Prevalence and associated factors of self-medication among the college students in Tehran

1 Department of Public Health, Maragheh university of Medical Sciences, Maragheh, Iran. 2 Department of Public Health, School of Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 3 Social Determinants of Health Research Center, Kurdistan University of Medical Sciences, Sanandaj, Iran. 4 Department of health education, School of Health, Kermanshah University of Medical Sciences, Kermanshah, Iran . 5 Health Network of Gilan-e Gharb, Kermanshah University of Medical Sciences, Kermanshah, Iran.


INTRODUCTION
Self-Medication is the provision and consumption of drugs for the treatment of ailments and diagnosed symptoms by people (Fresle and Wolfheim, 1997).Any medication without earlier medical advice regardless of the cause, amount, and duration of use is considered as Self-Medication (WHO, 2001).Today, self-medication is one of the greatest social, economic and public health problems in many countries such as Iran (Bennadi, 2014).This occurs through the consumption of an industrial or home-made drug, providing the medicines without prescription, use of previously prescribed drugs in similar cases, use of residual or additional drugs at home, or refusing to take a prescribed drug currently (WHO Guidelines, 2000).It also includes the use of alternative therapies such as herbal remedies, dietary supplements, drugs that are traditionally made at home, use of medications prescribed for a person to treat other family members; especially in treatment children and the elderly (WHO Drug Information, 2000).Evidence suggests that there is no the correct pattern of drug consumption in Iran and medicinal system is faced with the some problem such as of excessive, inappropriate and arbitrary drug consumption (Tavakoli, 2001).Among the causes of high drug consumption in Iran compared to the average and standard in the world, can be pointed to self-medication without a prescription, and common false culture of drug use (Davati et al., 2008).Incorrect use of medicines is a global problem and has been reported in European countries about 68% (Bretagne et al., 2006) and in America about 42% (Combest et al., 2005).Previous studies also have shown that the prevalence of self-medication among students is high, so that have been reported as follow: 65.2% in medical student of Bangladesh (Alam et al., 2015), 88.18% in Karnataka, India (Patil et al., 2014), 76% in Karachi (Zafar et al., 2008).Studies also have shown that the prevalence of self-medication in Iranian students have ranged between 35 and 83% (Purreza et al., 2013;Khaksar et al., 2006;Baghiani and Ehrampoush, 2006).From the most important causes influencing this behavior can be pointed to economic problems, lack of access to doctors, not enough time for medical consultation and availability of drugs (Khaksar et al., 2006), busy doctors' offices, incomplete delivery or similar delivery of drugs by pharmacies, previous use of some drug and healing, similar symptoms (Heidari et al., 2000) waste of time and the possibility of dismissal from work (Asefzadeh et al., 2002).Now selfmedication has led to increased bacterial resistance, failure in optimal treatment, unintentional and intentional poisonings, drug market disruption, financial loss, and \ increasing per capita of drugs consumption in the community (Hughes et al., 2001).Arbitrary medication can also lead to delays and disruption in disease diagnosis, heightening a disease, impaired treatments, increasing the side-effects, and even life endangerment (WHO Global strategy for Containment, 2001).Due to the continuous expansion of self-medication phenomenon in the community and individual direct role in the selection and use of drugs, this study was conducted to determine the prevalence of self-medication and its associated factors among students in Tehran.

METHODS
This was a cross sectional descriptive study which was conducted in 2016.The population of this research was students studying in universities in Tehran.These universities include: University of Tehran, Shahid Beheshti University, and Islamic Azad University.The samples were selected by cluster sampling method.In this process; one third of the total colleges from each university were selected randomly as a cluster and within the each cluster, samples were recruited through convenient sampling method.The total number of clusters was 89 schools and out of which we selected 30 colleges (one-third) considering the number of faculties at each university.To determine the number of samples, maximum prevalence were considered (P = 0.5), and with confidence of 95% (α = 0.05) and the amount of acceptable error (d = 0.03), the sample size was calculated 1067 people.Considering the Cluster Effect equal to 2.1, the volume was increased to 1300 people.The number of samples in each of the universities was calculated according to the number of students and considering the sex ratio of students (60% female and 40% male).Students were enrolled who were willing to cooperate in the study, had no any diagnosed chronic diseases, or were not treated during the study period.Data collection tool in this study was a researcher made questionnaire, based on previous national and foreign studies.The questionnaire was composed of 5 sections including questions related to demographic data (7 questions), questions related to knowledge (10 questions), questions related to situations where self-medication is carried out (14 questions), questions about types of drugs used (16 questions), and questions about the causes of self-medication (15 items).To determine the validity of questionnaire, the content validity ratio (CVR) was calculated using the comments of a panel of experts, as well as by referring to the table of Lawsche in whichthe items were considered as important and necessary items if they had a calculated ratio greater than 0.62 and an acceptable level of statistical significance (p <0.05).To calculate the content validity index (CVI), experts were asked to rate the question based on simplicity, clarity and relevance using 4-part Likert scale.The items with CVI score higher than 0.79, between 0.7 to 0.79, and less than 0.7 were considered as appropriate, questionable, and unacceptable respectively and finally unacceptable items were excluded.The final version of the questionnaire was offered to 30 students and 10 days later again those same people completed the questionnaires.Spearman-Brown correlation coefficient to determine the Test-retest reliability and Cronbach's alpha for the internal consistency of items were 0.74, and was 0.78 respectively.
To collect the data, the researchers went to college and gave questionnaires the students.After explaining the purpose of study and ensuring participants from the confidentiality of information, Informed consent form on the front page of the questionnaire was obtained from participants and then they completed questionnaires about 30 minutes.Data were analyzed with SPSS version 19 and using the central indices, t-test, chisquare, Pearson correlation coefficient and logistic regression.

RESULTS
From 1,300 selected sample size, 1269 people responded to the questionnaire with a mean age of 21.13±1.19years (response rate=97.6%).766 of the responders were woman (60.35%) and 503 of them were man (39.65%).other demographic information regarding research subjects shows in Table 1.The results showed that the rate self-medication in the past six months in subjects was 80.7%.The highest rate of selfmedication was related to headache 65.4%, colds 41.9%, menstrual difficulties in women 49.3%, and cough or sore throat 27.2%, respectively (Table 2).Also the most frequenteddrugs used for self-medication were: Analgesic 65.2%, cold tablets 53.1%, and antibiotics 42%, respectively (Table 3).The most important reasons for the self-medication given with subjects were: simplification of the disease (64.6%), having previous experience of the disease and its treatment (40%), a positive result of earlier self-medication, and lack of belief to the doctors both with 30%.On the other hand lack of access to a doctor, restrictions on physical or mental condition, and belief about safety of medications had the lowest frequency (Table 4).In this study gender, type of college, insurance status, and marital status were evaluated to assess the possible relationship with self-medication.Results showed that there was a statistically significant differences between self-medication with gender, university, and level of knowledge (p <0.05).So that nonmedical students are more likely to do self-medication (OR = 3.42) and those with poor knowledge compared to students with good knowledge are more likely to performed self-medication (OR = 9.2).There were not significant differences between having/not having health insurance, and marital status with self-medication (Table 5).

DISCUSSION
In this study, 80.7 percent of respondents cited the history of self-medication in the past six months.A review study in Iran has estimated the overall rate of self-medication in the general population about 53%, among students 67%, in housewives 36%, and in the elderly 68% (Azami-Aghdash et al., 2015).Studies in other countries have reported a high prevalence of self-medication in students, for example92.3% in Slovenia, (Klemenc-Ketis et al., 2010)76% in Karachi (Zafar et al., 2008), and 98% in Palestine (Sawalha, 2008).Some other studies have reported the self-medication in the students lower than the mentioned rates above, for example in students of Islamabad, Pakistan 42% (Hussain and Khanum, 2008) as well as in Nigerian students 56.9% (Olayemi et al., 2010).
In our study, headaches, colds, menstrual problems, cough, and sore throat were most cases conducive to selftreatment.These findings are consistent with results of other studies (Pandya et al., 2013;Kasulkar and Gupta, 2013;Zafar et al., 2008;Sawalha, 2008).In the most mentioned studies, headache is the most common cause of self-medication which can be explained that headache is a common symptom and exists in most diseases; therefore patients have to take medicine to relieve headaches.On the other hand in the general population of Iran, the highest rate of self-medication is performed on respiratory diseases (Azami-Aghdash et al., 2015).Also in our study, most drugs used for self-medication were: Analgesic, cold tablets, and antibiotics, respectively.According to most diseases and conditions conducive to self-medication, (headaches, colds, menstrual issues and cough and sore throat), it is logical that people are taking such drugs for self-medication.Studies in the general population also show that analgesics and antibiotics were the most drugs used for selfmedication (Sahebi et al., 2009;Seyam, 2003).Also, 79.4 percent of those who had treatment for cold had consumed antibiotics (Moghadamnia and Ghadimi, 2001).In studies conducted in other countries, similar results have been obtained (Lukovic et al., 2014;Pandya et al., 2013;Kasulkar and Gupta, 2013).
As the results of this study showed, the arbitrary use of antibiotics is high (42% of all people).In the study of Sarahroodi, 42.3 percent of medical students and 48% of non-medical students had self-medication with antibiotics, of which 73.3 percent had used for respiratory problems such as sore throat and colds (Sarahroodi and Arzi, 2014).Patil and colleagues reported that antibiotics among undergraduate medical students were the most commonly self-medicated and reported by 248 (63.91%) students, out of which only 92 (37.1%) students completed the full course of antibiotic regimen (Patil et al., 2014).Also, in many studies, arbitrary use of antibiotics with more than 30 percent was one of the five leading drugs in self-medication (Pandya et al., 2013;El Ezz and Ez-Elarab, 2011;Sawalha, 2008;Zafar et al., 2008).
In our study, people had a self-medication because they had underestimated and simplified their disease, had previous experience of the disease and its treatment, and had a positive result of earlier self-medication.This finding confirms the results of other studies (Sawalha, 2015;Lukovic et al., 2014;Zafar et al., 2008).On the other hand in some studies, the main reasons for self-medication were reported the appropriate information about diseases and medicine (Khaksar et al., 2006) and lack of time (Ali et al., 2010) respectively.
In this study there was a significant difference between sex and self-medication and the self-medication in men was higher than women, in these terms the finding of this study are consistent with results of other studies (Lukovic et al., 2014;Purreza et al., 2013;Khaksar et al., 2006), however in some studies, the selfmedication have been reported in men higher than women (Sawalha, 2008).In addition, studies in the general population have shown that self-treatment in Iranian women is higher than men (Seyam, 2003).The results also showed that awareness and university had been correlated with the degree of self-medication in the past six months.Self-medication in people who had better knowledge and were students at the Medical Universities were lower than the other groups.This finding confirms the results of other studies (Lukovic et al., 2014;Sawalha, 2008).

Limitations
Our study has some limitations.First, the study was cross-sectional, and each variable was measured only once; exposure and outcome were measured simultaneously, and this issue prevented the detection of the causal relationships.Second, the study was based on self-reported data and participants were asked about the period of the last 6 months, which may be some wrong data were collected and analyzed in the study because recall bias.

CONCLUSION
Self-medication among students is very important.Our study and other studies have shown high levels of Self-medication in this group of society.In our study self-medicate was associated with being male, lower awareness and non-medical student.On the other hand reducing self-medication with antibiotics is required to adopt strict rules and regulations that people cannot afford these drugs without a prescription.As well as conducting education about the negative effects of drugs for students and other community groups is essential.
Financial support and sponsorship: Nil.

Table 1 :
Demographic characteristics of participants.

Table 2 :
Frequency of conditions and situations leads to self-medication.

Table 3 :
Frequency of drugs used for self-medication in the past 6 months.

Table 4 :
Reasons for the self-medication in perspective of student.

Table 5 :
Factors affecting self-medication at the past 6 months.