Assessing the Perceptions and Practice of Self-Medication among Bangladeshi Undergraduate Pharmacy Students

Objectives: To evaluate the perceptions and extent of practicing self-medication among undergraduate pharmacy students. Methods: This cross-sectional, questionnaire-based study was conducted over a six month period (January to June 2016) among undergraduate pharmacy students in five reputable public universities of Bangladesh. It involved face-to-face interviews regarding self-medication of 250 respondents selected by simple random sampling. Results: Self-medication was reported by 88.0% of students. Antipyretics (58.40%) were mostly preferred for the treatment of fever and headaches. The major cause for self-medication was minor illness (59.60%, p = 0.73) while previous prescriptions were the main source of knowledge as well as the major factor (52.80%, p = 0.94) dominating the self-medication practice. The results also demonstrated 88.80% of students had previous knowledge on self-medication and 83.60% of students always checked the information on the label; mainly the expiry date before use (85.60%). A significant (p < 0.05) portion of the students (51% male and 43% female) perceived it was an acceptable practice as they considered self-medication to be a segment of self-care. Furthermore, students demonstrated differences in their response level towards the adverse effect of drugs, the health hazard by a higher dose of drug, a physician’s help in case of side effects, taking medicine without proper knowledge, and stopping selling medicine without prescription. Conclusions: Self-medication was commonly used among pharmacy students primarily for minor illnesses using over-the-counter medications. Although it is an inevitable practice for them it should be considered an important public health problem as this practice may increase the misuse or irrational use of medicines.


Introduction
Self-medication is a human trait in which an individual (or a member of the individuals' family) selects and uses medicines or any other substances for the treatment of self-recognized or self-diagnosed physical or psychological ailments [1]. Conventionally it has been described as the intake of drugs, herbs or other home remedies on an individual's own persuasion or taking the advice of another person without consulting a physician [2,3]. Thus it forms an integral part of patients' self-care which in fact is the first choice and is one of the most crucial tools when an

Study Area
To conduct the study, the pharmacy department of five public universities of Bangladesh namely Dhaka University, Jahangirnagar University, Chittagong University, Comilla University, and Noakhali Science and Technology University were chosen as the study area. The above mentioned universities were chosen by the field investigators based on the availability and accessibility of the participants. Time and distance were also the key factors for the selection of the study areas.

Study Participants
The study included 250 undergraduate students (131 male and 119 female) enrolled in a Bachelor of Pharmacy program who understood English, aged between 18-25 years and were permanent residents of Bangladesh, with different socioeconomic backgrounds from five different public universities. Both residential and nonresidential students were selected randomly, i.e., we did not consider whether the students were resident or non-resident in different halls of the university. Before data collection each and every participant was clearly informed about the purpose of the study and a written consent was taken from each of the respondents.

Participants and Eligibility Criteria
This study included only those respondents who were easily available for data collection and interested to provide information willingly. Those who did not feel comfortable to give information were excluded from the study.

Sampling and Sample Size
A simple random sampling technique was used for the selection of study participants. The sample size was calculated assuming that 50% of the undergraduate pharmacy students had a tendency of self-medication practice with 5% margin of error and 95% confidence interval. The sample size was calculated to be 232. However, to ensure more representative data, we selected a larger sample size of 250 for this study.

Data Collection
The procedure of data collection was segmented into three steps. The first step was to fill out the questionnaire including socio-demographic information by the study subjects. The second step was to discuss the study protocol, and the final step was to cross-check the questionnaires filled by the respondents. The questionnaire was adopted from a formerly published study which was developed, standardized, and previously used by Kumar et al. [4] for undergraduate pharmacy students. The questionnaire was divided into four segments and consisted of 16 close-ended and 11 open-ended questions. Section 1 contained questions related to socio-demographic information of the respondents. Section 2 included questions about the practice of self-medication by the respondents. Section 3 was concerned with the knowledge and awareness related questions of the respondents while Section 4 was on questions related to the perception of the respondents regarding self-medication practice.
The questionnaire was distributed to the selected student together with a written consent form that explained the purpose of the research and assured them of their confidentiality. The interviews lasted for 15 min and included a range of questions about self-medication along with an explanation about self-medication, its main principles, as well as evidence based and practical demonstration. The questionnaire was constructed in English and translated to Bengali by the interviewers to make the questions easily understandable to the participants during the interview. They were asked to complete the questionnaire immediately. The authors were present on hand to answer questions or clarify any doubts that they might have.

Statistical Analysis
Data analyses were conducted using SPSS software version 20.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistics was used for the calculation of proportions. The Chi-square test was performed to measure the association between the demographic characteristics and responses to understanding, perceptions and self-use of medication. The p values were calculated by the Chi-square test. An alpha level of 0.05 or less was considered significant. The Microsoft excel program was used for data analysis and for chart, graph, and diagram preparation. Table 1 shows that 52.40% of the students were male while female students comprised 47.60%. Among all the pharmacy students 26% was from the 1st year, 26.00% from the 2nd year, 26.00% from the 3rd year, and 22.00% from the 4th year. The lowest number of students was in the age group <18 years with a percentage of 5.20% while the highest number of students was in the 21-25 years age group with a percentage of 63.60%. Another 31.20% of students was in the age group 18-20 years. Among the respondents 80.40% of respondents was from an urban area and 19.60% was from a rural area.  Table 2 describes the practice of self-medication by pharmacy students (from 1st year to 4th year) from five reputable public universities of Bangladesh. From the table we get a clear scenario that the majority of students reported practicing self-medication (88.0%). The practice of self-medication among both male and female students (45.20% and 42.80% respectively) was almost similar with no significant difference (p > 0.05).  Table 3 demonstrates that the use of self-medication practice for different complications differed insignificantly (p > 0.05) between male and female students. It can also be seen from the table that Pharmacy 2018, 6, 6 5 of 12 students used self-medication for headache (71.20%); cough, cold/flu (61.20%); diarrhea (47.60%); pain (42.80%); stomach ache (32.80%); vomiting (32.00%); rash/allergies (23.60%), and skin problems (16.40%) respectively. Here the percentage of using self-medication for fever was highest and the value was least for ear problems. The purpose of self-practicing of medications by the students was categorized into seven broad categories ( Table 3). The majority of the students (59.60%) used self-medication because they thought that they did not need to see a doctor for a minor illness. Easy availability of medicines (32.20%) and emergency use (32.00%) were the secondary reasons for practicing self-medication. Meanwhile quick relief (30.80%), lack of time to consult doctor (25.60%), sufficient pharmacological knowledge (19.20%), and cost effectiveness (12.80%) were other reasons behind self-medication of drugs. The table shows some high values on the purpose of using self-medication, but none of the values was significant (p > 0.05).

Purpose of Self-Medication Practice
Different categories of medicine which were self-medicated by the students for the treatment of ailments are listed in Table 3. From the table it is clear that the use of different classes of drugs showed no difference in use between males and females. Among the drugs the rate of antipyretic consumption was highest (58.40%) by the students whereas analgesics (49.20%); anti-diarrheal (39.20%); Pharmacy 2018, 6, 6 6 of 12 antacid (38.80%); vitamins (31.60%); anti-allergic (29.20%); cosmetics (22.00%), and anti-diabetics (15.60%) were also used by them. It was found that among different types of drugs students used ophthalmic preparations the least with a percentage of 1.60%. Figure 1 represents the pharmacy students' (1st to 4th year) source of information on the medications self-prescribed by them. From the diagram we get a clear picture that the majority of the male and female students considered an old prescription for common illness (56% and 58% respectively) and academic knowledge (62% and 55% respectively) as their primary sources of information on self-medicated drugs. It was an interesting finding that male students gathered information about medicines from friends (32%), internet (35%), and advertisement (30%) and this rate was higher in comparison to female students. thought that they did not need to see a doctor for a minor illness. Easy availability of medicines (32.20%) and emergency use (32.00%) were the secondary reasons for practicing self-medication. Meanwhile quick relief (30.80%), lack of time to consult doctor (25.60%), sufficient pharmacological knowledge (19.20%), and cost effectiveness (12.80%) were other reasons behind self-medication of drugs. The table shows some high values on the purpose of using self-medication, but none of the values was significant (p > 0.05).

Sources of Information on Self-Medication Practice
Different categories of medicine which were self-medicated by the students for the treatment of ailments are listed in Table 3. From the table it is clear that the use of different classes of drugs showed no difference in use between males and females. Among the drugs the rate of antipyretic consumption was highest (58.40%) by the students whereas analgesics (49.20%); anti-diarrheal (39.20%); antacid (38.80%); vitamins (31.60%); anti-allergic (29.20%); cosmetics (22.00%), and anti-diabetics (15.60%) were also used by them. It was found that among different types of drugs students used ophthalmic preparations the least with a percentage of 1.60%. Figure 1 represents the pharmacy students' (1st to 4th year) source of information on the medications self-prescribed by them. From the diagram we get a clear picture that the majority of the male and female students considered an old prescription for common illness (56% and 58% respectively) and academic knowledge (62% and 55% respectively) as their primary sources of information on self-medicated drugs. It was an interesting finding that male students gathered information about medicines from friends (32%), internet (35%), and advertisement (30%) and this rate was higher in comparison to female students.   Table 4 represents a pharmacy student's opinion on the factors (predefined categories from the survey) which influence the practice of self-medication. A major portion of the students (52.80%) said that they had self-prescribed a drug based on the previous doctor's prescription for the same disease. Another 50.80% students had previous experience of practicing self-medication while the opinions of family members (45.20%) and of friends (15.20%) were also influential factors for self-medication practice by the students. Advertisement (6.00%) and recommendation by local people (5.60%) were the least influential factors for self-prescription of medications.  Table 5 is concerned with the information relating to pharmacy students' perceived knowledge on self-medication practice. The table illustrates that most of the students who had self-prescribed medication for different diseases knew about self-medication (88.80%) previously. Among the students 83.6% had a tendency to check the package insert while 85.6% students had a sound attitude towards checking the expiry date of the drug before using it. Furthermore 67.6% students had concerns about the importance of completing the course of the drug. All the results differed significantly (p < 0.05) when compared between male and female students.  Figure 2 represents the pharmacy students' (1st to 4th year) approach on self-prescription of medication for self-healthcare. From the figure it is clear that the students' concept about self-medication was classified into three categories namely good practice, acceptable practice, and not acceptable practice. Both male (51%) and female (43%) considered self-medication an acceptable practice while another 17% male and 13% female students considered self-practice of medication was good. Moreover the diagram also shows that 32% male and 44% female students thought self-medication was not an acceptable practice.

Attitude towards Self-Medication
Pharmacy 2018, 6, 6 8 of 13 Table 6 represents the students' attitudes on self-medication among 1st to 4th year pharmacy students of five reputed public universities. The answer level is given as "yes" and "no". The majority of students had a positive attitude on self-medication. A very negligible number of students had a negative attitude.
The tabulated results show differences in response level of the students to some survey items such as self-medication is a part of self-care; the idea about drugs side effects; health hazard on increased dose of a drug; physician's help in case of side effects; taking medicine without proper knowledge, and stopping selling medicine without prescription. The observed answers were significant (p < 0.05) in the case of concern about the impact of increased dose of drug, for no need of drug treatment in mild medical cases, for overlooking physicians and not selling drugs without prescription, while for other modalities the results were not significant (p > 0.05). Figure 2. Attitude of the students towards self-medication. Data is represented as percentage (%) for the two groups. Table 6. Attitude of the students towards Self-medication.

Modality
Year   Table 6 represents the students' attitudes on self-medication among 1st to 4th year pharmacy students of five reputed public universities. The answer level is given as "yes" and "no". The majority of students had a positive attitude on self-medication. A very negligible number of students had a negative attitude. Table 6. Attitude of the students towards Self-medication.

Modality
Year The tabulated results show differences in response level of the students to some survey items such as self-medication is a part of self-care; the idea about drugs side effects; health hazard on increased dose of a drug; physician's help in case of side effects; taking medicine without proper knowledge, and stopping selling medicine without prescription. The observed answers were significant (p < 0.05) in the case of concern about the impact of increased dose of drug, for no need of drug treatment in mild medical cases, for overlooking physicians and not selling drugs without prescription, while for other modalities the results were not significant (p > 0.05).

Discussion
People have always been very cautious about their personal health status and for this they have used self-medication, a feature of healthcare, from ancient times. Although self-medication has Pharmacy 2018, 6, 6 9 of 12 many pros and cons it depends on who uses it and how it is used for self-treatment [4]. We focused on pharmacy students because they have adequate knowledge of medicine in theory and are more cautious about the safety of drugs which is lacking in other student groups or in the general population. Thus a pharmacy student's view on the self-medication practice can be considered as a major factor to judge the characteristics of their future prescription pattern. Students of Bangladesh frequently use self-medication and gender difference has not been shown to have any influence on the practice of self-medication. The reason behind insignificant gender differences in the overall exercise of self-medication may be the study format that allowed the respondents to select drugs by themselves [5]. In our study we found that about 88.0% of the students self-practice different types of medication. A similar type of study was conducted by Kumar et al. [4] in coastal south India and signified that the amplitude of self-medication practice was 78.90% among medical students. Other similar studies also demonstrated the prevalence rate of self-medication ranged between 57.1% and 92% among the medicals students in India [22]. Several research works carried out in other developing countries revealed that the prevalence of self-medication was 38.5% and 43.2% among medical, pharmacy, and health science students in Ethiopia [22,23], 51% among citizens in Slovenia [24], 55.3% and 55% among medical students in Pakistan [25] and Egypt [26] respectively, 56.9% among medical undergraduate students in Nigeria [27], and 80.9% among female university students in Malaysia [28]. The major influential reason behind the higher propensity of self-medication might be the unregulated easy availability of all categories of medicine without prescription.
Similar to some previously published articles [22,[29][30][31], headache, common cold, fever, pain, and vomiting were the most common symptoms for self-administration of medications mentioned by the respondents. It was quoted in our research report that the most common cause for self-treatment with drugs was the insignificance of the illness which did not require a doctor's visit. Similar outcomes were reported by the study conducted in India [7,32]. This type of attitude of the respondents may be attributed to a disregard and absence of consciousness about the advancement of diseases. Sometimes the people who practice medication for self-treatment may suffer from a serious illness as the symptoms of many diseases are primarily mild but wrong diagnosis and treatment may promote serious health hazards. However, in agreement with other studies, easy availability of medicines [4,6], quick relief [16], and time saving [33] were found to be the other causatives for preferring self-medication practice.
As stated earlier, antipyretics, analgesics, antacids, and antidiarrheal drugs were the most common classes of drugs self-prescribed for treatment by almost all of the respondents in our study. Almost identical observations were found in the studies conducted in India [4,34], Pakistan [32], Iran [35], and Ethiopia [8] where these common classes of drugs were frequently used by medical students. Meanwhile, the use of antibiotics was different to that of analgesics and antipyretics. This tendency is because of the knowledge of pharmacy graduates on the resistance and side effects of antibiotics. It is well known that proper medicinal knowledge can promote a good prescribing pattern of pharmacists. However, at the same time inappropriate or irrational use of these drugs can lead to various hazardous effects including the reduction in the capability of microbial flora to resist detrimental microorganisms, the development of multidrug resistance, addiction, toxicity, and other related syndromes [32]. Therefore, such kind of practice should be discouraged.
Our study found that the key factor for self-medication practice by the participants was their adequate pharmacological knowledge which they had gathered from their academic courses. These findings are similar to those from studies conducted in Nepal [7], India [4,33], Malaysia [36], Ethiopia [8], and Pakistan [32]. The second major source of information on self-prescribed drugs was from previous prescriptions for the same illness and this result was analogous to the findings of the study conducted in India [4,33]. Further, other researches conveyed in India [34] and Ethiopia [8] reported the internet as another common source of knowledge on self-prescribed medicines which was the third common source of information in our study results.
The fact that majority (52.80%) of the respondents gathered information about self-medication from the previously prescribed medicines of physicians was consistent with the research work conducted earlier [37]. However as the respondents were younger, they were also influenced by other sources like previous illness experiences, opinions of family members, friends and local people, and advertisement. This result resembles formerly conducted research findings [23,37]. All the students irrespective of the year of the study reported that they were completely aware of the treatment procedure using self-medication. They were also cautious about completing the dose of the medicine, checking the instructions given on the insert before using and also looking for the expiry date of the drug before using it. Less awareness was noted among 1st year students which was similar to the findings of Kalyan et al. [38] and Sontakke et al. [34] Non-inclusion of pharmacology as a subject in the 1st year curriculum could be the reason.
In this research work, about 73.2% of the respondents believed the practice of self-medication to be part of their own health-care and the proportion was higher than the reports from India [34], Ethiopia [22], and Pakistan [25]. Self-medication can only be considered a part of self-care if legitimate use of medicaments can be ensured. It may lead to accidental drug toxicity as there is always a risk of using expired drugs and also sharing with friends or taking medicines that have been actually prescribed for other problems [4,29,32,39].

Limitations
The study had some limitations as we faced some complications during the survey. First, we covered only five universities due to shortage of time for the research work. If we had conducted the study in more universities we would have got a more extensive scenario on the self-medication practice among the university students of Bangladesh. Second, many students were busy with their examinations, and lab work for training purposes; so collecting data from them was slightly difficult. Third, students of 1st year and 2nd year were less familiar with some terminologies and complication were created during the understanding of the questionnaire. They had to be given extra explanation. Finally, social desirability bias may have impacted the responses since the interviews were done in person Also the survey did not distinguish between the uses of OTC drugs in self-medication vs. prescription drugs such as antibiotics and may have resulted in confusion among respondents. The survey was not revalidated after translation and may have resulted in some changes in the survey items.

Conclusions
This descriptive study has demonstrated that self-practice of medication is very common among undergraduate pharmacy students of five renowned universities which was facilitated by the easy availability of drugs and information from previous prescriptions. The use of antibiotics, antidepressants, and sedative among a small segment of students without proper follow up or lab tests by healthcare providers may lead to serious health hazards, not only to the students themselves but also to those to whom they suggest the medication. Therefore, it is the sole responsibility of the health care professionals and drug regulatory authorities to ensure the safe use of drugs and control the exercise of self-administration of medications by describing the total impact of the drugs on the body to the students. As the study was confined to the pharmacy student population, further research is needed to test the prevalence of self-medication practices among the general population and how these differ by type of medication. Furthermore steps should be taken to monitor the drug selling system by stake holders especially of those drugs with potentially harmful effects.