A Cross-Sectional Survey Among Medical and Pharmacy Students Regarding Knowledge, Attitudes, and Practices of Toward Self-Medication in Qassim University, Buraydah, Saudi Arabia.

Background: Self-Medication (SM) is common practice worldwide in both developed and developing countries. SM is referred as self consuming of medication without consulting a physician for either diagnosis or treatment. This study aims to assess the knowledge, attitudes and practices toward SM among medical and pharmacy students. Methods: This cross-sectional study was conducted among medical and pharmacy students in Qassim university, Buraydah, Saudi Arabia, during the period 2020-2021. Multistage random sampling technique was used to recruit students. The data were collected through questionnaire. Results: Three hundred and sixteen of 342 students were recruited. This study showed that the majority (94.6%) of students had good knowledge of self-medication. Additionally, the following characteristics were signicantly associated with good knowledge: being female, and Pharmacy students. Overall mean score for the attitudes towards self-medication shows that 58.4% of the total sample had high agreements towards the questions of the attitudes toward self-medication. More than half (63.9%) of the students reported that they practice self- medication in the last 6 months. Pain killers was the most common medication used for self- medication by the majority of the students (88.29%). The majority (77.8%) of respondents reported that they feel condent about the use of self-medication. Conclusions: In conclusion, students' knowledge of self-medication appears to be good and signicantly high among pharmacy students in comparison to medical students. Therefor, medical and pharmacy students should be viewed as important contributors to the public health care system, and future health professionals should be properly educated on good pharmacy practice and responsible self-medication. applicable

several problems such as pharmaceutical reactions, possible increase of antimicrobial resistance, and waste of resources 4 .
There are several worldwide surveys have investigated the SM practices among university students which found a high SM prevalence in Bangladesh (88%), 5 Jordan (86.7%), 6 and Egypt (52.7%). 7 Likewise, in Gadjah Mada University, Indonesia 8 and Jiangsu University, China 9 revealed that SM with antibiotics was practiced by 49% and 47.9% of the respondents, respectively. In Ethiopia, the prevalence of SM among university students across studies has been 32.7-70.8%. [10][11][12] in Saudi Arabia, few published health studies have been conducted to nd out the prevalence of SM practice among university students. Which show a varying prevalence of SM 3,13−16 . Two of these studies were carried out at Al-Qassim University 13,16 .
Medical and pharmacy students are generally different from other university students as they are exposed to knowledge about diseases and drugs which makes SM easy to practice. Therefore, pharmacists and physicians have an important role in providing useful recommendations on the proper and safe use of a pharmaceutical drug. To the best of our knowledge, no study has been focused on investigate knowledge, attitude, and practice of medical and pharmacy students toward SM in Al-Qassim regain. Therefore, our objective is to assess the knowledge, attitude, and practice of medical and pharmacy students toward SM in Qassim University. and to examine the association between the students' demographic characteristics and their knowledge and attitudes.

Study setting
A cross-sectional study was conducted using questionnaire among medical and pharmacy students in Qassim university, Buraydah, Saudi Arabia, during the period 2020-2021.
A multistage random sampling technique was followed in this study to choose the respective number of student. Medical and pharmacy college, as well as each entry-year, will be considered as stratums, and within the stratums, students will be simple random selected. All medical and pharmacy students from year one to year ve will be included. Medical and pharmacy students who were not available during the study period and who were not volunteers to participate will be excluded.

Sample size
The sample size was calculated using a standard sample size equation "n = z2p(1-p)/e2" and an assumed proportion of 50% (proportion of students who had good knowledge and attitude toward selfmedication). Using a 95% con dence interval and a 5% margin of error, the sample size was estimated to be 285 and was adjusted to 342 to compensate for the non-response rate.

Participants and survey instrument
The questionnaire was developed by the principal investigator based on the study objectives and after a literature review of similar studies. A panel of 3 physicians, all of whom provide clinical care for patients familiar with the survey's development, assessed the questionnaire for appropriateness, accuracy, and relevance and were asked to critique the questionnaire's content. To ensure the face validity of the questionnaire, it was presented to a sample of 20 students in a pilot study and then nalized. The results of the piloted questionnaires were not included in the analysis.
As the research was conducted during the COVID-19 pandemic, students were asked to join a Zoom meeting conducted by the investigators for research keeping the value of social distancing in mind. The aims of the study were explained to the students and they were asked for consent. A standard pretested questionnaire was prepared using Google forms, was emailed to 349 students After receiving their consent. Two reminder emails were sent at an interval of 1 month.
The questionnaire is divided into four sections with a total of 33 questions. The rst section pertains to demographic characteristics, including age, gender, level of education, and nationality.
The second section assesses the students' knowledge regarding SM. The response choices for knowledge items include "yes", "no" and "do not know". Correct answers were scored as 1, while incorrect answers and "do not know" were scored as 0. The total knowledge score ranges from 0 to 7 (7items).
Total score ranged between 0 to 7; Since poor level considered for the total score (0, 1, 2, 3 and 4) out of (7) and good level considered for the total score (5, 6 and 7) out of (7) The third section assesses the attitudes of students towards SM. Five-point Likert scale items were used; strongly agree responses were scored as 5, agree as 4, uncertain as 3, disagree as 2, and strongly disagree as 1.

Data management and analysis plan
The data collected through google form were recoded and entered using the Statistical Package Statistical Package of (SPSS v.26) were used to describe the basic features of the data in the study, through frequencies, percentages. Spearman's rho test used to test the relation between the knowledge and attitudes toward self-medication; since both are tested using its ordinal values. Chi-squared test (χ2) were used to nd the association between the level of knowledge (poor-good) and socio-demographic variables. Finally, ANOVA test used to nd the differences in mean score of attitude with its 5-Likert scale according to socio-demographic variables.

Ethical considerations
Approval for the study was obtained from the Institutional Review Board, College of Medicine, Qassim University (no. 20-07-03), Qassim, Saudi Arabia. Each participant received the questionnaire and was informed about the objective of the present study. All participants provided an informed google consent form. The Institutional Review Board has agreed that completing the questionnaire will imply consent.

Demographic information
Three hundred and sixteen of 342 students completed the questionnaires (response rate of 92%). Table 1 shows that the total sample size was (316), 54.4% were female while 45.6% were male, the highest age group was (21-23) with 68.7% of the total sample, 83.5% were living in Urban and 16.5% living in Rural. About Specialty, 50.3% found for Medicine and 49.7% for Pharmacy. About education level, the highest percent were 34.5% for the rst year. 86.1% hadn't health insurance; since 88.3% hadn't any medical illness. Knowledge of self-medication More than half (81.6%) of students had adequate knowledge that SM is de ned as self-consuming of medication without getting advice from a physician. Moreover, the majority (94.3%) of of students knew that all medications (prescription, OTC and herbal) have adverse effects. Most of them (94.9%) recognized the importance of seeking physician help in case of drug adverse effects. A total of 308 (97.5%) students were aware that using medications with unknown substances in patients with liver and kidney disease is dangerous, and approximately all students realized that Increasing or decreasing medication dose without a doctor consultation can be dangerous. More than half (88.3%) of students knew that SM can mask signs and symptoms of some disease (Table 2) Total score knowledge ranged between 0 to 7; Since poor level considered for the total score (0, 1, 2, 3 and 4) out of (7) and good level considered for the total score (5, 6 and 7) out of (7). Results shows that 17 students out of 316 which represent 5.4% of the total sample had poor knowledge of SM with total score less than 5, while 299 ss, which represent 94.6% had good knowledge of SM with total score (5 and above). Table 3 demonstrates a statistically signi cant association (P < .05) between good knowledge and the following student characteristics: being female, and Pharmacy students.  Students' attitudes towards self-medication Table 4 shows the student's responds to the seven questions of the attitudes towards self-medication. The highest mean score was 3.49 out of 5 point scale for (The availability of OTC medicines and the belief on its safety leading me to use self-medication), followed by mean score 3.29 for (Easy access to healthcare information and facilities, the main cause that medical and pharmacy student use selfmedication). While the least mean score of agreements was 1.98 out of 5 scale for (No need for training to use self-medication?). Overall mean score for the attitudes towards SM was 2.92 out of 5 scale, with Std. Deviation of 0.692 which represent about 58.4% of the total sample had high agreements towards the questions of the attitudes toward SM in Qassim university, Saudi Arabia. Table 5 demonstrates a statistically signi cant (P < .05) in the mean score of the attitude and the following student characteristics: being male, being 21-23 years' old, and being pharmacy students.  Table 6 demonstrates a statistically signi cant negative relation between knowledge and selfmedication part of self care (r= -0.152, p< 0.05). The higher the good knowledge of SM the less believing that self-medication part of self care. In addition, there is a statistically signi cant negative relation between knowledge and recommendation self medication to others (r= -0.143, p< 0.05). The higher the good knowledge of SM the less recommendation self medication to others. The students' practice toward the statements about SM have been illustrated in Table 7. More than half (63.9%) of the students reported that they practice self-medication in the last 6 months. The majority (79.1%) of respondents knew the medication classi cation of OTC & prescription drugs. Pain killers was the most common medication used for self-medication by the majority of the students (88.29%), followed by antipyretics (49.68%). It was also observed that (36.71%) of the students reported to have self-medicated with Antihistamine, others are listed in Table 7.
More than half (64.56%) of respondents reported that most frequent causes of practice SM were headache followed by cough & common cold (34.8%). Others like fever, Acne, menstrual problems, body pain and allergy with respective episodes of (31%, 28.48%, 24.68%, 20.89%, and 14.87%). More than half (64.87%) of respondents reported that their personal knowledge was the major source of information for the practice of self-medication. Approximately two-thirds (69.3%) of respondents knew the potential adverse reactions of the drug. The majority (94.3%) of respondents reported that they obtained SM from Pharmacy, (12%) used SM from Herbal store.
More than half (67%) of respondents reported that has self-medicated because of non-seriousness of the illness followed by quick relief (63.61%). Approximately one-thirds (22.5%) of respondents reported that they have experienced a negative side effect after self-medication. approximately 69% of them reported side effect from the drug. The majority (77.8%) of respondents reported that they feel con dent about the use of self-medication.

Discussion
To our knowledge, this study was the rst to assess the knowledge, attitudes and practices of medical and pharmacy students regarding SM in Qassim university. It has demonstrated essential ndings. First, this study showed that the majority (94.6%) of the students had good knowledge scores. Second, more than half (58.4%) of students had agreement attitudes towards SM. Third, the majority of the students had low practice scores.
SM for minor diseases and non-serious health conditions appears to be a common practice among students. In Saudi Arabia and other countries, the prevalence of SM practice varies widely throughout all demographic groups.
A study by Alshahrani, reported the highest prevalence of SM practice in Saudi Arabia, whereas Makeen et al. reported the lowest frequency (98.7%, and 11.4%, respectively) 3,17 . This nding is similar to another study conducted in Saudi Arabia, which found that 64.8 % of medical students practice self-medication. 14 Variations in study sample demographics, research methodology, data collection methodologies, and variation in response rates across studies may have resulted in a wide range of prevalence across different regions.
SM appears to be more prevalent among students than in the general population. One study on Ethiopian medical and pharmacy students found a 38.5 % prevalence. 18 SM was also reported by 44.8 % of Bahraini medical students, 19 78.6 % of Indian medical students, 20 and 55.2 % of Egyptian medical students. 21 SM was reported by 98 % of Palestinian students in another survey. 22 Two European studies, one on Slovenian students and the other on Serbian students, found a frequency of 92.3% and 79.9%, respectively. [23][24] This could be attributable to a variety of factors, including students' greater pharmacological and clinical education, as well as their better Internet access.
Regarding knowledge, 94.6% of our students had good knowledge. The ratio of pharmacy students who had good knowledge on this issue was signi cantly higher in comparison with medical students (P < 0.05). This observation is most likely due to differences in educational courses and curriculums in these elds. Furthermore, female students had signi cantly higher knowledge than male (P = 0.05). This nding is similar to a study conducted among pharmacy students in Iran. 25 With regard to the practice of self-medication, our results showed that 63.9 % of the pharmacy and medical students of Qassim University who participated in the study had at least one episode of SM during the past 6 months. Adequate knowledge, and the non-acute nature of the condition were identi ed to be the most important reasons for self-medication. Likewise to two studies conducted in China and Brazil, they concluded that the most common reason for SM was a non-serious or transient disease (45%, and 46%, respectively) . [26][27] In a Rwandan study, not having a serious disease was the most common reason for SM among university students. 28 Financial and insurance issues have been reported as other reasons for self-medication. 29 Another study found that bad behavior of health care providers, being too far away from the clinic, and low e cacy of prescribed drugs were all used as justi cations for university students to self-medicate. 30 The most widely utilized medications for SM among our students were painkillers and antipyretics (60%).Similarly, our ndings were in line with the ndings of the majority of similar studies. Painkillers (60%) and antipyretics were the most commonly used drugs for SM among our students. Likewise, our results were consistent with the ndings of most similar studies 21,31,32 . In other studies, NSAIDs 27,33 , antibiotics 27,28,30 , pain killers 30,33 drugs were reported as the most common drugs used for selfmedication. In a study conducted in Pakistan, OTC drugs were found to be the most commonly used pharmaceuticals (98.3%) by medical undergraduate students 34 . The primary reason for using analgesics and antipyretics for SM is that they do not require a medical prescription and are easily and quickly available in pharmacies and other general stores nearby. Our study also revealed that very few students anticipated adverse drug reactions, indicating that all students, regardless of study level, have at least basic knowledge of the drugs used for self-medication.
Students' attitudes toward SM revealed that a large number of students agreed that SM is an important part of self-care. As a result, students should be aware of the dangers of improper medication use, which can lead to drug resistance, toxicity, and increased adverse effects. Despite the fact that the majority of students use self-medication, they do not recommend it to others. This attitude explains why most students' perceptions of SM changed as they gained knowledge during their studies.
A limitation of this study is the use of a survey tool that has not undergone prior reliability and validity testing. In addition, the result of this study cannot be generalised to other populations in the country because KAP might be greatly in uenced by socio-demographic factors of the population. More studies on the SM need to be performed, especially with the raising SM practice in the region.

Conclusions
In conclusion, students' knowledge of SM appears to be good and signi cantly high among pharmacy students in comparison to medical students.
Therefor, medical and pharmacy students should be viewed as important contributors to the public health care system, and future health professionals should be properly educated on good pharmacy practice and responsible self-medication.

Declarations
Ethics approval and consent to participate The study was approved by the Institutional Review Board, College of Medicine, Qassim University (no. E-18-0488), Qassim, Saudi Arabia. Each participant was informed in detail, and his/her consent was obtained before the data collection.
All methods were carried out in accordance with relevant guidelines and regulations, notably the Declaration of Helsinki.

Consent for publication
All participants provided an informed google consent form to publish this study.

Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests
The authors have declared no competing interests.

Funding
There was no funding for this study.
Authors' contributions RD and WT were responsible for the conception of the research idea and the study design, data collection, analysis, interpretation, and drafting of the manuscript. All authors read and approved the nal manuscript.