Trends in practices of self-medication with antibiotics among medical undergraduates in India



   Table of Contents   ORIGINAL ARTICLE Year : 2022  |  Volume : 14  |  Issue : 1  |  Page : 19-24  

Trends in practices of self-medication with antibiotics among medical undergraduates in India

Nusrat Nabi1, Zenis Baluja1, Shoma Mukherjee1, Sunil Kohli2
1 Department of Pharmacology, Hamdard Institute of Medical Sciences and Research, New Delhi, India
2 Department of Medicine, Hamdard Institute of Medical Sciences and Research, New Delhi, India

Date of Submission22-Mar-2021Date of Decision30-Apr-2021Date of Acceptance18-May-2021Date of Web Publication19-May-2022

Correspondence Address:
Dr. Shoma Mukherjee
Department of Pharmacology, School of Medical Sciences & Research, Sharda University, Greater Noida, U.P- 201306
India
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Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jpbs.jpbs_17_21

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   Abstract 


Background: Self-medication with antibiotics (SMA) without the consultation of a professional is a serious health concern and can lead to serious health hazard. This study was designed to evaluate the trends in SMA behavior and risk factors in medical undergraduates to further explore the association between SMA practices and adverse drug events (ADEs). Materials and Methods: This cross-sectional questionnaire-based study was carried out among 360 volunteering medical undergraduates at a tertiary care teaching hospital in New Delhi. Results: 67.78% of students (244/360) gave a history of SMA practice with females dominating (54.09%). Out of 244 students giving a positive history of SMA, 182 (74.59%) experienced ADE, reflecting a strong positive association between the two. Convenience (86.07%) was observed to be the main reason of practicing SMA in this study. Over-the-counter sale of prescription-only drugs, namely antibiotics by the community pharmacies, is as high as 90.16%, leading to the main source of acquiring antibiotics for self-medication. Fever (47.54%) and respiratory infections (39.34%) emerged as the major indications for SMA. Extended-spectrum penicillins (60.66%) were the most commonly used class of antibiotics for SMA. Conclusion: Our findings endorse high SMA prevalence among Indian medical students. Strict regulations on antibiotic sales and public education reinforced by strong antibiotic stewardship program at all levels are highly recommended.

Keywords: Adverse drug event, antimicrobial resistance, medical undergraduates, self-medication with antibiotic, self-prescription


How to cite this article:
Nabi N, Baluja Z, Mukherjee S, Kohli S. Trends in practices of self-medication with antibiotics among medical undergraduates in India. J Pharm Bioall Sci 2022;14:19-24
How to cite this URL:
Nabi N, Baluja Z, Mukherjee S, Kohli S. Trends in practices of self-medication with antibiotics among medical undergraduates in India. J Pharm Bioall Sci [serial online] 2022 [cited 2022 May 20];14:19-24. Available from: 
https://www.jpbsonline.org/text.asp?2022/14/1/19/345503    Introduction Top

Self-medication with antibiotics (SMA) is the use of drugs to cure self-diagnosed disease or its associated symptoms leading to intermittent or continued consumption of a prescribed drug for a chronic or a recurrent health condition.[1] SMA without the consultation of a professional is a serious health hazard.[2] As per an estimate, more than 50% of antibiotics are procured without a valid prescription and misused as over-the-counter drugs all over the world.[3] Around 3%–19% of the general population are practicing SMA in developed countries and 9%-100% in developing countries.[4] This irrational use of antibiotics without any professional advice is responsible for several adverse drug events (ADEs), drug toxicity, resistance to the antibiotic, and ultimately failure of treatment of the underlying disease.[3],[5] An adverse event or experience is defined as any untoward medical occurrence that may present during treatment with a drug but which does not necessarily have a causal relationship with this treatment.[6] ADEs have a strong association with SMA but rarely reported due to lack of awareness, difficulties in follow-up, and critical causality assessment to establish adverse drug reactions (ADR).[7]

SMA often leads to irrational treatment and antibiotic resistance. Emergence of multidrug-resistant bacterial strains are, thus, posing a serious threat to medical management of infectious diseases.[8],[9] The overall treatment period gets prolonged due to resistant strains, leading to longer duration of illness, prolonged hospital stay, and increase in total expenditure calling for urgent need to reserve our antibiotics pool. Hence, well-formulated and detailed studies on the trends of antibiotics usage (SMA) are the stepping stones toward planning and implementing strategies to prevent indiscriminate use of antibiotics.

With this background, the current study was planned to evaluate the prevalence and factors associated with SMA, highlighting the prevalence of ADE among the undergraduate medical students.

   Materials and Methods Top

Study design, study population & study period

This was a cross sectional questionnaire based survey and the study population comprised of medical students from 4th, 5th, 6th, and 7th semester of a tertiary care teaching hospital in New Delhi, India. The study was conducted over a period of 4 months and data were collected between October 2019 to February 2020.

Sampling method and sample size

A purposive sampling method was used. 4th, 5th, 6th, and 7th semester undergraduate medical students who have an exposure to pharmacology were invited to take part in the survey. Out of a total strength of 400 students, 360 participated voluntarily in the survey.

Techniques of data collection

A structured and pretested questionnaire in English, designed after a thorough literature review of comparable studies, was modified and drafted as per the local needs.[7],[10] A pilot study was done on 10 students to validate the questionnaire, and these students were not enrolled in the study. Three hundred and sixty students (out of 390) who consented to be a part of the study were enrolled. Students were briefed, questionnaire was distributed and each student was requested to respond independently within a time frame of 30 minutes. Owing to the ingrained issues around validity and reliability of self-administered questionnaire, the cognitive validity of the responses was ascertained by requesting the students to accurately outline the questions and their knowledge on the topic. In addition, the situational validity was ascertained by ensuring that participating students responded to the questions individually to accord anonymity and any fear of stigmatization on their response. The reliability of the responses from the participant students in the main study was compared with the results of the pilot testing of questionnaire.[11],[12]

The questionnaire included 13 questions regarding the demographic profile and trends in SMA practice among the students. SMA was defined as taking over-the-counter antibiotics without prescription for self-treatment. Information on demographic characteristics and semester was recorded.

Data analysis

The data entry and analysis were performed using Microsoft Excel and SPSS version 17.0 (SPSS Statistics for Windows. Version 17.0 Chicago, SPSS Inc). Frequency tables of major factors influencing self-medications were generated. Frequencies and proportions were calculated.

Ethical considerations

The research study was approved by the Institutional Ethics Committee. The study population was informed that the data gathered would be anonymized and will be used for only publication and that the study participation was entirely voluntary.

   Results Top

Sociodemographic characteristics of the recruited participants

The demographic profile and general characteristics of the participating medical undergraduates as a function of their SMA practices are given in [Table 1]. The students between 19 and 23 years with a mean age of 20 years participated in the study. Around 68% (67.78%) of students (244/360) gave a history of practicing SMA with females outnumbering (54.09%) the males. Out of 244 students with a positive history of SMA, 53.27% gave a history of multiple (defined by >1) SMA practice. Further 74.59% (182/244) students practicing SMA experienced ADEs, reflecting a strong positive association.

Table 1: Demographic profile and general characteristics of participants as a function of self-medication with antibiotic practices

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The results of [Table 2] show common practices during SMA. Of the 244 students with SMA, the practice of reading drug literature before use was minimal (77.8% never read a literature). Around 7% patients always changes the dose of antibiotic and 40% discontinued therapy after symptoms got relieved. The outcome of such self medication was restricted to partial relief only, responded by as high as 51% responders. Attitude toward SMA was still deemed acceptable by the 58% of participating students either generally or during an emergency.

The graphical presentation in [Figure 1],[Figure 2],[Figure 3],[Figure 4] reflects convenience (86.07%) as the main reason of SMA, community pharmacy (90.16%) as the main source of acquiring antibiotics for self-medication, fever (47.54%) as the major indication followed by respiratory infections (39.34%), and gastrointestinal problems with 35.25%. Extended-spectrum penicillins (60.66%) were the most commonly used class of antibiotics.

Figure 1: Common reasons for self-medication with antibiotics. *Past experience. ϮKnowledge of Antimicrobials

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   Discussion Top

The prevalence of SMA practices: One of the major observations of this survey is the alarmingly high (67.78%) prevalence of SMA among the medical undergraduates of North India. The outcome of this study is on similar lines with those that of SMA patterns in various developing nations where the overall median proportion of self-medication reported is around 38.80%.[13] When it comes to university students of different countries, the SMA rates have been reported between 24%–90%[14],[15],[16] in contrast to Europe and other developed countries where only 1%–4% of prevalence rate was found for SMA,[4] indicating that strict regulations as far as over-the-counter (OTC) sales of antibiotics are concerned.

Inappropriate practices in SMA: Literature search showed that the most common inappropriate practices in the non-prescription use of antibiotics includes using antibiotics as prophylaxis,[17],[18],[19],[20] as analgesic,[18] for the treatment of viral infections[21],[22],[23],[24],[25],[26] and usage at reduced dose.[27],[28],[29] Further studies showed that changing antibiotic without consulting the doctor[27] and not taking antibiotics for the prescribed period which included either reducing the duration of treatment (mostly <5 days[27],[28]) or prolonging the duration of treatment (mostly more than 7 days).[17],[19] Similar to a study by Belkina et al.,[27] our findings reflect that around 41% respondents discontinued their antibiotic after disappearance of symptoms.

Association between self reported ADE and SMA practices: As per our study, it was concluded that there was a strong positive association between self reported ADE and SMA practices. About 74.59% of the students were observed to have suffered from ADEs in the group practicing SMA. In contrast to the current study, experience of ADEs was found to be much lower in an online survey conducted at a Chinese University where only 13.3% of self medicated students had experienced ADEs. Thirty two out of 42 students stopped taking antibiotics and the reason for such a disparity could be either racial difference or lack of awareness.[7]

Possible reasons for SMA: It was observed in our study that convenience (86.07%), past experience of the illness (24.59%), and prior knowledge of antibiotics (20.49%) were the most commonly cited reasons for SMA. These reasons are consistent with the findings from other studies in the developing countries.[30],[31],[32] The root causes leading to SMA in India are majorly due to poor regulation of antibiotic sale and use[18],[31], lack of awareness of consequences of inappropriate antibiotic use and misconceptions about antibiotics and the disease etiology.[25],[26] Female being more cautious about self-care and prone to SMA for menstrual symptoms may explain the higher prevalence in female gender.[33],[34] It is noteworthy that although our students had a good antibiotic knowledge, they had poor SMA practices and attitude. Such deficient translation of knowledge into practices and behavior has also been reported among other Indian and Turkish University students.[14],[15]

Common sources for acquiring the self-medicated antibiotics: Previous studies have reported that the majority of the populations acquired self-medicated antibiotics from a variety of sources, such as pharmacies, stored leftover drugs, friends/relatives, or online purchase.[25],[28] Since pharmacies were the main source of acquiring antibiotics in this study, pharmacists could play an important role in educating patients, rationalizing antibiotic use, and stopping antibiotic sales without a prescription.[13] Moreover, the manufacturer's fixed packaging, driven by cost of economics often results in under- or- oversupply of antibiotics, contributing to antibiotic resistance.[35] Such oversupply of antibiotics observed in an Indian study[36] is similar to ours, with left over antibiotics being the second most important source of self- medicated antibiotics.

The most common indications for which the respondents would self-medicate match in totality with those across the globe,[22],[25] which are fever (47.54%), respiratory tract infections (39.34%), and GIT associated problems (35.25%). These are predominantly viral in origin and therefore not treated with antibiotics. This finding is concordant with reported results from studies in the Euro-Mediterranean region[37] and developing countries.[13]

Antibiotics frequently used for self-medication: As evaluated by the data from previous studies, some of the antibiotics commonly used for self-medication were extended-spectrum penicillins (amoxicillin/amoxicillin–clavulanic acid), macrolides, cephalosporins, fluoroquinolones, and tetracycline.[26],[31],[38]

However, the extended-spectrum penicillins (60.66%) were the most commonly used class of antibiotics for self-medication in our study, followed by quinolones (33.61%) and cephalosporins (20.49%). The high use of extended-spectrum penicillins without prescription may be due to penicillin's widespread reputation, its low cost, and the fact that it does not have disturbing side effects, unlike other classes of antibiotic.[25]

Recommendations to reduce the irrational use of antibiotics: By far the most effective way to counter SMA, according to various studies across the globe was public education[39],[40] through mass media campaigns[31],[38] and implementation of strict law against OTC sale of 'prescription-only drugs'.[3],[41],[42] Strict national policy in South Korea and Chile, which prohibits physicians from dispensing drugs has considerably brought down antibiotic usage and improved rationale use of antibiotics by limiting unnecessary prescription for irrelevant conditions like viral infections.[43],[44]

Literature search of recent studies across the globe concluded as following:

Torres et al. concluded that nonprescribed antibiotic utilization was perceived as an expression of self care where participants experience self perceived symptoms[45] Haque et al., found SMA common amongst Malaysian students despite understanding the drawbacks of SMA and that even the medical students self medicate.[46] A study of SMA in a health center in Riyadh (2016) showed that the prevalence of self-prescription was as high as 78.7%, while the practice is slightly better among medical students in India in our study (67.78%). The most common predictors were friend's advice and proximity of the participants to pharmacy[47] in contrast to our study where friends and relatives contributed to only 13.11%.

   Conclusion Top

It can be concluded from the findings of our survey that SMA is highly prevalent among medical undergraduates with convenience and OTC sale of antibiotics as the main reason and source of self-medication, respectively. We also observed a strong association of experiencing adverse events with SMA practices. A student being the future prescribing physician, it is critical to impress upon the significance of rational use of antibiotics with the increasing burden of antimicrobial resistance, justified by the recent incorporation of antimicrobial stewardship in the pharmacology curriculum. However, to address the irrational use of antimicrobials, enforcing regulatory measures on OTC antibiotic sale, restricting access to prescription only medications, controlling physician over prescribing, and further incorporating it into a strong national/global network is highly recommended. The results of our study suggest conducting large-scale prospective longitudinal studies to determine the level of antimicrobial resistance, treatment failure, and confirm causality of ADRs associated with SMA practices.

Study limitations

The limitations of such self-reported studies are risk of recall bias and obtaining socially desirable responses. Moreover, students practicing SMA could have been attracted to this study; which could also have introduced bias in SMA frequency estimates and generalizing our findings.

Acknowledgment

The authors would like to express their sincere thanks to all the students who volunteered to participate in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 

   References Top
1.World Health Organization (WHO) 2000.WHO Guidelines for the Regulatory Assessment of Medicinal Products for Use in Self-Medication. WHO/EDM/QSM/00.1. Geneva: WHO; 2000.  Back to cited text no. 1
    2.Pan H, Cui B, Zhang D, Farrar J, Law F, Ba-Thein W. Prior knowledge, older age, and higher allowance are risk factors for self-medication with antibiotics among university students in southern China. PLoS One 2012;7:e41314.  Back to cited text no. 2
    3.Morgan DJ, Okeke IN, Laxminarayan R, Perencevich EN, Weisenberg S. Non-prescription antimicrobial use worldwide: A systematic review. Lancet Infect Dis 2011;11:692-701.  Back to cited text no. 3
    4.Grigoryan L, Haaijer-Ruskamp FM, Burgerhof JG, Mechtler R, Deschepper R, Tambic-Andrasevic A, et al. Self-medication with antimicrobial drugs in Europe. Emerg Infect Dis 2006;12:452-9.  Back to cited text no. 4
    5.Goossens H, Ferech M, Vander Stichele R, Elseviers M; ESAC Project Group. Outpatient antibiotic use in Europe and association with resistance: A cross-national database study. Lancet 2005;365:579-87.  Back to cited text no. 5
    6.Available from: https://apps.who.int/iris/bitstream/handle/10665/67378/WHO_EDM_QSM_2002.2.pdf?sequence=1&isAllowed=y. [Last accessed 2020 Dec 18].  Back to cited text no. 6
    7.Zhu X, Pan H, Yang Z, Cui B, Zhang D, Ba-Thein W. Self-medication practices with antibiotics among Chinese university students. Public Health 2016;130:78-83.  Back to cited text no. 7
    8.Centers for Disease Control and Prevention (CDC). Antibiotic Resistance Threats in the United States, (2013). Atlanta, GA: CDC; 2013.  Back to cited text no. 8
    9.Kumarasamy KK, Toleman MA, Walsh TR, Bagaria J, Butt F, Balakrishnan R, et al. Emergence of a new antibiotic resistance mechanism in India, Pakistan, and the UK: A molecular, biological, and epidemiological study. Lancet Infect Dis 2010;10:597-602.  Back to cited text no. 9
    10.Faten A, Aljamea ZI, Almahasnah R, Alkhalifah K, Basalelah L, Alhomoud FK. Self-medication and self-prescription with antibiotics in the Middle East – Do they really happen? A systematic review of the prevalence, possible reasons, and outcomes. Int J Infect Dis 2017;57:3-12.  Back to cited text no. 10
    11.Validity_of_Self_Report. Available from: https://minnetonkas chools.org. [Last accessed on 2021 May 14]  Back to cited text no. 11
    12.Validity and Reliability of a Self-Report Instrument to Assess Social Support and Physical Environmental Correlates of Physical Activity in Adolescents | BMC Public Health | Full Text. Available from: https://biomedcentral.com. [Last accessed on 2021 May 14].  Back to cited text no. 12
    13.Ocan M, Obuku EA, Bwanga F, Akena D, Richard S, Ogwal-Okeng J, et al. Household antimicrobial self-medication: A systematic review and meta-analysis of the burden, risk factors and outcomes in developing countries. BMC Public Health 2015;15:742.  Back to cited text no. 13
    14.Aditya S, Rattan A. Self-medication among dental undergraduate students with antibiotics: Looking beyond the known. Asian J Pharm Clin Res 2013;6:132e5.  Back to cited text no. 14
    15.Buke C, Hosgor-Limoncu M, Ermertcan S, Ciceklioglu M, Tuncel M, Kose T, et al. Irrational use of antibiotics amonguniversity students. J Infect 2005;51:135-9.  Back to cited text no. 15
    16.Awad AI, Eltayeb IB. Self-medication practices with antibiotics and antimalarials among Sudanese under graduateuniversity students. Ann Pharmacother 2007;41:1249-55.  Back to cited text no. 16
    17.Emeka PM, Al-Omar M, Khan TM. Public attitude and justification to purchase antibiotics in the Eastern region Al Ahsa of Saudi Arabia. Saudi Pharm J 2014;22:550-4.  Back to cited text no. 17
    18.Shehadeh M, Suaifan G, Darwish RM, Wazaify M, Zaru L, Alja'fari S. Knowledge, attitudes and behavior regarding antibiotics use and misuse among adults in the community of Jordan. A pilot study. Saudi Pharm J 2012;20:125-33.  Back to cited text no. 18
    19.Al zoubi K, Al-Azzam S, Alhusban A, Mukattash T, Al-Zubaidy S, Alomari N, et al. An audit on the knowledge, beliefs and attitudes about the uses and side-effects of antibiotics among outpatients attending 2 teaching hospitals in Jordan. East Mediterr Health J 2013;19:478-84.  Back to cited text no. 19
    20.Buke AC, Ermertcan S, Hosgor-Limoncu M, Ciceklioglu M, Eren S. Rational antibiotic use and academic staff. Int J Antimicrob Agents 2003;21:63-6.  Back to cited text no. 20
    21.Sarahroodi S, Arzi A. Self medication with antibiotics, is it a problem among Iranian college students in Tehran? J Biol Sci 2009;9:829-32.  Back to cited text no. 21
    22.Awad AI, Aboud EA. Knowledge, attitude and practice towards antibiotic use among the public in Kuwait. PLoS One 2015;10:e0117910.  Back to cited text no. 22
    23.Al-Bakri AG, Bustanji Y, Yousef AM. Community consumption of antibacterial drugs within the Jordanian population: Sources, patterns and appropriateness. Int J Antimicrob Agents 2005;26:389-95.  Back to cited text no. 23
    24.Darwish DA, Abdelmalek S, Abu Dayyih W, Hamadi S. Awareness of antibiotic use and antimicrobial resistance in the Iraqi community in Jordan. J Infect Dev Ctries 2014;8:616-23.  Back to cited text no. 24
    25.Cheaito L, Azizi S, Saleh N, Salameh P. Assessment of self-medication in population buying antibiotics in pharmacies: A pilot study from Beirut and its suburbs. Int J Public Health 2014;59:319-27.  Back to cited text no. 25
    26.Alakhali K, Alzomar A, Khan N, Alavudeen SS. Misuse of antibiotics and awareness of antibiotic hazard among the public and medical professionals in Thamar province, in Republic of Yemen. Pharm Glob IJCP 2013;4:1-4.  Back to cited text no. 26
    27.Belkina T, Alwarafi A, Hussein Eltom E, Tadjieva N, Kubena A, Vlcek J. Antibiotic use and knowledge in the community of Yemen, Saudi Arabia, and Uzbekistan. J Infect Dev Ctries 2014;8:424-9.  Back to cited text no. 27
    28.Suaifan G, Shehadeh M, Darwish D, Al-Ijel H, Yousef AM, Darwish RM. A cross-sectional study on knowledge, attitude and behavior related to antibiotic use and resistance among medical and non-medical university students in Jordan. Afr J Pharm Pharmacol 2012;6:763-70.  Back to cited text no. 28
    29.Barah F, Gonçalves V. Antibiotic use and knowledge in the community in Kalamoon, Syrian Arab Republic: A cross-sectional study. East Mediterr Health J 2010;16:516-21.  Back to cited text no. 29
    30.Edwards IR, Aronson JK. Adverse drug reactions: Definitions, diagnosis, and management. Lancet 2000;356:1255-9.  Back to cited text no. 30
    31.Abasaeed A, Vlcek J, Abuelkhair M, Kubena A. Self-medication with antibiotics by the community of Abu Dhabi Emirate, United Arab Emirates. J Infect Dev Ctries 2009;3:491-7.  Back to cited text no. 31
    32.Ilhan MN, Durukan E, Ilhan SO, Aksakal FN, Ozkan S, Bumin MA. Self-medication with antibiotics: Questionnaire survey among primary care center attendants. Pharmacoepidemiol Drug Saf 2009;18:1150-7.  Back to cited text no. 32
    33.Sapkota AR, Coker ME, Rosenberg Goldstein RE, Atkinson NL, Sweet SJ, Sopeju PO, et al. Self-medication with antibiotics for the treatment of menstrual symptoms in Southwest Nigeria: A cross-sectional study. BMC Public Health 2010;10:610.  Back to cited text no. 33
    34.Lucas R, Lunet N, Carvalho R, Langa J, Muanantatha M, Nkunda LP, et al. Patterns in the use of medicines byuniversity students in Maputo, Mozambique. Cad Saude Publica 2007;23:2845-52.  Back to cited text no. 34
    35.McGuire TM, Smith J, Mar CD. The match between common antibiotics packaging and guidelines for their use in Australia. Aust N Z J Public Health 2015;39:569-72.  Back to cited text no. 35
    36.Mukherjee S, Saha N. Correlation of recommendations of treatment guidelines and frequently prescribed antibiotics: Evaluation of their pharmaceutical pack size. Basic Clin Pharmacol Toxicol 2018;122:317-21.  Back to cited text no. 36
    37.Scicluna EA, Borg MA, Gür D, Taher I, Redjeb SB, Elnassar Z, et al. Self-medication with antibiotics in the ambulatory care setting within the Euro- Mediterranean region; results from the ARMed project. J Infect Public Health 2009;2:189-97.  Back to cited text no. 37
    38.Al Rasheed A, Yagoub U, Alkhashan H, Abdelhay O, Alawwad A, Al Aboud A, et al. Prevalence and predictors of self-medication with antibiotics in al wazarat health center,Riyadh City, KSA. Biomed Res Int 2016;2016:1-8. http://dx.doi.org/10.1155/2016/3916874.  Back to cited text no. 38
    39.Shah BK. Knowledge that upper respiratory tract infection resolves on its own is associated with more appropriate healthseeking behaviour and antibiotic cognition. Singapore Med J 2006;47:1012.  Back to cited text no. 39
    40.Croft DR, Knobloch MJ, Chyou PH, Ellen DV, Janette C, Davis JP, et al. Impact of a child care educational intervention on parent knowledge about appropriate antibiotic use. WMJ 2007;106:78-84.  Back to cited text no. 40
    41.Askarian M, Maharlouie N. Irrational antibiotic use among secondary school teachers and university faculty members in Shiraz, Iran. Int J Prev Med 2012;3:839-45.  Back to cited text no. 41
    42.Raz R, Edelstein H, Grigoryan L, Haaijer-Ruskamp FM. Self-medication with antibiotics by a population in northern Israel. Isr Med Assoc J 2005;7:722-5.  Back to cited text no. 42
    43.Togoobaatar G, Ikeda N, Ali M, Sonomjamts M, Dashdemberel S, Mori R, et al. Survey of non-prescribed use of antibiotics for children in an urban community in Mongolia. Bull World Health Organ 2010;88:930-6.  Back to cited text no. 43
    44.Park S, Soumerai SB, Adams AS, Finkelstein JA, Jang S, Ross-Degnan D. Antibiotic use following a Korean national policy to prohibit medication dispensing by physicians. Health Policy Plan 2005;20:302-9.  Back to cited text no. 44
    45.Torres NF, Solomon VP, Middleton LE. Patterns of self-medication with antibiotics in Maputo City: A qualitative study. Antimicrob Resist Infect Control 2019;8:161.  Back to cited text no. 45
    46.Haque M, Rahman A, Mckimm J, Kibria GM, Majumdar AA, Haque SZ, et al. Self medication of antibiotics: Investigating practice among university students at the Malaysian National Defence University. Infect Drug Resist 2019;12:1333-51.  Back to cited text no. 46
    47.Rasheed AA, Yagoub U, Alkhashan H, Abdelkay O, Alawwad A, Abound AA, et al. Prevalence and predictors of self- medication with antibiotics in Al Wazarat Health Center, Riyadh City, KSA. Biomed Res Int 2016;2016:1-8.  Back to cited text no. 47
    
  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
  [Table 1], [Table 2]
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