Self-medication practices and their characteristics among Iran university students

Background: Self-medication in students as educated people is one of the most important health issues. It is known that inappropriate self-medication is harmful for individuals due to some potential risks and also harmful to the government because disrupts the drug market and increases the per capita nancial drug consumption. Thus, the aim of this study is to investigate the habits related to rational use of drug (RUD) and the prevalence of self-medication practices among students. Methods: A cross-sectional study was conducted in 2021 at Jahrom universities/Iran using an electronic “Self-medication practices and medication habits” questionnaire. The 848 students from four healthcare and non-healthcare faculties participated in the study. Results: The prevalence of self-medication among students was 44.8%. The most common medicines on self-medication were cold remedies and sedatives in about 33%. About 47% of students had used antibiotics without a doctor's prescription. The internet and social networks were the source of information about the RUD in about 40% of students. There was no difference in RUD between medical and non-medical students (OR = 0.865, 95% CI: 659-1.134). RUD in students with underlying disease was higher than students without underlying disease (OR = 2.8, 95% CI: 1.39-5.60). Conclusions: Self-medication was high prevalence in students. The best strategy in this high level of self-medication is to raise students' awareness and knowledge by colleges about potential risk of self-medication practices.


Introduction
Drug is one of the basic needs of the general public and a strategic commodity in all countries.
Signi cant advances in the eld of medicine have paved the way for more and more people to have access to medicine. The consequence is the formation of a harmful social phenomenon namely the irrational use of drugs (IRUD).
Common types of IRUD include inappropriate use of antibiotics, overuse of injection when the oral drug would be more appropriate, use of many medicines per prescription, prescribing medicine regardless of clinical guidelines, failure to follow drug orders and self-medication (1). Self-medication is the rst behavior of patients in the face of the early symptoms of diseases and common health problems. Selfmedication and related habits can cause a number of side effects, including intoxication and bacterial resistance, drug dependency, and obscuring the symptoms of a serious illness (2,3). IRUD disrupts the drug market and increases the per capita nancial drug consumption, which has put the countries' economies under pressure.
Today, the self-medication has increased in the world, and its prevalence is higher in developing countries (4). Previous studies have reported prevalence rates of about 87% in India (5), 86.4% in Brazil (6), 55% in Egypt (7). The prevalence of self-medication in Iran is also not desirable (83.3%) (8). According to the World Health Organization, Iran is the second largest country in Asia after China in terms of drug consumption and is among the top 20 countries in the world (9). Therefore, self-medication and IRUD have become one of the problems in the Iranian health sector.
Self-medication in students as educated people in the community is one of the most important health issues. They are considered as role models for other people in health behaviors. Because of their active role in the media and the Internet, they can play a more important role in this area. On the other hand, they are more vulnerable and prone to self-medication due to their social status, more contact with people in the community, and their responsibilities as future parents (10)(11)(12). Previous studies revealed that the prevalence of self-medication practice seemed to be high worldwide among students. According to the study conducted by Okyay and Erdoğ, it was illustrated that the prevalence of self-medication in students was 63.4% and the most common drugs used by students without prescription were analgesics, antibiotics and cold remedies (13). A study conducted by Gupta et al. showed that the prevalence of selfmedication among students was 78% and fever and a headache were the most common diseases that were treated with self-medication (14). Scienti c studies investigating IRUD and associated factors in Iran have shown that the prevalence of self-medication has been between 18 and 87% (15). On the other hand, many studies have shown that people with higher levels of education have more IRUD habits (16,17). Therefore, the aim of this study is to investigate the habits related to rational use of drug (RUD) and the prevalence of self-medication practices among students in Jahrom, Iran.

Study design and setting
A cross-sectional study took place in Jahrom, a city in southeast of Iran. The study aimed to evaluate drug use habits of university students. Data were collected using an electronic "Self-medication practices and medication habits" questionnaire consisting of 24 questions. To design the questionnaire, 10 articles were selected, and its components were created by studying the relevant contents. The face validity and its content validity of was approved by six specialists. The reliability of the questionnaire was tested by using of Cronbach's alpha of 0.91. The values of coe cients were also assessed for every construct. In the questionnaire the rst part pertains to the demographic characteristics. The second part includes questions related to students' RUD, while the third part is related to self-medication. The study protocol was con rmed by Scienti c Researches Ethics Committee of Jahrom University of Medical Science (ID number: IR.JUMS.REC.1399.004). Informed consents were obtained from students and participation in the study was voluntary.

Participants
This study was formed by 8,320 students from two public universities and two private universities. They attended the healthcare and non-healthcare faculties participated in the study. The sample size was calculated to be as 848 students in the 95% con dence interval and with a 5% margin of error. Guest students, non-Iranian students, students with chronic diseases and students who do not wish to participate in the study have been excluded from the study.

Data collection and measurement
The calculated sample size was distributed by multistage sampling method according to density of students in four universities. Intracluster Correlation was 1.5. Data collection period was ve months between January 2021 and May 2021.
We used SPSS for Windows software for data analysis (SPSS, Chicago, IL, USA). Descriptive statistics were presented as frequencies and percentages in tables. Data were analyzed with Pearson chi-square test and regression logistic test.

Results
The number of participants were 848 university students. The female participants were 65.2%. The majority of them had an average socio-economic status (58.7%), and 86.7% were single. Students were mostly aged between 19 and 46 years (Mean ± SD, 22 ± 2.3 years.). 4.5% (n=38) had a chronic disease ( Table 1).
The prevalence of self-medication among students was 44.8% (n=380). The most common medicines on self-medication were cold remedies and sedatives in about 33% (Fig. 1). 27% of students buy medicines from pharmacy without any illness and kept them at home. About 8% (n = 65) of students nished the course of treatment, and 31.3% (n = 265) of students stopped taking the drug after consulting a physician or pharmacist. 40.7% (n= 345) of students had 1-5 packages of unused or un nished medicine at home and about one-third of students (35.2%) had discarded about 1-3 packages of medicine per year due to the expiration date (Table 2).
About one-third of students (277) always read the label on the drug before taking it, and 52% (n= 441) of students fully understood the contents of the drug brochure. 40% (343) of students had experienced side effects of the drugs, while 52% (n= 439) of students stated that they consulted a doctor in case of drug side effects (Table 2)..
About two-thirds of students (n=581) had a history of antibiotic use in the past 12 months, of which about 47% (n=400) of students had used antibiotics without a doctor's prescription ( Table 2). The most frequent cases of students taking antibiotics were during nasal discharge and fever, which were in 32% (n=269) and 23% (n=191), respectively (Fig. 2).
Half of the students (n=477) were familiar with the term RUD ( Table 2). The internet and social networks were the source of information about the RUD (Figure 3) in about 40% (n=307) of students. The results showed that there was no signi cant difference between students' behaviors in case of familiarity with the term RUD and unfamiliarity with this term (Table 3).

Discussion
In this study we evaluated habits related to RUD and estimate the prevalence of self-medication among students in Jahrom, Iran. According to the World Health Organization, more than half of the drugs prescribed, distributed and sold worldwide have not been required (18). Self-medication is an activity in which medications are usually provided by people who may not have a need for it. According to scienti c studies in different countries, the prevalence of self-medication varies according to the targeted population (16,19). A higher prevalence rate has been reported in developing countries (12). However, students were among the groups in which the rate of self-medication was reported to be high (13,20). The prevalence of self-medication was higher among medical students, and other health related elds (19). In present study, the prevalence of self-medication practice among students was 44.8%.
In our study, the two most widely used medicines in self-medication were cold remedies and sedatives by most 33%. In most studies carried out in Iran, Turkey, Saudi Arabia, Finland and Spain two other medicines, analgesics and antibiotics, have been included in this group (13,21,22). This result indicates similarity in the results of studies on medicines used in self-medication. So that in our study had a 47% prevalence of antibiotic use among students.
In a study carried out in 2020 in Iran, the self-medication prevalence with the antibiotic was reported as 53.3% among nursing students (23). This rate has been higher than our study. It's thought that the decrease probably was due to the Iran policy for antibiotics and prescribing pattern to limit the antibiotics recently (24). Self-medication with antibiotics in students is a topic that many studies have been done on it and is more common in medical students (25).
This study stated the existence of one to ve packages of unused or un nished drugs at home in about 41% and the existence of one to three packages of expired drugs within a year in about 35% at home. This result indicates the typical example of economic burden of IRUD in Iran. Irrational house storage is a global problem. In a systematic review, the prevalence of medicine storage was 35% to 100%, and the wastage of medicine was 17%. The review stated that southwest Asia region had the highest storage and wastage rates of medicines among urban households (26).
In our study, about one-third of the students reported reading the label on the medicines that they used. However, 52% of them fully understood the contents of the drug brochure. This result is less than the results of the study conducted in Turkey, which reported over 64% of students read the instructions on the prospectus (13). The results of another study indicated that Turkish and Thai students were less likely to notice medication brochures (13,27).
Social media and the internet have been the main source of information for students on RUD in this study. Students' perception of how physicians prescribe drugs are provides a signi cant relationship toward their understanding of RUD and safe use of drug treatments as Putu Eka Arimbawa study stated in Indonesia (28). Receiving medication information from the social media and internet among students in comparison with television and radio and other source, shows the importance of this area. Providing media-based educational content in universities can be effective in increasing students' awareness of RUD.
The results of the study of Tesfaye et al. indicate that medical students in Ethiopia tend to practice selfmedication more often than non-medical students, as well as have greater knowledge towards selfmedication (29). Conversely, in Iran, our result identi ed no difference in RUD between medical and nonmedical students.

Conclusions
Self-medication was high prevalence in students in Jahrom, Iran. It seems that the best strategy in this high level of self-medication is to raise students' awareness and knowledge by colleges about potential risk of self-medication practices. Behavioral programs and improving the understanding of drug labels especially on appropriate products can help to control the habits in self-medications.

Declarations
Ethics approval and consent to participate The Ethics Review Board of Jahrom University of Medical Sciences (JUMS) approved the present study with the following number: IR.JUMS.REC.1399.004. also, all the participants were informed about the research and completed the consent form. All methods were carried out in relevant regulations and guidelines.

Consent for publication
Not applicable Availability of data and materials All data generated or analysed during this study are included in this published article.   Figure 1 The most common medicines the students of University had consumed without prescription