Assessment of Self-Medication Practices and Associated Factors by Clinical Pharmacists in a Rural Population of Arunachal Pradesh, India

Self-Medication (SM), according to the World Health Organization (WHO), is the use of prescription drugs for intermittent or continuous treatment of chronic or recurrent illnesses or symptoms, as well as the use of drugs to treat disorders or symptoms that oneself diagnoses.¹ Based on accessible information, in developing countries, almost 80% of all medications can be purchased without a prescription.² SM, as an element of self-care, is the use of medications without a prescription from a medical practitioner to treat self-identified illnesses.³ This may also include using herbs, sharing medications with friends or family members, storing and reusing or refilling prescription medicines without medical assistance.⁴ The practice of SM must be based on a reliable and authentic source of drug information. Failure to do so may result in irrational drug use, wasted resources, an increase in antibiotic resistance cases, adverse drug reactions and prolonged morbidity.⁵ Over-the- Counter (OTC) drug is more common than prescription drug use globally in the context of SM.⁶ Despite being widely used safe and effective for SM, OTC medications can have even negative effects if used improperly. This is particularly true for vulnerable populations, such as children and the elderly and occurs when users are unaware of the proper dosage, potential side effects and interactions in pregnancy and other physiological conditions.⁷

In India, the prevalence of SM practice varies from 8.3% to 92%.^8, Many people do not seek medical attention when they become ill. They either go to a retail pharmacy to buy it or they approach to a neighbor who might have some medication left over from their past illness and procure it from them.¹⁰ SM is a common practice in India as it offers people a cost-effective alternative for their ailments.¹¹ In India, OTC medications are not categorized separately and those that do not fall under the schedule of prescription medications are typically marketed as such.¹² On other hand according to International Pharmaceutical Federation (FIP), it is a pharmacist’s responsibility to ensure that a patient receives the necessary drug information for the safe and effective use of medications.¹³ Therefore, using Over-the-Counter medications (OTC) without the guidance of a licensed pharmacist or medical professional may have major consequences.

In India, most studies on SM have focused heavily on its prevalence, Perceptions and contributing factors.¹⁴ However, no study has been conducted to educate people about their medications for SM.

So, the main aim of this study was to evaluate SM practice and its influencing factors and to educate the general public about their medications and serious complications of SM through drug-specific patient counseling.

It was a Cross-sectional prospective community based unicentric study. The study was conducted for a period of 10 months from July 2022 to May 2023 in a newly established Drug Information and Patient Counseling Centre and its Mobile Pharmaceutical Care Unit in Jollang village of Arunachal Pradesh, India.

A total of 312 subjects were interviewed during the study period, of which 237 were found to be eligible for the study and enrolled for final assessment. Ethical clearance was obtained before the initiation of the study. All study objectives, as well as data protection and analysis methods, were explained. All study protocols were approved by the institutional ethics committee of Sanjeevani Cancer Hospital, Chhattisgarh, India.

After extensive literature research, a self-structured questionnaire was developed in English. The content of the questionnaire was checked by the team of experts. It was translated into Hindi (local language) by the investigator and the tool was reviewed by a Hindi language expert. Before data collection, the research objective was explained and informed consent was obtained. The study questionnaire was divided into three Parts. Section one contained subjects Sociodemographic details. Section two contained questions about self-medication behavior such as reasons for self-medication, diseases or symptoms for which SM was done, drug used for self-medication, source of information about the drug used, knowledge about the drug and Section three included participants’ feedback on clinical pharmacists’ advice on medications and awareness of the serious consequences of SM practices. The questionnaire was verbally administered to individuals with impaired vision or illiteracy who were unable to read it by themselves.

The Statistical Package for Social Sciences (SPSS) V26 was used to perform the statistical analysis. The data was acquired; compiled and categorized. Continuous data were expressed as mean standard deviation, while descriptive analysis was expressed as percentage. The results were presented in bar charts and frequency distributions.

i) Age more than or equal to 18 years. ii) The study subject must be residents of the study area. iii) Mentally healthy. iv) He or She is able to communicate in at least one of the following ways: speaking or writing. v) ^e study subjects must have used any drug category without a prescription of a medical practitioner at the time of study or use within the last three months.

Subjects having confirmation or diagnosis of having psychiatric problems or disorders. ii) She/he is having confirmation of alcohol or any drug intoxication. iii) She/he not willing to provide necessary details

Of the total 312 participants, 237 were found to have practiced SM and their average age ranged from 18 to over 60, with a standard deviation of 11.35 and a mean of 31.60. Most respondents had a college degree (52.32%), a high school education (21.94%) and less than a high school education (25.32%). SM was observed to be higher in men (138; 58.23%) than in women (99; 41.77). A review of the participants’ monthly income revealed that self-medication was high (131; 55.27%) among those in the 5000-25000 income range (Table 1).

The SM practice for common health related complains was as follows: Headache (43; 18.14%), Fever (39; 16.14%), Heart Burn (28; 11.81%), Allergy and Skin Infection (26; 10.97%), Cough and Cold (26; 10.97%), Contraceptives (24;10.12%), General weakness (17;7.17%), Sexual Problem (14;5.9%), Menstrual Cramps (8;3.37%), Weight Gain (5;2.1%),Blood Pressure (3;1.26%),Knee Pain (2;0.84%), Diabetes(2;0.84%) (Figure 1).

The drugs used for SM were classified according to their pharmacological profiles as follows: Analgesic and antipyretics (57; 24.05%), Acid Suppressants/PPIs (41; 17.29%), Herbal Supplements (29; 16.45%), antibiotics (33; 13.92%), Expectorants/Antitussive (26; 10.97%), Steroids (17; 17.17%), Oral Contraceptives (13; 5.48%), antihistamines (2; 0.84%), vitamin and calcium supplements (9; 3.79%) (Figure 2).

The rural population cited the following reasons for practicing SM: financial constraints (123; 51.89%), Lack of availability of? Health Practitioner (56; 23.62%), to save time (47; 19.83%), Issue not serious (12; 5.06) (Table 2).

Upon evaluation, it was found that only 22.36% of respondents knew the correct dosage. 91.40% knew the administration route, less than 10% (7.17%) knew about side effects, a very small percentage (1.27%) knew about possible drug interactions and a mere 12.24% were aware about the drug’s indication or contraindication. Furthermore, 18% of the respondents also reported taking prescription drugs in addition to SM (Table 3).

Following are found to be the source of drug information for SM: Unauthorized Health Practitioners (132; 55.7%), Pharmacist (42; 17.72%), Nurses (11; 4.64%), Medical Practitioner (9; 3.80%), others (43; 18.14%) which includes friends, family members and old prescriptions (Table 3).

Feedback question one asked, “Did you fully comprehend the drug’s information that was provided? After analysis, it was discovered that the majority of respondents (200, 84.39%) fully understood the information provided by the CP, despite the fact that half of the respondents (30; 12.66%) tended to somewhat agree that they had understood the information provided. Six people were indifferent about whether or not the information was clearly understood, while one person disagreed.

The assessment of the second question asked, “Whether respondents would be interested in using this type of service again?” It was found that (205; 86.50%) of the respondents strongly supported for the future use of service, while (20; 8.44%) tended to agree with future provision of the service and twelve remained neutral in their opinion

Analysis of the third question, “Do you find the level of service satisfactory?” showed that 191 respondents (80.59%) strongly agreed that the service was effective, while 29 respondents (12.24%), thought it was somewhat good, 15 respondents (6.33%) remained neutral and 2 respondents (0.84%) disagreed that the service was good.

Upon assessing the fourth feedback question, “Is it necessary to seek advice from a healthcare professional before self-medication?” it was discovered that 180 respondents (75.95%) strongly agreed to consult a Health care professional, 50 respondents (21.10%) were somewhat agreed to consult, six (2.53%) remained neutral and one was somewhat disagreed to consult a health care professional (Table 4).

Gaining understanding of SM practice and related factors in the rural population was the primary goal of this study. The aspects that have been the subject of a thorough discussion are listed below.

Socio-demographic Analysis of the data obtained revealed that the prevalence of SM in the area was found to be 67.13%. This is lower than various studies conducted in rural populations in other parts of India.^15, The present study shows that SM is high in men than in women. This result was not consistent with the results of other studies where the number of women was high.^17, It was discovered that more people with higher education but middle-class incomes practiced SM, which is consistent with a study carried out in Indian scenario.¹⁹ The reason could be: Due to the poor economic situation, people may not be able to afford the branded drugs and the cost of laboratory tests prescribed by medical practitioners.

Figure 2:
Graph representing various Pharmacological categories of drugs used for SM.

Figure 1:
Graph representing various complains for which SM was done.

The major complaints for which SM was done were headache (18.14%) and fever (16.14%). Similar results were found in other studies conducted in India.^20, Additionally, In our study people did SM for other complaints also which are as follows: Heart Burn (28; 11.81%), Allergy and Skin Infection (26; 10.97%), Cough and Cold (26; 10.97%), Contraceptives (24; 10.12%), General weakness (17; 7.17%), Sexual Problem (14; 5.9%), Menstrual Cramps (8; 3.37%), Weight Gain (5;2.1%), Blood Pressure (3; 1.26%), Knee Pain (2; 0.84%) and Diabetes(2; 0.84%). This is more or less similar in other studies conducted in India and Nigeria.²²

On analysis of Pharmacological categorization of SM drugs, it is observed that analgesics and antipyretics were commonly used for SM, which is similar to the other studies conducted in India.²³ The other commonly used drug categories was acid inhibitors/ PPIs, which is similar to the results of international study.²⁴ As in? India, these are Over-the-Counter (OTC) medications that are considered safe and useful for treating minor ailments. Although useful, using it in inappropriate doses also poses some risks. Next to PPIs antibiotics were widely used without a prescription which is similar to the other studies conducted in developing nations.²⁵ Although schedule H1 in India restricts the sale of antibiotics without a doctor’s prescription, but they are easily available locally without a prescription.²⁶ Herbal supplements were also used next to antibiotics for their basic ailments which are similar to the findings of other studies.²⁷ The reason could be their belief in traditional medicines as herbal medicines are believed to have no side effects. Expectorants/Antitussive, antihistaminic, oral contraceptives were also used for SM by respondents in this study. This is similar to other study as well.²⁸

In our study the major source of drug information for SM was found to be other which includes internet, advertisement, friend and family. Which is in contrast with a study conducted in Jordan were pharmacist was found to be the major source.²⁹ The reason could be the widespread use of internet sources and social media by the general public these days. Next to the other source Unauthorized Health Practitioners (UHP) were also involved in higher number 43 (18.14%). As in rural areas availability of qualified health practitioners is a big challenge in India.³⁰ So, people are frequently visiting UHP for their common ailments.

On evaluation of drug knowledge of the respondents, it was found that only 22.36% of the respondents knew the correct dosage. 91.40% knew the administration route, less than 10% (7.17%) knew about side effects, a very small percentage (1.27%) knew about possible drug interactions and a mere 12.24% were aware about the drug’s indication or contraindication. Furthermore, 18% of the respondents also reported taking prescription drugs in addition to SM.

A study conducted in Iran assessed participants’ overall knowledge of common medications, including prescription, over-the-counter and herbal medications and their probable ADRs.³¹ However, our study evaluated individual drug under self-medication and provided appropriate counseling about the drug and consequences of SM to prevent the general public from drug related harms.

In our study the reasons for SM were as follows: financial crisis and lack of availably of health practitioner, Problem is not serious and to save time. These results are almost similar with the studies conducted in Sudan.³² These explanations, however, depend on the surroundings and study populations in the areas where the research were conducted.

When analyzing the respondents’ feedback after the consultation, it was found that the majority of respondents understood the information provided about the drug, they were using for SM. 80% of respondents were strongly agreed to use the service in the future. Most of the respondents (80.59%) strongly agreed that the service delivered was effective and more than 75% agreed to see a Pharmacist or Doctor before SM. This type of study has not been done in India where people have been educated about the drug they are using for SM.

In the current study, the prevalence of self-medication was determined to be 67.13%. Male gender has been found to be linked to a higher probability of taking medications without a doctor’s prescription. Furthermore, it was found that a higher education did not prevent people from developing the habit of self-medication; rather, it played a significant role in it. Hence, to encourage the public to understand the serious consequences of SM, the Drug Control Agency and healthcare policymakers need to invest some resources in this effort by engaging clinical pharmacists. This will help change the general public’s attitude towards SM practices and may protect the general public from drug-related harm.

The authors would like to thank Mr. Franco Gohain, M. Pharm., Pharmacology, for his support in making this work possible.