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103
Journal of Pharmaceutical Technology, Research and
Management Vol 4, No. 2,
November 2016 pp. 103–127
DOI: 10.15415/jptrm.2016.42007
Self-medication in Developing Countries a Systematic Review
MEENA PARULEKAR, NANDAKUMAR MEKOTH, C.M. RAMESH, AJIT PARULEKAR
Goa Institute of Management Sanquelim, Poriem –Sattari, Goa
Email: mail:[email protected]
Received: June 7, 2016 | Revised: July 11, 2016 | Accepted: Sept. 5, 2016
Published online: November 02, 2016 The Author(s) 2016. This article is published with open access at www.chitkara.edu.in/publications
Abstract: Self-medication is common in developing countries where it has both economic and social implications. On the one hand, it is viewed as a large component of self-care, which relies heavily on the consumer’s expertise in terms of experience of the consumer, when it comes to medication use. On the other hand, if not practiced correctly it can lead to multiple issues including abuse and drug resistance. Across surveys conducted in developing countries the reasons why people self-medicate has been studied, to understand the determinants of self-medication and to explain the influence of knowledge and information on self-medication practices. To understand the same a detailed systematic literature review based on survey findings on self-medication in developing countries was carried out. From a total of 52 survey articles, 25 surveys were selected for the present review. From the survey outcomes it was found that the cost, time and past experience with the medicine and symptom were key determinants while healthcare professionals emerged to be the primary sources of information and knowledge for self-medication practices. The prevalence of self-medication as a phenomenon is high and it has both potential benefits and associated risks with it. To ensure that the risks and benefits of medicine usage are known by consumers, we really need to look at and design suitable interventions to promote responsible self-medication and in turn, rational drug use in the developing world.
Keywords: Self-medication, determinants, phenomenon, review, medicine
Parulekar, M Mekoth, NK Ramesh, CM Parulekar, A
104
1. INTRODUCTION
‘Self-medication’ is a global phenomenon. On the one hand, it is viewed as a large component of self-care, which relies heavily on the consumer’s expertise in terms of experience of the consumer, when it comes to medication use. On the other hand, if not practiced correctly it can lead to multiple issues including abuse and drug resistance.
Across the world, a consumer on an average suffers from at least one aspect of un-wellness in a 4-week period. Accordingly, 50% of people wait for the symptoms to subside, 25% take resort of prescription medicines while the remaining 25% turn to OTC (over-the-counter) medicines for relief. The graph below shows percentage of conditions treated with OTC’s by consumers in 10 nations. US and South Africa has the highest percentages of self-medication, only the reasons differ. While in the US it is more of a cost and time saving alternative, in South Africa it is high due to lower levels of infrastructure and professional staff. (wsmibro.pdf, 2005)
The WHO guidelines 2000 define self- medication as the use of medication by a patient on his own initiative or on the advice of a pharmacist or a lay person instead of consulting a medical practitioner. While in most of the developed world, it is synonymous with use of over-the-counter medications (responsible self-medication); the developing world faces a vast plethora of issues around
Graph1: Percentage of common conditions treated with OTC’s.
Self- medication in Developing
Countries a Systematic Review
105
the phenomenon. Some of these issues could be highlighted as self-medication with prescription drugs, misuse of antibiotics, overuse of injections, overuse of relatively safe medicines and unsafe use of herbal medicines (Hardon Anita et al, 2001).
Accordingly, the following two types of self-medication are commonly practiced worldwide and can be represented thus:
Self –medication in developing countries can be better understood as a phenomenon within the following two contexts (Geest Van Der Sjaak et al, 1990):
1. Economic-Infrastructural context: Accessibility to primary healthcare, Cost of medicines and development of alternative system of treatment are major concerns. For example: In rural areas in many developing countries like Cameroon for example, the public health system does not function properly, hence an alternative system develops.
2. Cultural-Cognitive beliefs: There are underlying beliefs that individuals hold when it comes to medicine use and are specific to communities and regions around the world. For example, Guatemalan villager’s categorized medicines as hot or cold based on their own classification system.
According to a survey conducted on 20, 000 consumers in 10 cities in India by Lybrate (doctor- patient –end-to-end communication platform)), it was found that over 52 % Indians indulge in self-medication practices (The Hindu, New Delhi, April 2015). Most studies reporting prevalence of self-medication are very specific (with respect to regional and cultural contexts). As reported (Sandeep A et al, 2013) prevalence rates are high, 68% in European countries and as high as 92% for adolescents in India. Such high prevalence rates are a
Table 1: Self-medication (worldwide)*.
Responsible Self-medication Irresponsible self-medicationWide acceptance and availability of OTC products
Wide acceptance and availability of both OTC and prescription products
Careful use of OTC products, reading the label
Irrational use of OTC and prescription products (for example, self-prescription, use of prescription products on recommendation, non-medical use of a prescription drug
OTC products usage as safe and effective when compared to prescription products
Probability of Drug-Drug interactions higher due to improper use of different systems of medicine, combined use of OTC and prescription drugs.
*compiled by the author
Parulekar, M Mekoth, NK Ramesh, CM Parulekar, A
106
cause of concern in a developing country especially when responsible self-medication is already a huge challenge. As reported in the book, Advances in Drug research and application, though there is a vast amount of research being done to measure self-medication practices including in children, there is sparse epidemiological data available worldwide (Ashton Acton, 2011).
According to World Drug Report 2010, the misuse of prescription drugs including opioids, benzodiazepines and synthetic prescription stimulants is a growing health problem in both developing and developed countries. In their study (Ruiz et al, 2010) the authors have highlighted the dangers of self-medication including polypharmacy, dependence and drug interactions. Thus, it becomes important to understand the various dimensions of this phenomenon including risks and benefits so that appropriate health interventions can be designed to promote rational drug use in the country.
2. OBJECTIVE
The main objective of this systematic review on self-medication is:1. To identify the determinants of self-medication practices in developing
countries.2. To study the influence of knowledge and information on self-medication in
developing countries.
3. METHODOLOGY
A manual search strategy was adopted to obtain research papers on Self-medication in developing countries. The search was primarily carried out using PUBMED, Ebsco, Proquest and Google scholar search engines and the key words used for the search were self-medication, reasons and determinants. A total of 52 survey articles were thus obtained.
See Figure 1 for flowchart of the articles selected for this review:
3.1 Inclusion and exclusion criteria
Articles are included based on types of surveys conducted, sample size, research methodology adopted and findings. Surveys conducted in the developed countries in the west were deliberately not included to take into account the economic and infra structural contexts unique to developing countries.
Studies selected for the review were surveys on self-medication in developing countries in the time period year 2000 to 2016. From a total of 52 different surveys conducted in developing countries, 25 were selected for this review. They were accordingly numbered as S1 to S25. These surveys were included based on the following criteria:
Self- medication in Developing
Countries a Systematic Review
107
1. Studies included a population of both young and elderly. Because self –medication is being increasingly practiced by the young, which has its own, associated risks, it is necessary to understand the determinants and influence of information across these varying segments of the population.
2. Studies necessarily had information about the reasons or factors that promote or lead to an increase in the self-medication habits in consumers.
3. Surveys had a sample size of over 100 respondents 4. Surveys on children, pregnant women were excluded from the review.
The 25 survey articles selected for the review were then read and information obtained from them was used for analysis. Table II lists the summary of these selected studies.
Figure 1: Flow chart showing the selection of articles for review.
52 survey articles from Google scholar, ProQuest and Ebsco
Titles shortlisted after OTC removal, (n=44)
Total articles after removal of OTC and Antibiotic SM (n=36)
Articles excluded (n=8) Antibiotic self-medication(SM)
Articles excluded (n=8) OTC research
Articles excluded (n=8) general
Total articles after removal of general (n=28)
Articles excluded (n=3) thesis
Total Articles final (n=25)
Parulekar, M Mekoth, NK Ramesh, CM Parulekar, A
108
Tabl
e 2:
Sum
mar
y of
incl
uded
stud
ies.
Stud
yC
ount
ryP
reva
lenc
e of
Sel
f-m
edic
atio
n
Stud
y M
etho
dolo
gy
Pro
port
ion
of s
ampl
e pa
rtic
ipan
ts
Len
gth
of
stud
yT
ypes
of
re
ques
ts fo
r
Self
-med
icat
ion
S1 P
anka
j Jai
n, In
do-g
loba
l jo
urna
l of P
harm
aceu
tical
Sc
ienc
es, 2
012
Har
yana
, In
dia
37.4
% o
f w
hich
28.
2%
was
by
Self-
med
icat
ion
befo
re th
ey
cam
e fo
r cu
rren
t sel
f-m
edic
atio
n
Surv
ey m
etho
d in
com
mun
ity
phar
mac
ies-
st
ruct
ured
in
terv
iew
qu
estio
nnai
re
680
fem
ales
(a
ctua
l dru
g us
ers
and
mes
seng
ers)
1225
mal
es
(act
ual d
rug
user
s an
d m
esse
nger
s)
One
yea
r40
.1%
wer
e fo
rA
nti-m
icro
bial
S2 P
ahuj
a R
itu, I
JDD
R, 2
011
Del
hi, I
ndia
61%
(a
nalg
esic
s an
d an
tipyr
etic
s)
Des
crip
tive
surv
ey- o
nlin
e ex
plor
ator
y.
Judg
men
tal
sam
plin
g te
chni
que
103
(out
of 3
42
resp
onde
nts)
Res
pons
e ra
te:3
0%
Five
m
onth
s67
%-
Croc
in-fe
ver
Azi
thro
myc
in an
d D
-col
d- 2
9.8%
an
d V
icks
Act
ion
500
–col
d 25
.5%
S3 R
ohit
Ver
ma,
Asi
an
jour
nal o
f pha
rmac
eutic
al
and
clin
ical
rese
arch
, 201
0
Nor
th In
dia
87.0
%
(pro
fess
iona
l st
uden
ts)
Que
stio
nnai
re
base
d de
scrip
tive
surv
ey
1022
stud
ents
(1
075
tota
l pa
rtici
pant
s)
Not
sp
ecifi
ed61
.27%
- Cro
cin
follo
wed
by
Dis
prin
and
C
ombi
flam
S4 P
anka
j Gup
ta, A
sian
jo
urna
l of P
harm
aceu
tical
an
d cl
inic
al re
sear
ch, 2
011
Indi
a(u
rban
slum
co
mm
unity
)
55.9
%C
ross
sect
iona
l st
udy
760
hous
ehol
ds(2
68 m
ales
, 492
fe
mal
es)
Not
sp
ecifi
edM
eds f
or
head
ache
, fev
er,
ache
s, al
lerg
ies
and
diar
rhoe
a.
old
drug
pac
ks,
old
pres
crip
tions
sh
own
or
sym
ptom
s ex
plai
ned
Self- medication in Developing
Countries a Systematic Review
109
S5 M
alvi
Rite
sh, I
RJP
201
1B
hopa
l, In
dia
77.3
%Q
uest
ionn
aire
ba
sed
surv
ey11
6 pe
ople
(5
8.6%
- mal
e,
41.3
%- f
emal
e)
Not
sp
ecifi
edFe
ver a
nd p
ain
cate
gorie
s. Pa
race
tam
ol,
Dis
prin
, C
ombi
flam
and
C
ipro
floxa
cin.
O
TC w
ere
used
fo
r SM
S6 Z
afar
Sye
d, Jo
urna
l of
Pak
Med
Ass
oc.,
2008
Kar
achi
, Pa
kist
an76
%C
ross
sect
iona
l su
rvey
572
parti
cipa
nts
(Mal
e: fe
mal
e rat
io
1:1.
5) 2
95 m
edic
al
stude
nts a
nd 2
77
wer
e non
-med
ical
stu
dent
s. Re
spon
se
rate
95.
3%
Jan-
Feb
2007
Hea
dach
es,
feve
r and
flu
like
sym
ptom
s
S7 S
onta
kke
SD, I
nt. j
ourn
al
of B
iolo
gica
l and
Med
ical
R
esea
rch,
201
1
Nag
pur,
Indi
a77
.98%
- 1st
year
, 74.
71%
- 3rd
yea
r
Com
para
tive
stud
y be
twee
n fir
st y
ear
and
third
ye
ar m
edic
al
stud
ents
. Cro
ss-
sect
iona
l stu
dy,
pre-
valid
ated
qu
estio
nnai
re.
159
– 1st
yea
r (89
m
en, 7
0 w
omen
)17
8- 3
rd y
ear (
106
men
, 72
wom
en)
Not
sp
ecifi
edA
nalg
esic
s and
an
tipyr
etic
s fo
llow
ed b
y an
ti-
hist
amin
ics a
nd
antim
icro
bial
s
S8 H
usai
n et
al,
Afr
ican
jo
urna
l of P
harm
acy
and
Phar
mac
olog
y, 2
011
Paki
stan
15.7
% in
ur
ban
area
s
To 8
.3%
in
rura
l are
as.
Ran
dom
ized
cr
oss s
ectio
nal
mul
ti-ce
nter
st
udy
1850
hou
ses,
550
rura
l and
130
0 ur
ban.
Res
pons
e ra
te 1
850/
2100
- 88
.10%
June
20
09-
May
201
0
Mod
ern
drug
s av
aila
ble
in
64.2
% o
f ho
useh
olds
. 63%
- m
edic
ines
from
lo
cal p
harm
acie
s in
urb
an a
reas
Parulekar, M Mekoth, NK Ramesh, CM Parulekar, A
110
S9 S
. Kay
alvi
zhi,
IJEI
MS
Sout
h In
dia
80.1
3%Q
uest
ionn
aire
ba
sed
desc
riptiv
e st
udy
1017
resp
onde
nts,
605
–mal
e,
412-
fem
ale
Sept
embe
r – N
ovem
ber
2010
Hea
dach
e, fe
ver
and
coug
h, c
old
and
sore
thro
at.
S10
Girm
a B
elec
ha G
utem
a,
J of A
pplie
d Ph
arm
aceu
tical
Sc
ienc
es, 2
011
Ethi
opia
43.2
4%D
escr
iptiv
e cr
oss s
ectio
nal
stud
y
307
heal
th
scie
nces
stud
ents
.28
3 re
spon
dent
s, re
spon
se ra
te –
92
.2%
Apr
il-
June
201
1Pa
race
tam
ol,
NSA
IDS
follo
wed
by
antib
iotic
s
S11
P.R
.Sha
nkar
, Par
tha
Shen
oy, B
MC
Fam
ily
Prac
tice
2002
Nep
al59
%of
re
spon
dent
s ha
d se
lf-m
edic
ated
in
the
6 m
onth
s pr
eced
ing
the
stud
y
Sem
i- st
ruct
ured
qu
estio
nnai
re
base
d st
udy
142
resp
onde
nts,
117
–mal
es,
25- f
emal
es
Aug
ust
2001
Para
ceta
mol
fo
llow
ed b
y an
alge
sics
S12
A.O
.Afo
labi
, Ann
als o
f A
fric
an M
edic
ine,
200
8N
iger
ia59
.5- 7
2.1%
Pret
este
d se
mi
stru
ctur
ed
ques
tionn
aire
205
mar
ket
wom
enN
ot
spec
ified
Med
s rec
ogni
zed
by tr
ade
or
gene
ric n
ames
S13
Al M
otas
sem
M.Y
ouss
ef,
Phar
m W
orld
Sci
.200
8Jo
rdan
42.5
%C
ross
sect
iona
l ob
serv
atio
nal
stud
y
819
out o
f 132
6 pa
tient
s (61
.2%
)D
ecem
ber
2003
and
A
pril
2004
No
spec
ific
cate
gory
m
entio
ned,
med
s as
ked
for b
y br
and
nam
es
Tabl
e 2:
Con
tinue
d
Stud
yC
ount
ryP
reva
lenc
e of
Sel
f-m
edic
atio
n
Stud
y M
etho
dolo
gy
Pro
port
ion
of s
ampl
e pa
rtic
ipan
ts
Len
gth
of
stud
yT
ypes
of
re
ques
ts fo
r
Self
-med
icat
ion
Self- medication in Developing
Countries a Systematic Review
111
S14
Hen
ry Ja
mes
, Med
Pr
inc.
Pra
ct, 2
006
Bah
rain
44.8
%Q
uest
ionn
aire
ba
sed
desc
riptiv
e st
udy
153
stud
ents
, 43
mal
es a
nd
91 fe
mal
es
Nov
embe
r 20
04H
eada
che,
cou
gh
and
cold
, sor
e th
roat
S15
Push
pa R
Wije
sing
he,
WH
O S
outh
-Eas
t Asi
a Jo
urna
l of P
ublic
Hea
lth,
2012
Sri L
anka
33.9
%- u
rban
, 35
.3%
- rur
alC
omm
unity
ba
sed
cros
s-
sect
iona
l stu
dy
1800
resp
onde
nts,
94.9
% re
spon
se
rate
2010
No
spec
ific
cate
gory
m
entio
ned
S16
Hus
ain
S.M
allik
, Sel
f-m
ed b
ehav
ior i
n Pa
kist
an,
Sout
hern
Med
Rev
iew
201
0
Paki
stan
7.1%
- rur
al,
2.6%
- urb
anR
ando
miz
ed
cros
s sec
tiona
l qu
estio
nnai
re
base
d st
udy
1346
hou
seho
lds
Janu
ary
2007
- Jul
y 20
08
Ant
ibio
tics,
anal
gesi
cs,
vita
min
s and
m
iner
als
S17
Bal
amur
ugan
E, B
JMP,
20
11So
uth
Indi
a71
%C
ross
sect
iona
l su
rvey
200
parti
cipa
nts
6 m
onth
s in
200
9H
eada
che,
st
omac
h ac
he,
coug
h an
d
feve
rS1
8 Fe
rnan
do R
uiz,
” SM
in
olde
r peo
ple”
, Dru
gs A
ging
20
09
Mex
ico
50%
and
m
ore
Obs
erva
tiona
l, de
scrip
tive,
cr
oss s
ectio
nal
stud
y
245
olde
r adu
lts
(152
wom
en a
nd
93 m
en )
Sept
embe
r an
d O
ctob
er
2006
Mus
cle
and
jo
int p
ain,
up
per r
espi
rato
ry
tract
and
cou
ghS1
9 So
nia
et a
l,”C
ondi
tions
, fr
eque
ncie
s and
soci
o de
mog
raph
ic fa
ctor
s lea
ding
to
self-
med
icat
ion
in
Sarg
odha
, Pak
ista
n, 2
013
Paki
stan
83%
Des
crip
tive,
cr
oss-
sect
iona
l st
udy
300
univ
ersi
ty
stud
ents
Janu
ary
to A
pril
2013
Med
s for
he
adac
he,
com
mon
col
d,
coug
h, fe
ver,
cons
tipat
ion,
di
arrh
ea.
Parulekar, M Mekoth, NK Ramesh, CM Parulekar, A
112
S20S
ande
ep A
,”Se
lf-m
edic
atio
n: K
now
ledg
e an
d pr
actic
e am
ong
rura
l and
ur
ban
popu
latio
n”20
13
Man
dya,
M
adhy
a Pr
ades
h42
.5%
Que
stio
nnai
re
base
d su
rvey
120
resp
onde
nts
Mar
ch
and
Apr
il 20
13
Feve
r rel
ievi
ng
med
s, pa
in
kille
rs, c
ough
m
edic
ines
and
an
ti-al
lerg
ics
S21S
hyam
Sun
der K
esha
ri,
“Pre
vale
nce
and
patte
rn o
f se
lf-m
edic
atio
n pr
actic
es in
ru
ral B
arab
anki
”, 2
014
Bar
aban
ki, U
ttar
Prad
esh
69.6
%Cr
oss –
sect
iona
l H
ouse
-to-h
ouse
su
rvey
168
resp
onde
nts
Oct
ober
20
13 to
M
arch
20
14
Feve
r, pa
in,
resp
irato
ry
sym
ptom
s fo
llow
ed b
y in
fect
ions
, he
adac
he a
nd
diar
rhea
S 22
Akr
am A
hmad
, M
uham
mad
Um
air K
han
“Eva
luat
ion
of k
now
ledg
e,
attit
ude
and
prac
tice
abou
t se
lf-m
edic
atio
n am
ong
rura
l and
urb
an n
orth
Indi
an
popu
latio
n, ij
pcr 2
015
Mor
adab
ad,
Utta
r Pra
desh
100.
0%
(soc
io-
econ
omic
ba
ckgr
ound
)
Com
mun
ity
base
d cr
oss-
sect
iona
l stu
dy
380
resp
onde
nts
Mar
ch to
M
ay 2
014
Ana
lges
ics,
alar
min
g us
e in
chr
onic
co
nditi
ons i
n ru
ral a
reas
.
S23V
arun
Kum
ar, A
bha
Man
gal”
Prev
alen
ce a
nd
patte
rn o
f sel
f-m
edic
atio
n in
an
urb
an a
rea
of D
elhi
, Ind
ia
2015
Del
hi92
.8%
(urb
an
area
s)C
ross
-sec
tiona
l st
udy
236
resp
onde
nts
Mar
ch
and
Apr
il 20
13
Com
mon
col
d an
d fe
ver
Tabl
e 2:
Con
tinue
d
Stud
yC
ount
ryP
reva
lenc
e of
Sel
f-m
edic
atio
n
Stud
y M
etho
dolo
gy
Pro
port
ion
of s
ampl
e pa
rtic
ipan
ts
Len
gth
of
stud
yT
ypes
of
re
ques
ts fo
r
Self
-med
icat
ion
Self- medication in Developing
Countries a Systematic Review
113
S24N
agar
ajai
ah
BH
,”Pr
eval
ence
and
pat
tern
of
self-
med
icat
ion
prac
tices
am
ong
popu
latio
n of
thre
e di
stric
ts o
f Sou
th K
arna
taka
, 20
16
Kar
nata
ka78
.63%
Que
stio
nnai
re
base
d st
udy
5489
resp
onde
nts
2016
Join
t pai
ns,
gast
ric
sym
ptom
s, he
adac
he, f
ever
S25A
rava
mut
han
Ana
ndha
saya
nam
,”
Ass
essm
ent o
f sel
f-m
edic
atio
n pr
actic
es,
cons
umer
s dru
g kn
owle
dge
and
cons
umpt
ion
patte
rns a
t Ti
rur c
ity, K
eral
a, 2
016
Ker
ala,
Indi
a62
.2%
Que
stio
nnai
re
base
d su
rvey
500
resp
onde
nts
May
201
4 to
Feb
20
15
Res
pira
tory
tra
ct in
fect
ion,
G
I inf
ectio
n,
head
ache
and
fe
ver.
Parulekar, M Mekoth, NK Ramesh, CM Parulekar, A
114
4. RESULTS
The surveys selected were mainly of descriptive, cross –sectional, questionnaire type and the duration of the study ranged from two months to one year. Total number of respondents studied was 19, 973 across the 25 surveys. These surveys were carried out independently in the countries during the period 2000-2016. The respondents included young students in colleges with both a medical and non-medical background and adults among others. Many of the surveys were conducted in Asia of which fourteen were in India, three in Pakistan and one was conducted in Sri Lanka.
5. DISCUSSION
5.1 Self-medication prevalence
The overall prevalence of self-medication ranged from 8.3% (Husain et al, 2011) in the sample population studied to 87% (Husain S, 2010) across the 25 surveys selected for the review. S22 (socio-economic background of sample) and S23 (only urban areas) had higher prevalence rates but the data on prevalence was not considered due to limitations of the samples. In some studies, self-medication prevalence was higher in females, 59.8% vs 48.9%in males (Gupta Pankaj et al, 2011, Balamurugan E, 2011)
5.2 Determinants of self-medication practices
Across the surveys, lack of time, cost saving and mildness of disease/symptoms were cited as the major reasons for self-medication.(Verma Rohit, 2010, Sontakke SD, 2011, Balamurugan E, 2011, Malvi Reetesh, 2011) Socio-economic conditions, prior experience with the medicine and emergency use were the other key determinants.( Pahuja Ritu, 2011, Gupta Pankaj, 2011, S.Kayalvizhi, 2010, James Henry, 2006). Expected self-medication was higher in urban areas than in rural areas ( Wijesinghe Pushpa, 2012). No major differences were noticed in self-medication patterns in men and women. Categories of medicines that were utilized for self-medication range from analgesics, anti-microbials, anti- pyretics and antibiotics. Vitamins and minerals are also common categories used for self-medication by consumers. (Husain S, 2010). It was interesting to note that selection of products for self-medication was based on previous experience with the similar medicine or disease symptoms. (Al Motassem, 2008, Zafar Syed, 2008, Afolabi A.O., 2008).
There is an emerging trend of increasing self-medication in the past five years (2011-2016) and this can be attributed to factors like people showing
Self- medication in Developing
Countries a Systematic Review
115
sympathy for ill relatives and friends, unavailability of healthcare services in rural areas, unawareness, misbeliefs and advertisements by pharmaceutical companies( Akram Ahmad, 2015). It was interesting to note that though self-medication has increased among the common population, many of the people consuming drugs by self-medication do not follow instructions regarding dose, duration and instruction for use with many non-prescription drugs thus making them vulnerable to side effects.
The rural areas in India are fast catching up with self-medication practices with reportedly higher percentages of use for analgesics and antipyretics (Akram Ahmad, 2015). In addition, the usage of products by self-medication in chronic conditions is increasing among the rural population, which is an area of concern.
Many of the classes of drugs used by self-medication in developing countries consist of drugs under Schedule H (Drugs and Cosmetics Act, 1940). However; they inevitably are consumed by self-medication without the consumer many times being unaware of their side effects in the dosage consumed. For example in the survey (Malvi Reetesh, 2011) 16 participants (13.7%) used Diclofenac among the analgesics category and 10 participants, (8.6%) used Ciprofloxacin as an antibiotic for self-medication (Total Sample size: 116 participants). In a study (Akram Ahmad, 2015) on rural and urban self-medication pattern in North India, it was found that respondents (380) self-medicated across a wide range of therapeutic categories as shown below:
The above graph clearly indicates that there a lot of drug categories which are being misused by self-medication and the trend is increasing in the rural areas. Most of these drugs have harmful side effects and are known to cause drug-drug interactions when not used carefully with other drugs or drug combinations.
5.3 Influence of knowledge/ information on self-medication
These could be categorized depending on the sources of information and knowledge. Some of the common sources of information are listed below. The percentages listed are specific to particular studies but a pattern could be seen. The most preferred source of information was healthcare professionals followed by friends and family suggesting that medicine use in different cultures across countries may have a major role to play in self-medication habits (Verma Rohit, 2010, Malvi Reetesh, 2011, Pahuja Ritu, 2011, Gupta Pankaj, 2011, S. Kayalvizhi, 2010). It is interesting to note that in most studies, though the respondents were knowledgeable about the medicine used for self-medication, they were not adequately informed about the risks of self- medication, which is really a cause of concern (Zafar Syed,
Parulekar, M Mekoth, NK Ramesh, CM Parulekar, A
116
Table 3: Determinants of Self-Medication practices.
Study Reference Reasons for Self-Medication
S1 Jain Pankaj, 2012 Emergency use, disease not serious, prevention of diseases, prior experience about the drug, less expensive in terms of time and money.
S2 Pahuja Ritu, 2011 Did not feel the need to consult a doctor for minor illness, unavailability of medical practitioner in nearby community and economical.
S3 Verma Rohit, Asian journal of pharmaceutical and clinical research, 2010
Time saving, did not need advice for minor illness, economic, fear from crowd at clinic.
S4 Pankaj Gupta, Asian journal of Pharmaceutical and clinical research, 2011
No time /could not afford to miss work, mild illness, doctor’s clinic too far, monetary constraints, previous good experience with the drug, Not one student had knowledge about complete profile of the drug being consumed by self- medication.
S5 Malvi Ritesh, IRJP 2011 Time saving, did not need advice for minor illness, economic, fear from crowd at clinic.
S6 Zafar Syed, Journal of Pak Med Assoc., 2008
43% alter regimen of prescribed meds, 61.9% stop taking prescribed medicine without consulting a doctor 82.5% felt that it is necessary to consult a doctor before taking a new medicine. Previous experience, problem too trivial, urgency of problem, advice from friend was enough, convenience, lack of time, cost of consultation, availability of transport.
Graph 2: Consumption of different classes of drugs by participants (Akram Ahmad, 2015).
Self- medication in Developing
Countries a Systematic Review
117
S7 Sontakke SD, Int. Journal of Biological and Medical Research, 2011
Time saving, easy availability, convenient and economical.
S8 Husain et al, African Journal of Pharmacy and Pharmacology, 2011
Age, gender, education, family, society, law, availability of drugs, exposure to ads and nature of illness. Self-medication leads to inadequate drug utilization patterns.
S9 S. Kayalvizhi, IJEIMS Mild illness, previous experience of treating similar illness, economic considerations and a lack of availability of health personnel.
S10 Girma Belecha Gutema, J of Applied Pharmaceutical Sciences, 2011
Confidence in time in relation to self-treatment. People’s belief that only safe medicines are sold without prescription and that OTC medicines do not usually have side effects
S11 P.R.Shankar, Partha Shenoy, BMC Family Practice, 2002
Alternative medicine- Herbs and medicinal plants- Self-medication. Self-medication was started once fever, headache did not subside in 24 hours.Illness was mild, did not require services of the doctor. Previous experience of similar illness, even if they go they will be prescribed the same medicine.Patient’s satisfaction with healthcare provider, cost of drugs, educational level, socioeconomic factors, age, and gender.
S12 A.O.Afolabi, Annals of African Medicine, 2008
118 respondents felt it cured their ailment and saved their time and money. 15 felt they had the independence to take care of themselves. For all age groups, respondents used medicines in combination than single doses. Most of the respondents recognized medicines by their trade or generic names.
S13 Al Motassem M.Youssef, Pharm World Sci.2008
Patients select products based on previous experience with similar products or similar diseases.Non-prescription drug supply pattern is of three kinds-by prescription, by direct Self-medication (OTC’s) and indirect Self-medication –sought advice of pharmacy staff before buying the medicine.
S14 Henry James, Med Princ. Pract, 2006
Previous experience, mild illness and shortage of time.
Parulekar, M Mekoth, NK Ramesh, CM Parulekar, A
118
S15 Wijesinghe R Pushpa, WHO South-East Asia Journal of Public Health, 2012
Self-medication was higher in urban than rural areas of Sri Lanka. Usage of traditional medicines for Self-medication was higher in rural areas. Self-medication was higher in urban males than urban females. Lower number of symptom count as a proxy measure of lower severity of illness emerged as a strong predictor of Self-medication.
S16 Husain S. Mallik, Self-med behavior in Pakistan, Southern Med Review 2010
No differences in health seeking behavior with respect to private sector in rural and urban Pakistan.
S17 Balamurugan E, BJMP, 2011 Self- med in South India
Lack of time to visit a doctor (41.5%) followed by minor illness and quick relief. Females were more likely to use Self-medication than males.
S18 Fernando Ruiz,” Self-medication in older people”, Drugs Aging 2009
Self-medication was significantly higher in older people who stayed alone than in those who were married and among the illiterate and who belonged to low socio-economic groups. Muscle and joint pain most common reason for self-medication followed by hypertension. No differences between self-medication practices in men and women.
S19 Imtiaz Sonia et al, Conditions, frequencies and socio demographic factors leading to self-medication in Sargodha, Pakistan, 2013
High consultation cost, minor illness, friends’ advice and easy availability of all drugs from drug stores without prescription.
S24 Nagarajaiah BH, Preva-lence and pattern of self-medication practices among population of three districts of South Karnataka, 2016
The most important reason for increase in trend of self-medication is easy availability of all categories of medicines-OTC, prescription or Schedule X drugs without a prescription
TABLE III: Continued
Study Reasons for Self-Medication
2008). Some of the respondents also did not check the expiry date of the medicine before consuming it by self-medication (Gupta Pankaj, 2011).
For non-prescription medicines, the physician and pharmacist was the most important source of information for self-medication. Table IV lists this information accordingly.
Self- medication in Developing
Countries a Systematic Review
119
7. CONCLUSION
As per the guiding principles in self-medication (WSMI, 1998) “the first key to developing a drug policy which includes self-medication is to draw a distinction between those products which require more active involvement by a doctor or other qualified health professional for safe and effective use-prescription medicines, and those products which are safe and effective for use by consumers on the basis of their marketing authorization and labeling-nonprescription medicines”.
Accordingly, some of the major challenges that can be seen for a developing country with respect to self-medication could be literacy levels in the common population, Affordability of medicines and lack of accessibility to primary healthcare. Easy availability of medicines at pharmacies and convenience stores compounds the problem thus making the consumer vulnerable to risks of self-medication.
It is hence necessary to design interventions to tackle the growing problems associated with self-medication practices. The first step towards achieving this is through educating the masses about the dangers and side effects about the drugs used by self-medication. These programs have to be initiated at the grassroots level in rural areas where there are many consumers who do not hesitate to spend on healthcare and are not at all aware about risks and benefits of drugs being used by self-medication (Wijesinghe Pushpa, 2012, Gupta Pankaj, 2012). The second mechanism in a country like ours would be through active involvement of the pharmacist in patient interactions over-the-counter (Jain Pankaj et al, 2012, Malvi Reetesh, 2011). This is probably the best interface where a healthcare professional can consult the consumer
Table 4: Influence of Knowledge/ Information on self-medication.
Sources of Information/Knowledge Percentage
Doctors 39%Chemists/Pharmacists 40% and aboveFriends 18.9%Advertisements 25.2%Family 18.9%Internet 6.8%Books 7%Television 7.1%Previous prescription 21.5%
Parulekar, M Mekoth, NK Ramesh, CM Parulekar, A
120
TA
BL
E V
: Kno
wle
dge/
Info
rmat
ion
and
self-
med
icat
ion.
Art
icle
/Sur
vey
Stud
y D
esig
nY
ear
Sam
ple
char
acte
rist
ics
Kno
wle
dge/
info
rmat
ion
S1 Ja
in P
anka
j, 20
12Su
rvey
met
hod,
st
ruct
ured
in
terv
iew
sche
dule
Soci
o de
mog
raph
ic
char
acte
ristic
s and
pr
ospe
ctiv
e SM
May
200
9 –
June
201
0H
arya
na –
com
mun
ity
phar
mac
ies
Con
sum
ers p
urch
asin
g dr
ugs
with
out p
resc
riptio
n.19
05 re
spon
ses f
rom
200
0 Q
in
60
com
mun
ity p
harm
acie
s
39%
- hea
lth p
rofe
ssio
nals
, 24
%- a
dvic
e fr
om fr
iend
s and
fam
ily15
%- p
harm
acis
t14
%-r
ead
prod
uct i
nfor
mat
ion
on
pack
/labe
l
S2 P
ahuj
a R
itu,
IJD
DR
, 201
1Ex
plor
ator
y si
mpl
e Q
uest
ionn
aire
su
rvey
.
Feb-
June
20
1110
3 ph
arm
acy
stud
ents
, Ju
dgm
enta
l sam
plin
g m
etho
d. O
nlin
e su
rvey
Info
rmat
ion
abou
t med
s fro
m
phar
mac
ies (
39.2
%).
24.7
%- l
earn
ed
SM fr
om p
ast p
resc
riptio
ns o
f doc
tors
. Fr
iend
s, ad
verti
sem
ents
and
boo
ks
wer
e ot
her s
ourc
esS3
Ver
ma
Roh
it,
Asi
an jo
urna
l of
phar
mac
eutic
al a
nd
clin
ical
rese
arch
, 20
10
Des
crip
tive
surv
eyJa
n- m
arch
20
10A
dole
scen
t beh
avio
r10
22 st
uden
ts, 2
inst
itutio
ns
UP
tech
nica
l Uni
vers
ity
Doc
tors
– 8
0.82
% (p
rior i
llnes
s)Fr
iend
s-36
.98%
Phar
mac
ists
-31.
2%A
dver
tisem
ents
-13.
2%B
ooks
-7%
S4 G
upta
Pan
kaj,
Asi
an jo
urna
l of
Phar
mac
eutic
al
and
clin
ical
re
sear
ch, 2
011
Cro
ss se
ctio
nal
base
d st
udy
2011
Urb
an sl
um c
omm
unity
- M
alaw
i in
Mum
bai.
Sem
i st
ruct
ured
Q 7
60 fa
mili
es
Loca
l pha
rmac
ists
-42.
1%Pr
evio
us c
onsu
ltatio
n-25
.4%
Fr
iend
s – 1
3.2%
Tele
visi
on-7
.1%
Inte
rnet
-3.5
%O
nly
21.4
% c
heck
ed e
xpiry
dat
e be
fore
usi
ng th
e m
edic
ine.
Self- medication in Developing
Countries a Systematic Review
121
S5 M
alvi
Rite
sh,
IRJP
201
1Q
uest
ionn
aire
ba
sed
surv
ey20
11D
escr
iptiv
e su
rvey
, 116
re
spon
dent
s in
Bho
pal
Che
mis
t- 56
.8%
Adv
ertis
emen
ts-2
5.2%
Frie
nds –
18.9
%Fa
mily
–18
.9%
Inte
rnet
-6.8
%
SM(s
elf-
med
icat
ion)
- mos
t pre
vale
nt
in y
oung
mal
es, p
refe
renc
e fo
r al
lopa
thic
dru
gsS6
Zaf
ar S
yed,
Jo
urna
l of P
ak
Med
Ass
oc.,
2008
Cro
ss se
ctio
nal
surv
ey
Jan-
Feb
2007
Con
veni
ence
sam
ple,
st
uden
ts in
Kar
achi
572
stud
ents
Stud
ents
stat
ed th
at th
ey k
new
it is
ha
rmfu
l to
self-
med
icat
e bu
t the
y la
cked
com
plet
e kn
owle
dge.
No
sign
ifica
nt d
iffer
ence
s bet
wee
n SM
pr
actic
es o
f med
ical
and
non
-med
ical
st
uden
tsS7
Son
takk
e,
Com
para
tive
stud
y C
ross
sect
iona
l su
rvey
2011
339
stud
ents
Aw
aren
ess o
f OTC
and
adv
ts.d
isad
vts.
stud
ied
SM –
no
advt
s.ana
lges
ics a
nd
antip
yret
ics c
omm
on c
ateg
orie
s.H
ighe
r use
am
ong
seni
ors b
ecau
se
they
are
mor
e aw
are
of si
de e
ffec
tsS
8 H
usai
n et
al,
Afr
ican
jour
nal
of P
harm
acy
and
Phar
mac
olog
y,
2011
Cro
ss se
ctio
nal
stud
y m
ulti
cent
re
in fi
ve c
ities
of
Paki
stan
2011
Stra
tified
sam
ple
of 2
100
hous
ehol
dsC
omm
on a
mon
g pe
ople
rela
ted
to
heal
thca
re. A
vaila
bilit
y of
mod
ern
drug
s in
both
urb
an a
nd ru
ral a
reas
an
alge
sics
wer
e fir
st fo
llow
ed b
y an
timic
robi
als.
Parulekar, M Mekoth, NK Ramesh, CM Parulekar, A
122
S 9
S. K
ayal
vizh
i, IJ
EIM
SD
escr
iptiv
e st
udy
Que
stio
nnai
re
base
d
Sept
-Nov
20
10Th
ree
inst
itutio
ns in
Sou
th
Indi
a-11
89 st
uden
ts64
.2 %
felt
that
the
phar
mac
ist p
laye
d a
maj
or ro
le in
SM
of n
on-p
resc
ribed
m
eds o
ver t
he c
ount
er.
80.8
2% le
arnt
abo
ut m
edic
ines
from
pr
evio
us p
resc
riptio
n pr
ovid
ed d
urin
g pr
ior i
llnes
s. Fr
iend
s, ph
arm
acis
t, ad
verti
sem
ents
and
boo
ks c
ompr
ised
th
e ot
her s
ourc
es.
S10
Girm
a B
elec
ha G
utem
a,
J of A
pplie
d Ph
arm
aceu
tical
Sc
ienc
es,
2011
Des
crip
tive
cros
s se
ctio
nal s
tudy
Ju
ne 2
011
307
stud
ents
in M
ekel
le
Uni
vers
itySe
lf-de
cisi
ons (
64%
) fol
low
ed b
y fa
mily
and
frie
nds (
20%
). R
eadi
ng
mat
eria
l (30
.5%
). Ph
ysic
ians
an
d Ph
arm
acis
ts a
re m
ost w
idel
y pr
efer
red
sour
ces o
f inf
orm
atio
n fo
r no
npre
scrip
tion
med
icin
es in
form
atio
n
S 11
P.R
.Sha
nkar
, Pa
rtha
Shen
oy,
BM
C F
amily
Pr
actic
e 20
02
Sem
i stru
ctur
ed
Que
stio
nnai
re in
N
epal
Rur
al a
nd u
rban
po
pula
tion
Aug
ust
2001
142
resp
onde
nts i
n N
epal
.U
nava
ilabi
lity
of p
reci
se in
form
atio
n du
ring
the
surv
ey
Com
poun
ders
, tra
ditio
nal m
edic
ine
prac
titio
ners
and
hea
lth a
ssis
tant
s –
sour
ces o
f inf
orm
atio
n re
gard
ing
med
s an
d ot
her h
ealth
pro
tect
ion
mea
sure
s.S1
2 A
.O.A
fola
bi,
Ann
als o
f Afr
ican
M
edic
ine,
200
8
Cro
ss se
ctio
nal
surv
ey o
f wom
en
in N
iger
ia
2008
205
wom
en, m
ultis
tage
sa
mpl
ing
tech
niqu
ePa
tent
med
icin
e de
aler
s, (3
1.4%
), m
edic
al p
ract
ition
ers a
nd st
aff
(20.
6%) h
ospi
tals
and
pha
rmac
ies.
Adv
ertis
emen
t, fa
mily
mem
bers
and
pr
evio
us e
xper
ienc
e w
ith th
e ill
ness
TA
BL
E V
: Con
tinu
ed
Art
icle
/Sur
vey
Stud
y D
esig
nY
ear
Sam
ple
char
acte
rist
ics
Kno
wle
dge/
info
rmat
ion
Self- medication in Developing
Countries a Systematic Review
123
S13
Al M
otas
sem
M
.You
ssef
, Pha
rm
Wor
ld S
ci.2
008
Cro
ss se
ctio
nal
obse
rvat
iona
l st
udy
Dec
embe
r 20
03- A
pril
2004
800
cust
omer
sPe
ople
tend
to se
lect
med
icin
es b
ased
on
adv
ice
rece
ived
from
pha
rmac
y st
aff,
frie
nds /
neig
hbor
s, in
form
al
advi
ce fr
om d
octo
rs, n
urse
sS1
4 H
enry
Jam
es,
Med
Prin
c .P
ract
, 20
06
Que
stio
nnai
re
base
d de
scrip
tive
stud
y
Nov
embe
r 20
0413
4 st
uden
ts, s
elf-
deve
lope
d pr
e va
lidat
ed Q
Influ
ence
of k
now
ledg
e on
atti
tude
to
war
ds se
lf-m
edic
atio
n- it
mak
es
them
mor
e ca
refu
l. K
now
ledg
e ab
out b
enefi
ts a
nd ri
sks o
f SM
was
ad
equa
te.
S15
Wije
sing
he
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S 16
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Parulekar, M Mekoth, NK Ramesh, CM Parulekar, A
124
S18
Self-
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Self- medication in Developing
Countries a Systematic Review
125
on various aspects of drug safety and efficacy. There are already a number of positive changes initiated in this direction, for example GPP (Good Pharmacy Practices, FIP/WHO guidelines, 2011).
From the provider perspective, especially in a country like India, there are two major issues or challenges one can observe with respect to self-medication practices in the society. One is we do not have a specific OTC listing of drugs (Jain Pankaj, 2012) so in practice a lot of prescription drugs get used over-the-counter. In addition, there are diverse medicine systems in practice (Malvi Reetesh, 2011) and there is no mechanism to gather discrete information on self-medication across various medicine categories (freely available) being used by consumers. These are a larger set of issues and will need policy interventions from the government in the future.
Amidst this, self-medication practices can pose serious challenges if medicines either prescription or over-the –counter get misused, over used or underutilized. To ensure that the risks and benefits of medicine usage are known by consumers, we really need to look at and design interventions to promote healthy self-medication and in turn, rational drug use in the developing world.
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