Open Access

Pharmacology education and antibiotic self-medication among medical students: a cross-sectional study

BMC Research Notes201710:337

https://doi.org/10.1186/s13104-017-2688-4

Received: 6 July 2017

Accepted: 22 July 2017

Published: 27 July 2017

Abstract

Objective

Pharmacology teaches rational prescribing. Self-medication among medical students is recognised as a threat to rational prescribing. Antibiotic self-medication could cause antibiotic resistance among medical students. We aimed to find an association between pharmacology education and antibiotic self-medication.

Results

Overall, 39% [(110/285) 95% CI 32.9–44.3] of students were found to have antibiotic self-medication. The percentage for antibiotic self-medication progressively increased with the year of study. The percentage of antibiotic self-medication was significantly high in the “Formal Pharmacology Education” group (47%—77/165) in comparison to the “No Formal Pharmacology Education” group (28%—33/120) (P = 0.001032). Overall, the most common self-prescribed antibiotic was amoxicillin (56%—62/110).

Keywords

Pharmacology Medical education Self-medication Medical undergraduates Antibiotics

Introduction

Medical education uses a wide range of teaching methodologies [1]. In Sri Lanka (SL) medical students read for a Bachelor of Medicine and Bachelor of Surgery (MBBS) degree similar to United Kingdom [2]; Pharmacology is learnt in 3rd and 4th years and includes rational prescribing and legal provisions involved in prescribing and dispensing [3, 4]. After obtaining the MBBS degree it is mandatory to complete a 1-year internship to obtain registration at the Medical Council. This registration provides the legal mandate to prescribe. No pharmacist can dispense prescription-only drugs without a valid prescription from a doctor. Despite these regulations, dispensing without a prescription, self-medication and prescribing by unqualified are common.

World Health Organization (WHO) defines self-medication as “use of pharmaceutical or medicinal products by the consumer to treat self-recognized disorders or symptoms, the intermittent or continued use of a medication previously prescribed by a physician for chronic or recurring disease or symptom, or the use of medication recommended by lay sources or health workers not entitled to prescribe medicine” [5]. Self-reliance, convenience and low cost are perceived benefits of self-medication. Potential risks are incorrect diagnosis, delay or failure to seek medical advice, risk of adverse effects, development of resistant microbes and incorrect prescribing [5]. A Spanish study revealed females, students, lonely people, urban dwellers, people with better education and aged more than 40 are more likely to self medicate [6].

A meta-analysis in 2014 showed 4–92% prevalence of self-medication among adolescents in South American and European countries [7]. Antibiotic self-medication has been recorded among university students; 44% in Romania [8], 13% in Sri Lanka [9] and 39% in Nigeria [10]. Another meta-analysis (2015) showed 38.8% (95% CI 29.5–48.1%) antimicrobial self-medication in low and middle-income countries [11]. Symptoms related to infections of respiratory, gastro-intestinal, skin, eye and ear, and urinary systems, and malaria are the reasons for self-medication; medicines commonly used are antibacterials and antimalarials. Representatives of pharmaceutical companies, pharmacists, relatives, friends and drug leaflets were the most common sources of information. Past successful use is a reason for repeated self-medication. Antimicrobial drugs were obtained from pharmacies, hospitals, leftovers from earlier purchase and friends [11].

A Sri Lankan study reported a significantly higher percentage of self-medication in an urban district [12.2%] compared to a rural district [7.9%] [12]. Another study revealed amoxicillin (95.4%) as the most common antibiotic and the upper respiratory tract infection (84.9%) as the most common illness related to self-medication [9].

According to WHO, antibiotic resistance is defined as “resistance of a microorganism to an antimicrobial drug that was originally effective for treatment of infections caused by it”. This leads to hampered infection control, increased cost and mortality. Although the evolution of resistant strains is a natural phenomenon, certain human actions accelerate its emergence and spread. WHO requests to use antimicrobial drugs, only when prescribed by a doctor [13].

Pharmacology education could encourage antibiotic self-medication among students. Medical students are exposed to infection during their clinical work and are at higher risk of infections. We assessed the association between pharmacology education and antibiotic self-medication practices among undergraduates.

Main text

Methods

A descriptive cross-sectional study was conducted from March to July 2016 among undergraduates of Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Anuradhapura. Anuradhapura is 210 km away from the capital of Sri Lanka (Colombo). It has a population of nearly 856,500 [14]. 94.6% belong to the rural sector [14]. Agriculture is their main occupation (55%) [15]. The teaching hospital is situated 10 km away and the nearest pharmacy is located 5 km away from the faculty. The State Pharmaceutical Corporation’s retail sales outlet and several other private pharmacies are located closer to the Teaching Hospital.

All students of the faculty were approached and 696 out of 902 gave consent. First and second-years were categorised into No Formal Pharmacology Education (NFPE) group and third, fourth and fifth-years were categorised into students with Formal Pharmacology Education (FPE). The posthoc calculation of power was 90.9% (parameters used: percentage of antibiotic self-medication among FPE = 47%, percentage among NFPE = 28%, number of subjects in FPE = 165, number of subjects in NFPE = 120, margin of error = 5%).

We used a self-administered questionnaire to collect data on demography and antibiotic self-medication. The questions on antibiotic medication were adapted from a pre-validated questionnaire which was used in Jordan, with permission [16]. Question number 6 was modified from “What was the name of this antibiotic?” to “What were the names of these antibiotics?”. Parents occupation was classified according to International Standard Classification of Occupations [17].

The questionnaire, information sheet and consent form were given to students by trained MBBS qualified data collectors. Students were expected to leave back the questionnaires (filled/blank) and the consent forms on their seats after the lecture. To maintain confidentiality and prevent coercion, permanent lecturers at the faculty were not involved in describing, obtaining consent or collection of the questionnaires. First- and second authors analysed data using Microsoft Excel. Percentages were used to describe the demography and prevalence of antibiotic self-medication. Chi square test was used to find a significance of antibiotic self-medication between the two study groups (FPE vs NFPE).

Results

Participation rate was satisfactory [77% (696/902)] with 86% (154/180) in the first year, 94% (172/183) in the second year, 61% (110/181) in the third year, 68% (125/185) in the fourth year and 78% (135/173) in the fifth year. NFPE category had 47% students (326/696). Mean age of the participants was 23.2 (SD ±1.6) years. 71% (491/696) were females. The majority of the participants were Buddhist (85%) and from the district of Gampaha (15%). 50% were staying near the faculty, 44% near the Teaching Hospital and the rest were travelling from home. Fathers of students were mostly “professionals” (37%) whereas the mothers were housewives (60%).

During last month, 40.9% [(285/696) 95% CI 37.3–44.6%] have taken antibiotics and 165 were students with FPE. Of them 39% [(110/285) 95% CI 32.9–44.3%] self-medicated with increasing number self-medicating as they progress through the medical faculty; 23% (14/60) students were from the first year, 33% (19/57) from second year, 39% (23/59) from third year, 46% (25/54) from fourth year and 53% (29/55) from fifth year. Students with FPE (70%; 77/110) were the majority among those who self-medicated with antibiotics. Self-medication was significant among students with FPE (47%—77/165) compared to students with NFPE (28%—33/120) (Chi square statistic = 10.7689; P = 0.001032).

Among those who had antibiotics, 70% (200/285) were females. They were the majority among all those who self-medicated (57%—63/110). However, self-medication was significantly high among males (55%—47/85) compared to females (32%—63/200) (Chi square statistic = 14.2496; P = 0.00016).

A sore throat (46%—51/110) was the most common symptom for antibiotic self-medication. Previous experience of using the same drug was the most common reason for antibiotic self-medication (89%—98/110). Drugs have been obtained from retail pharmacies 82% (90/110), relatives or friends (14%—15/110) and leftover drugs at home (6%—5//110). Amoxicillin was the main self-prescribed antibiotic (56%—62/110). The dose was based on previous knowledge (45%—49/110). The majority of the participants have taken the antibiotic for 1–3 days (68%—75/110).

Of students who self medicate with FPE, most lived near the Teaching Hospital (91%—70/77) and with NFPE most lived near the faculty (91%—30/33). Symptoms related to upper respiratory tract were the most common illness associated with antibiotic self-medication in both groups (NFPE—72% and FPE—85%) (Table 1).
Table 1

Symptoms for which antibiotic self-medication was used

Symptoms

% (n = 33)

Symptoms

% (n = 77)

NFPE group

FPE group

Runny nose

30

Sore throat

60

Flu

21

Runny nose

12

Sore throat

15

Flu

10

Abscess

12

Diarrhoea

09

Toothache

10

Toothache

04

Tonsil infection

06

Sinusitis

03

Ear infection

06

Acne

01

  

Oral ulcers

01

Total

100

Total

100

NFPE No Formal Pharmacology Education, FPE Formal Pharmacology Education

Previous experience is the most common explanation for antibiotic self-medication given by the students with and without FPE (97% vs 86%) (Table 2). Retail pharmacies were the most common source of supply for antibiotics in both NFPE and FPE (Table 2). 1–3 days was the usual duration of antibiotic usage in both NFPE and FPE groups (Table 2). Amoxicillin was the main self-prescribed antibiotic in both NFPE and FPE groups, followed by ciprofloxacin in NFPE and co-amoxiclav in FPE (Table 3).
Table 2

Features of antibiotic self-mediation in NFPE and FPE group

NFPE group

% (n = 33)

FPE group

% (n = 77)

Reasons for self-medication

Previous experience

97

Previous experience

86

No access to physician care

03

No access to physician care

06

  

Poor economic status

04

  

No specific reason

04

Source of antibiotic supply

Retail pharmacy

79

Retail pharmacy

83

Relatives and friends

18

Relatives and friends

12

Household

03

Household

05

Source of information on the use of the antibiotic

Previous knowledge

28

Previous knowledge

52

Physician

24

Physician

22

Pharmacist

24

Leaflet

09

Relative or friend

24

Relative or friend

05

  

British National Formulary

05

  

Pharmacist

04

  

Internet

03

Duration of antibiotic usage in each episode of self-medication (days)

1–3

85

1–3

61

4–7

12

4–7

34

>7

03

>7

05

NFPE No Formal Pharmacology Education, FPE Formal Pharmacology Education

Table 3

Top 5 antibiotics used in self-medication

Antibioticsa

% (n = 33)

Antibioticsa

% (n = 77)

NFPE group

FPE group

Amoxicillin

58

Amoxicillin

56

Ciprofloxacin

06

Co-amoxiclav

21

Tetracycline

06

Azithromycin

12

Co-amoxiclav

06

Ciprofloxacin

12

Cefalexin

03

Cefalexin

08

NFPE No Formal Pharmacology Education, FPE Formal Pharmacology Education

aA participant could name more than one antibiotic, therefore total of percentage can be >100

Discussion

The percentage of antibiotic self-medication progressively increased with the number of years spent in the undergraduate education. However, few encouraging signs were present. Students with FPE used antibiotics for a longer period. This may indicate their knowledge on the half-life of drugs, steady state concentration and time dependent killing.

A runny nose and flu were among the top three symptoms in both groups (Table 1). This clearly indicates inappropriate antibiotic use for viral infections.

Studies from West Bengal [18], Bahrain [19], Belgrade [20], Southern China [21] and Netherland [22] have shown a positive association between pharmacology education and self-medication. This is compatible with the present study. A Spanish study found high self medication by females [6] contrary to our findings.

Previous studies have also shown that the most common symptom was sore throat [16, 19, 21, 23, 24], reason was previous positive experience [16, 2528], the source of the drug was retail pharmacy [24, 29, 30], antibiotic was amoxicillin [8, 9, 16, 23, 24] and source of information was previous knowledge [16] with regards to antibiotic self-medication.

It is alarming to note that the retail pharmacies were the main source of antibiotic self-medication. The current regulations prohibit dispensing of prescription-only antibiotic without a valid prescription. However, there is a lack of monitoring and oversight of retail pharmacies.

Amoxicillin is a useful first-line antibiotic for many common infections. Rampant, irrational use leads to resistance. Ciprofloxacin, a quinolone, was among the top five self-medicated antibiotics for both the groups. Drugs from the quinolone group of antibiotics are reserved as a second-line drug for tuberculosis. Anuradhapura has a high incidence (30.8 per 105) and death (3.5 per 105) rates for tuberculosis [31]. Blind use of ciprofloxacin makes medical students vulnerable to drug-resistant tuberculosis.

Students with FPE stay near the Teaching Hospital with easy access to state and private pharmacies. This could be a potential confounding factor causing high prevalence of self-medication.

The findings of the study warrant the need to improve access to medical care, reform pharmacology teaching and monitor drug dispensing at retail pharmacies. These could reduce the amount of self-medication in this population.

Limitations

Findings of this study cannot establish a causal association neither it could be generalised because this is a cross-sectional study conducted at one medical faculty. A nationwide study including all other medical faculties of SL would be appropriate. However, the findings are unique because this faculty is located in a rural area with fewer pharmacies around. Confounders of the study could be access to retail pharmacies, the occupation of the parents (parents being health care workers might predispose to self-medication) and inadequate knowledge of pharmacology and microbiology among the students of FPE group. Exclusion of the above confounders is methodologically challenging.

Abbreviations

FPE: 

Formal Pharmacology Education

MBBS: 

Bachelor of Medicine, Bachelor of Surgery

NFPE: 

No Formal Pharmacology Education

SL: 

Sri Lanka

WHO: 

World Health Organization

Declarations

Authors’ contributions

DR and BW conceived the idea of the study and all authors participated in designing the study. SB, SP and CS were involved in data collection. DR and BW were involved in the analysis of data. All authors were involved in the interpretation of data. DR drafted the manuscript and BW, SS, SB, SP, CS and CJ critically revised it. All authors read and approved the final manuscript.

Acknowledgements

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Availability of data and materials

All data generated or analysed during this study are included in this published article.

Consent for publication

Consent to publish the information provided by the participants was obtained, provided that it will not be possible to identify individual participants in any way.

Ethics approval and consent to participate

Ethical clearance was obtained from the Ethics Review Committee, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka (ERC/2016/08). Institutional permission was obtained from the Dean, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka. Informed written consent to participate was obtained from all participants.

Funding

The study was self-funded.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Department of Pharmacology, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka
(2)
Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka
(3)
Department of Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka

References

  1. Wojtczak A, Schwarz MR. Minimum essential requirements and standards in medical education. Institute for international medical education. http://www.iime.org/documents/vs.htm. Accessed 9 Aug 2016.
  2. Bachelors of Medicine and Surgery. World eBook Library—eBook|Read eBooks online. World Heritage Encyclopedia. 2016. http://www.ebooklibrary.org/articles/bachelors_of_medicine_and_surgery. Accessed 9 Aug 2016.
  3. Department of Pharmacology—undergraduate programme. Faculty of Medicine, University of Kelaniya. 2016. http://www.kln.ac.lk/medicine/depts/pharmacology/module.html. Accessed 9 Aug 2016.
  4. Pharmacology curriculum. Faculty of Medicine, University of Jaffna. 2011. http://www.jfn.ac.lk/med/wp-content/uploads/2012/04/CURRICULUM-2011-I.pdf. Accessed 9 Aug 2016.
  5. World Health Organization. Guidelines for the regulatory assessment of medicinal products for use in self-medication. Geneva: World Health Organization; 2000. http://apps.who.int/medicinedocs/pdf/.
  6. Figueiras A, Caamaño F, Gestal-Otero JJ. Sociodemographic factors related to self-medication in Spain. Eur J Epidemiol. 2000;16(1):19–26.View ArticlePubMedGoogle Scholar
  7. Gualano MR, Bert F, Passi S, Stillo M, Galis V, Manzoli L, et al. Use of self-medication among adolescents: a systematic review and meta-analysis. Eur J Public Health. 2014;25(3):444–50.View ArticlePubMedGoogle Scholar
  8. Damian L, Lupuşoru CE, Ghiciuc CM. Self-medication with antimicrobial drugs among university students in a Northeast region of Romania. Rev Med Chir Soc Med Nat Iasi. 2014;118(1):160–4.PubMedGoogle Scholar
  9. Kumarathunga RMST. Assessment of self-medication practices among health sciences related students in University of Peradeniya [dissertation]. Peradeniya: University of Peradeniya; 2010.Google Scholar
  10. Fadare JO, Tamuno I. Antibiotic self—medication among university medical undergraduates in Northern Nigeria. J Public Health Epidemiol. 2011;3(5):217–20.Google Scholar
  11. Ocan M, Obuku EA, Bwanga F, Akena D, Richard S, Ogwal-Okeng J, et al. Household antimicrobial self-medication: a systematic review and meta-analysis of the burden, risk factors and outcomes in developing countries. BMC Public Health. 2015;15(1):742.View ArticlePubMedPubMed CentralGoogle Scholar
  12. Wijesinghe P, Jayakody RL, Seneviratne RA. Prevalence and predictors of self-medication in a selected urban and rural district of Sri Lanka. WHO South-East Asia J Public Health. 2012;1(1):28–41.View ArticlePubMedGoogle Scholar
  13. WHO. Antimicrobial resistance. WHO. World Health Organization; 2016. http://www.who.int/mediacentre/factsheets/fs194/en/. Accessed 4 Aug 2016.
  14. Census of Population and Housing, Department of Census and Statistics, Ministry of Finance and Planning; 2012. http://www.statistics.gov.lk/pophousat/cph2011/pages/activities/reports/cph_2012_5per_rpt.pdf.
  15. Annual Bulletin, Sri Lanka Labour Force Survey, Department of Census and Statistics, Ministry of Finance and Planning. 2014. http://www.statistics.gov.lk/samplesurvey/LFS_AnnualBulletin_2014-f.pdf.
  16. Al-Azzam SI, Al-Husein BA, Alzoubi F, Masadeh MM, Al-Horani MAS. Self-medication with antibiotics in Jordanian population. Int J Occup Med Environ Health. 2007;20(4):373–80. https://www.researchgate.net/publication/5684794_Self-Medication_with_Antibiotics_in_Jordanian_Population.
  17. International Labour Office. International Standard Classification of Occupations, Isco-08. Geneva: World Health Organization; 2012. p. 1–420.Google Scholar
  18. Banerjee I, Bhadury T. Self-medication practice among undergraduate medical students in a tertiary care medical college, West Bengal. J Postgr Med. 2012;58(2):127–31.View ArticleGoogle Scholar
  19. James H, Handu SS, Khaja KA, Sequeira RP. Influence of medical training on self-medication by students. Int J Clin Pharmacol Ther. 2008;46(1):23–9.View ArticlePubMedGoogle Scholar
  20. Lukovic JA, Miletic V, Pekmezovic T, Trajkovic G, Ratkovic N, Aleksic D, et al. Self-medication practices and risk factors for self-medication among medical students in Belgrade, Serbia. PLoS ONE. 2014;9(12):1–14.View ArticleGoogle Scholar
  21. Pan H, Cui B, Zhang D, Farrar J, Law F, Ba-Thein W, et al. Prior knowledge, older age, and higher allowance are risk factors for self-medication with antibiotics among University Students in Southern China. PLoS ONE. 2012;7(7):e41314.View ArticlePubMedPubMed CentralGoogle Scholar
  22. Van der Veer T, Frings-Dresen MHW, Sluiter JK. Health behaviors, care needs and attitudes towards self-prescription: A cross-sectional survey among Dutchmedical students. PLoS ONE. 2011;6(11):28038.View ArticleGoogle Scholar
  23. Kumar N, Kanchan T, Unnikrishnan B, Rekha T, Mithra P, Kulkarni V, et al. Perceptions and practices of self-medication among medical students in coastal South India. PLoS ONE. 2013;8(8):2–6.Google Scholar
  24. Grigoryan L, Haaijer-Ruskamp FM, Burgerhof JGM, Mechtler R, Deschepper R, Tambic-Andrasevic A, et al. Self-medication with antimicrobial drugs in Europe. Emerg Infect Dis. 2006;12(3):452–9.View ArticlePubMedPubMed CentralGoogle Scholar
  25. Abay SM, Amelo W. Assessment of self-medication practices among medical, pharmacy, and health science students in Gondar University, Ethiopia. J Young Pharm. 2010;2(3):306–10.View ArticlePubMedPubMed CentralGoogle Scholar
  26. Belachew Gutema G, Alemayehu Gadisa D, Fikadu Berhe D, Hadgu Berhe A, Ghezu Hadera M, Solomon Hailu G, et al. Self-medication practices among health sciences students: the case of Mekelle University. J Appl Pharm Sci. 2011;01:183–9.Google Scholar
  27. Zafar SN, Syed R, Waqar S, Irani FA, Saleem S. Prescription of medicines by medical students of Karachi, Pakistan: a cross-sectional study. BMC Public Health. 2008;8:162.View ArticlePubMedPubMed CentralGoogle Scholar
  28. James H, Handu SS, Al Khaja KA, Otoom S, Sequeira RP. Evaluation of the knowledge, attitude and practice of self-medication among first-year medical students. Med Princ Pract. 2006;15(4):270–5.View ArticlePubMedGoogle Scholar
  29. Shaghaghi A, Asadi M, Allahverdipour H. Predictors of self-medication behavior: a systematic review. Iran J Public Health. 2014;43(2):136–46.PubMedPubMed CentralGoogle Scholar
  30. Pavydė E, Veikutis V, Mačiulienė A, Mačiulis V, Petrikonis K, Stankevičius E. Public knowledge, beliefs and behavior on antibiotic use and self-medication in Lithuania. Int J Environ Res Public Health. 2015;12(6):7002–16.View ArticlePubMedPubMed CentralGoogle Scholar
  31. Incidence, prevalence and death rates associated with tuberculosis (TB). Department of Census and Statistics—Sri Lanka. 2010. http://www.statistics.gov.lk/MDG/indicatorsupdate/MDGWebTables24.pdf.

Copyright

© The Author(s) 2017

Advertisement