self-medication and indiscriminate use of antibiotics without prescription in chennai, india: a...
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Objective: To explore the use of self-medication with antibiotics among the general population in Chennai in the state of Tamilnadu Methods: A total of 1021 adults aged 18 and above were approached and 781 subjects (76.4%) were participated in this study from the period of Jan - March 2014 in Chennai. Face to face interviews were conducted using a structured questionnaire was used to collect data on the socio-demographic details, use of antibiotics, and self-medication with antibiotics with or without prescription, source of antibiotics obtained and most common symptoms/Disease for which antibiotics were frequently used. Results: The prevalence of self-medication with antibiotics in Chennai was 39.1%. Among the eligible representative sample 781, Males 424(54.3%) and females 357(45.7%) were reported the frequent use of self-medication with antibiotics. The use of self-medication with antibiotics was found to be statistically significantly associated with age, income. The major source of obtaining antibiotics without medical prescription was the Pharmacy (PTRANSCRIPT
ISSN No:2321 – 8630, V – 1, I – 1, 2014 Journal Club for Pharmaceutical Sciences (JCPS)
Manuscript No: JCPS/RES/2014/25, Received On: 18/09/2014 , Accepted On : 29/09/2014, Published On: 12/10/2014
RESEARCH ARTICLE
© All Rights Reserved by “Journals Club & Co.” 130
Self-Medication and Indiscriminate Use of Antibiotics Without Prescription in Chennai, India: A Major Public Health Problem
1*Nandakumar Ganesan, 2Siva Subramanian, 3Jaikumar, 4Harish Rawat, 5Senthil Kumar
1Department of Public Health, Supreme Council of Health Doha, Qatar. 2Pulla TKR College of Pharmacy, Hyderabad, AP
3Sree Lakshmi Narayana Institute of Medical Sciences, Pondicherry, Tamilnadu 4Tata consultancy services, Noida, New Delhi
5Dept of Pharmacology, R.V.S College of Pharmaceutical Sciences, Coimbatore, Tamilnadu
ABSTRACT To explore the use of self-medication with antibiotics among the general population in Chennai in the state of Tamilnadu. A total of 1021 adults aged 18 and above were approached and 781 subjects (76.4%) were participated in this study from the period of Jan - March 2014 in Chennai. Face to face interviews were conducted using a structured questionnaire to collect data on the socio-demographic details, use of antibiotics, and self-medication with antibiotics with or without prescription, source of antibiotics obtained and most common symptoms/Disease for which antibiotics were frequently used. The prevalence of self-medication with antibiotics in Chennai was 39.1%. Among the eligible representative sample 781, Males 424(54.3%) and females 357(45.7%) were reported the frequent use of self-medication with antibiotics. The use of self-medication with antibiotics was found to be statistically significantly associated with age, income. The major source of obtaining antibiotics without medical prescription was the Pharmacy (P<0.001). Self-medication with antibiotics is common and more prevalent among general population and it is recommended that further research study is needed in this area to know more about it and to understand it better. Doctor’s contribution and altitude is must for minimize or reduce the misuse of antibiotics in the city of Chennai.
KEYWORDS
Prevalence, Antibiotics, Self-medication, Chennai, Cefuroxime
INTRODUCTION
Alexander Fleming started the history of
antibiotics in the 1920s by discovery of
penicillin’s, When penicillin’s was first
introduced and used widely, and it was
spoken as wonder drug, then penicillin was
used for much more infections caused by
various organisms.1 In 1929, Alexander
Fleming said that, the time may come
when penicillin can be bought by anyone
from the medical shops, and when a man
Address for Correspondence: Nandakumar Ganesan, Department of Public Health, Supreme Council of Health Doha, Qatar Email: [email protected], [email protected]
Self-Medication and Indiscriminate Use of Antibiotics Without Prescription in Chennai, India: A Major Public Health Problem
© All Rights Reserved by “Journals Club & Co.” 131
who may gets under dose himself by
exposing his microbes to non lethal action
of drugs which makes them more
resistance.1 According to Alexander
Fleming suggestions, Antibiotics need to
be prescribed in a judicious manner and
more than 100 millions outpatient
prescriptions are unnecessary.2 In early
stages, 70 & 80s study revealed that more
than 60% of the doctors/physician used
antibiotics to treat even common cold on
their patients. 3
Antibiotics can be defined as a
substance derived from living organisms,
usually bacteria or molds, and it is able to
kill microorganisms or inhibit their
growth. In fact, the word antibiotic means
life destroying. Whereas antibiotics were
originally grown from natural components
for the use of treatment of parasitic
diseases, today they are often synthetically
produced to help combat bacterial
infections.4 Self-medication can be
defined as the use of drugs to treat self
diagnosed symptoms or the intermittent or
continued use of prescribed medication for
chronic or recurrent disease or symptoms. 5
Data is not available from Chennai
regarding the level of self medication and
using antibiotics without prescription.
Although, pharmacies in Chennai are not
allowed to sell antibiotics without a valid
prescription by a licensed practitioner.
Thus, this study will provide an important
data regarding the self medication and use
of antibiotics without prescription among
population. The result can be useful for
developing policies and regulations
regarding the indiscriminate use of
antibiotics and other medications in
Chennai.
The prevalence of self-medication with
antibiotics was high in Chennai because,
this is the fact that not only Chennai, all
over India most of the drugs easily
available or obtained from the community
pharmacies and retail drug store without
valid medical prescription. As a result of
this, minor ailments are often treated with
most powerful antibiotics. Despite the
introduction of essential drug list by world
health organization (WHO) with concept
of limited number of drugs supply for
betterment of prescriptions and to reduces
the cost of healthcare.5
METHODS
This is prospective cross-sectional survey
based study on general population which
included subjects aged between 18 -55
years old. Participants who refused to
provide consent will be excluded from the
study and subjects were selected randomly
by using simple random sampling
technique. Data collection took place from
the period of three month between Jan -
March 2014. The questionnaires with a
Self-Medication and Indiscriminate Use of Antibiotics Without Prescription in Chennai, India: A Major Public Health Problem
© All Rights Reserved by “Journals Club & Co.” 132
letter of explanation, structured, validated
questionnaire were distributed to the
subjects studying in college and university
and general population. College and
university students and general population
completed the questionnaires and returned
them to the interviewer. A total of 1021
populations were approached and 781
subjects participated in the study giving a
response rate of 76.4%.The questionnaire
had three parts. The first part included the
socio-demographic details of the studied
subjects; the second part included the type
of antibiotics used; Source of Obtaining
Antibiotics and Common
Symptoms/Disease for which antibiotics
were self used. There is no ethical
clearance for the study was obtained
because of this survey based study.
Informed consent was obtained from
individual subject before each interview
starts. The statistical analysis was
performed by using the Statistical Package
for Social Sciences (IBM SPSS version
19.0, SPSS Inc, Chicago, Illinois).The data
were collected and computed into SPSS
statistical software. Frequency with
percentage will be calculated for all
categorical variables and mean with
standard deviation for continuous scale
data. The Chi-square and Fisher’s exact
tests (two-tailed) were performed to test
for differences in proportions of
categorical variables between two or more
groups. Student-t test was used to ascertain
the significance of differences between
mean values of two continuous variables.
The level P<0.05 was considered as cut-off
value for significance.
RESULTS
Table 1 shows the socio-demographic
characteristics of the studied subjects with
and without self-medication. Overall mean
age was 32.8± 9.5 years old with 27.1±9.3
years old among self-medication group
and 36.4±7.7 years old among non Self
medication group, Among the studied
subjects 424(54.3%) were males while
357(45.7%) were females. Males were
more 271(88.0%) vs. 37(12.0%) in self-
medication group while females were
more 320(67.7%) Vs 153(32.3%) in non
self- medication group (P<0.001). Most of
the respondents were in the age group 26-
34 years (30.6%). The majority of them
were College/University education
(28.6%), with middle level of income
(42.9%) and the difference in educational
level, and occupation status was not
statistically significant between self-
medication and non self medication group
(P=0.583; P=0.139 respectively).
Table 2 shows the Prevalence of Self-
Medication with antibiotics according to
gender of the studied subjects. Prevalence
of Ciprofloxacin, Azithromycin and
efaclor self-medication was higher among
Self-Medication and Indiscriminate Use of Antibiotics Without Prescription in Chennai, India: A Major Public Health Problem
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studied male subjects as compared to
females (5.7%Vs1.7); 23.1%Vs16.5%) and
21.7%Vs15.1%) respectively) with Values
0.004, 0.022, and 0.019 respectively. In
addition, prevalence of erythromycin,
Norfloxacin and Cefuroxime was higher
among females as compare to males
(P<0.001; 0.045 and 0.002).
Table 3 and figure 1 shows the source of
obtaining antibiotics and common
symptoms/Disease for which antibiotics
were self-used. Difference between males
and females in terms of obtaining
antibiotics and common medical
symptoms/Disease were higher significant
with P<0.001 for each. Higher proportions
among males are obtaining antibiotics
from Doctor/ dentist while more
proportions among females are obtaining
antibiotics from community pharmacies
and friends. The commonest symptoms
among males for self-medication are cold
while on other hand toothache is the most
common symptoms among females.
DISCUSSION
Use of self-medication with antibiotics
without valid medical prescription is a
serious health problem which may leads to
increases bacterial resistance and several
side effects. Antibiotics are the most
powerful agents used for various bacterial
infections and acts as bacteriostatic and
bactericidal action. Inappropriate use of
antibiotics may drug cause resistance,
adverse effects and may lift up the cost of
the treatment.6
In present study 39.1% of the subjects
practiced self-medication with antibiotics
without medical prescription within the
period of three month before the study
starts. The excessive use of inappropriate
and insufficient doses of antibiotics in
developing countries is a major public
concern because it can lead to numerous
complications to the society. 7 In Malta, the
public perception towards antibiotics use
in the general population around 19.2 % of
the cases took without medical
prescription. 8 A similar study revealed in
Philippines, 66.2% of the cases were
purchased antibiotics without
prescriptions, mainly penicillin V was used
among Filipino population.9 In another
study reported from Vietnam ,cough
(34.1%),sore throat (32.0%)and diaherroea
(8.8%) were treated by antibiotics without
prescriptions ,even though patient does not
know what does it mean.10 In similar to
results of the study in Turkey11 with 45.8%
of self medication with antibiotics and also
in Jordan12 (40.7%) and other studies in
Sudan13 (48%), Lithuania14 (39.9) and
USA15 (43%), Mexico16 (5%), Finland17
(28.1%) and finally Palestine18 (19.9%).
Self-Medication and Indiscriminate Use of Antibiotics Without Prescription in Chennai, India: A Major Public Health Problem
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Table 1. Socio-demographics characteristics of the studied population according to the Self-Medication and Non-Self Medication (N=781)
Variable Total N=781 n(%
Self-Medication N=308 n(%)
Non-Self Medication N=473 n(%)
P-Value
Age (Mean±SD) 32.8±9.5 27.1±9.3 36.4±7.7 <0.001 Age Group 18-25 Years 242(31.0) 105(34.1) 137(29.0) 26-34 Years 206(26.4) 84(27.3) 122(25.8) 35-44 Years 204(26.1) 83(26.9) 121(25.6) 0.048 45-54 Years 68(8.7) 21(6.8) 47(9.9) >55 Years 61(7.8) 15(4.9) 46(9.7) Sex Male 424(54.3) 271(88.0) 153(32.3) Female 357(45.7) 37(12.0) 320(67.7) <0.001 Education Level Illiterate 62(7.9) 22(7.1) 40(8.5) Primary 220(28.2) 89(28.9) 131(27.7) Secondary 81(10.4) 38(12.3) 43(9.1) 0.583 Diploma 191(24.5) 71(23.1) 120(25.4) College/university 88(28.6) 229(29.0) Occupation Not working 263(33.7) 103(33.4) 160(33.8) College student 138(17.7) 42(13.6) 96(20.3) Private officer 221(28.3) 92(29.9) 129(27.3) 0.139 Govt officer 101(12.9) 45(14.6) 56(11.80) Business 58(7.4) 26(8.4) 32(6.8) Income/month*INR <5000 131(16.8) 50(16.2) 81(17.1) 5000-14,999 294(37.6) 132(42.9) 162(34.2) <0.001 15000-19,999 208(26.6) 90(29.2) 118(24.9) >20000 148(19.0) 36(11.7) 112(23.2)
*INR=Indian Rupees
Table 2. Prevalence of Self-Medication with antibiotics according to gender wise (N=781)
Antibiotics* Male N=424 n(%) Female N=357 n(%) P-Value Amoxicillin 295(69.6%) 209(58.5) 0.001
Augmentin 92(21.7) 54(15.1) 0.019 Ciprofloxacin 24(5.7) 6(1.7) 0.004
Doxycyline 34(8.0) 15(4.2) 0.028 Erythromycin 190(44.8) 247(69.2) <0.001 Azithromycin 98(23.1) 59(16.5) 0.022 Norfloxacin 109(25.7) 115(32.2) 0.045 Cefuroxime 89(21.0) 109(30.5) 0.002
Cefixime 137(32.3) 101(28.3) 0.224
Self-Medication and Indiscriminate Use of Antibiotics Without Prescription in Chennai, India: A Major Public Health Problem
© All Rights Reserved by “Journals Club & Co.” 135
* Multivariable don’t add to100%
Table 3. Source of Obtaining Antibiotics and Common Symptoms for which antibiotics were self –Medicated (N=781)
Variable Male N=424 n(%)
Female N=357 n(%)
P-Value
Source of Antibiotics Prescription Prescription from Doctor/Physician
107(25.2) 75(21.0)
Prescription from Dentist 86(20.3) 38(10.6) From Community Pharmacy 190(44.8) 181(50.7) <0.001 Friends 41(9.7) 63(17.6) Common Symptoms Coughs and sore throat 51(12.0) 29(8.1) Cold and fever 202(47.6) 131(36.7) Ear Infections 52(12.3) 48(13.4) <0.001 Flu conditions 68(16.0) 71(19.9) Toothache 51(12.0) 78(21.8)
Figure 1. The most common medical symptoms or conditions for which antibiotics were self-medicated (N=781)
Excessive use of antibiotics may increase
antimicrobial resistance and the burden of
chronic disease and several side effects
and also lift up the cost of healthcare
services. Without prescription, antibiotics
use will not be effective against infectious
disease. Most of the surgical methods and
chemo therapies are not possible without
antibiotics to fight against infection. These
are consequences please bear in mind
when use of antibiotics without valid
medical prescription. However, no studies
47.6
1612.3 12.1 12
36.7
19.9
13.4
8.2
21.8
05
101520253035404550
Cold andfever
Fluconditions
EarInfections
Coughsand sore
throat
Toothache
Common Symptoms
%
MaleFemale
Self-Medication and Indiscriminate Use of Antibiotics Without Prescription in Chennai, India: A Major Public Health Problem
© All Rights Reserved by “Journals Club & Co.” 136
have been reported regarding misuse of
antibiotics along with self-medication in
the state of Tamilnadu, Chennai.
Therefore, the objective of the present
study was to determine the prevalence of
self-medication with antibiotics and its
possible impact on misuse of antibiotics
and other possible socio-demographic
factors.
Antibiotics meant for bacterial infection
and mostly antibiotics misuse is caused by
lack of education or awareness campaign
etc. Improper use of antibiotics may
increase the bacterial resistance and
antibiotics are best medication for
bacterial infection and doctors/physician,
who knew that antibiotics are not effective
against viral infections. Most of the
antibiotics do not cure the common cold
because it is caused by virus not bacteria.
Most of doctors prescribing powerful
antibiotics when patients comes with mild
or moderate or severe cold with infections
,many antibiotics are misused because of
the patients does not adhere to doctors
/physician introductions and some of
patients going to pharmacies or retail drug
store asking antibiotics for common cold
or sore throat from pharmacist as a OTC
drugs. These kind of pharmacy
practices/physician or Doctor Practice may
result in the misuse of antibiotics and it
will leads to development of bacterial
resistance.6 Improper use of antibiotics
may increase the cost of treatment which
leads to prolongation of infections and, use
of antibiotics become ineffective for future
use on the certain bacterial disease. 7
There is several documented method to
prevent the inappropriate use of powerful
antibiotics, such as health education,
Doctor-patients communication and
changing or implementing the antibiotics
policy.
Health education is important contributing
factors for misuse of antibiotics. Health
education would be good measurement for
reducing the excessive use of
antibiotics19,20 and clinic and community
based health education method could be
more efficient in delivering messages to
public about inappropriate of use of self-
medication with antibiotics.21 Doctor-
patients communication is also very good
effective method to reduce the antibiotics
misuse21 and some developing
organizational policies or implementing of
exist one, to support cautious use of
antibiotics21,22, even though; some
organization and institution believes that a
computerized antibiotics therapy program
would improve the quality of the patient
care23 Although implementing the
antibiotics policy may decrease the misuse
of antibiotics as well as increase the
patient satisfaction.
Self-Medication and Indiscriminate Use of Antibiotics Without Prescription in Chennai, India: A Major Public Health Problem
© All Rights Reserved by “Journals Club & Co.” 137
Misuse of antibiotics may be caused by
several causative factors, such as socio-
economic, cultural, cognitive and
educational.23 In USA, Most of the
pediatrician reported that, parental
pressure to prescribe non indicated use of
antibiotics.24 Another study done in
Kuwait city, half of the physicians are
forced to prescribe the antibiotics by their
parents.25 Socio-economic status must be
considered as an important factor for
influencing the rise of antibiotics misuse.
25 Use of self-medication with antibiotics
without prescription from pharmacies or
other sources are common practice
throughout world, especially in developed
and developing countries,27 Availability of
antibiotics without prescription, lack of
regulation, unrestricted access to
antibiotics from pharmacies and
pharmacist are dispensing antibiotics
without known to the cause of infection,
27,28 these factors common for self-
medication with antibiotics. Moreover,
Self- medication is a significantly growing
public health problem in developed and
developing countries.27 Improper use of
antibiotics is presently one of the major
public health issues worldwide. 29,30,31
Besides, misuse of antibiotics was found
to be significantly common in children,
mainly when present with upper
respiratory tract infection (URTIs).27
In present study shows that patients are
likely to follow this pattern from low
income population. The risks of buying
antibiotics without doctor prescription
were associated with age, income, etc. The
public perception of buying antibiotics
without prescription, it is more expensive
to see or consult the doctor or physician
and very poor satisfaction with the
medical practitioners in the Chennai city.
The most common medical symptoms
treated by antibiotics were upper
respiratory tract infections (URTI)
particularly coughs and cold, sore throat
with pharmacies about 47.5% of the cases.
This present study clearly state that need
for unlimited health education Campaigns
on proper use of antibiotics among the
general population in Chennai city.
Powerful antibiotics like cefadroxyl,
cefatoxine, cefdinor, cefetamet, and
cefuroxyne, which are used for post
operative medication to treat the infections
in the body, which are being used
indiscriminately, resulting in severe health
problem to public who use the powerful
antibiotics. Retail pharmacist or
community pharmacist are supposed to
dispense scheduled drugs only with valid
medical prescriptions which has been
prescribed by qualified doctor or
physician or consultant and pharmacist
who violate the such pharmacy law must
Self-Medication and Indiscriminate Use of Antibiotics Without Prescription in Chennai, India: A Major Public Health Problem
© All Rights Reserved by “Journals Club & Co.” 138
be punished on the spot. Self-medication
with antibiotics has the potential hazard to
individual patient’s health as well as
public at huge level. This will create an
impact on antibiotics resistance health
related problem, our present study
revealed that immediate implementation
for public health education and the
enforcement of regulations regarding the
use of antibiotics without prescription in
Chennai.
Limitations in This Study:
The main limitation of this study is, it’s
cross sectional nature which have inherent
weakness in inferring causality. Also,
cross sectional survey are unable to
provide conclusive temporal association.
Therefore, results of this study should be
generalized with caution and failure to
evaluate all the risk factors and interview
all the population involved due to time
constraints.
Although, this study only estimates the
prevalence of self-medication with
antibiotics with the patterns of utilization
of non-prescribed antibiotics. No such
studies have been documented regarding
misuse of antibiotics along with self-
medication in the Chennai. Therefore, the
objective of the present study was to
determine the prevalence of self-
medication with antibiotics and its possible
impact on misuse of antibiotics and other
possible socio-demographic factors.
However, present study was not a
population-based survey and as a result
was neither representative nor could
exclude sample bias. In addition, that study
did not discover the reasons of self
medication using antibiotics, which are
important for understanding such behavior.
The present study is the first population-
based survey in an urban area in Chennai
to estimate the prevalence, source of
obtaining antibiotics and common
symptoms for which antibiotics were self –
Medicated.
CONCLUSION
Chennai has a considerably high prevalence of
self-medication with antibiotics. A strong
educational activity for the general public must
be initiated and doctors and physicians should
teach their patients not to use powerful
antibiotics without valid medical prescriptions
for any conditions. Even though, the concern
pharmaceutical regulatory authorities in the state
pharmacy council must focus on the selling
antibiotics without prescription from pharmacy
store, as a result of public health problem owing
to the increase of misuse and bacterial
resistance. In such circumstances, penalties and
imprisonment should be imposed on the retail or
community pharmacists who violate such
pharmacy laws.
Self-Medication and Indiscriminate Use of Antibiotics Without Prescription in Chennai, India: A Major Public Health Problem
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Self-Medication and Indiscriminate Use of Antibiotics Without Prescription in Chennai, India: A Major Public Health Problem
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HOW TO CITE THIS ARTICLE
Ganesan, N., Subramanian, S., Jaikumar, Rawat, H., Kumar S. (2014). Self-Medication and Indiscriminate Use of Antibiotics Without Prescription in Chennai, India: A Major Public
Health Problem. Journal Club for Pharmaceutical Sciences (JCPS), 1(I), 130-141.