Self-medication practice and associated factors among adults in Wolaita Soddo town, Southern Ethiopia

Background: Self-medication is the selection and use of medicines by individuals to treat their self-recognized illnesses or symptoms. Self-medication can decrease costs and enable health professionals to concentrate on more serious health problems. Aim: To assess self-medication practice and associated factors among adults in Wolaita Soddo town, Southern Ethiopia, 2017. Methods: An institution-based cross-sectional study was conducted from September 30 to October 30, 2017. A multi-stage sampling technique of drug retail outlets in Wolaita Soddo town was employed to identify 623 individuals that came to buy drugs in the past three months. Data was collected using a structured questionnaire. Results: About 33.7% of the respondents had practiced self-medication in the past 3 months. Multivariate analysis revealed that female sex (adjusted odds ratio (AOR) = 2.22, 95% confidence interval (CI): 1.47–3.36), low income (AOR = 3.95, 95% CI: 2.32–6.73) and higher educational level (AOR = 5.79, 95% CI: 2.47–13.58) were the independent factors significantly affecting the practice of self-medication with drugs. Headache/fever (32.4%), respiratory tract infections (31.4%) and gastrointestinal diseases (16.2%) were the most frequently reported illnesses or symptoms of illnesses that prompted self-medication of study participants. Conclusion: Health education campaigns, strict legislations on dispensing drugs from private pharmacies, and improving accessibility and affordability of health care are among the important interventions required to change people’s health-seeking behavior and prevent the potential risks of self-medication.

T he World Health Organization (WHO) defines self-medication as the selection and use of medicines by individuals to treat self-recognized illnesses or symptoms (1). It is an element of self-care in which people utilize traditional or modern medicine without consulting a physician, either for diagnosis, prescription or surveillance of treatment. Self-medication comprises obtaining medicines without authorized prescription, resubmitting old prescriptions to buy medicines, using medicines in share with relatives or social life members, or utilizing leftover medicines stored at home (2).
A cross-sectional study conducted on prevalence and pattern of SMP in an urban area of Delhi, India showed that the major sources of information for self-medication were past experience (46.5%) followed by a physician's old prescription (43.8%), recommendation by chemists (35.6%) and family members' opinion (35.6%) (8). Similarly in Alexandria, Egypt, the most common source of advice or information about self-medication with drugs was an old prescription (73.9%), pharmacists (42.7%), and an older person in the household or friend (30.5%) (26).
A study conducted in Addis Ababa showed that 39% of drug consumers received advice from health professionals like physicians, nurses and health assistants but without formal prescriptions. About 23.5% of participants were advised by friends, relatives or neighbors, who themselves had no background in the health profession. Pharmacists or other personnel working in pharmacies were found to be sources of advice for 15.4% of respondents, whereas 20% of respondents received no advice but had information on the drugs from labels, leaflets or promotional materials (18).
Studies conducted in different countries have shown that age, sex, poor health status, inconvenient access or services (3), along with education (9), place of residence, marital status, occupation, old age group (6), and presence of chronic diseases (26), were factors for self-medication. Convenience of pharmacy, friend/peer pressure and advertisements (28), unavailability of physicians, prior experience treating the same illness and requirement of emergency care were other factors for self-medication (29).
In a study on self-medication practice in Mekelle, Ethiopia, the main reasons for self-medication were belief that the illness is mild (21.7%), previous experience of illness/ medicine (20.7%), inexpensive and time-saving (20.2%), belief that it was an emergency situation (17%), and prevention of known or unknown illness (16.9%) (24).
Studies indicate that self-medication is the first response to illness among people with low income (30). A study conducted in Addis Ababa indicated that the most common reasons for self-medication were non-seriousness of illness (36.6%), emergency situations (19.8%), prior experience (18.2%), and less expensive in terms of time and money (12.6%) (18).

Study setting and population
This study was conducted in Wolaita Soddo town, 327 km from the capital city of Addis Ababa. Wolaita Soddo town has an estimated population of 140,105 number. It has 30 drug retail outlets (DROs), two hospitals, three health centers, 11 health posts and 21 private health institutions that provide health services to the community.

Study design
An institution-based cross-sectional study was conducted in nine DROs from September 30 to October 30, 2017 in the Wolaita zone of Soddo town.

Study population
All adult people >18 years of age who attend DROs to buy drugs.

Inclusion criteria
Adults (age >18 years) who buy drugs with or without a prescription from the selected DROs in Wolaita Soddo town during the study period.

Exclusion criteria
People who were not able or willing to sign informed consent.

Self-medication practice and associated factors
Sample size determination The sample size was calculated using single population proportion formula.
where n: sample size; p: estimated prevalence of self-medication; Z: percentile of standard normal distribution corresponding to 95% confidence level; d: the margin of error which is 0.05. By using the anticipated population proportion of 24.4% from a previous study (21), the sample size calculated as Hence, the design effect of the study was 2 and the sample become 566. The total sample size when 10% non-response was added became 623.
Sampling procedure A multistage sampling technique was conducted to select study participants. All types of drug retail outlet such as pharmacies, drug stores and drug vendors were used. About 9 drug retail outlets were selected randomly from the total drug retail outlet and then individuals were selected systematically.

Data collection and Analysis procedure
A face to face interview was conducted with individuals coming to selected pharmacies to buy drugs during the data collection period. After gaining informed consent from the participant, background information and possible factors were collected.

Data collection tool
A pre-structured questionnaire was developed and translated into the local language, Amharic. To ensure consistency, it was then retranslated to English.

Data Quality control
Four health professionals who had previous experience on data collection were selected and trained for one day. The questionnaire was pre-tested on 5% of the actual sample size before data collection. The data was checked for completeness and consistency. The Hosmer and Lemeshow test for Goodness-of-fit of the model was done (p = 0.698).

Data processing and analysis
Data was coded and entered into the computer with EPIdata version 3.1 and exported to SPSS version 20 for analysis. Descriptive statistics such as frequencies, percentage and tables were used to present the respondent's result. Independent variables with p < 0.25 on bivariate analysis became a candidate for multivariable analysis. Univariate and multivariate logistic regression was fitted to identify associated factors with 95% CI using p-value < 0.05. were Protestant in their religion and 328 (52.6%) were married (Table 1).

Source of advice and way of requesting drugs
The most frequent source of advice for self-medication in the present study were pharmacists 117 (55.7%), other healthcare providers such as nurses and health assistants 41 (19.5%) and friends 34 (16.2%). Drug consumers were also asked how they requested the drugs they used. About 101 (48.1%) of drug consumers made their requests by relating the symptoms of their illness to a pharmacy professional, 82 (39%) of them by telling the specific name of drug, whereas 22 (10.5%) mentioned the class to which the drug belongs. Nevertheless, 2.4% of respondents requested the drug by showing an old sample of the drug or drug products (Table 3).

Reasons for self-medication
About 165 (26.5%) of the study participants believed that the disease was mild. However, 164 (26.3%) of the participants opinion was inexpensiveness and 95 (15.2%) to save their time ( Table 4).

Factors associated with self-medication practice
The multivariable logistic regression model showed that sex, educational status and income were statistically associated with self-medication practice. Female respondents were about twice more likely to practice self-medication than males (AOR=2.22, 95% CI: 1.47-3.36) (p < 0.05). Respondents with higher educational level were 5.8 times more likely to practice self-medication compared to those having no formal education (AOR = 5.79, 95% CI: 2.47-13.58) (p < 0.05). Study participants with low monthly income were found to be 4 times more likely to practice self-medication compared to those with higher income levels (AOR=3.95, 95% CI = 2.32-6.73)(p < 0.05) ( Table 6).

Discussion
Self-medication has an important role in the care of minor illness. It can decrease cost and enable health professionals to concentrate on more serious health problems. (3, 31) On  Self-medication practice and associated factors the other hand, self-medication is a potential contributor to human pathogen resistance to antibiotics. Its potential risks include incorrect self-diagnosis, delay in medical treatment, incorrect treatment choice, severe adverse reactions, incorrect dosage, and drug dependence and abuse (32).
In the present study the prevalence of self-medication was 33.7% (95% Cl: 37.2, 42.2). This finding is in line with other studies carried out in different parts of the world such as Saudi Arabia (35.4%) (3) and South India (35.9%) (33). This result is also similar to studies carried out in different parts of Ethiopia such as Assendabo, Southwest Ethiopia (39.2%) (20) and Nekemte (36.7%) (34,19). On the other hand, the prevalence of SMP in this study is lower than those conducted in India (92.8%), 8 Sudan   (2) and Silte (24.4%) (21). This might be due to sociodemographic factors such as educational status, socio-economic status and living status of the study participants. Moreover, the prevalence of self-medication could not be compared across different studies due to the varying nature of definitions used, recall period considered, region selected and methodology adopted, the role of country culture, healthcare systems and the perceived role of health professionals. Data from the present study showed that sex, income and educational status had significant association with self-medication practice. Female respondents were more likely to practice self-medication than males. This finding is consistent with studies conducted in Brazil (9), Iran (36), Italy (11), Greece (12), Serbia (37), Arsi University (38), Kolladiba (19). The fact that females have significant social roles, are more strongly self-care oriented than male and have more active involvement in household activities making them tend not to seek other medical service are other reasons for the increased practice of self-medication among females (12). However, contradicting literature showing that men self-medicate more than women were found in South Karnakata (23), and Saudi Arabia (3).
This study showed that respondents with low socio-economic status were more likely to practice self-medication compared to those with higher income, which is in line with studies conducted in Kharthoum (16) and Kolladiba (19). In the majority of economically deprived countries, nearly 60-80% of health related problems are treated through self-medication as a lower cost alternative. As WHO indicated, self-medication provides a cheap alternative to people who cannot afford to pay healthcare costs, and thus, self-medication is often the first response to illness among people with low income (20,39). Most people prefer self-medication than going to health facilities because of high costs of laboratory diagnosis and other services.
In this study, participants with higher educational status practice self-medication higher than those with no formal education, which is consistent with previous studies conducted in Iran (36), Spain (13), Greece (12), Rajasthan (40), and India (8). Respondents with college and university educational level have more knowledge about common diseases and drugs for self-treatment than those who are less educated. Moreover, people with higher educational status have more self-confidence in self-diagnosis and self-medication, especially where there is acute illness and as a result they are capable of identifying appropriate drugs to treat their symptoms, whereas less educated people prefer a medical consultation (12).
Headache was the primary symptom for practicing self-medication in the present study, which is supported by studies conducted in Karachi (5), Pakistan (4), Mekelle (24), Kolladiba (19), Silte (21). However, this finding contradicts results from a study conducted in Addis Ababa (18), in which gastrointestinal disease was the most frequently reported illness for self-medication. In this study, cough/common cold, gastrointestinal disease and malaria were the most frequently reported illnesses following headache that necessitated self-medication, consistent with findings in Kolladiba, Ethiopia (19) In the present study, analgesics/antipyretics were the most frequently utilized drug classes as indicated in other studies done in Brazil (9), India (41), Kolladiba (19), Mekelle (24), Jimma (27) and Southwest Ethiopia (42). This is because these drugs are used to treat mild common symptoms such as headache, fever and pain. It confirms that analgesics/antipyretics are the most commonly utilized over the counter drugs for self-medication. Similarly, antibiotics and antimalarials were frequently utilized drug classes next to analgesics in the present study, which is in line with studies conducted in Iraq (25), Jimma (27), India (41), Kolladiba (19), Southwest Ethiopia (42), Arsi University (38) and Addis Ababa (18).
In the present study, mildness of disease, inexpensiveness of self-medication, and saving time were pointed out as major reasons for self-medication, supported by studies conducted in Mekelle (24), Addis Ababa (18), Rajasthan (40), Sudan (16) and Sire town (2).

Conclusion
According to our study, self-medication is practiced for both over-the-counter and prescription only drugs. Respondents who were female, having low socio-economic status, divorced and higher educated were more likely to practice self-medication. Headache/fever, RTIs and GITs were the most frequently reported symptoms of illnesses that prompted self-medication. The major reasons for SMP were mildness of disease, inexpensiveness of self-medication and saving time. Analgesics/antipyretics, Antibiotics, and Antimalarials were the most frequently requested drug classes. Health professionals, especially community pharmacists, need to educate people on the benefits and risks of self-medication to encourage responsible self-medication. Future research to assess the practice of Self-medication should be conducted.

Declaration
Ethics approval and consent to participate An ethical approval was obtained from the Ethical Review Committee of Wolaita Soddo University, College of Health Sciences, Research and Community Service Office. Official support letter was obtained from Wolaita Soddo University and Wolaita zone health department for undertaking the study. An informed consent was obtained from each of the study participants. Each participant took part in the study after verbal consent was approved.