Status of self-medication and the relevant factors regarding drug efficacy and safety as important considerations among adolescents aged 12-18 in China: a cross-sectional study

doi:10.21203/rs.3.rs-2579057/v1

Background: Self-medication is widely practiced among adolescents, and inappropriate self-medication can cause irreversible damage to adolescents' health. The attributes of over-the-counter medications influence adolescents' behavior when self-medicating.

Method: Multi-stage sampling was used to conduct a questionaire investigation in Mainland China in 2021. The questionnaire contains sociodemographic characteristics and several scales, the presence of self-medication behavior and the types of drugs they self-medicated, and important considerations when self-medicating. After a statistical description of the data, logistic regression were used to analyse the factors related to the types of drugs in self-medication as well as the consideration of drug efficacy and safety

Result: 1065 questionnaires were returned and 969 were valid, with an effective rate of 90.99%. The self-medication rate among Chinese aged 12-18 was 96.61%. 65.84% considered drug safety as an essential consideration, and 58.72% took drug efficacy as an important consideration. The multi-factor regression showed that those with better health care scores were more likely to consider drug efficacy as an essential factor(OR=1.554 P＜0.05);those with high family healthy lifestyle scores were more likely to focus on efficacy(OR=1.483 P<0.05). Family health status and monthly per capita household income were associated with whether respondents took drug safety as an important consideration. Those with higher per capita monthly household income (≥$641) were less inclined to consider safety as an essential factor(OR=0.544 P<0.001). Investigators with beller disease prevention were more likely to consider drug safety as an essential factor(OR=2.247 P<0.001);those with better family health resources were more likely to consider drug safety as an essential factor (OR=1.516 P＜0.05).

Conclusion: Self-medication is prevalent among 12-18-year-old adolescents in China. Demographic and sociological characteristics, health literacy, and family health status were associated with the likelihood that adolescents would focus on the safety and efficacy of medication when self-medicating. Health literacy and family health status were positively correlated with the likelihood of considering the efficacy and safety of drugs as important factors when self-medicating. Authorities should take measures to regulate adolescents' self-medication behaviour, strengthen health education for adolescents and their supervisors, and improve their health literacy to reduce the harm caused by inappropriate self-medication.

China

Adolescents

Self-medication

Efficacy Safety

Self-medication (SM), defined as the selection and use of drugs to treat self-diagnosed illnesses or symptoms, or the intermittent or continued use of prescribed drugs for chronic or recurrent disease or symptoms(World Health Organization, 2000), is a widespread phenomenon among adolescents around the world (Gualanoet.al, 2015; Elong Ekambiet.al, 2019; Mathiaset.al, 2020; Skarsteinet.al, 2018). Adolescents often choose over-the-counter (OTC) drugs for SM, which are inexpensive and accessible without a doctor’s prescription through pharmacies(Shehnazet.al, 2014).

When children enter adolescence, the responsibility for health care often shifts from parents and other caregivers to themselves. So, as adolescents age, people tend to assume greater autonomy in medication self-management(Rutter, 2015). A study in New Hampshire, USA, in 2012 showed that, by 16 years old, approximately 90% of adolescents self-medicate with OTC medication(Abelet.al, 2012). Also, there are many factors related to the medicine selection for types of medicine in SM. These factors influence adolescents' judgement of their own illnesses and thus their choice of drug’s types when self-medicating. Different types of OTC drugs are used with different frequencies in adolescent self-medication from the perspective of adolescents’ characteristics, gender, educational level, and socio-economic status associated with their medicine selection (Jameset.al, 2006). According to a study in Norway in 2021, among adolescents, 33% of females and 13% of males used OTC analgesics weekly(Jonassenet.al, 2021).In 2012, a Brazilian study found that girls aged 11 and 15 years(Bertoldiet.al, 2012) declared to take different types of drugs, especially painkillers (Kizaet.al, 2021), and this behaviour has begun to expand to younger ages(Sloand & Vessey, 2001). In terms of the properties of the drug, the type, efficacy and safety are usually related to the adolescent's choice of self-medication. Studies showed that OTC analgesics(Kizaet.al, 2021), antipyretics(Mathiaset.al, 2020), cough suppressants(C.-H. Leeet.al, 2017), antibiotics(Elong Ekambiet.al, 2019), and anti-inflammatory drugs (Italiaet.al, 2015)were widely used among adolescents.

US adolescents reported dextromethorphan hydrobromide (DXM)-containing medications as the most commonly misused OTCs(Benotschet.al, 2014; Finkelsteinet.al, 2017; Vidoureket.al, 2014). Acetaminophen, an ingredient in many OTC cough and cold medications, is a widely used analgesic for mild pain or fever among young people(Wilsonet.al, 2010).However, adolescents are more likely to misuse OTC medication due to their wrong drug use cognition and limited medication knowledge, thus increasing significant health risks (Holmströmet.al, 2014). Of note, medication overdoses associated with the misuse of common OTCs are widespread. One study in Pakistan in 2021 found that adolescents ages 12-18 years accounted for the highest number of emergency department visits for medication overdoses, most commonly caused by acetaminophen, other NSAIDs, and cough medicine(Schillieet.al, 2009). Intoxication can occur from a single or repeated dose over the recommended acetaminophen amount, and overdose can lead to liver damage or hepatic failure(Jensenet.al, 2014; Wilsonet.al, 2010). In addition, excessive intake of cough suppressant dextromethorphan may cause mental disorders, including hallucinations and delusions, which is also an important reason for the excessive use of the drug by some teenagers(Romanelli & Smith, 2009).

Based on the current situation, the study aims to assess the prevalence of self-medication practice among adolescents and factors they considered when purchasing and using over-the-counter drugs. The findings are expected to provide research evidence for health policy and help decrease the inappropriate use of OTC drugs in adolescents.

For a detailed description of the method section see our previous study(Ge et.al, 2022; Zhang et.al, 2022).

Study Design

The research data came from China Family Health Index-2021 (CFHI-2021) 2021 China Family Health Index Survey General Report, 2021). The investigation conducted multi-stage sampling in mainland China. This study was approved by the Medical Ethics Committee of Jinan University (Approval number: JNUKY-2021-018).

Participants

Sample size

In the cross-sectional investigation, the bilateral test's sample size formula (Formula 1) was used to calculate the minimum sample size. The test level was set as α=0.05, p referring to the proportion of adolescents who had self-medicated behaviour reported in Taiwan, China in 2019, which was 33.9%(Miaoet.al, 2019), and the allowable error δ was set as 0.1. According to the sample size formula, the required sample size of N=780 was calculated for this study. Considering 15% of questionnaire inefficiency, the sample size was 918. In this study, 1065 questionnaires were collected, which was more than the minimum sample size.

Inclusion criteria

(1) Age ≥12 years old and ≤18 years old. Considering that the respondents may fill in nominal age (the age filled in was greater than their actual age) when filling in the age, the 18-year-old respondents were included in this study; (2) Have purchased and used OTC drugs on their own (answer "yes" to the question whether you have purchased and used OTC drugs on your own); (3) Participate in the study and fill in the informed consent form voluntarily; (4) Participants can complete the network questionnaire by themselves or with the help of investigators.

Exclusion criteria

(1) People with unconsciousness or mental disorders; (2) Those who were participating in other similar research projects.

In this study, 1065 questionnaires were collected, and logic checks were carried out on the questionnaires. 62 questionnaires with logic inconsistency and less than 240 seconds of filling time were excluded, and 34 questionnaires with no self-medication behaviour were excluded. Finally, 969 respondents were included, and the effective recovery rate of questionnaires was 90.99%.

Instruments

The questionnaire consists of three parts. The first part investigated the demographic and sociological characteristics of respondents, such as gender, age, province, nationality, permanent residence (urban and rural), education level, number of siblings, per capita monthly family income(RMB to the USD exchange rate is the average rate for August 2021) etc. The second part investigated the status quo and essential considerations of adolescents' self-medication behaviour, consisting of 3 questions (1 single-choice and 2 multiple-choice questions). The third part is a series of standard scales, including the Short Form Health Literacy Instrument (HLS-SF12), Family Health Scale-Short Form (FHS-SF), the Patient Health Questionnaire-9 (PHQ-9) and the General Anxiety Disorder-7(GAD-7).

The status quo and important considerations of residents' self-medication behaviour

The first single-choice question was "Have you ever purchased and used OTC drugs by yourself?" , which was designed to ask whether the respondents had self-medicated. Those who answered "no" were excluded from the study. The first multiple-choice question was, "What kinds of OTC drugs have you purchased and used on your own?" It was designed to investigate the types of OTC drugs the respondents had purchased and used by themselves. The second multiple-choice question was "Which of the following factors do you think are the important factors for you to consider when you purchase OTC drugs by yourself?" to investigate the essential factors for the subjects to purchase OTC drugs by themselves. For each respondent, the order of the two multiple-choice questions was set as random to minimize bias in the study.

Health Literacy Scale Short Form 12 Items

The Health Literacy Scale Short Form 12 Items (HLS-SF12) was used to study the respondents' Health Literacy (HL). The scale includes 3 dimensions of health care, disease prevention and health promotion, with 12 items. Each item is scored at 4 levels (1= very difficult, 2= difficult, 3= easy, 4= very easy). The standardized HL index is calculated using the formula. The index range is 0-50, and its score positively correlates with the respondents' health literacy. The calculation formula is index = (x−1) × (50/3), and x is the average score of the items in one dimension or the whole scale of one respondent. 1 is the lowest possible value of the average (at this time, the minimum value of the index is 0), 3 is the range of the average score, and 50 is the maximum value of the index(Duonget.al, 2019). The higher the index, the higher the health literacy level of the respondents. In this study, the Cronbach's coefficient of HLS-SF12 was 0.937, and the Cronbach's coefficient of health care, disease prevention and health promotion subscales were 0.850, 0.856 and 0.871, respectively, indicating good reliability. Concerning relevant literature, the health literacy of the respondents was divided into the high group (more than 33 points) and the low group (33 points or less). The grouping rules of each subscale were consistent with those of the full scale(Cheong et.al, 2021).

Family Health Scale-Short Form

The Family Health Scale-Short Form (FHS-SF) was developed by Crandall and Weiss-Laxer et al. and translated into Chinese by Wang Fei et al. according to the standard translation process of the Scale. FHS-SF includes 10 items, 4 dimensions. Each dimension comprises 2-3 items with higher factor loading and weight extracted from the 4 dimensions of the Family Health Scale-long Form(FHS-LF). The 4 dimensions are Family/social/emotional health processes, Family healthy lifestyle, Family health resources, and external social supports. Each item adopts the Likert 5-level scoring method, among which the sixth, ninth and tenth adopt reverse scoring; the higher the score is, the higher the family health level is(Wanget.al, 2022). In this study, the Cronbach's coefficient of the FHS-SF scale was 0.851, and the Cronbach's coefficient of the family/social/emotional health process, healthy family lifestyle, family health resources and family external social support subscales were 0.911, 0.874, 0.784 and 0.760, respectively, indicating good reliability. Each dimension of the scale was included in this study for analysis. The respondents were divided into the high group (greater than or equal to the median) and low group (less than the median) according to the score of each dimension of FHS-SF.

Mental health status

In this study, the Patient Health Questionision-9(PHQ-9) and the General Anxiety Disorder-7(GAD-7) were used to measure the mental health status of the respondents. In this study, the Cronbach's coefficient of the Patient Health Questionnaire-9 (PHQ-9)and the General Anxiety Disorder-7(GAD-7) were 0.926 and 0.953, respectively, indicating good reliability.

PHQ-9 was developed by Spitzer et al.(Spitzeret.al, 1999), which was used to measure the actual feelings of the respondents over nearly two weeks. The likert four-point scoring method was adopted to evaluate the following 9 aspects: decreased interest, low mood, sleep disturbance, fatigue, eating disorder, inferiority complex, difficulty concentrating, psychomotor delay, and suicidal symptoms. The main statistical index of this scale is the total score, and the total value of PHQ ranges from 0 to 27 points. The higher the score, the higher the degree of depression. In this study, according to the scoring rules, the respondents were divided into two groups: no depression (4 points or less) and possible depression (more than 4 points).

GAD-7 was developed by Spitzer et al. (2006)(Spitzeret.al, 2006) to measure the degree of anxiety. It uses the number of days with related symptoms in the last two weeks as the evaluation standard. The degree of tension and anxiety, uncontrollable worry, excessive worry, inability to relax, inability to sit still, irritability, anger, and fear were respectively assessed. The main statistical index of this scale is the total score, which is scored by Likert four points. The total score ranges from 0 to 21, mainly used to assess the severity of anxiety symptoms; the higher the score, the higher the degree of anxiety. In this study, according to the scoring rules, the respondents were divided into two groups: no anxiety (score 4 or less) and possible anxiety (score more than 4).

Statistical analysis

Statistical analysis was performed using SPSS 25.0 (SPSS, Inc., Chicago, IL, USA Network Version from Peking University, Address: 162.105.134.153). In this study, all scale scores were transformed into binary variables (high and low groups) by referring to relevant literature(Ferketich, 1991). The classification variables were represented by frequency (component ratio), and univariate binary logistic regression was used for univariate analysis. Multivariate binary stepwise Logistic regression was used (α=0.05 and α=0.10 were the inclusion criteria and exclusion criteria of variables, respectively) to analyse the factors related to the consideration of drug efficacy and safety among respondents. The test level was α=0.05. Finally, the respondents were divided into different subgroups according to gender and permanent residence, and multivariate binary stepwise Logistic regression was carried out for different subgroups to do a subgroup analysis.

Quality control

Two rounds of preliminary investigations were conducted before the formal investigation. Based on the results of the preliminary investigations, we modified the content of the questionnaire. Trained investigators distributed questionnaires and registered respondents’ codes one on one. Every Sunday night, the research staff communicated with the investigators and summarized, evaluated and gave feedback on the questionnaires they collected. After the questionnaire was collected, the logic check and data screening were carried out by two people back to back. When analysing the data, if an outlier was found, the research team would find the original questionnaire and check it with the investigator before proceeding to the next step.

Harman’s single factor test

This study examined common method bias using the Harman’s single-factor test. The results showed that the number of factors with a characteristic root greater than one was five. The variance contribution of the first principal factor was 32.09%, which did not exceed 40%, indicating that there was no obvious common method bias.

Demographic and sociological characteristics of respondents and important considerations in their self-medication behaviors

There were a few more female respondents than male respondents in this study; the largest number of respondents were from eastern China, and most of the respondents' usual place of residence was urban. The demographic and sociological characteristics are shown in Table 1.

The findings showed that 96.61% (969/1003) of Chinese 12-18 years old had self-medication behaviours, and the top two types of OTC drugs purchased and used by 12-18 years old were vitamins/minerals (542, 55.93%) and antipyretics and analgesics (491, 50.67%). In this study, self-purchase and use of gynecological medication were included only for female respondents. Because only women tend to buy these drugs, the purchase of these drugs by men was not analysed in this study. The percentage of respondents who had purchased and used gynecological drugs on their own was 4.33% of all female respondents. Of the 22 people who chose "other" and filled in the blanks, 12 filled in "anti-cold medicine", 2 filled in "ibuprofen", 2 filled in "digestive medicine", "anti-inflammatory", broad-spectrum antibiotic "Amoxicillin", eye drops and Niuhuang antidote tablets were each filled by one person, as shown in Figure 1.

The top two important considerations when purchasing OTC medicines were the safety of the medicine (638 participants, 65.84%) and the efficacy of the medicine (569 participants, 58.72%) ,as shown in Figure 2.

Table 1 General demographic characteristics of participants (N=969)

Variable	Number	Percentage
Location
Eastern China	464	47.88%
Middle China	270	27.86%
Western China	235	24.25%
Place of residence
Urban	694	71.62%
Rural	275	28.38%
Monthly income^a
￥0-4500	525	54.18%
￥4501-15000	407	42.00%
≥￥15001	37	3.82%
Gender
Male	403	41.59%
Female	566	58.41%
Ethnicity
Han	893	92.16%
Minorities	76	7.84%
Education level
Undergoing higher education	327	33.75%
Not in higher education	642	66.25%
Only child
Yes	310	31.99%
No	659	68.01%

a:￥4500(equal to＄696.59),￥4501(equal to＄696.75),￥15000(equal to＄2321.98),￥15001(equal to＄2322.14)

Participant scores on the scales

The scores of HLS-SF12, FHS-SF, PHQ-9 and GAD-7 are shown in Table 2. As none of the scale scores met a normal distribution, the median, upper and lower quartiles were used to describe the concentration and dispersion degree trends of each scale score. The details of the scale scores for each scale are shown in Table 2.

Table 2 Scores on each scale

	Appraisal Content	No. of items	Score range	Kolmogorow-Smironov Z	P value from K-S test		Median	Q1-Q3	NO. and percentage of high score group	NO. and percentage of low score group
HLS-SF12	Total scale	12	0-50	0.187	<0.001	33.33		31.94-38.89	637(69.45%)	296(30.55%)
	Healthcare	4	0-50	0.221	<0.001	33.33		29.17-41.67	723(74.61%)	246(25.39%)
	Disease prevention	4	0-50	0.252	<0.001	33.33		33.33-41.67	730(75.34%)	239(24.66%)
	Health promotion	4	0-50	0.258	<0.001	33.33		33.33-41.67	780(80.50%)	189(19.50%)
FHS-SF	Total scale	10	20-50	0.066	<0.001		39.00	34.00-44.00	701(72.34%)	268(27.66%)
	Family/social/emotional health process	3	3-15	0.162	<0.001		12.00	10.00-14.00	625(64.50%)	344(35.50%)
	Family healthy lifestyle	2	2-10	0.186	<0.001		8.00	7.00-10.00	675(69.66%)	294(30.34%)
	Family health resources	3	3-15	0.106	<0.001		11.00	9.00-14.00	567(58.51%)	402(41.49%)
	External family social support	2	2-10	0.187	<0.001		8.00	6.00-9.00	594(61.30%)	375(38.70%)
PHQ-9	Depressive tendencies	9	0-27	0.138	<0.001		5.00	1.00-9.00	393(40.56%)	576(59.44%)
GAD-7	Anxiety tendencies	7	0-21	0.182	<0.001		3.00	0.00-7.00	525(54.18%)	444(45.82%)

Univariate binary logistic regression analysis of the types of OTC drugs purchased by participants

Univariate binary logistic regression analysis was used to conduct a univariate analysis of the types of OTC drugs the participants had purchased and used on their own. The differences in whether the participants had purchased and used OTC antipyretic and analgesic drugs by location, ethnicity, and education were statistically significant (P<0.05). Statistically significant differences (P<0.05) were found in whether participants with different education and family health status had purchased and used antimicrobial OTC drugs independently. Statistically significant differences (P<0.05) were found between participants with different usual residences, gender, family health status, and anxiety status on whether they had purchased and used OTC Chinese patent medicine on their own. See supplementary Materials, S2 Table for details.

Univariate binary logistic regression of participants regard drug efficacy and safety as important considerations in purchasing OTC

Univariate binary logistic regression analysis of the variables related to the efficacy and safety of the drugs considered by the respondents when purchasing OTC drugs was conducted. Differences in whether participants with different health care scores in health literacy, different family/social/emotional health process scores in family health, different family health lifestyle scores, different family health resource scores, and different anxiety status focused on the factor of drug efficacy when purchasing OTC medications were statistically significant (P<0.05). Statistically significant differences (P<0.05) were found between respondents with different monthly per capita household income, different disease prevention scores in health literacy, different family/social/emotional health process scores in family health, different family health lifestyle scores, and different family health resource scores on the factor of whether they focused on drug safety when purchasing OTC. See supplementary Materials, S3 Table for details..

Multifactor analysis of whether the efficacy or safety of drugs is an important consideration for respondents purchasing OTC drugs by themselves

Drug efficacy

This study conducted a binary stepwise logistic regression analysis using whether respondents considered drug efficacy as an essential consideration as the dependent variable and respondents' demographic and sociological characteristics and scale score grading as independent variables.

The Omnibus test result of the established model is P<0.05, the -2 log-likelihood value is 1294.898, and the Hosmer-Lameshaw test result is P=0.932>0.05, indicating that the model is of good quality. Logistic regression analysis indicated that health care literacy and family healthy lifestyle was associated with whether respondents considered drug efficacy as an essential consideration when purchasing OTC. Compared to those with lower health care literacy, those with better health care literacy are more likely to consider drug efficacy as an essential factor(OR=1.554，95%CI 1.157-2.088 P＜0.05). The high family healthy lifestyle score group was more likely to cite efficacy as an important factor than the low family healthy lifestyle score group(OR=1.483, 95%CI 1.121-1.963. P<0.05). See Table 3 for details.

Table 3 Multivariate binary stepwise logistic regression results: whether respondents consider drug efficacy as an important consideration in purchasing OTC

Variable	β	SE	P	OR	95%CI
Health care (control group = low score group)
high score group	0.441	0.151	0.003	1.554	1.157-2.088
Family Healthy Lifestyle (control group = low score group)
high score group	0.394	0.143	0.006	1.483	1.121-1.963

Drug Safety

This study conducted a binary stepwise logistic regression analysis using whether respondents considered drug safety as an essential consideration as the dependent variable and respondents' demographic and sociological characteristics and scale score grading as independent variables.

The Omnibus test result of the established model is P<0.05, the -2 log-likelihood value is 1193.749, and the Hosmer-Lameshaw test result is P=0.998>0.05, indicating that the model is of good quality. Logistic regression analysis indicated that monthly per capita household income, disease prevention literacy, and household health resources were associated with whether respondents considered drug safety as an essential consideration when purchasing OTC. Participants with higher monthly per capita household income (≥￥4,501≈＄696.75) are less likely to consider safety as an essential factor than those with lower monthly per capita household income (≤￥4,500≈＄696.59)(OR=0.544, 95%CI 0.459-0.792 P<0.001); compared to respondents with lower disease prevention scores, respondents with higher disease prevention scores were more likely to consider drug safety as an essential factor(OR=2.247，95CI% 1.699-2.973 P<0.001)；The safety of medications was more likely to be an essential consideration for those with better family health resources in their family health status than for those with worse family health resources in their family health status(OR=1.516，95%CI 1.112-2.067 P＜0.05)，For details, see Table 4.

Table 4 Multivariate binary stepwise logistic regression results: whether respondents consider drug safety as an important consideration in purchasing OTC

Variable	β	SE	P	OR	95%CI
Monthly income (RMB)^a (control group =＜￥4500)
≥￥4501	-0.610	0.143	<0.001	0.544	0.459-0.792
Disease Prevention (control group = low score group)
high score group	0.416	0.158	0.008	1.516	1.112-2.067
Family Health Resources (control group = low score group)
high score group	0.810	0.143	<0.001	2.247	1.699-2.973

a:￥4500(equal to＄696.59),￥4501(equal to＄696.75),￥15000(equal to＄2321.98),￥150001(equal to＄2322.14)

Subgroup analysis was used with subgroup classification based on gender and usual residence to explore the variability of factors related to the dependent variable among different subgroups. The study results showed that the model built using data from each subgroup was generally consistent with the total model. See Supplementary Materials, S4-S7 Table for details.

Chinese adolescents’ self medication behaviors

Currently, nearly half of the people in the world do not have access to basic health services. Self-care has become a crucial way to promote primary health care and protect health for all. Thus self-medication is widely used by people around the world as an important means of self-care. Studies have shown that self-medication is common among adolescents in countries including China, Australia, Malaysia, etc. (De Sanctiset.al, 2020; Self Care Interventions, 2022). In this study, the self-medication rate of Chinese adolescents aged 12-18 years is as high as 96.61%, indicating that most Chinese adolescents in this age group have self-medication experience.

Among all kinds of OTC drugs, the respondents who bought vitamins/minerals by themselves account for the most significant proportion, indicating that most adolescents require vitamin/mineral supplementation. This phenomenon may be related to the fact that they are in a critical period of growth. At this stage, they are influenced by outside influences (e.g. health education at school, promotion by pharmaceutical manufacturers, etc.) to take vitamins/minerals in order to grow taller, or to reduce the occurrence of limb cramps. Previous studies(Baxteret.al, 2021; Mogireet.al, 2020)showed that most adolescents had faced different kinds of vitamin and mineral deficiencies for various reasons such as body growth, diet, exercise, and so forth. The proportion of respondents who bought antipyretic and analgesic drugs was in second place, revealing that most adolescents purchase OTC drugs to relieve fever or pain (dysmenorrhea, headache, muscle pain, joint pain, etc.). A Portuguese study also showed that headache was the most common problem causing self-medication among adolescents (Almeidaet.al, 2020). Of the 22 who answered "others," 12 answered "anti-cold medicine", suggesting that some adolescents self-medicate to treat upper respiratory tract infections and flu. Similar to this finding, the Portuguese study showed that the presence of symptoms of upper respiratory infections was also a reason for adolescents to carry out self-medication(Almeidaet.al, 2020).

Factors related to drug efficacy or safety as an important consideration in Chinese adolescents

Proportion of important considerations when self medicating

The results showed that Chinese adolescents aged 12-18 years pay more attention to the safety, efficacy and price of the drugs when buying OTC drugs, but less consideration was given to the characteristics such as drug taste and exquisite packaging. This is similar to the research results of Xu Jing et al. (XU Jing et.al, 2016) , suggesting that adolescents aged 12 to 18 pay more attention to the practicability of drugs when choosing and purchasing OTC drugs, and pay less attention to the attributes unrelated to the purpose of drugs such as packaging.

Drug efficacy

The results of univariate logistic regression analysis showed that the score of health care on the health literacy scale and the score on the family health scale were significantly related to the consideration of drug efficacy. Multivariate stepwise logistic regression analysis further found that better healthcare literacy would improve people's attention to the efficacy of drugs. Health literacy refers to an individual's ability to discover, understand, evaluate, and apply health-related information (Sørensenet.al, 2012). In the HLS-SF12 scale, the items in the healthcare dimension mainly involved disease treatment and drug-related information(Miaoet.al, 2019). Therefore, people with higher scores in the healthcare dimension tend to be more aware of drug information and better judge the advantages and disadvantages of treatment options, paying more attention to the therapeutic effect of drugs. In addition, those with high family healthy lifestyle scores were more likely to consider drug efficacy an essential factor. Family is the most basic unit of social life, and a healthy lifestyle manifests good family function. It helps family members to actively understand the knowledge and skills related to drug treatment and change their cognition and behaviour to maintain a healthy state(WANG Yan et.al, 2019; ZHANG Wei et.al, 2022). Therefore, people with high family healthy lifestyle scores usually have a strong health awareness and pay more attention to the efficacy of drugs.

Drug safety

The results of univariate logistic regression analysis showed that the family income per capita, the score of the disease prevention dimension in the health literacy scale and the score of the family health scale were significantly related to the emphasis on drug safety. Multivariate stepwise logistic regression analysis further found that compared with those with higher per capita monthly household income, those with lower per capita monthly household income were more likely to regard drug safety as an essential factor. Sun Shan once pointed out that groups with different economic conditions have apparent differences in OTC drug consumption and expenditure patterns. The lower income group is obliged to receive the drug treatment generally after the disease when pain has affected the everyday work and life of the case(SUN, 2018). Therefore, they usually pay more attention to the safety of drugs and hope to avoid secondary drug treatment expenses and secondary physical injuries caused by adverse drug reactions or side effects. At the same time, the higher the score for disease prevention, the more inclined people will be to consider drug safety as an essential factor. In the HLS-SF12 scale, the items of the disease prevention dimension mainly involve emotion management, physical examination cognition and vaccine demand. Therefore, people with higher scores in the disease prevention dimension are more effective in protecting themselves from disease. As a result, they will naturally pay more attention to the drug's safety and carefully judge whether the drug will cause other diseases or adverse reactions.

Regarding family health status, those with better family health resources were more willing to consider drug safety as an essential factor. Household health resources refer to the material and non-material assets a household can carry out daily activities and perform its functions, including money, housing, and health care(Crandallet.al, 2020; Daineset.al, 2021). Therefore, those with better family health resources have better access to healthcare resources and are more likely to obtain medical care and scientific medication knowledge, so they pay more attention to drug safety.

Suggestion

Self-medication plays an integral role in complementing health care and treating diseases. Especially under the influence of the COVID-19 pandemic, many Chinese adolescents who have just entered university need to comply with the epidemic prevention and control regulations of their schools, which may inconvenience their medical treatment. Scientific and rational self-medication can make adolescents get treatment at a lower cost and a higher convenience. However, adolescents' inappropriate self-medication behaviour may negatively affect their health. Adolescents' judgment and self-care abilities are typically far worse than adults. It is necessary to strengthen the management of OTC drugs sold to adolescents and health education on self-medication for adolescents. The respondents included in this study were aged between 12 and 18 years, and this range included those in tertiary education and those who were not. Since both have changed dramatically in knowledge and lifestyle, the suggestions will be made towards health departments, drug manufacturers and distributors, media, schools and families for respondents with different education levels.

First, health authorities should establish a regulatory system, especially for adolescents who buy OTC drugs, pay attention to their self-medication needs, and make adolescents able to purchase the drugs they need with the help of pharmacists or other professional medical staff. Secondly, drug manufacturers should make the labels of OTC drugs more easily identifiable on the drug packaging and make it easier to explain how to use drugs scientifically and correctly in the outer packaging and instructions. Adolescents who do not receive higher education spend most of their time in the family and school environment. Therefore, for these adolescents, the role of schools and families in the scientific use of OTC drugs should be valued. Schools should pass more scientific knowledge of medication in class, and families should pass correct and scientific medication concepts. For those receiving higher education, health education on the scientific use of non-prescription drugs should be promoted in classrooms, associations, publicity posters and other forms on university campuses. In addition, these university students are exposed to many online media, so the media should pay attention to the accuracy of information when transmitting medication information. Health authorities should pay attention to and regulate online OTC drug purchase channels and strengthen the monitoring of online OTC drug sales. Finally, adolescents and their families should take the initiative to learn how to scientifically identify and use OTC drugs. In a randomized controlled trial in Japan, proactive use of self-medication knowledge provided by pharmacists was shown to be effective in promoting safe self-medication behaviour among the public(Tachiet.al, 2020); Other studies have shown that the drug use behaviour of adolescents can be improved to a certain extent with the intervention of media(Scalziet.al, 2018).

Strengths and limitations of the study

Strengths

This study has several strengths. First, we used data from a nationwide cross-sectional investigation in 2021 and used a multi-stage sampling method to extract samples to obtain a representative sample. In addition, this study combined family health, health literacy and mental health status to analyse adolescents' non-prescription drug purchase behaviour, which enriched the theoretical application value of health literacy in the field of adolescent self-medication. At the same time, targeted suggestions were given for the health promotion and health education practice of scientific medication in adolescents in the future, and further practical contributions were made.

Limitations

This study also has several limitations. First, the data are solely on self-report questionnaires, which can be affected by social expectations, self-report errors, and poor memory. Second, this study used a cross-sectional design. The results were used only to explore the factors associated with the dependent variable, which did not allow causal inferences to be made based on the findings. Third, the participants of this study were Chinese adolescents; since adolescence is a unique stage in life, this study only represents Chinese adolescents, so the results are difficult to generalize to other countries. This limitation could be addressed in future studies by ensuring that the countries or regions of the participants are more diverse. The characteristics of adolescents' behaviour and other critical factors they consider when purchasing OTC medications are likely to change further in subsequent years.

Most Chinese adolescents aged 12-18 years use OTC drugs for self-medication. Monthly family income was negatively correlated with the possibility of taking the safety of drugs as an essential consideration. In contrast, health literacy and family health status were positively correlated with the possibility of taking the efficacy and safety of drugs as an essential consideration. This study explored the variables related to whether the efficacy and safety of drugs were considered important considerations when adolescents self-medication, which provided research ideas for the future exploration of the factors to be considered when adolescents self-medication was used to standardize the follow-up study of adolescent self-medication behaviour and to provide a basis for relevant departments to formulate policies to regulate adolescent self-medication behaviour. Follow-up studies can further explore the variables related to the importance of other factors in adolescents' self-medication and the intervention models and methods to promote rational self-medication in adolescents.

Ethical Approval and Consent to participate: The study was conducted in accordance with the ethical standards set forth in the Helsinki Declaration (1983). This study was approved by the Medical Ethics Committee of Jinan University (Approval number: JNUKY-2021-018).

Consent for publication： Not applicable. Availability of data and material.

Availability of data and materials： All data, models, and code generated or used during the study appear in the submitted article.

Competing interests：The authors declare that they have no competing interests

Funding："Hainan Province Specialized Key Discipline - Public Health and Preventive Medicine" Construction Project

Authors' contributions：

Conceptualization: Pu Ge

Data Curation: Keping Pu,Rong Ling

Formal Analysis: Pu Ge

Methodology: Diyue Liu, Ayidana Kaierdebieke

Writing – Original Draft Preparation: Diyue Liu, Xialei Li, Mengjie Huang

Writing – Review & Editing: Wenying Hong, Lijun Zhu, Wenbian Yu, Jiale Qi

Supervision: Xinying Sun, Yibo Wu, Qiqin Feng

Acknowledgements：The authors hereby declare that this study acknowledges the financial support provided by the "Hainan Province Specialized Key Discipline - Public Health and Preventive Medicine" Construction Project for this study

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No competing interests reported.

Supplementarymaterials.docx

Status of self-medication and the relevant factors regarding drug efficacy and safety as important considerations among adolescents aged 12-18 in China: a cross-sectional study

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Abstract

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Introduction

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Discussion

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