Prevalence, determinants and practices of self-medication with antibiotics – a population based survey in Taif, Kingdom of Saudi Aarabiaksa

Abstract

Self-medication with antibiotics is a global health problem and it leads to the emergence of resistant bacteria. The study was conducted to determine the prevalence of self-medication with antibiotics and to identify its determinants and to investigate consumers practices during self-medication. A cross-sectional population-based survey was carried out in Taif City, KSA during July-October 2014. Adults people (> 18 years) were included and interviewed through face-to-face method using a structured questionnaire. Data was processed using SPSS (version 21). Logistic analysis was used to identify determinants of self-medication with antibiotic. P value < 0.05 was considered as statistically significant. Convenience method of sampling was adopted and a total of 400 participants were included, of them 228 (57.0%) were males and 291(72.8%) aged < 40 year. Overall, 148 (37.0%) interviewees had satisfactory knowledge about antibiotics. Residents of town were more knowledgeable than outside- town dwellers, (38.8% vs. 4.8% respectively),[OR 14.4 (1.9-109.5), (P= 0.010)]. Out of all participants 391 (97.8%) used antibiotic during the last year, of them 315 (80.6%) self-medicated themselves with antibiotics. Multivariate analysis identified male gender as the only factor that significantly associated with self-medication practice [OR 1.8 (1.1-3.1), (P= 0.018). The majority (90.5%) obtained antibiotics for self-medication from community pharmacies. Self-medication with antibiotics was prevalent among the studied population. Great efforts are needed to educate the public and to develop and implement stringent polices to limit over- the- counter sale of antibiotics in community pharmacies.

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Abubaker, et al., Int J Res Pharm Sci 2015, 5(2) ; 51 – 56
51
Available online at www.ijrpsonline.com
Research Article
Prevalence, determinants and practices of self-medication with
antibiotics – a population based survey in Taif, Kingdom of Saudi
Aarabiaksa
Yousif MA, Abubaker IE
ABSTRACT
Self-medication with antibiotics is a global health problem and it leads to the emergence of
resistant bacteria. The study was conducted to determine the prevalence of self-medication
with antibiotics and to identify its determinants and to investigate consumers practices
during self-medication. A cross-sectional population-based survey was carried out in Taif
City, KSA during July-October 2014. Adults people (> 18 years) were included and
interviewed through face-to-face method using a structured questionnaire. Data was
processed using SPSS (version 21). Logistic analysis was used to identify determinants of
self-medication with antibiotic. P value < 0.05 was considered as statistically significant.
Convenience method of sampling was adopted and a total of 400 participants were included,
of them 228 (57.0%) were males and 291(72.8%) aged < 40 year. Overall, 148 (37.0%)
interviewees had satisfactory knowledge about antibiotics. Residents of town were more
knowledgeable than outside- town dwellers, (38.8% vs. 4.8% respectively),[OR 14.4 (1.9-
109.5), (P= 0.010)]. Out of all participants 391 (97.8%) used antibiotic during the last year,
of them 315 (80.6%) self-medicated themselves with antibiotics. Multivariate analysis
identified male gender as the only factor that significantly associated with self-medication
practice [OR 1.8 (1.1-3.1), (P= 0.018). The majority (90.5%) obtained antibiotics for self-
medication from community pharmacies. Self-medication with antibiotics was prevalent
among the studied population. Great efforts are needed to educate the public and to develop
and implement stringent polices to limit over- the- counter sale of antibiotics in community
pharmacies.
INTRODUCTION
Self-medication is the selection and use of medicines by
individuals to treat self-recognized illnesses or symptoms
and it is considered as one element of self-care1. Several
factors that lead to self-medication were quoted in the
literature. The presence of chronic illness and older age
were found to be associated with the consumption of over-
the- counter drug and self-medication practice2. Some
individuals do not want to seek a medical help for minor
illnesses and considered themselves have good
experiences with self-medication3. Ramay et al reported
that female visited the pharmacy more often than male
to self-medicate and perceived little risk in its practice4. In
addition, literacy and public health education were
identified as major factors that affect the pattern of self-
medication5. Self-medication with antibiotics was
documented in different developed and developing
countries with different prevalence rates and determinants .
Bonkor et al6 reported a 70% prevalence rate with 35% of
the respondents suffered from treatment failure. In China
Pan et al7 found a prevalence rate of 47.8% of self-
medication with antibiotics among university students.
They identified prior knowledge, older age and higher
allowance as important risk factors associated with self-
medication practices. Nearly 40% of the respondents
participated in a study conducted in Jordan practiced self-
medication with antibiotics with a main reason for self-
medication was the previous experience on the efficacy of
treatment 8. Lower rate of 7.3% of self-medication to treat
minor upper respiratory tract infection was documented in
International Journal
of Research in
Pharmacy and Science
Pharmacy Practice Research Unit
College of Pharmacy, Taif
University, Al-Haweiah, Taif
Kingdom of Saudi Arabia
Address for Correspondence
Abubaker Ibrahim Elbur
E-mail : bakarelbu@yahoo.co.uk
Received: 19-05-2015
Review completed: 21-06-2015
Accepted: 30-06-2015
Access this article online
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Website:
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Key words: Prevalence, Determinants, Practices, self-medication, Antibiotics

Abubaker, et al., Int J Res Pharm Sci 2015, 5(2) ; 51 – 56
52
a population-based survey in Indonesia with gender, health
insurance and marital status as predicators of the intension
to self-medication 9. In a rural setting and within the past
12 months prior a study conducted in Greece 44.5% of the
participants admitted the use of non-prescribed antibiotic
with a third quarter of them obtained these drugs from
community pharmacies10. High prevalence of self-
medication with antibiotics was identified in Lithuania
treat mainly tonsillitis, bronchitis, and upper respiratory
infections11. The situation In Saudi Arabia as documented
in few studies was not better than observed in the above
mentioned countries. In the capital of the country
consumers were found to be with poor knowledge and
awareness with the consequences of using medicines
without prescriptions and antibiotics were ranked as top
agents used for self-medication12. Consumers in the
Eastern part of the country used antibiotics without
medical advice not only for treatment but also for
prophylactic purposes 13.In a survey in the Central Region
of the country; low income, having more than two
children, parents' poor knowledge about antibiotics,
inappropriate beliefs and practices were identified as risk
factors for self-medication of children with antibiotics 14.
This study was conducted in Taif City in the Western part
of the country to identify gaps in knowledge of Saudi
consumers about antibiotics, determine the prevalence of
self-medication with these agents, to identify determinants
of self-medication (if any) and to investigate consumers
practices during self-medication.
MATERIALS AND METHODS
A cross –sectional population-based survey was conducted
in Taif, Saudi Arabia during four month period (July-
October 2014). Interviewers met with the participants in
public places in Taif City (malls, restaurants, parks, etc..).
Saudi adults (18 years) from both gender were included.
Consumers self- medicated themselves with topical
antibiotics and who refused to participate were excluded.
Convenience method of sampling was adopted and the
sample was calculated based on the last population
census15.The data was collected by semi-final pharmacy
students through face-to-face interview method using
structured questionnaire. The questionnaire was adapted
from standardized questionnaire with slight
modifications16. It was into Arabic language using
forward-backward translation method in collaboration with
English Language Center, Taif University, Kingdom of
Saudi Arabia. The first part of the questionnaire was
designed to collect data on: participants background
characteristics (gender, age, residence, marital status,
educational level, current employment status, and monthly
income). The second part was designed to collect data on
respondents' general knowledge on antibiotics through four
structured questions: What are antibiotics used for and
effect of high doses in patient faster recovery, effect of low
dose in the prevention of adverse reactions and the
association of irrational drug use of antibiotics with the
emergence of bacterial resistance. Participants who
successfully answered all knowledge questions correctly
were classified as having satisfactory knowledge about
antibiotics. The third part covered interviewees' self-
medication practices: using antibiotics without medical
prescription or not in the previous 12 months, frequency of
self- medication during that period, reasons for self-
medication, symptoms or diseases for using antibiotics,
source of obtaining antibiotics, duration of use, source of
information about the selected antibiotic regarding
effectiveness, dosage and safety. Also this part contained
questions on frequencies of changing the dose, switching
to another antibiotic and time of stopping antibiotic. The
questionnaire was tested with a group of ten participants to
clarify structure and language. Minor changes were
suggested and adopted in the final questionnaire. Data was
processed using the Statistical Package for Social Sciences
(SPSS) software (version 21). Descriptive statistics were
used to describe all variables. Multi variable logistic
analysis was used to identify predictors of both knowledge
and self- medication practices. Predictors variables include
the socio- demographic characteristics of the participants
which include; gender, age, residence, level of education,
marital status, occupation and monthly income. P values of
<0.05 was considered statistically significant.
RESULTS
Participants’ demographic characteristics:
A total of 400 participants were included in the study, of
them 228 (57.0%) were males and 291(72.8%) aged <40
year. Residents of town were 379 (94.8%) and 303 (75.8%)
attained university educational level. Table (1) showed
participants' demographic characteristics.
Table 1: Participants background characteristics
Background characteristic
Frequency
Percent
Gender
Male
Female
228
172
57.0
43.0
Age in year
< 40
>40
291
109
72.8
27.3
Residence
Town
Outside town
379
021
94.8
05.2
Educational level
University
Below University
303
097
75.8
24.2
Marital status
Married
Single
281
119
70.3
29.7
Occupation
Working
Not working
294
106
73.5
26.5
Monthly income in SR
< 10000
>10000
227
173
56.8
43.2
Total
400
100

Abubaker, et al., Int J Res Pharm Sci 2015, 5(2) ; 51 – 56
53
Participants’ knowledge about antibiotics:
Slightly more than two third of the interviewees believed
that antibiotics can be used to treat viral or both bacterial
and viral infections. Nearly 20% of the participants thought
that higher doses of antibiotics result in faster recovery
compared to 29.5% had the misconception that lower doses
result in less adverse reactions. The contribution of
irrational use of antibiotics to the emergence of drug
resistance was known by 258 (64.5%), patients responses
to knowledge items were shown in table (2). Overall, out
of all interviewees 148 (37.0%) were classified as having
satisfactory knowledge about antibiotics. Multivariate
analysis identified residence as an important background
characteristic that significantly associated with satisfactory
knowledge about antibiotics, residents of town (38.8%)
were more knowledgeable than outside town dwellers
(4.8%), [OR 14.4 (1.9-109.5), (P= 0.010)], as shown in
table (3).
Table 2: Participants ‘ knowledge about antibiotics
Question
Frequency
Percent
Antibiotic used to treat
Viral infection
Bacterial infection
Viral+ bacterial infection
Others
128
124
143
003
32.0
31.0
35.7
01.3
Higher doses result in faster recovery
Yes
No
Don’t know
078
259
063
19.4
64.8
15.8
Lower doses result in less adverse
reactions
Yes
No
Don’t know
118
180
102
29.5
45.0
25.5
Irrational use of antibiotics lead to
bacterial resistance
Yes
No
I don’t know
258
066
76
64.5
16.5
19.0
Table 3: Determinants of participants’ knowledge
about antibiotics
Covariates
%
Yes
n
Univariable
analysis crude
OR( 95% CL)
P
value
Multivariable
analysis adjusted
OR( 95% CL)
P
value
Gender
Male
Female
39.9
33.1
228
172
1
1.3(0.9-2.0)
0.165
Age group
in year
> 40
< 40
35.7
40.4
291
109
1
0.8 (0.5-
1.3)
0.394
Residence
Town
Outside
38.8
04.8
379
21
1
12.7(1.7-
95.4)
0.014
1
14.4(1.9-
109.5)
Educational
level
University
Below
university
38.6
32.0
303
97
1
1.3(0.8-2.2)
0.238
Total
400
Self-medication practices
Out of all participants 391 (97.8%) used antibiotics during
the last year, of them 315 (80.6%) self-medicated
themselves with antibiotics. Multivariate analysis
identified male gender as the only factor that significantly
associated with self-medication practice [OR 1.8 (1.1-3.1),
(P= 0.018)], as shown in table (4), regarding the reasons
for self- medication, 235 (74.6%) consumers practiced it
because of its convenience.
Table 4: Predicators of self-medication with antibiotics
Covariates
%
Yes
n
Univariable
analysis crude
OR( 95% CL)
P
value
Multivariable
analysis adjusted
OR ( 95% CL)
P
value
Gender
Male
Female
84.0
75.9
225
166
1
1.7(1.0-
2.8)
0.047
1
1.8(1.1-
3.1)
0.018
Age group in
year
> 40
< 40
79.5
83.3
288
108
1
0.8(0.4-
1.4)
0.393
Residence
Town
Outside Town
80.3
85.0
371
020
1
0.7(0.2-
2.5)
0.608
Educational
level
University
Below
university
79.7
83.3
295
096
1
0.8(0.4-
1.4)
0.430
Marital status
Married
single
80.6
80.5
273
118
1
1.0
(0.8-
1.2)
0.986
Occupation
Working
Not working
79.0
84.8
286
105
1
0.7(0.4-
1.2)
0.206
Monthly income
SR
<10000
>10000
79.0
82.6
219
172
1
0.8(0.5-
1.3)
0.337
Total
100
391
Most of the participants 218 (69.2%) selected antibiotics
for self-medication based on a recommendation from
community pharmacists and nearly 48% their selection
based on antibiotic type. The majority of participants 285
(90.5%) obtained antibiotics form community pharmacies.

Abubaker, et al., Int J Res Pharm Sci 2015, 5(2) ; 51 – 56
54
Table 4 (a): Practices during self-medication with
antibiotics
Practice
Percent
(n=
315)
Practice
Percent
(n=
315)
Number of self-
medication
Once
Twice
Trice
More
Don’t remember
19.0
31.1
23.8
19.7
06.3
Changing the dose
Yes, always
Yes, sometimes
Never
06.3
36.8
56.8
Basis of Selection
of antibiotic
Recommendation of
community
pharmacist
Opinion of family
member
Opinion of a friend
Own experience
Previous doctor
prescription
others
69.2
23.5
14.9
39.7
36.8
1.3
Switching to another
antibiotic
Yes, always
Yes, sometimes
Never
5.7
37.5
43.5
Factors considered
for selection of
antibiotic
Type of antibiotic
Brand of antibiotic
Price of antibiotic
Indication for use
Adverse reactions
Others
47.9
11.7
35.6
46.7
19.4
03.8
Number of antibiotic
taken during single
illness
One
Two
Three
83.2
15.6
1.3
Source of
antibiotic
Community
Pharmacies
Leftover
others
90.5
19.0
02.5
Take the same antibiotic
with different names at
the same time
Yes
No
20.3
79.7
Checking
instructions in
package insert
Yes, always
Yes, sometimes
Never
41.6
45.4
13.0
Stop antibiotic use
After symptoms disappear
After a few days regardless
of the outcome
Few days after recovery
After the antibiotic ran out
At the completion of the
course
after consulting a
doctor/pharmacist
Others
37.1
13.7
28.6
14.6
27.6
Dose
determination
Consulting doctor
Consulting
pharmacist
Family member
Internet
Media
Previous experience
Guessing
24.1
60.0
12.4
05.4
01.3
27.9
04.1
Sixty percent of the consumers determined antibiotic dose
by consulting a pharmacist. Slightly more than 56% of the
participants admitted that they never change the dosage of
antibiotics deliberately during the course of treatment. The
main reasons for changing the dose as disclosed by the
participants were worsening condition, improving
condition and the drug was insufficient to complete the
treatment 37.5%, 27.9 and 22.8% respectively. Of the
consumers, 118 (37.5%) admitted that they sometimes
switch to another antibiotic during self- medication
compared to 18 (5.7%) others did it always. The major
reasons for switching were the former antibiotic did not
work and the former antibiotic ran out 62.5% and 18.3%
respectively. Participants who stop antibiotic after
symptoms disappear were 117(37.1%). However,
43(13.7%) stopped it after few days regardless of the
outcome. When asked about the practice of self-medication
with antibiotics for self health care 64 (20.3%) of the
participants said that “it is a good practice” while172
(54.6%) considered it acceptable practice and 79 (25.1%)
considered it not acceptable practice. Out of all participants
practiced self-medication with antibiotic 123 (39.0%)
thought they can treat common infectious diseases with
antibiotic successfully, while 146 (46.3%) were not sure
and 46 (14.6%) said "they cannot".
DISCUSSION
The study of irrational use of antibiotics by the public is an
important issue due to its serious related medical, societal
and economic consequences. Self-medication with these
agents is considered as one of the malpractices that need
to be investigated in -depth to understand why people
practice it and what are the predicators of this behavior.
One of the aims of this survey was to measure respondents’
knowledge about antibiotics. Despite the fact that nearly
three quarter of the interviewees attained university level
of education; the results indicated poor knowledge about
antibiotics. The finding is bad indicator reflecting the
absence of public education on antibiotics. Respondent's
residence was identified as an important predictor of
knowledge about antibiotics, town dwellers were more
knowledgeable. The observed difference may be attributed
to the difference in the provided and access to the media.
Town dwellers have many chances to come across
considerable information about antibiotics from different
health facilities and well-trained healthcare providers. The
second aim was to identify the prevalence of self-
medication and its determinants. The results showed that
self-medication was highly prevalent in this setting and it
was in agreement with the rate identified in another study
17 and higher than the rates of 18.7% and 43% quoted in
other studies 18and 19respectively.Many reasons may justify
the observed high rate of self-medication. Firstly, the
misconception that antibiotics are used to treat viral
infection is strongly linked to consumers practice in using
these agents to treat minor upper respiratory tract
infections of viral etiologies. The study area is a high
altitude one with variations in the weather during the year
which subject consumers to multiple common colds
attacks. Secondly, despite the fact antibiotics sale without
prescription was forbidden by health authorities, they are
available for sale as over-the-counter medicines. Stringent
policies are urgently needed to ban antibiotics sale as over-
the-counter agent. In this respect, heath authorities can best
utilize the experience of some countries which successfully
implemented such policies. Pharmacies owners as
investors should be involved in the formulation of such
policies to ensure their commitment. Thirdly, as disclosed

Abubaker, et al., Int J Res Pharm Sci 2015, 5(2) ; 51 – 56
55
by the participants the acquisition of antibiotics from
community outlets is convenience compared to visiting
health care facilities for illnesses they considered it as
minor ones. Similarly researchers in the above mentioned
study 6 reported that the main reasons for self-medication
were decreased cost and medical care in hospitals
associated with long delay. As documented in the current
study nearly third quarter of the interviewees was either
employees or doing their own private business. Most
probably they will not find enough time to visit healthcare
facilities despite the fact that these facilities are well-
distributed in the city. Health authorities can establish
clinics governmental workplaces to enhance access to
medical services. On the other hand, males were practiced
self-medication more than females. This finding can be
linked with the above mentioned one, as most of the
females were housewives who have enough time to seek a
medical advice at the health care facilities. In contrary,
other researchers documented high prevalence of self-
medication with antibiotics among women compared to
men20.It was expected that respondents’ higher educational
level increases their awareness about the consequences of
irrational use of antibiotics without prescriptions, but
unfortunately it was not. In contrast, in study in Albina the
impact of this factor was obvious, as adult with low and
medium educational level were most likely to self-
medicate themselves 21. The third aim was to investigate
the consumers' practices during the process of self-
medication. Analysis of the respondents' practices during
self-medication revealed many misconceptions. Most of
the participants selected antibiotics based on
recommendations from pharmacists, however others
consults friends, family members and depend on previous
experience. The role of healthcare providers is to advice
the patients not to repeat antibiotic if he/she experience the
same symptoms. In some recurrent infections the
causative agent may be resistant or acquired resistance
during the first course of therapy, so using the same
antibiotic will increase patient suffering. Consultation of
the pharmacist was a positive finding, but the pharmacist
should be aware and has the proper knowledge to handle
such cases. In Hong Kong a considerable number of the
public interviewed agreed about to consult a pharmacist
before using over-the-counter drugs 22. Nearly 37% of the
respondents stop antibiotics after disappearance of the
symptoms and did not complete the course of therapy. In
contrast, 46% of the participants in the above mentioned
survey6 did not comply with the completion of the full
course of therapy. Another serious findings documented in
the current study was that a considerable number of
interviewees sometimes change antibiotic dose and
switching to another antibiotic for different reasons.
Similarly such practices were observed in China, as over
44% of participants in that study had changed antibiotic
dosage and 36.5% had switched to another antibiotic
during the treatment course 23. This study was not without
limitations. Firstly, it was conducted in Taif City which
may limit the generalizability of the results to all country.
In the future and in order to in-depth investigate self-
medication practice large number of people need to include
from different regions in the Kingdom. Secondly,
respondents depend on their memories to recall their
practice of using antibiotics during the last year so recall
bias are expected. Thirdly, the number of male participants
included in the study was more than females. Culturally In
Saudi and particularly in the study area it is difficult to
recruit females in such type of studies. In conclusion, self-
medication with antibiotics was prevalent in Taif City and
it was significantly associated with male gender. The
participants had numerous misconceptions during the
process of practice self-medication which contribute badly
to the identified irrational use of antibiotics. Public
education at all level is needed together with stringent
policies to ban or reduce over-the–counter sale of
antibiotics in community pharmacies.
ACKNOWLEDGEMENT
This work was supported by the Secretariat of
Postgraduates and Scientific Research, Taif University.
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