Assessment of self-medication practices with antibiotics among undergraduate university students in Rwanda

Introduction Antimicrobial resistance (AR) is on a rise as one of the major global public health threats. It is therefore important to assess contributory factors to the rise in the cases of resistance reported. The main objective of this study was to assess the self-medication practices with antibiotics among the University of Rwanda students in Huye Campus. Methods A sample of 570 students from all levels and colleges of the University of Rwanda in Huye Campus were selected using a simple random sampling to participate in this study. A questionnaire was administered to be answered individually by the consented respondents where the self-medication practices with antibiotics in the past 6 months were assessed. The results were statistically analyzed using SPSS v.16. Results The study showed that 12.1% (n=69) practiced self-medication with antibiotics. The major reason for self-medication with antibiotics was illness not serious to have a consultation (50.72%). The main diseases being treated were common cold/fever/cough (47.83%). The most used antibiotic for self-medication was Amoxicillin capsules (59.42%), while the main source of antibiotics was the community pharmacy (72.42%). Conclusion Self-medication with antibiotics is not uncommon among the university students. Regarding the main reasons of self-medication with antibiotics, diseases being treated, and the antibiotics used, it was found that all these may be related to the students' lack of knowledge about the need for rational use of antibiotics and a study was needed to confirm it.


Introduction
Globally, self-medication was found to be on the rise [1]. Selfmedication has been defined as "the taking of drugs, herbs or home remedies on one's own initiative, or on the advice of another person, without consulting a doctor" [2]. Major problems related to selfmedication include wastage of resources, increased resistance of pathogens (which generally cause serious health hazards such as adverse reactions), prolonged suffering and drug dependence [3].
Among other considered medications being used without a prescription, in developing countries, are antibiotics [4]. Selfmedication, particularly with antibiotics, has been widely encouraged by unregulated supply chains. This may increase the risk of inappropriate use and the selection of resistant bacterial strains [5,6]. Self-medication may be helpful in facilitating the recovery from some minor illnesses. However, risks and benefits should be weighed reasonably as some serious problems may be due to the self-use of medications [7]. Medicines allowed for self-medication are those called Over-the-counter (OTC) drugs, and they can be dispensed without a doctor's prescription through pharmacies, mostly in the less developed countries [8]. Over the counter (OTC) drugs are a form of self-medication as the buyer diagnoses their own illness and buys a specific drug to treat it [4]. OTC drugs provide symptom relief for conditions that do not always require medical intervention. Selfmedication has been used widely to combat behavioral and psychological problems such as smoking. Pharmacists can help patients to choose the right OTC smoking cessation products to help them successfully quit smoking. Up to 300,000 people each year are able to reduce their risk of lung cancer, emphysema, stroke, heart attack, and complications in pregnancy because of self-care products, which are readily available. For example, non-prescription nicotine helps people to quit smoking [9]. Self medication has certain advantages as it is convenient, economical, and reduces wastage of medical resources on minor illnesses. However, as the disease recognized may not be correct, there is a delay in meeting a health care worker; the side effects of the medication are not known; inappropriate usage of antibiotics can lead to drug resistance; and taking the same drug with other drugs can lead to drug interactions and sometimes, drug addiction [10,11]. Among the people who practice self-medication, particularly with antibiotics, some researchers have shown that university students are included [12].
This study aimed to assess the self-medication practices with antibiotics among, the University of Rwanda students in Huye Campus.

Methods
The study was conducted among undergraduate students of the A sample of 570 students from all colleges of the UR in Huye Campus was selected to participate in this study using simple random sampling. A questionnaire was administered to be answered individually by the consented respondents, where self-medication with antibiotics in the past 6 months was assessed. The results were statistically analyzed using SPSS v.16, and the results were shown in frequency and percentages.
Participants' inclusion criteria: this study included people who fulfill the following criteria: must be a registered undergraduate student of UR; must have been physically located in the UR for at least 6 months; must consent to participate in this research project.
Participants' exclusion criteria: this study didn't take into consideration: people who were not UR/Huye campus undergraduate students; people who haven't been in the university for up to 6 months; and people who didn't consent to participate in the study.
Regarding the permission to conduct this research, a research proposal was presented to the Department of Pharmacy in UR, HUYE Campus requesting a recommendation addressed to the dean of students in the campus to collect data from the university students.
The participants' informed consent to the study was also required and was signed by the respondents as a proof of their will to participate.
The participants answered the questionnaires individually and could withdraw at anytime or choose not to complete the questionnaire.

Discussion
With prevalence of 12.1% (n=69), data from this study indicates that irrational use of antibiotics is practiced among university students.
This proportion is less to that reported among tertiary level students in Accra [13], where the prevalence of SMA stood at 70%. By comparison, the prevalence of SMA among tertiary level students reported 53.5% in Nigeria [14], 76% in Pakistan [15], and 45% in Iran [16]. Studies have also found that educated people have a greater tendency to practice self-medication than illiterates. Higher levels of education and professional status have been associated with and considered as a predictive factor for self-medication [17,18]. The study shows that female students engaged in self-medication with antibiotics more than male students. The differences in frequencies of self medication between gender agrees with a study done among tertiary level students in Accra, Ghana, in which the prevalence of self medication with antibiotics was 67% and 73%, Male and female respectively. It is suggested that the difference may be partly due to the female monthly menstrual cycle during which there are hormonal changes and relatively low immunity. At such times in their cycle, females may feel reluctant to visit the hospital and hence their higher frequency of self medication. This is partly confirmed by a study in Nigeria which showed that 25% of women employed antibiotics to treat menstrual symptom [13,14]. However, the relationship between gender and self-medication was not assessed by this study.
Nevertheless, other studies showed that self-medication patterns are influenced by age, gender, education level, family, society, medical knowledge, perception of illness, self-care orientation, and drug advertisements [19]. Regarding the reasons of self-medication with antibiotics, majority (50.72%) practiced SMA because they thought the illness was not serious and results are in line with another research conducted among the university students of Karachi [20], where it is said that the main reason for SMA was "illness not serious" and other shown reasons in this study. This main reason of SMA showed that students might think an illness is not serious while it is.
This may be related to the lack of knowledge about health concerns, particularly the rational use of antibiotics. Findings are comparable with a study done among Chinese university students where some likely reasons for high SMA rates in China were misconceptions about antibiotic use for flu-like symptoms, false confidence in antibiotic use, high medical costs at health care centers, long waiting hours for outpatient services in hospitals and clinics, lack of trust in prescribing physicians, easy access to antibiotics, and profit-driven persuasion by community pharmacists [21].
The high extent of self-medication by students could be due to their belief that it would provide quick relief from illness. That was also seen in a study done by Angamo and Wabe in 2012 [22]. The use of antibiotics was high in all illness categories including conditions for which antibiotics were not recommended by WHO [23], such as common cold and diarrhea. This finding was similar to studies from Southwestern Nigeria. The study done on self-medication with antibiotics, among the university students revealed that antibiotics were used for respiratory diseases [12]. However, these diseases might have not been well treated through SMA because the students didn't follow the health care delivery process as a whole. This might result to the exacerbation of the disease or other health complications. Misuse of antibiotics is due to diagnostic uncertainty, lack of prescriber knowledge, lack of opportunity for follow-up, easy availability of antibiotics, and lack of treatment guidelines [24]. where antibiotics used in self-medication was 41.4% and the main source was community pharmacies [25,26]. The community pharmacies contributed a lot to SMA by dispensing the non-prescribed antibiotics. This concerns the pharmacy profession regulation enforcements, as students would not have gotten antibiotics if the community pharmacies refused to dispense them without a prescription [13]. It would be indispensable to embrace strict antibiotic guidelines which have shown affirmative outcome. A good example is the Chilean Ministry of Health, which has strictly restricted the purchase of antibiotics without medical prescription since 1999.
This action resulted in a 43% decrease in antibiotic use in the outpatient setting [27], which represents an impressive result. Our study had some limitations as it exclusively considered students that live within the UR/HUYE Campus, without considering the students who live outside the campus or in nearby regions. Also, the UR Huye Campus includes all colleges except CE, which is located in Kigali.

Conclusion
Our study observed self-medication with antibiotics among students in University of Rwanda/ Huye Campus. Educating the university students more about the dangers of self-medication with antibiotics and rational use of antibiotics may be adequate to stop selfmedication with antibiotics. In addition to strengthening the regulation on dispensing antibiotics without prescriptions is essential, as the community pharmacies are the major source of antibiotics used in self-medication with antibiotics.
What is known about this topic  Prevalence of self-medication is likely to be influenced by the knowledge of medications;  Self-medication is a common practice in university students.
What this study adds  Our study suggests that female students practice SMA more than males and another study proved this relationship;  The community pharmacies were found to be the main source of antibiotics used in self-medication. Had they refused to dispense the antibiotics without a prescription, SMA would have been considerably reduced.

Competing interests
The authors declare no competing interests.

Authors' contributions
All the authors participated in the research drafting, design, analysis of data, and conceptualization.

Acknowledgements
We acknowledge the support provided by Dr Diane Ashiru-Oredope, Global AMR lead for Commonwealth Pharmacists Association, in reviewing the manuscript and providing advice on improvement. Table 1: distribution of self-medication with antibiotics by gender