Systematic review of the self-medication practice among medical students across South Asian countries

Background: Self – medication is the act of using pharmaceuticals without consulting a doctor, though a universal definition is still problematic. Humans believe that their health is their own responsibility. Therefore, they self-medicate to safeguard and maintain their own health. Prevalence of self-medication is high across SOUTH ASIAN countries. The reason to take self-medication is the lack of interaction to the physician and availability of OTC in pharmacies without prescription. People usually self-medicate over the counter drugs and dietary supplements to relieve symptoms of mental discomfort, tension and pain. Aims & Objectives: The aim of the study is to determine the prevalence of self-medication use and factors of self-medication practice among the patients. To determine the disease condition, category of drugs being used and the conditions which causes ADRS. Material & Method Study Design: Primary sources for this review were Pubmed and Cochrane. Study protocols follow PRISMA Flow statement. Research conducted based on English language. It has two criteria including Inclusion Criteria and Exclusion criteria. Conclusion: Thus, it is concluded that SOUTH ASIAN countries have a high frequency of self-medication which is linked to the inappropriate use of drugs. Thus, we should develop measures to lower the drug related health risks among these countries. The problem of non-prescription medication usage can be lessened with the implementation of educational initiatives at both levels; general public and health care professionals, as well as the enforcement of laws governing antibiotic non-prescription use.


INTRODUCTION
Self-medication can be described as the act of using pharmaceuticals either independently or upon suggestion from others without consulting a healthcare professional, although establishing a universally accepted definition remains challenging (Inder et al., 2018).
According to the World Health Organization, self-medication entails individuals choosing and utilizing medicines, including herbal and traditional remedies, to address self-perceived illnesses or symptoms.It also encompasses the occasional or ongoing use of medications initially prescribed by a physician for chronic or recurring conditions (Chindhalore et al., 2020).Self-medication involves independently using prescription drugs, refilling prescriptions based on prior usage, or sharing medications with acquaintances or family members (Bukhari et al., 2022).
As the cost of healthcare escalated and the prevalence of chronic non-communicable diseases rose, the practice of responsibly using over the counter (OTC) medications as part of self-care, alongside activities such as hygiene, nutrition, and exercise, became more prevalent (Patil et al., 2017).The World Health Organization (WHO) has introduced the term "responsible self-medication", referring to the procurement and usage of OTC medications in accordance with prescribed guidelines for treating minor ailments (Shahid et al., 2023).Engaging in responsible self-medication promotes overall health by empowering individuals to address minor health concerns effectively.For self-medication to be effective and safe, patients must assume full responsibility, akin to that of a competent doctor.This includes accurately identifying diseases or symptoms, administering the correct dosage, understanding potential outcomes, and taking precautionary measures to prevent side effects and associated disorders (Patil et al., 2017).
Self-medication constitutes a crucial aspect of patients' self-care, serving as the primary recourse for addressing common health issues that do not warrant professional medical attention (Seam et al., 2018).In situations where resources are limited, appropriate selfmedication proves to be both time and cost-efficient, offering relief from minor ailments (Shrestha et al., 2021).Additionally, the advantages of self-medication extend to the convenience and autonomy it affords individuals in managing or alleviating minor symptoms or conditions (Islam and Hossain, 2019).Approximately 300,000 individuals are shielded from emphysema, lung cancer, and stroke risks with the aid of over-the-counter (OTC) cessation products (Shahid et al., 2023).While the World Health Organization (WHO) advocates for self-medication in treating mild ailments, it also cautions against its pitfalls, such as adverse side effects and the development of pathogen resistance (Malik et al., 2019).
Self-medication is associated with a range of issues including incorrect diagnoses, hazardous drug interactions, drug abuse or dependency, antibiotic resistance, adverse pharmacological reactions, and polypharmacy (Inder et al., 2018).Antimicrobial resistance significantly undermines the efficacy of antibiotics (Shahid et al., 2023).Self-medication exerts a substantial impact on the healthcare sector due to its dual nature of positive and negative consequences (Islam and Hossain, 2019).Moreover, self-medication may heighten the risk of drug interactions and disease progression (Chindhalore et al., 2020).Self-medication presents various adverse effects, such as allergic reactions, dependence, and potentially severe or fatal outcomes.Consequently, diagnosing conditions can become challenging for clinicians due to self-medication practices, which, for instance, involve the use of NSAIDs and heighten the risk of stroke (Khan et al., 2018).
Globally, the prevalence of self-medication is notably high, with rates approximately reaching 68.07% in Europe, 92% in Kuwait, 31.02% in India, and 59.4% in Nepal.In Pakistan, research indicates a confirmed incidence of around 51.02% (Shahid et al., 2023).
Across Asia, the prevalence varies widely, spanning from 4% to 75%, while it stands at a mere 3% in northern Europe (Alam et al., 2015).A meta-analysis conducted in 2014 revealed that adolescents in South American and European countries practiced selfmedication between 4% to 92% of the time (Rathish et al., 2017).Moreover, the utilization of self-medication ranges from 32.5% to 81.5% across both urban and rural communities (Pandya et al., 2013).
In developed countries, NPM (non-prescription medicine), encompassing over-the-counter medications, is reportedly utilized by between half and two-thirds of the population (Bhandari et al., 2018).Non-prescription or over-the-counter (OTC) medications, typically available at pharmacies without a prescription, are commonly used for self-medication (Bhandari et al., 2018).Analgesics are the most commonly utilized class of drugs purchased over the counter to alleviate various types of pain.These include nonopioids such as aspirin, ibuprofen, and diclofenac, as well as opioids such as morphine and pethidine (Chindhalore et al., 2020).Self-medication extends beyond OTC medications and may also involve the use of prescription drugs, such as antibiotics, particularly in countries with lenient regulations and unrestricted access to prescription medications.

MATERIAL AND METHOD
The main sources utilized for this review were PubMed and Cochrane.The study protocols adhered to the PRISMA flow statement recommendations.The search for research studies involved using keywords such as 'self-medication', 'medical students', 'South Asian countries', and '2010-2023'.Besides, various electronic databases were employed, along with manual searches on Google Scholar, to gather relevant research for this review.Numerous research projects were considered, with inclusion criteria focusing on studies conducted in English and examining self-medication between 2010-2020.The studies of south asian countries were taken.
The studies were on self medication.
The studies with cross-sectional design were included.
The studies were in English language.

Exclusion Criteria
The following were the exclusion criteria: The studies on non medical students and general population.
The studies on other than South Asian countries.
The researches that were written in languages other than English.
The studies with other than cross-sectional design.
The studies conducted before the year 2010.

Data Extraction
The data extracted from the included studies were comprised author details, year of the study, country of the study, mean age, gender, departments of medical students in the included studies, study design, indications, sources and reasons of self-medication.

RESULTS
Through an electronic database search, 65 unique study articles were identified, out of which 60 studies were scrutinized after eliminating rejected and duplicate information.Six records that did not align with the necessary keywords were excluded, resulting in 54 study reports remaining on the shortlist.Upon further examination for full-text publications, it was discovered that 12 studies among the 54 research articles were conference proceedings (abstracts) published in special editions or issues of journals and were not available in full text.Therefore, 42 studies were left for additional assessment after eliminating these conference abstracts.Among the 42 shortlisted studies, 30 were evaluated for the current systematic review, while 12 were excluded as they did not meet the inclusion criteria.The PRISMA flow diagram (Figure 1) provides a detailed overview of this process.Most of the included studies had appropriate sample sizes and study designs.Their findings were consistent and well-defined.Additionally, none of the research included in this systematic review showed any indications of conflict of interest.

Study Characteristics
The details of authors, setting (institute and country) of research, study design, time interval of data collection, sampling technique, sample size, students' category, age and gender of students, complains, medication being used, sources of information/medicine and reasons for medication were analysed.All 30 included studies were conducted in South Asia, of which most of these were in India which were 14, 6 in Pakistan, 5 in Nepal, 4 in Bangladesh and only 1 in Sri Lanka.Almost all of these were cross sectional studies and sampling technique used was questionnaire.The total population of these studies was 9070 which included the students of MBBS, BDS, DPT, Pharmacy, Nursing and Allied sciences and Health science.The age of the students lies between the range from 19.32 ± 0.82 years to 23.2 ± 1.6 years.Prevalence of self-medication is 14% in South Asia; 13% in US; 11% in Australia and Germany; 9% in Spain, UK, and Sweden; 8% in Switzerland, Mexico and Italy (Bennadi, 2013).

Figure 1 PRISMA flow diagram for systematic review
According to several studies, between 88 and 95% of medical students self-medicate, with self-medication approximately equally prevalent in both sexes (Bukhari et al., 2022).Incidence of self-medication among medical students of Karnataka, India was reported to be as high as 88.18% as well as, 76% in Karachi, 65.2% in Bangladesh (Islam and Hossain, 2019).Suggested by pharmacist to take medication without any prescription from health care professionals or any family, friend suggested to take medication.People pick a lot of information from internet to treat their own disease.Mostly a pharmacist suggests taking medication without any authentic order of health care professional (Syed et al., 2014).In the research mostly university going student used pharmaceutical product without consultation to any physician.Students who belong the degree of medicine like pharmacy and other medical profession like MBBS, BDS etc they take medication on their own behalf of their limited knowledge (Yasmin et al., 2022).Students goes to medical college or universities have knowledge about different disease and preferred their medication, so they take their medication on their own (Karmacharya et al., 2018).

Identification of studies via databases and registers
Identification Screening Included pain, eye disease, gastritis, myalgia, back pain, stomachache, bacterial and viral infections, tooth pain, sore throat, ulcer in mouth, sinusitis, abscess, and insomnia.OTC medications and dietary supplements are the substances that people self-medicate with the most frequency.In addition to analgesics, cold syrups, antibiotics, antimalarial are occasionally used as self-administration medications (Seam et al., 2018).Studies have indicated that the burden of self-medication with antibiotics is greater in poor nations compared to developed nations (Alam et al., 2015).The majority of students took NSAIDS, antibiotics, paracetamol, antihistamines, gastrointestinal medications, and herbal remedies for self-medication (Bukhari et al., 2022).
In some studies package inserts and consulting physician were the sources of information for self-medication.The reasons for selfmedication were mildness of illness, lack of time to visit physician, seeking quick relief, cost effectiveness, ease and convenience, much information, prior experience, opinion from family members, emergency, long waiting time at clinics.Some took self-medication because of privacy reasons, enough pharmacological knowledge, physician advice wasn't effective, travelling problem, unfriendly government hospitals, exploitation by private hospitals.Some thought their problem wasn't important and some didn't trust their physicians.

AXIS tool
AXIS tool is the critical appraisal of Cross-sectional studies for the systematic evaluation of clinical research to examine trustworthiness, significance, and relevancy.The AXIS tool is a robust assessment instrument designed for evaluating the quality of interventional observational studies, encompassing cohort and case-control studies.Additionally, it serves to address the quality of study design and the potential for bias in cross-sectional studies.This tool is valuable for assessing the credibility, pertinence, and reliability of clinical research.As described in (Table 1 & 2).

Discussion
Justification of Discussion and Other Potential Funding Sources and   (Yasmin et al., 2022).Reason to take self-medication includes lack of interaction to the physician, availablityof OTC drugs in pharmacies without any prescription (anyone can purchase these), insufficient time to visit physician and being unable to get consultation.Brief ailment is also a reason of taking self-medication (Bagewadi et al., 2018).In Bangladesh price of self-medication is economical for people who are unable to bear expense by appointment of health care professional (Wegbom et al., 2021).Lack of transport facility is also a cause taking medication without consulting physician.
Psychologically patient feel pleasant to take medication according to their previous knowledge (Yasmin et  In this review common sources of information for self-medication by students were books, advice of family members, friends, internet, drug adds, prescription used by others with same illness, textbooks, and seniors.The student's self-medicated from previous prescription, leftover medicines or took the medicine form pharmacy.Similarly, according to a study of Brazil the practice of self medication was influenced, in the students' opinion, by friends and family, the usage of prior prescriptions, awareness of previously used medications, and media marketing (TV, radio, and internet) (Gama and Secoli, 2017).While in another study majority of individuals engaged in self-medication due to their familiarity with the drug and the information that the pharmacy's pharmacist had given them.Just a small percentage of SM practitioners acknowledged obtaining their information from outside sources (Rashid et al., 2020).
Similarly, according to a study of China the primary justifications given by the respondents for choosing self-medication were that the illness's severity did not warrant a visit to the doctor, that seeing a doctor would be too much trouble, that they did not have time, that the medication was based on prior experience, that friends or peers had recommended it, and that the costs were excessive (Lei et al., 2018).These explanations agree with the results of other research conducted in developing countries.The influence of the pharmacy owner in maximising revenue, consumer pressure, and lax regulatory frameworks have all been linked to the non-prescription sale of antibiotics in studies involving pharmacists in Saudi Arabia and Qatar (Bahnassi, 2016;Black et al., 2014).Therefore, it will take vigorous enforcement of regulations as well as community awareness initiatives to restrict the selling of drugs without a prescription.
The healthcare system is already struggling with a lack of resources, and antibiotic resistance is expected to make matters worse financially.
This is particularly true since hospital stays for patients with resistant illnesses are usually longer and more costly second-line medications are required.South Asian Association for Regional Cooperation (SAARC), and the Ministries of Health of WHO SEAR member countries must develop targeted interventions that centre on these prevalent inappropriate medicine use practices.Therefore, by upholding and regulating laws and regulations pertaining to the dispensing of medicines in pharmacies and by raising public knowledge of adverse drug reactions, the emergence of superinfections, and antibiotic resistance, the situation in the WHO SEAR can be changed.Policymakers need to take the necessary steps to ensure that relevant policies are developed and implemented in order to address these issues.Following Measures were taken to avoid self-medication: By teaching all local pharmacists how to treat mild illnesses and avoid non-prescription sales of prescription-only medications (Susheela et al., 2018) Education training not only to public, pharmacist and pharmacy students (Susheela et al., 2018) Another way is not providing OTC drugs to pharmacist (Bagewadi et al., 2018).
Not give permission pharmacy graduate to sell drug (Bagewadi et al., 2018).
Awareness about dosing schedule to avoid resistance (Malik et al., 2019).
They should not allow to prescribe medicine until they become a certified prescriber.
Give information about rational use of antibiotics by making part of their academic course (Mandal et al., 2020) Cross-Sectional Studies (AXIS tool) during COVID-19

Table 2
Study characteristics of the included studies (Gillani et al., 2017)dies, Psychoactive were commonly used by population of a study conducted in Iran(Abdi et al., 2018).Paracetamol, ibuprofen, azithromycin, cetrizine, doxycycline, pantoprazole, metoclopramide, ORS, itraconazole, cefixime, levofloxacin, seconidazole, ofloxacin, diclofnac, tetracycline, co-amoxiclav were frequently used medicines by medical students in this review article.Whereas ciprofloxacin, cloxacillin, amoxicillin and co-trimoxazole were commonly used drugs by non-medical students according to a study of Ali Hassan Gillani(Gillani et al., 2017).The choice of drug selection for same indication may vary due to availability of the drug, trust or goodwill of different brands for same chemical molecules, difference in cost of similar molecules of different brands etc.