly such as reducing the cost of the treatment [
3], numerous pitfalls are associated with the inappropriate use of SM including: delay in the treatment, drug–drug interactions, masking of symptoms, adverse drug reactions (ADR), and most importantly antimicrobial resistance (AMR) [
3,
4]. AMR was affirmed by the WHO as one of the major problems facing humanity [
5]. Overuse and misuse of antibiotics through inadequate dosing, incomplete dose, extensive veterinary use, public beliefs that antibiotics can cure any conditions, overprescribing, non-prescription, and self-medication with antibiotics (SMA) are common factors that are associated with the development of AMR [
6,
7]. SMA in low to middle-income countries (LMICs) is thought to be more prevalent, mainly owing to the combined effect of external factors such as dispensing antibiotics without prescription and internal factors like economic status [
6,
8].
Worldwide, effective implementation of rational antibiotic prescription is lacking despite the availability of issued legislation. This is quite understandable when you come to know that two-thirds of antibiotics are available without prescription in the pharmaceutical sector as stated by WHO [
9]. Additionally, a recent study estimated that half of the antibiotics were purchased without prescription globally, the same study outlined that non-prescription use of antibiotics reached 82% in some middle-eastern countries [
10]. In LMICs, the SM and inappropriate antibiotic practice was declared to be more intensive, according to a meta-analysis published in 2021, in which SMA was outlined to be ranging between 50–93.8% [
8]. Another meta-analysis review reported 55.7% as an overall median prevalence of SM with antibiotics in Africa [
11]. The same study pointed to the highest prevalence of SMA identified in the west and north African sub-regions [
11].
Antibiotics in Sudan are listed under prescription only medicine, albeit the presence of clear regulations, which prohibit dispensing of antibiotics as over the counter drug, antibiotics in Sudan like its counterpart from developing countries can be accessed easily. Most of the antibiotics were purchased from pharmacies in several regions in Sudan [
12,
13,
14]. This is compatible with the preceding report which revealed that more than 80% of the pharmacists in Sudan frequently dispense antibiotics without prescription [
15].
A study conducted in Khartoum state showed that more than 80% of the communities were self-medicated, among them approximately one-third (28.7%) were antibiotic utilizers [
13]. The prevalence of SMA in Khartoum state has been described by Abdelmoneim Awad et al. to be 73.9% in 2005 [
16]. Another recent study reported a prevalence of 60.3% among Sudanese undergraduate medical students [
17]. Most of the studies which were carried out in Sudan pointed toward the association of SMA with age, gender, income, and level of education [
13,
16,
17,
18]. It is worth mentioning that penicillin antibiotics were declared to be the most commonly prescribed antibiotics in most of the studies [
17,
19].
Given the above backdrop, the present study aimed at providing an updated and comprehensive nationwide estimation of the prevalence of SMA in general Sudanese communities and its association with socio-demographic factors, also the study investigated predictors of SMA including the most common reasons and ailments behind SMA and the most frequently self-medicated antibiotics.
3. Discussion
SMA is one of the common factors which precipitate AMR, yet if effective implementations are adopted it can be easily controlled. Tracking SM behaviors of public individuals are of paramount importance since it facilitates the development of preventable measures towards this condition. Moreover, it also uncovers the weakest domains in the health system. It was on these grounds that the current nationwide survey was conducted to determine the prevalence of SMA in different Sudanese states, as well as to provide an insight into the reasons, and factors associated with SMA.
The current cross-sectional survey indicated that the prevalence of SMA among the Sudanese community was 71.3%. The reported figure lies in the middle of local and regional figures in previous studies. For instance; locally, one of the earliest and most comprehensive surveys conducted by Abdelmoneim Awad et al. in 2005 reported a prevalence of 73.1% [
16], while a recent study which included Sudanese university medical students reported that antibiotics were self-medicated by 60% of the students [
17]. Regionally, a meta-analysis review pooled the prevalence of SMA in Africa using 40 studies from 19 countries and the computed prevalence ranged from 50–93.8% [
11]. On the other hand, another systematic review outlined the proportion of SMA in middle-eastern countries to be in the range of 12.1–93.1% [
10]. Our finding points towards a higher prevalence of SMA in Sudan, unfortunately, it also emphasizes the fact that the practice of SMA in Sudan has remained consistent throughout the last 20 years.
Different reasons behind SMA were mentioned previously, such as cost saving, previous experience, and convenience which were reported repeatedly. However, less frequently, the emergence of illness, and the long delays in clinic have been reported [
1,
20,
21,
22]. Likewise, participants in the present study cited convenience (63.3%) and cost-saving (41%) as common reasons for SMA (
Table 2). The finding is consistent with the results reported previously in Sudan, Malaysia, India, and Ethiopia [
14,
23,
24,
25].
The present study illustrated the common ailments for SMA. Generally, SMA to manage upper respiratory tract infections (URT) such as tonsillitis (55.5%), cough (45%), runny nose (37.8%), and nasal decongestion (33.4%) were higher than other ailments which comprise fever (31.9%), pain (29.1%), diarrhea (21.9%), and wound infection (14.9%) (
Table 3). This finding is in line with previous studies conducted in Sudan, Tanzania, and India [
12,
21,
23]. Bearing in mind that most of the URT infections are of viral origin, and antibacterial agents must be preserved only for bacterial infections which indeed requires a series of investigations and diagnoses provided by health care specialists, and considering that this pattern remains consistent in Sudan through the last 20 years with a gradual increment, health authorities in Sudan should effectively implement an antimicrobial stewardship program to optimize the utilization of antimicrobial agents.
Health services in Sudan are provided by different bodies including: government, private sectors, army, police, universities, and civil society [
26]. The national health insurance fund (NHIF) is an extension of social health insurance which was introduced in 1994, the finance of NHIF is based on cost sharing (national social system based on the cooperation between the government and community) [
27]. The coverage in all states is around 50% (except Khartoum = 70%), and the out of pocket share in Sudan is reported to be 70% [
27,
28]. Nearly one third (30.7%) of the participants from the present study were not medically insured (
Table 1). Further, insurance status was significantly associated with SMA (
p-value < 0.00), binary logistic regression indicated that medically non-insured participants were less likely to use antibiotics as SM in comparison to insured participants (COR: 0.656; 95% CI (0.506–0.718), (AOR: 0.645; 95% CI (0.487–0.855) (
Table 4). Similar findings have been reported previously in Pakistan [
12]. Additionally, 41% declared cost saving as one of the main reasons behind SMA. On the other hand, participants with secondary school and post-graduates were less likely to take SMA compared to primary school levels of education (
Table 4). This pattern is not limited to this study, and it has been observed in previous studies in Lebanon, Uganda, and Malaysia [
18,
29,
30]. However, it contradicted studies carried out in Sudan, Eritrea, and Bangladesh [
16,
20,
31]. Such a finding is best explained by the fact that educated individuals understand the difficulties in discriminating infectious diseases and knew the consequences of SMA, therefore, they prefer to visit doctors instead of self-medicating.
Previous studies outlined that the main focus of community pharmacists in Sudan is to efficiently prescribe medications [
32,
33]. A considerable proportion of the participants from the present study sought antibiotics mainly from the community pharmacies (90%), and the remaining participants obtain antibiotics from leftover medication (
Table 5). Previous researchers in Sudan reported a similar pattern [
14,
17]. This finding indicated that the gap between the actual role of the community pharmacist which is extended to include patient counseling and education is a promising area for mitigating SMA.
Additionally, more than half of the participants in this study (51.9%) thought that SMA is not an acceptable practice (
Table 5 and
Table 6). Paradoxically, the practice of the participants diverges from rationality, when you come to know that 41% of the participants change the dosage of the antibiotics deliberately (
Table 5). Moreover, the fact that a high percentage of the enrolled participants switch antibiotics harmonizes with the finding that only 37% stop taking antibiotics after dosage completions. The abovementioned malpractice is consistent with previous studies conducted in India (24%), Malaysia (41%), and Egypt (71%) that participants change the dosage of antibiotics during usage [
23,
24,
34]. In Afghanistan, 33% of the participants stop taking antibiotics [
35], while in Malaysia 35.3% of university students switch the dosage of antibiotics [
24]. Given the above backdrop, it is not surprising that at the national level multi drug resistant and extensively drug-resistant isolates detected from clinical specimens are increasingly reported [
7,
36,
37].
Participants in the current study cited amoxicillin/clavulanic acid as the most common antibiotic used as SM (32.5%), followed by amoxicillin (26.5%), azithromycin, and metronidazole (25.3%) (
Table 6). Similar results were observed previously in Sudan [
14,
16], where azithromycin (29.9%) and amoxicillin/clavulanic (26.8%) were found to be the most common antibiotics self-medicated by university students [
17]. Multiple studies in Africa and the Middle-East concluded the extensive use of beta-lactam antibiotics especially amoxicillin and amoxicillin/clavulanic as SM [
10,
11]. It is however, worth mentioning that earlier studies in Sudan reported amoxicillin as the most common antibiotic used in comparison to the present study and a recent study in 2022 [
12,
16]. This shift can be explained by the fact that patients always seek the most effective antibiotics, or it might be due to extensive promotion applied by different companies to promote their antibiotics (amoxicillin/clavulanic).
Besides accelerating antimicrobial resistance, SMA can also be associated with ADR. One-fifth (21.8%) of study participants reported that they experienced ADR (
Table 6). This is slightly lower than a previous study in Malaysia (28.3%) [
5]. Alarmingly, a considerable amount of the participants either switched the antibiotics or continued the antibiotic with the rate of 20.8% and 11.3%, respectively. ADRs associated with antibiotics ranged from mild side effects such as GIT symptoms to life-threatening conditions such as anaphylactic shock which is associated with a large number of antibiotics impacting patients’ health as well as cost [
25,
38].
The finding from the present study can be partially generalized to the overall Sudanese community owing to the large and diverse sample size. However, one of the limitations of this study was the recall bias since not all participants were able to exactly remember for instance the types of antibiotics. Further, the study was subjected to selection bias, since it was conducted during the daytime in public areas, it is for this reason most of the participants were aged below 39 years old. Additionally, the questionnaire used in the present study adopted close-ended limited options which made it difficult for some respondents to express their opinions.