Association between Knowledge of Self Medication and Adherence among Medical Students in Dhaka, Bangladesh

 

Shammin Haque¹*, Nazmun N. Alam¹, Sumaiya Mushroor², Nusrat Sultana³

¹Assistant Professor, Department of Pharmacology, Dr. Sirajul Islam Medical College and Hospital, Dhaka, Bangladesh

²Assistant Professor, Department of Community Medicine, Dr. Sirajul Islam Medical College and Hospital, Dhaka, Bangladesh

³Assistant Professor, Department of Pharmacology, Medical College for Women and Hospital, Dhaka, Bangladesh

 

ABSTRACT:

Objective: To find the association between knowledge of self medication and adherence among the medical students in a private medical college in Dhaka, Bangladesh. Material and methods: This descriptive cross-sectional study was carried out among 204 medical students of Dr. Sirajul Islam Medical College, Dhaka from October to December 2016. A pre-designed and pre-tested questionnaire was used for data collection. Data was analyzed for counts and percentages. Association between knowledge of self medication and adherence was assessed by using Chi square test. Results: Majority of the students (70%) disagree with practice of self medication. Eighty percent of them find medical knowledge necessary for self medication. Most of the students have knowledge about importance of completing the treatment schedule. There is a rising trend of knowledge level about the hazards of treatment discontinuation without doctor’s advice, with final year students possessing maximum information. Adherence among 204 students are observed as, only 5.4% students never forget to take medicines, 18.6% do not change dose, frequency or course duration and 2.9% do not discontinue treatment without doctor’s advice. 28.4% take doctor’s advice when symptoms persist and 20.6% take when adverse effects occur. There was significant association between knowledge of self medication with adherence among the students (p<0.05). Conclusion: High level of knowledge of self medication is present among medical students associated with low level of adherence. Students must be motivated about the improvement of adherence to prove a positive influence of knowledge about self medication.

 

 

INTRODUCTION:

Self-medication is defined as obtaining and consuming drugs without the advice of a physician either for diagnosis, prescription or surveillance of treatment¹. Self- medication involves the use of medicine by the people who want to treat self-recognized symptoms by themselves. Self-medication thus forms an essential part of self-care, which also includes non-drug self-treatment, social support in illness, and first aid in everyday life².  It is now becoming a common practice in many countries mainly due to lack of access to health care, easy availability of OTC drugs in market and poor drug regulatory practices³. Self medication is currently a globally rising trend. It is also prevalent among the practicing physicians^4,5. Self-medications in a country with low literacy level like Bangladesh is very important where prescription medicines are freely available. This may pose serious risks related to inappropriate and irrational personal use of medicines⁶.

 

Infact, even medical students are prone to self medication due to more exposure to medical knowledge. The prevalence rates of self medication are high amongst this population as evident from previous studies, 92.7% in India⁷, 55% in Egypt⁸ and 88% in Pakistan⁹. Similar studies have been carried out in Bangladesh among various target populations. A high prevalence of use of antibiotics and other self medicated drugs among common people were 26.69% and 73.31%, respectively¹⁰. Another study among medical and pharmacy students found 87% of them self medicated¹¹. Safe self medication practice can provide a cheap alternative mode of treatment in developing nations, where people face hazards affording the clinical services.  It is also time saving, regarding travelling to health centres and visiting a physician. WHO guidelines (2000) stated that improvements in people’s general knowledge, level of education and socioeconomic status in many countries form a reasonable basis for successful self medication. Medical conditions are effectively treated, only if patients adhere to their therapeutic regimen, including those who self medicate. Positive outcomes from self medication can be predicted provided that adherence is optimum. Behavioral interventions focus on helping patients build the skills necessary to adhere to a treatment regimen or perform self-care¹².

 

Thus the primary goal of behavioral interventions is to improve knowledge, promote self-efficacy, and self care skills¹³. Some common reasons played vital role in the occurrence of non-adherence to medications in all populations such as, patients forget to take their medicines, active rejection of therapy, expensive medication, large number of medicines to be taken simultaneously, lack of health improvement, side-effects and absence of signs of illness¹⁴. British studies found that medication is not continued as prescribed in 50% of cases¹⁵, while non-adherence causes ~30%-50% of treatment failures and 125,000 deaths annually¹⁶. Monitoring systems, a partnership between patients, physicians and pharmacists and the provision of education and information to all concerned on safe self medication, are proposed strategies for maximizing benefit and minimizing risk¹⁷. Medical students represent a learned proportion of a nation’s population. They will become physicians and healthcare educators in future. It is vital to assess their knowledge of rationalism regarding utilization and prescription of medicines. Priority of patients should be the sole concern among medical students, to avoid non adherence to treatment when dealing with them. Hence, they should build up a positive attitude towards adherence when they self medicate. Studies on relation between knowledge of self medication with adherence are rare in developing countries like Bangladesh. The objective of the present study is to determine the association between knowledge of self medication and adherence among the medical students in a private medical college in Bangladesh.

 

MATERIAL AND METHODS:

This descriptive cross-sectional study was carried out among the undergraduate medical students of Dr. Sirajul Islam Medical College, Dhaka, from October to December 2016. A pre-designed and pre-tested questionnaire comprising of closed ended questions was used. Students were informed briefly about the procedure of completing the questionnaire and were assured about the confidentiality of all information. After taking informed consent, the students voluntarily participated in the study.

 

The questionnaire included students’ demographic data along with two other sections, one related to knowledge and attitude about self medication and the other related to adherence to treatment regimen. Only completed questionnaires were finally included in the study. Data were analysed using Microsoft Excel and results were expressed using descriptive statistics such as frequency and percentages. All questions had multiple options, therefore, the sum of percentage is not always 100%. Chi square test were used for testing the statistical significance. The statistical significance was set at p ≤ 0.05.

 

RESULTS:

Table 1: Demographic profile of students

Demographic traits	n (%)
Age (mean ± SD) yrs	21.5 ± 1.9
Gender Female Male	115 (56.4) 89 (43.6)
Parent’s occupation Health personnel Non-health personnel	27 (13.2) 177 (86.8)
Year of MBBS 1st year 2nd year 3rd year 4th year 5th year	Total 48 (100) 58 (100) 20 (100) 34 (100) 44 (100)
Total	204 (100)

 

This study was conducted among 204 MBBS students, where 89(43.6%) participants were males and 115(56.4%) were females. Their mean age was 21.5 ± 1.9 years (ranging from 19 to 24 years). Among them, 48(23.5%), 58(28.4%), 20(9.8%), 34(16.7%) and 44(21.6%) were studying in 1^st, 2^nd, 3^rd, 4^th and 5^th year respectively (Table 1). We observed that 166(81.4%) of them practiced self medication in the preceding one year.

 

Figure 1: Attitude on self medication practice

 

Figure 1 shows the proportion of students who stated whether practice of self medication is good or not. Among 204 students, 143(70%) disagree with practice of self medication, 33(16%) agree and 28(14%) do not know whether it is good or not. Figure 2 shows the proportion of students who stated whether medical knowledge is necessary for self medication. Majority of them 163(80%) stated it is necessary, 28(14%) do not find it necessary and 13(6%) do not know if it is necessary or not.

 

Figure 2: Knowledge necessary for self medication

 

Figure 3 represents the percentage of students’ awareness about the importance of duration of treatment and dose of medicine with frequency of administration. Among a total of 204 students, 163(79.9%) and 165(80.9%) know it is important to complete the course duration of treatment with correct dose and dosing frequency, respectively. Some students think course duration is not important and also, dose and dosing frequency, 24(11.8%) and 20(9.8%), respectively. Few of them 17(8.3%), have no idea about the importance of course duration and correct dose and frequency, 19(9.3%).

 

Figure 3: Knowledge of importance of treatment schedule

 

Figure 4 shows the students’ knowledge related to different hazards due to incomplete course of treatment. 18(37.5%), 24(41.4%), 8(40%), 17(50.0%) and 26(59.1%) students of 1^st, 2^nd, 3^rd, 4^th and 5^th year respectively, know that disease is not cured with incomplete course. 12(25.0%), 12(20.7%), 7(35%), 13(38.2%), 25(56.8%) students of 1^st, 2^nd, 3^rd, 4^th and 5^th year respectively, know adverse effects will occur. 18(37.5%), 32(55.2%), 14(70%), 26(76.5%), and 35(79.5%)  students of 1^st, 2^nd, 3^rd, 4^th and 5^th year respectively, know that disease might relapse. 14(29.2%), 28(48.3%), 13(65%), 22(64.7%) and 33(75%) students 1^st, 2^nd, 3^rd, 4^th and 5^th year respectively, know that resistance will occur in case of incomplete antibiotic course. A rising level of knowledge is seen from 1^st to 5^th year, with final year students having maximum knowledge about related outcomes. Among all students, majority of them 171(83.8%) know that expired medicines cannot be used, 14(6.9%) know it can be used and, others 19(9.3%) are not sure whether it can be used or not.

 

Figure 4: Knowledge of hazards of treatment discontinuation without doctor’s advice

 

 

This study also revealed that, among 204 students, 102(50%) study participants sometimes read the package inserts provided with the medicine, 19(9.3%) always read it and 83(40.7%) never read. Table 2 depicts the scenario of students’ adherence related to drug intake. 180(88.2%) of them sometimes forget to take medication, 13(6.4%) forget regularly and a few 11(5.4%) students never forget. We also observed that they adopted some initiatives to avoid forgetfulness during medicine consumption.

 

Table 2: Students’ adherence related to drug intake

	n(%)
Forget to take drug Regularly Sometimes Never	13(6.4) 180(88.2) 11(5.4)
Methods to avoid forgetfulness Take drug at same time daily Keep drug in visible place Use reminder alarms None of them Activities without doctor’s advice Change course duration Change dose Change frequency None of the above	81(39.7) 139(68.1) 44(21.6) 7(3.4)   96(47.1) 53(26.0) 46(22.5) 38(18.6)

 

Most of them, 139(68.1%) keep medicine in a visible place, followed by the ones who prefer to take medication at same time daily 81(39.7%), while some use reminder alarms 44(21.6%) and, non adherent ones 7(3.4%) take no action to avoid forgetfulness. Despite of being aware of importance of course duration, dose and drug frequency, the students mentioned they change course duration 96(47.1%), change dose 53(26.0%), change frequency of administration 46(22.5%) without doctor’s advice, while a minority of 38(18.6%) change none of them without doctor’s advice.

 

The students also discontinue treatment for various reasons without doctor’s advice as shown in Figure 5. 113(55.4%) students discontinue treatment on improvement, followed by 68(33.3%) who discontinue to avoid adverse effects, 65(31.9%) upon no improvement, 19(9.3%) to avoid polypharmacy and a few of them 6(2.9%) do not discontinue without doctor’s advice. In figure 6, activities of the students during persistent symptoms and adverse effects are presented. In case of persistent symptoms, 58(28.4%) take doctor’s advice, followed by 54(26.5%) who change the medicine and 50(24.5%) stop taking medicine. Similarly when adverse effects occur, 94(46.1%) stop taking medicine followed by 43(21.1%) change the medicine and 42(20.6%) take doctor’s advice. Regarding use of antibiotics, majority 112(54.9%) complete the course followed by 62(30.4%) who stop antibiotic immediately on recovery and 53(26.0%) stop on improvement. 157(77.0%) students plan to stock enough medicine before travelling anywhere, 37(18.1%) prefer to keep reminder notes, 30(14.7%) plan to use reminder alarms and 2(1.0%) have no plans.

 

Figure 5: Reasons for treatment discontinuation without doctor’s advice

 

Figure 6: Activities during persistent symptoms and adverse effects

 

In this study, a student is considered to have knowledge of self medication who knows the importance of treatment schedule, hazards of treatment discontinuation and omit the use of expired medicines. Also, a student is considered strictly adherent who never forget to take medicines, take initiative to avoid forgetfulness, does not change treatment schedule nor discontinue treatment without doctor’s advice, even when symptoms persist or adverse effects occur. There was significant association between knowledge of self medication with adherence among the students (Χ²= 6.2501, df= 1, p<0.05).

 

DISCUSSION:

In this study, the age range of respondents was from 19 to 24years. These undergraduate medical students, 1^st year upto 5^th year, belong to the young population category prone to self medication practice. This targeted group was chosen to evaluate their knowledge about self medication as they are in a learning process of principles and practices of medical science. This young age group is commonly involved in self medication practice^8,10. Prevalence of self medication is 81.4% in our study which may not be an influence of their parent’s profession, as only 13.2% of parents are related to healthcare sector. In fact, high prevalence might be due to easy availability of medical information. This study shows the attitude of respondents where majority (70%) of students disagree with practice of self medication. This might be due to incomplete knowledge among all participants regarding safe and effective self medication and its advantages, similar to a study¹⁸ (87.4%) but not to another⁸ (13%). We observed 80% students find medical knowledge necessary for self medication. A study in India¹⁹ matches with this result where 64.10% and 74.68% medical students, of 1^st and 2^nd year respectively, feel medical knowledge is a necessity. Maximum students in this study, 79.9% and 80.9% respectively, know it is important to complete the course of treatment with correct dose and dosing frequency without changing any of them. These findings are in congruence with a research²⁰, where only 6.7% were unaware that complete course of treatment should be taken. Also, 4% and 8% respondents were unaware about hazards of changing dose and frequency of administration. Hence, majority of respondents were aware about the above mentioned issues. Conversely, a different study²¹ revealed 87.26% were unaware about importance of dose and dosing frequency. Level of knowledge related to consequences of treatment discontinuation is found to be increasing from 1^st year to 5^th year. Majority of final year students know that an incomplete course may result in no disease recovery (59.1%), adverse effects occur (56.8%), relapse occurs (79.5%) and antibiotic resistance develops (75%). This rising level of knowledge and more caution may be the result of teaching Pharmacology (included in MBBS curriculum) to 3^rd and 4^th year students, that they are so much aware about the drugs. Other studies²² observed similar awareness of bacterial resistance (89.07%), rational use of drug (87.17%) and adverse effects (60.53%)^23, but different²⁴ findings were, 57.57% had no knowledge about drug resistance, probably because participants were university students and not medical students. Expired medicines cannot be used as stated by 83.8% students in this study, similar to Patel et al.¹⁹ (96.2%) being aware of expiry date.

 

Knowledge of self medication must be implemented in practical aspects of treatment to rationalize use of drugs. To accomplish this, patient adherence must be considered as an essential component of self medication. In the present study, adherence among medical students has also been observed. The observations regarding reading and following the package inserts are analogous with earlier studies²⁵ and in contrast with others^26,27. A minority group with high adherence (5.4%) never forget to take medicines^28,29 but majority forget sometimes or regularly and all participants plan to avoid forgetfulness, mainly by keeping medicines in a visible place (68.1%)^30,31. 18.6% of students do not change any duration, dose and frequency of regimen without doctor’s advise, neither do a minute proportion of 2.9% discontinue treatment without advice due to any reason, as El Ezz NFA and Ez-Elarab HS⁸ showed in their study but Zafar et al.¹⁸ did not.

 

28.4% of  students always take doctor’s advice when symptoms are not relieved, whether they change (26.5%) or discontinue (24.5%) the medicine or do neither of them, which is similar to the study of Mehta RK and Sharma S²⁰. where 38.7% students discontinued treatment without advice in case of persistent symptoms. When adverse effects occur during treatment, 46.1% stop the medicine, 21.1% change and 20.6% take doctor’s advice. This is in accordance to the findings by Kasulkar AA and Gupta M²⁷, where 53.3% stopped medication and consulted the doctor, while 26.1% started new medicine. In case of antibiotics, 54.9% complete the course and 30.4% stop immediately on recovery which is analogous to the study of Nishat et al³². Travelling plans include enough medicine stock for trip (77.0%) in majority of students.

CONCLUSION:

The present study observed, despite of high level of knowledge about self medication among the medical students, level of adherence is low. This may lead to more incidence of adverse effects, less recovery rates, more financial burden and finally patients losing trust upon doctors. To impose a positive influence of this knowledge, emphasis should be given to adherence. This achievement is possible by maintenance of education of medical students during the entire MBBS course, conducting workshops on rational use of medicines and teaching behavioral interventions to ensure better adherence. Our future physicians can build up strong doctor-patient relationships and also, implement adherence among themselves as well as the patients.  All present findings are based on a single centre study in Dhaka, Bangladesh. A pilot study need to be conducted among medical students in a national level to visualize the influence of knowledge of self medication and various levels of adherence on a large scale.

 

ACKNOWLEDGEMENT:

The researchers would like to thank all the students of  Dr. Sirajul Islam Medical College, Dhaka, Bangladesh, who have participated and gave their valuable opinion in this study.

 

REFERENCES:

1.     Montastruc JL, Bagheri H, Geraud T, Lapeyre-Mestre M. Pharmacovigilance of self-medication. Therapie 1997; 52: 105-10.

2.     Guidelines for the regulatory assessment of medicinal products for use in self-medication, WHO. 2000. Available from URL: http://apps.who.int/medicinedocs/pdf/s2218e/s2218e.pdf.  Accessed on 21 October, 2016.

3.     Kumari R, Kumar D, Bahl R and Gupta. Study of knowledge and practices of self medication among medical students at Jammu. Journal of Medical Sciences 2012; 15(2): 141-44.

4.     Selley P. Self-prescribing by doctors. Health Trends 1998; 20(4): 128–129.

5.     Hem E, Stokke G, Tyssen R, Grønvold NT, Vaglum P et al. Self prescribing among young Norwegian doctors: a nine-year follow-up study of a nationwide sample. Biomed Central Medicine 2005; 3:16. Available from URL:  http://bmcmedicine.biomedcentral.com/articles/10.1186/1741-7015-3-16.

6.     M Saidul Islam. Self-medications among higher educated population in Bangladesh: An Email-Based Exploratory Study. The Internet Journal of Health 2006; 5(2). Available from print.ispub.com/api/0/ispub-article/6868.

7.     Gupta S, Singh M. Self-medication among North Indian first-year undergraduate healthcare students: A questionnaire-based study. Tropical Journal of Medical Research 2016; 19(2): 162-7.

8.     El Ezz NFA, Ez-Elarab HS. Knowledge, attitude and practice of medical students towards self medication at Ain Shams University, Egypt. Journal of Preventive Medicine and Hygiene 2011; 52: 196-200.

9.     Azad AH, Afzal M, Rizwi F, Rajput AM. Self medication patterns amongst undergraduate medical students of a private medical college, Pakistan. Journal of Islamabad Medical and Dental College 2013; 2(4): 72-76.

10.  Biswas M, Roy MN, Manik MIN, Hossain MS, Alam SMT, Moniruzzaman M, Sultana S. Self medicated antibiotics in Bangladesh: a cross-sectional health survey conducted in the Rajshahi City. Available from URL:  http://www.biomedcentral.com/1471-2458/14/847. Accessed on October 10, 2016.

11.  Alam N, Saffoon N, Uddin R. Self‑medication among medical and pharmacy students in Bangladesh. Biomed Central Research Notes 2015; 8: 763.

12.  Bandura A. Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review 1977; 84:191–215. Available from URL: https://www.ncbi.nlm.nih.gov/pubmed/847061. Accessed on October 21, 2016.

13.   Rich M. Management of heart failure in the elderly. Heart Failure Review 2002; 7: 89-97.

14.  Saleh F, Mumu SJ, Ara F, Hafez MA and Ali L. Non-adherence to self-care practices and medication and health related quality of life among patients with type 2 diabetes: a cross-sectional study. Biomed Central Public Health 2014; 14: 431.

15.  Osterberg L, Blaschke T. Adherence to medication. New England Journal Of Medicine 2005; 353(5): 487-497.

16.  Edmondson D, Horowitz CR, Gold finger JZ, Fei K, Kronish IM. Concerns about medications mediate the association of post traumatic stress disorders with adherence to medication in stroke survivors. British Journal of Health Psychology 2013; 18(4): 799-813.

17.  Hughes CM, McElnay JC, Fleming GF. Benefits and risks of self medication. Drug Safety 2001; 24(14): 1027-37.

18.  Zafar SN, Syed R, Waqar S, Zubairi AJ, Vaqar T, Shaikh M, Yousaf W, Shahid S, Saleem S. Self-medication amongst University Students of Karachi: Prevalence, knowledge and attitudes. Journal of the Pakistan Medical Association 2008; 58(4): 213-217.

19.  Patel PM, Prajapati AK, Ganguly B, Gajjar BM. Study on impact of Pharmacology teaching on knowledge, attitude and practice on self-medication among medical students. International Journal of Medical Science and Public Health 2013; 2: 181-186.

20.  Mehta RK, Sharma S. Knowledge, Attitude and Practice of Self-Medication among Medical Students. IOSR Journal of Nursing and Health Science 2015; 4(1): 89-96.

21.  Wajantri P, Angadi MM, Masali KA, Shashank KJ and Sowmya B. A study on knowledge, attitude and practice about self medication among college students. International Journal of Health Sciences and Research 2013; 4(7): 2249-9571.

22.  Mosaddek ASM, Islam MZ, Rahman MF, Akter MS, Laizu J, Parvin R, Tabassum N, Simbak N, Haque M. A pilot study on evaluation of self-medication among undergraduate medical students in Dhaka, Bangladesh. Research Journal of Pharmacy and Technology 2014; 7(11): 1240-1245.

23.  Gaikwad NR, Patil AB, Khan TA. Comparative evaluation of knowledge, attitude and practice of self-medication among first and second year medical students. J Datta Meghe Institute of Medical Science University 2010; 5(3): 157-62.

24.  Idris T, Khanum S, Uddin MS, Asaduzaman M, Islam MA, Nasrin F, Haider SS. Study on self-medication practices among university students of Bangladesh. British Journal of Medicine and Medical Research 2016; 14(6): 1-8. Article no. BJMMR.24364.

25.  Gupta VK, Pathak SS. Assessment of awareness and knowledge about package inserts amongst medical students: A questionnaire based study. IOSR Journal of Pharmacy 2012; 2(2): 215-217.

26.  Sontakke SD, Bajait CS, Pimpalkhute SA, Jaiswal KM, Jaiswal SR. Comparative study of evaluation of self-medication practices in first and third year medical students. International Journal of Biological and Medical Research 2011; 2: 561-64.

27.  Kasulkar AA, Gupta M. Self Medication practices among medical students of a private institute Indian Journal of Pharmaceutical Sciences 2015 ;77(2): 178-182.

28.  Hungin AP, Rubin G, O’ Flanagan H. Factors influencing compliance in long-term proton pump inhibitor therapy in general practice. British Journal of General Practice 1999; 49: 463-464.

29.  Taj F, Tanwir M, Aly Z, Khowajah A, Tariq A, Syed F, Waqar F, Shahzada K. Factors associated with non-adherence among psychiatric patients at a tertiary care hospital, Karachi, Pakistan: A questionnaire based cross-sectional study. Journal of the Pakistan Medical Association 2008; 58(8): 432-6.

30.  Tips for managing your medications. Available from URL: http://www.campusmindworks.org/students/treatment/medication/medication management.asp. Accessed on October 10, 2016.

31.  Clinician’s Toolkit: A Guide to Medication and Lifestyle Adherence. Available from URL: https://www.lipid.org/practicetools/tools/adherence Accessed on October 10, 2016.

32.  Nishat C, Rashedul MI, Mehedi HM, Rouf MM. Prevalence of self medication of antibiotics among people in Bangladesh. Indian Journal of Pharmacy practice 2012; 5(4): 65-72.

 

 

Accepted on 22.05.2017           © RJPT All right reserved