The Role of the Internet in Influencing Self-Medication Behaviors Among Urban Residents in India:  A Cross-sectional Study

doi:10.21203/rs.3.rs-3555723/v1

Download PDF

Research Article

The Role of the Internet in Influencing Self-Medication Behaviors Among Urban Residents in India: A Cross-sectional Study

https://doi.org/10.21203/rs.3.rs-3555723/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted

You are reading this latest preprint version

Objective

The objective of the study was to understand the influence of the internet on self-medication practices amongst the laypeople residing across the three urban centres (Bengaluru, Amritsar, and Chennai).

Methodology:

This cross-sectional study explores the role of the internet in influencing self-medication behaviours among urban residents in three Indian cities: Bengaluru, Amritsar, and Chennai. A web-based questionnaire was administered to adults aged 18 and above, excluding medical and allied medical students, resulting in 350 valid responses.

Results

The findings reveal that 34.5% of respondents had engaged in self-medication in the past three months, with 35.5% of them citing the internet as a source of information for self-medication decisions. The study identified the most common reasons for self-medication, such as minor ailments not necessitating a healthcare provider's consultation (36%) and the convenience of timesaving (35.4%). Internet usage was more prevalent among participants aged 21–40 years, with Bengaluru reporting the highest internet-based self-medication instances (62%). When examining the role of the internet in self-medication, the study found that it significantly influenced decision-making in 26.7% of the cases. Participants primarily used internet search engines (87%) to gather information, with a focus on drug prices (60%) and common adverse effects (19%). Importantly, this study assessed the risk of adverse events associated with internet-based self-medication and found no statistically significant difference when compared to self-medication based on old prescriptions or advice from family and friends.

Conclusion

This study sheds light on the evolving patterns of self-medication practices in urban India, highlighting the growing role of the Internet as a source of information. While concerns about the internet's influence on self-medication exist, the study's findings suggest that it does not pose a significantly higher risk of adverse events compared to traditional sources of information. Further research on self-medication behaviours across diverse populations and regions is warranted to gain a comprehensive understanding of this prevalent healthcare practice.

Epidemiology

Self Medication

Patient Safety

Internet and source of health information

Consumer health

The World Health Organization (WHO) has officially defined self-medication as the utilization of drugs to address ailments or symptoms that individuals diagnose themselves. It also encompasses the occasional or continued use of prescribed medications for chronic or recurring conditions or symptoms. This definition extends to the use of medications by family members, particularly in cases involving the treatment of children or elderly individuals(1). Self-medication presents a significant global public health challenge, with its prevalence varying widely across different regions. Worldwide, it ranges from 11.7% to a staggering 92%. In developing nations, this practice is even more widespread, with rates ranging from 12.7–95%, while in Western countries, it is comparatively lower, often reported at around 3%(2, 3).

In India, self-medication is a widespread phenomenon, affecting both urban and rural populations. Approximately 37% of individuals in urban areas and 17% in rural areas engage in self-medication practices (3). Alarmingly, more than half of the adolescent population in India, exceeding 50%, resort to self-medication daily. The most commonly utilized medications for self-treatment are analgesics (4). One of the gravest concerns in this context is the high prevalence of self-medication with antibiotics, standing at 57.22%. This trend is not limited to specific demographics; it is observed among both medical students (51%) and non-medical students (49%). Furthermore, a study conducted among engineering students in Chennai revealed an astonishingly high self-medication prevalence rate of 77% (5).

This widespread practice of self-medication is particularly pronounced in developing countries like India, where a plethora of over the counter (OTC) drugs, known for their efficacy and safety, are easily accessible. However, it's crucial to recognize that the significant prevalence of self-medication in India is intrinsically linked to the critical issue of antimicrobial resistance. Additionally, it poses severe health risks, potentially resulting in prolonged suffering and adverse consequences (6).

The primary channels of information regarding self-medication drugs were local pharmacists, serving as the main source for 59.17% of respondents. Family members were consulted by 17.92% of respondents, while friends by 7.92%, advertisements by 2.92%, and the Internet 2.08% represented other noteworthy sources. It's worth noting that pharmacist consultation emerged as the most prevalent source of guidance for self-medication. Notably, certain predictors associated with the practice of self-medication included older age, the presence of chronic diseases, and having a monthly income or medical insurance that did not cover treatment expenses (3, 6–9).

In past decade India witnessed phenomenal rise in the number of Smartphone users, the cost of access to the internet fell below one dollar USD for one gigabyte of data. The COVID-19 pandemic also forced people to shift internet for obtaining health related information. The literature on influence of internet on self-medication is limited (9, 10). Thus, the current study was envisaged to answer the research questions; a) How does internet influence self-medication behaviour amongst Indian population, b) Has internet changed the buying patterns (shifted to e-pharmacies instead of brick-and-mortar store), c) Is their any difference in influence of internet for acute and chronic diseases.

Study Objective

The primary objective of the study was to understand the influence of internet on self-medication practices amongst the laypeople residing across the three urban centres (Bengaluru, Amritsar, and Chennai).

Study Design and Population

A multicentric cross-sectional study was conducted among the general population of three Indian cities (Amritsar, Bengaluru, Chennai) using a web-based questionnaire. Adults aged 18 years old or above were eligible to participate. Medical students or Allied Medical students were excluded from the study. Respondents who responded to the questionnaire within less than 1 min were excluded.

Sample size calculation and Sampling

We used Open AI powered Chat GPT 3.5 to estimate the sample size. It was 384 at a confidence level of 95%. We assumed that 50% of the population would practice self-medication with a 5% margin error.

N = Z² X p X(1 − p) / E2

Where:

n = required sample size
Z = Z-score corresponding to the desired confidence level (for a 95% confidence level, the Z-score is approximately 1.96)
p = estimated prevalence of the disease (expressed as a decimal, so 50% becomes 0.5)
E = margin of error (expressed as a decimal, so 5% becomes 0.05)

Plugging in the values we got N = 384.16, we rounded up the sample size to 386 and 20% non-response rate was added to arrive at final sample size of 460.

We used snowball sampling wherein invites were sent to 25 eligible acquaintances of the study investigators (most of them were professional acquaintances) in each city and they were asked to refer three more participants after the completion of survey. Emails were sent to all the referrals along with link to access web-based questionnaire. 430 total invitations were sent over the span of 2 months with 80 non-responses. The survey was open for two months, January and February 2023. Final number of responses received was 350.

Questionnaire development and measurement

We referred to the questions used in published literature on self-medication (11–13). The questionnaire was designed and administered in English.

The initial draft of the questionnaire consisted 28 questions divided into four sections: Demography, Knowledge Attitude and Practices (KAP) towards Self Medication, KAP on internet-based self-medication for acute conditions, KAP on internet-based self-medication for chronic conditions.

The KAP questionnaire used Likert scale of 0 to 3 to measure participants’ responses about self-medication. For example, a question asked “How often do you purchase medication from local pharmacist without consulting a medical professional or asking the pharmacist to suggest medication for specific conditions?” The options were 0 – Never, 1 – Sometimes, 2 – Often, 3 – Always. The KAP questionnaire also included questions about the reasons for purchasing medication without consulting healthcare professionals, with multiple-choice options. The first draft of the tool was administered to 5 experts (Community Pharmacist, Public Health Specialist, Health Management Student, Pharmacist, Clinical Researcher). The experts evaluated the tool in terms of clarity of understanding, flow of questions, repetition of questions and suggested their changes. A final draft was prepared after including comments from expert panel members.

The study protocol was submitted to the IIHMR Bangalore IRB and was approved vide letter IIHMRIRB/Q3/08/2023.

Statistical Analysis

The study utilized Stata Version 14 for data analysis, which involved computing descriptive statistics for all variables. The results were conveyed in the form of counts and percentages for categorical and nominal variables, while continuous variables were presented as means with corresponding standard deviations.

The data was primarily divided into two types: one participant-based information and another being instance based. An instance was defined as the number of times a participant practiced self-medication over the period of three months. Test for significance was employed to accept or reject the null hypothesis. The results are stratified into three sections, first focussing on overall study participants, second on participants who practice self-medication, and third on participants who have exclusively used the internet for self-medication.

From the total 350 participants, 175 (50%) participants were from Bengaluru, 98 (28%) participated from Amritsar, and 77 (22%) participated from Chennai. The mean age of the participants was 33.6 years (SD ± 8.4). Table 1 presents the detailed demographic information of the survey participants. For the context of self-medication, we set the context using WHO definition on self-medication(1), in context of India the consumer practices include consulting a registered medical practitioner (Modern medicine and Alternative medicine), also many Indians consult to Pharmacist (they mention the symptoms and pharmacist dispenses medication based on his knowledge and experience). Across the literature some papers have included consultation through pharmacist as self-medication, while some have excluded it from self-medication practice. As we used WHO definition, the pharmacist consultation treated as separate category of Allied Healthcare Professionals.

Out of the 350 participants 121 (34.5%) mentioned that they resorted to self-medication at least once in past three months from the date of survey (January and February 2023), and 43 out of the 121 reported that Internet was often source of information for self-medication related decisions. 167 (47%) mentioned that they have consulted Allied Healthcare Professionals but not consulted registered medical practitioners in past 3 months. While 62 (17.5%) reported they exclusively consulted registered medical practitioners only in past 3 months and not ever resorted to consult Allied Healthcare Professionals or Self Medication.

The most common reason for self-medication was reported as “Condition was minor to necessitate consultation of registered medical practitioner” (36%), followed by “Self-Medication was time savings” (35.4%), details of other factors is presented in Table 2.

When asked about the source of knowledge for self-medication (n = 121) “Use of Old Prescription” was the most common 50 (41%), followed by Internet 43 (35.5%), Consult to family members or friends 33 (27%), Other modes 18 (15%) included home based remedies, referred to advertisement over mass media.

When asked about the number of time participants practiced self-medication in the past three months (October, November, December 2022), a total of 891 instances were reported by the 121 participants, leading to an average of 7.3 instances of self-medication practice across 90 days, extrapolated to 2.4 instances in a month. The patterns were similar across the cities (P value 0.78) and across the age group (P value 0.42) without any statistical significance.

When asked about where the participants buy the medicines when practicing self-medication, Local Pharmacist (632 instances (71%)) was the most common source, followed by branded chain pharmacies like Med Plus, Apollo Pharmacy (237 instance (26.5%), only 22 (2.5%) instances were reported wherein participants purchase medicine from online stores or e-pharmacies.

We also inquired whether the participants who practiced self-medication had any adverse effects related to the self-medicated drug, 79 (8.8%) instances out of 891 were reported to have experienced adverse effects. A follow-up question on how participants managed adverse effects: 33 instances were managed by immediate cessation of medication, 27 instances required visit to registered medical practitioners, 7 instances required visit to allied healthcare professionals, 6 instances were managed by consulting to family or friends, and 6 instances were managed by using the internet (to verify if the adverse event is associated with the drug).

Stratified Analysis for Acute and Chronic Conditions

We specifically intended to ask the participants about the self-medication practices for acute and chronic conditions. The 121 participants who responded that they have practiced self-medication at least once in past three months from the date of survey were eligible to answer the section on acute and chronic conditions.

Out these 121 participants, 50 (41%) reported to practice self-medication exclusive to acute conditions, 40 (33%) reported to practice self-medication exclusive to chronic conditions, and 31 (25%) reported to practice self-medication for both acute and chronic conditions.

For acute conditions, Cough and Cold, Fever, and Acidity were the most common conditions wherein self-medication was practiced. The common sources of knowledge were: Internet (43%), Used Old Prescription (35%) Asked family or friends (12%), and Advertisement on Mass Media (10%). The most common mode of purchasing medication for acute conditions was Local Pharmacist, followed by Branded Chains and online store or e-pharmacies.

For chronic conditions, Join Pain followed by Hypertension and Diabetes were the most common conditions wherein self-medication was practiced. The common sources of Knowledge were: Old Prescription (68%), Internet (21%), Asked family or friends (6%), and Advertisement on Mass Media (5%). The most common mode of purchasing medication for chronic conditions was Local Pharmacist, followed by Branded Chains and online store or e-pharmacies.

Of the total 79 instances of adverse events reported due to self-medication, 39 were reported for Acute Conditions while 40 were reported for Chronic Conditions, there was no statistical difference in the reporting of adverse events across acute and chronic conditions (P value 0.87)

Analysis focussed on role of Internet for Self-Medication

Out of 121, 43 participants reported that the Internet was often a source of information for self-medication related decisions. Internet Search Engines like Google and Bing were used by 87% of the participants to search the information on medication, 10% participants used Wikipedia and 3% participants used specialised website like Medline Plus, Web MD to search information over the internet.

The 43 participants reported 238 (26.7%) instance out total 891 wherein they used internet to aid in decision making for self-medication. The aspects of information that aided in decision making: Price of the Durg (143 instances (60%)) was the most commonly searched information, followed by Common Adverse Effects (45 instances (19%)), branded name and generic name were searched during 31 (12.5%) of instances, and customer reviews were searched during 19 (8%) instances.

Smartphone was the most popular gadget used to access the information, with 40 (93%) participants out of 43 (100%) reporting exclusive use, 1 reported using tablet PC, and 2 reported using laptop computer. In terms of conditions, the most common condition was Headache (56 instances), followed Dandruff and Hair fall (43 instances), Cold and Cough (41 instances), Fever (28 instances), Running Nose (25 instances), Menstrual Cramps (18 instances), Oral Ulcer (12 instances), Diabetes (10 instances), Joint Pain (6 instances).

One of the hypothesis investigators tested during analysis was “individuals who exclusively used the internet for practicing self-medication were at a higher risk of adverse events compared to old prescriptions and asking family and friends”. The number of instances of adverse events for the Internet was 28, for Old Prescriptions was 19 and for Family and Friend was 32. We used logistic regression and the model yielded no statistically significant differences with P value of 0.913 (95% CI -6.783, 6.070) for relationship between adverse events reported for instances used internet and instances used old prescription. P value of 0.800 (95% CI -8.094, 6.241).

The age group reporting the maximum use of the internet for self-medication was 21–40 years with 207 (87%) instances reported from the younger age group. Of the three cities, Bengaluru reported the maximum instances of internet use for self-medication, with 147 (62%) instances, compared to Chennai with 67 (28%) and Amritsar with 24 (10%).

Table 1

Demographic Characteristics of the study participants (n = 350)
Variable	Category	n (%)
Age Group	Between 18 to 20 years	34 (10%)
	21 to 40 years	267 (76%)
	41 to 60 years	31 (9%)
	61 years and above	18 (6%)
Gender	Male	172 (49%)
	Female	175 (50%)
	Other	3 (1%)
Occupation	Students	180 (51%)
	Salaried Employee	98 (28%)
	Business Owner	21 (6%)
	Home Maker	21 (6%)
	Retired	25 (7%)
	Not disclosed	4 (2%)
Monthly Income	Less than 10,000 INR	23 (6.5%)
	10,000 to 25,000 INR	48 (13.7%)
	25,000 to 50,000 INR	51 (14.5%)
	Above 50,000 INR	66 (18.8%)
	Not disclosed	162 (46.3%)
Highest Education Attained	Primary Schooling	2 (0.5%)
	Secondary Schooling	28 (8%)
	Diploma	12 (4%)
	Graduate	221 (63%)
	Postgraduate	87 (25%)

Table 2

Reasons for self-medication reported amongst the 121 respondents who mentioned they resorted to self-medication at least once in past three month from the date of survey.
Reason for Self-Medication	n (%)
Condition was minor to necessitate consultation of registered medical practitioner	45 (36%)
Self-Medication was time saving	42 (35.4%)
Used Old Prescription	15 (12.5%)
High Cost to access healthcare provider	10 (8%)
Lack of trust on healthcare provider	4 (3.1%)
Healthcare provider difficult to reach	3 (2.8%)
Consulted to Family Member or Friends	2 (2.2%)

Table 3

Frequency of the conditions for which the participants practiced self-medication out of total 891 instances for three months.
Condition Name	n (%)
Cough and Cold	163 (18.2%)
Headache	150 (16.8%)
Dandruff and Hair fall	91 (10.2%)
Fever	91 (10.2%)
Running Nose	84 (9.4%)
Menstrual Cramps	67 (7.4%)
Muscle Spasm	48 (5.3%)
Hyperacidity	46 (5.1%)
Nausea and Vomiting	24 (2.6%)
Oral Ulcers	23 (2.5%)
Joint Pain and Arthritis	23 (2.5%)
Diarrhoea	22 (2.4%)
Skin Rashes	15 (1.6%)
Hypertension	13 (1.4%)
Diabetes	10 (1.1%)
Urinary Infections	8 (0.9%)
Asthma	7 (0.8%)
Earache	6 (0.7%)

The number of population relying on the internet for health information is increasing in India, with 60% of people reporting the use of internet for seeking health information (10). The study by Agarwal et. al(10) on the influence of Internet related to healthcare decisions reported that 4.47% of individuals opted for allopathic medications without seeking medical advice. Most people engaged in self-medication for minor ailments, while 11.6% took the initiative to diagnose and treat serious conditions such as heart disease, diabetes, cancer, and mental health issues without professional guidance. Additionally, 23.2% of respondents believed that obtaining health-related information from the internet posed no risks for self-medication, and 21% considered internet resources as potential alternatives to consulting a healthcare provider.

Another study by Iftikhar and Abaalkhail(14), reported social media messages were found to have an impact on decision-making for individuals regarding healthcare (P = 0.001). Indicating the Internet being accepted by an increasing number of the population as a source of information regarding healthcare.

Several studies across the literature published in India and neighbouring countries have not considered Internet as a source of knowledge aiding in self-medication(4, 8, 13, 15–19). The strength of the current study rests on the fact that it explores the role internet plays in decision making regarding self-medication. The current study also explores the risk of adverse events associated with various sources of knowledge associated with self-medication and provides evidence that there is no statistically significant difference in terms of adverse events associated with old prescriptions, referring to family or friends, or use of internet as source of information for self-medication. A recent paper by Rathod et.al (2) indicated that 2% of its participants referred to the internet as a source of knowledge for practising self-medication, which is much lower than 12% of our total study participants.

A study by Gupta and Chakraborty(16) indicated that 50% of the population used old prescription as a source of knowledge for self-medication, 31% inquired with family members and 12% with Friends. Similarly, our study reported old prescription at 41%, Family and Friends combined at 27%, while internet was reported as a source for 35.5% of participants, indicating some degree of shift towards the internet in our population.

“Health Condition being minor for not necessitating consultation with healthcare providers” was top reason for self-medication mentioned across multiple published articles(15, 16), similar to the findings of the current study. Cold and Cough, Fever were reported as the most common conditions wherein patients practiced self-medication(4, 8, 13, 15–19), similar to the findings of the current study.

The current study is only exploratory in nature and explores the patterns across urban centres of India, and data from semi urban and rural centres are not collected. The role of the internet across age groups, education levels, income groups, occupation and several other socio-demographic factors in self-medication could not be explored due the sample size limiting subgroup analysis.

A large-scale survey focussed on consumer preferences and practices in necessary to better understand role of the internet in self-medication practices and to document the evolving nature of consumer practices.

Self-Medication practice is common across the urban population of India. The internet is documented as the second common source of knowledge for self-medication after using old prescriptions. However, the risk of adverse events associated with using internet as source of information is similar to the risk associated with other sources of information like old prescriptions or references from family or friends. The internet is primarily used to compare prices and brands of drugs but is rarely used to purchase online medicine.

Competing interests: authors declare no competing interests

WHO_EDM_QSM_00.1_eng.pdf [Internet]. [cited 2023 Oct 1]. Available from: https://iris.who.int/bitstream/handle/10665/66154/WHO_EDM_QSM_00.1_eng.pdf
Rathod P, Sharma S, Ukey U, Sonpimpale B, Ughade S, Narlawar U, et al. Prevalence, Pattern, and Reasons for Self-Medication: A Community-Based Cross-Sectional Study From Central India. Cureus. 15(1):e33917.
Saha A, Zam D, Khan AA, Dutta P, Mannan A, Alam N. Prevalence and determinants of self-medication practices among general population: A cross-sectional study in Thimphu, Bhutan and Chattogram, Bangladesh. J Public Health Res. 2023;12(1):22799036231152327.
Mathias EG, D’souza A, Prabhu S. Self-Medication Practices among the Adolescent Population of South Karnataka, India. J Environ Public Health. 2020;2020:e9021819.
Chakravarthy SA, Maiya GR. Prevalence of self-medication and its associated factors among students of an engineering college in Chennai. J Fam Med Prim Care. 2021;10(3):1204–8.
Ray I, Bardhan M, Hasan MM, Sahito AM, Khan E, Patel S, et al. Over the counter drugs and self-medication: A worldwide paranoia and a troublesome situation in India during the COVID-19 pandemic. Ann Med Surg. 2022;78:103797.
Fricke S. Semantic Scholar. J Med Libr Assoc JMLA. 2018;106(1):145–7.
Jain S, Thakur A, Peepre K, Kaushal S, Kasar P. Prevalence of self-medication practices among the residents of urban slums located near govt. medical college, Jabalpur. Int J Community Med Public Health. 2018;5:811.
Nakakande J, Taremwa IM, Nanyingi M, Mugambe S. The Utility of Internet-Enabled Antibiotic Self-Medication and Its Associated Factors Among Patients Attending Private Clinics in Kawempe Division in Kampala Capital City, Uganda: Community-Based Cross-Sectional Study. Drug Healthc Patient Saf. 2023;Volume 15:85–91.
Agarwal T, Agarwal V, Agarwal P, Sharma D. Use of internet for practice of self-medication: We are heading toward an era of internet pharmacy. Med J Dr Patil Vidyapeeth. 2021;14(1):36.
Dubey P. Assessment of Self-Medication Practice for Oral Health Problems among People of Varanasi, Uttar-Pradesh, India [Internet]. Rochester, NY; 2022 [cited 2023 Oct 3]. Available from: https://papers.ssrn.com/abstract=4570842
Selvaraj K, Kumar SG, Ramalingam A. Prevalence of self-medication practices and its associated factors in Urban Puducherry, India. Perspect Clin Res. 2014;5(1):32–6.
Kumar N, Kanchan T, Unnikrishnan B, Rekha T, Mithra P, Kulkarni V, et al. Perceptions and Practices of Self-Medication among Medical Students in Coastal South India. PLOS ONE. 2013;8(8):e72247.
Iftikhar R, Abaalkhail B. Health-Seeking Influence Reflected by Online Health-Related Messages Received on Social Media: Cross-Sectional Survey. J Med Internet Res. 2017;19(11):e5989.
Ghimire P, Pant P, Khatiwada S, Ranjit S, Malla S, Pandey S. Self-medication practice in Kathmandu Metropolitan City: A cross-sectional study. SAGE Open Med. 2023;11:20503121231158966.
Gupta S, Chakraborty A. Pattern and practice of self medication among adults in an urban community of West Bengal. J Fam Med Prim Care. 2022;11(5):1858–62.
Gyawali S. Knowledge, Attitude and Practice of Self-Medication Among Basic Science Undergraduate Medical Students in a Medical School in Western Nepal. J Clin Diagn Res [Internet]. 2015 [cited 2023 Oct 4]; Available from: http://jcdr.net/article_fulltext.asp?issn=0973-709x&year=2015&volume=9&issue=12&page=FC17&issn=0973-709x&id=6988
Gyawali S, Rathore DS, Adhikari K, Shankar PR, Kc VK, Basnet S. Pharmacy practice and injection use in community pharmacies in Pokhara city, Western Nepal. BMC Health Serv Res. 2014;14(1):190.
Lukovic JA, Miletic V, Pekmezovic T, Trajkovic G, Ratkovic N, Aleksic D, et al. Self-Medication Practices and Risk Factors for Self-Medication among Medical Students in Belgrade, Serbia. Dacso CC, editor. PLoS ONE. 2014;9(12):e114644.

Download PDF

Version 1

posted

You are reading this latest preprint version

The Role of the Internet in Influencing Self-Medication Behaviors Among Urban Residents in India: A Cross-sectional Study

Status:

Version 1

Abstract

Objective

Methodology:

Results

Conclusion

Background

Study Objective

Methodology

Study Design and Population

Sample size calculation and Sampling

Questionnaire development and measurement

Statistical Analysis

Results

Stratified Analysis for Acute and Chronic Conditions

Analysis focussed on role of Internet for Self-Medication

Discussions

Conclusions

Declarations

References

Status:

Version 1