Evaluation of Knowledge, Attitude and Practice (KAP) about Self-medication among Adult Population of Eastern Province, Saudi Arabia

Introduction: Self-medication can be described as the use of medications with therapeutic intent without prescription or supervision of the physician. The World Health Organization has considered Selfmedications as one of self-care elements that comprise hygiene, nutrition, lifestyle, living condition, and income level. SelfCare is a practice that people do, to maintain wellness and prevent illness. Hence current study conducted to measure the prevalence of knowledge and attitude about selfmedication practice among the communities of Eastern province, Saudi Arabia. Methods: A cross-sectional descriptive study was conducted among 532 participants via an online survey. Survey questionnaire was distributed over the Social media platform. Results: The results indicate that among the age group 15 to 25 years (43.42%) there’s a high incidence of self-medication practice. Gender comparison indicated that females demonstrated a high prevalence of self-medication than males. Analysis of information from the university graduate students indicated that self-medication was high (46.05%) related with the knowledge of the Original Research Article Ali et al.; JPRI, 34(27A): 59-70, 2022; Article no.JPRI.85336 60 medications (68.6%). Major medicine that was being used to self-medicate was Analgesic/painkiller (80.26%). It is essential to mention that the use of antibiotic was slightly low (12%). Among the health problems that provoked self-medication, headache was the main health problem (58.83%). Conclusion: Self-medication was found to be alarmingly high among the population of Eastern Province, Saudi Arabia. So, it is imperative to increase the awareness among the population about the risk of this practice and how to practice self-medication more responsibly to avoid unwanted outcomes.


INTRODUCTION
Self-medication is a global phenomenon where in people throughout the world act on their own for their health. It is common in every region and age group varying in extent among people of community [1]. Self-medication can be described as the use of medications with therapeutic intent without prescription or supervision of the physician [2,3]. The World Health Organization has considered Self-medications as one of selfcare elements that comprise hygiene, nutrition, lifestyle, living condition, and income level. Self-Care is a practice that people do, to maintain wellness and prevent illness. Somewhere "responsible Self-medication" refers to the individual's practice to treat their illnesses with medications that don't require prescription and they are considered to be safe and effective when they are used properly and as directed. On the contrary, Self-Medication taken irresponsibly is discouraged as it may not only harm the patient resulting in adverse drug reactions (ADRs) and Drug-Drug interactions but may also increase the direct costs, including the cost of treatment and admission to hospital 1,4]. The patterns of taking Self-medication vary amidst different regions and populations, and are influenced by various characteristics, such as gender, age, educational level, self-care attitude, medical background, non-seriousness of illnesses and socioeconomic factors such as income and expenditure along with Health insurance [2]. With all the different contributing factors medications are usually obtained from home as a left-over, or from pharmacies and from family members [5].
Among all age groups, the elderly tend to have the highest tendency to seek self-medication because they suffer from various illnesses. Bodily changes associated with aging in addition to the changes in pharmacokinetics process (effect of the body on the drug such as drug metabolism and elimination) and the pharmacodynamics (effect of medicine on the body) may contribute to changes in the way the body reacts to medication. This ultimately resulting in reaction to medicine, congestion and aggravation of medicine effect which in turn can increase the adverse drug reactions (ADRs) and medicine interference [6]. Self-medication has its positives and negatives. Advantages of responsible self-medication includes cost cutting of treatment; evading long waiting times at clinics; treatment of previously diagnosed chronic disease, recurrent and minor diseases without referring to physicians; and encouraging the involvement of community pharmacists in selfcare practices, by advising patients about how to use the medications safely and effectively including the over-the-counter (OTC) medications [7]. Besides, self-medication has its disadvantages such as masked diagnosis, using excessive drug dosage, using drug for prolonged duration, drug and food interactions, Drug -Drug interaction, Adverse drug reactions (ADRs), polypharmacy and superinfection can occur in self-medicating individuals [3].
Self-Medication is provoked to treat various minor health conditions like Headache, fever, flue, and cough [2]. Usually these conditions are addressed in over the counter (OTC) medications. Some people may seek selfmedication to treat a previously diagnosed chronic condition such as Diabetes or Hypertension. Self-medication is more common nowadays due to increased exposure to pharmaceutical advertisement and social media like WhatsApp, facebook, twitter and Instagram [2]. This exposure has influenced people to seek medicine related information from social media. This practice leads to self-medication. Selfmedication happens when people purchase drugs, based on individual's experience that is shared on social media. A common reason among people to practice self-medication is, searching for their symptoms on Internet, diagnosing themselves and then choosing the desired medication without the guidance of the physician or pharmacist. A study that was carried in Saudi Arabia about "The use of social media among Saudi residents for medicines related information", indicated, 70% of the participants searched for medical related information on social media either on yearly, monthly, weekly and sometimes even on daily basis. Whereas. 29.3% of them. Had never used social media to search for medical related information. While this means that, social media may have a big impact on self-medication practice, it also important to consider that, it can be a major tool to mislead the public [8].
Most of the self-medications used are OTC, so there's a tendency for consumers to think that it is completely safe and has no side effects. Hence, the goal of our study is to evaluate the Knowledge, Attitude and Practice (KAP) about Self-medication among adult population of Eastern province, Saudi Arabia.

1 Study Plan
A cross-sectional descriptive study was conducted to assess the Knowledge, Attitude and Practice (KAP) about self-medication among population of the Eastern Province, Saudi Arabia. The study was carried out for a period of 2 months from 1st September 2019 to 31st October 2019.

Study Instrument
A self-administered questionnaire to collect data was designed. Items of questionnaire were formed after reviewing the available research literature. The final questionnaire was translated to Arabic language, the national language of all Saudis. The study investigators are provided to facilitate communication between the investigators and participants, and consent is given for participants to agree to take part in survey. Investigator also mentioned during research introduction to the respondents in the starting of the survey response will be anonymous, results will be expressed in terms of combination data regardless of individual response. The questionnaire included many sections and comprised of close-ended and multiple choices questions. Categories of variables identified were the demographics (Section 1) including age, gender, educational level, occupation, marital status, number of kids, health insurance. Section 2 was concerned with assessment of the knowledge and attitude of people to self-medication. Section 3 was concerned with people's opinions about selfmedications, frequency and the main reason for self-medication, self-medication and side effects, health problem that provoked self-medication, and medicine classes used for self-medication.

Study Sample Size and Collection of Data
The Raosoft® online sample calculator was used to calculate the sample size with the margin of error 5%, and confidence level of (CI) 95%. The recommended sample size was 385. Totally 800 convenient questionnaire survey links were distributed amongst the general public of the Eastern province, Saudi Arabia through social media and e-mail, of which 532(66.5%) completely answered the questionnaire.

Data Analysis
Analysis of data was performed using the Statistical Package for Social Science Version 23 (SPSS V.23) (Institute Inc: Cary, NC, USA). Demographic characteristics were applied to calculate the numbers (frequencies) and percentages; mean ±standard deviation). Associated factors within groups were calculated using the chi-square (χ2) test. A p-value 0.05 was considered statistically significant.

Demographic and Socioeconomic Characteristics
The total sample amounted to 532 participants. Most of the participants were aged between 15 and 25 (N=231, 43.42%) and around one fourth participants aged between 36 and 50 (N=148, 27.8%). Gender analysis revealed that the majority of participants were females (N=397, 74.6%). Approximately half of the participants were university graduates (N=245, 46.05%). Occupation-wise data revealed that one third was students (N=188, 35.33%) followed by Non-Health care workers (N=154, 28.9%). A little more than half of them were married (N=300, 56.39%) followed by (N=222, 41.72%) single. Half of them did not have children (N= 296, 50.56%) followed by one third who has more than 2 children (N= 165, 31.01%). Over half of them has health insurance (N=298, 56.01%). The demographic and socioeconomic information is tabulated in Table 1.

Frequency and Main Reason for Selfmedication
Over half of participants have gone through selfmedication at one time in the last three months (N=320, 60.15%) (p<0.001). Very small number of participants have never practiced selfmedication over the last three months (N=44, 8.27%) (p<0.001) details available in Table 4. Reveals that "Knowledge or previous experience" was the main cause f or self-medication for about half of participants (N=272, 51.12%) followed by the answer "mild severity of illness" which was the main cause for selfmedication for around fourth of participants (N=141, 26.5%). Reason for self-medication

DISCUSSION
Self-medication is a very common practice all rounds the world which leads to numerous complications that affect people's well-being. Every medication needs to be administered in the right route, right dose, at the right time, and for the right duration to obtain an effective response [9]. Using self-medication may lead to drug misuse and moreover an inappropriate dosage may cause more harm than benefits [10].
To use any medication, it becomes necessary that, they are used with proper indication from healthcare providers to avoid any harmful side effects. A lot of reasons and factors can lead to self-medication behaviours such as socioeconomic factors, lifestyle, readily available drugs, high medical consultation cost, time consuming clinical process, difficulty of nearby access to healthcare, past experience, and extensive advertisement [2]. Approximately 60.7% of participants in the current study are practicing self-medication during the last three months which are a very high value, based on the quantity of collected data. A comparable study conducted in Dammam, done on Public University Students (pharmacy and medical) indicated that the prevalence of self-medication was 26% [1]. A study in central province of Saudi Arabia showed that 49% of purchased medications are medications that must be dispensed only by prescription and 51% of them were OTC medications [11]. Also, another crosssectional study in different regions of Saudi Arabia showed that 81.4% of the participants reported of having used a prescription drug without first obtaining a physician's advice [12]. Another similar study among medical first-year students in Bahrain showed that 44.8% of them practiced self-medication [13].
In assessment of people Knowledge and Attitude about self-medication, it shows that 68.6% of participants know whether the purchased medication needs a prescription or not, in comparison to a study conducted in central Saudi Arabia only 31.8 % of participants have the knowledge about whether the purchased medication needs a prescription or not [11]. This indicates a higher level of awareness in the eastern province. Around 74% of participants have knowledge about, the route of administration, dosage, and side effects of the medicine, whereas only 38% of participants have used prescription medications along with purchased medication without prescription. Around 60% of participants have told the pharmacist about the used medication at home which indicates that people are aware of possible interactions that might occur with drug coadministration, also, this indicates that the pharmacist's involvement in such a situation can help in better outcomes.
Regarding people's opinions about selfmedications, one third of (33%) participants "usually" read the pamphlet when medication without prescription is purchased, in comparison to a study conducted in central Saudi Arabia, 43.7% of participants "always" read the pamphlet when medication without prescription is purchased [11]. In a study conducted in Jordan among medicine and pharmacy students, medicines were used according to instructions obtained mainly from the leaflet by 28.8% [7]. In the current study of 42.29% of participants answered with "always" for asking the pharmacist for more information in regards to the purchased medication. In such a practice pharmacist's involvement is greater in self-medication practice meaning a greater responsibility towards their patients and an increased need for accountability [4]. From the safety perspective, one third of participants (33%) think buying medication without prescription is "sometimes" a safe way of using medication, on other hand nearly one fourth (26.69%) of participants think buying medication without prescription is "Never" a safe way of using medication. In comparison to a study conducted in central Saudi Arabia 29.2% of participants think buying medication without prescription is "never" a safe way of using medication [11]. In the present study, around one third of participants (33.64%) believe that "sometimes" they should consult the pharmacist directly without seeing the physician, this means a greater responsibility on the pharmacist and increases the pharmacist enrolment in self-care practice. Pharmacist can treat some symptoms at a pharmacy but for serious illness counseling the pharmacist directly is a discouraged practice. In our study frequencies of practising selfmedication vary. Most practiced self-medication once in the last three months (60.15%), the number of participants who never practiced selfmedication (8.27%) is low in comparison to the overall collected data.
The overall motives for self-medication among population in the present study vary. Around 51.12% of the participants answered that they have the knowledge or previous experience of using medications, 26.5% of participants have practiced self-medication due to the mild severity of their illness. In comparison to a cross-sectional study in Saudi Arabia, the two major reasons for taking self-medication were difficult access to hospitals (45.6%), the other reason was, lack of effectiveness of primary healthcare centers (44.8%) [12]. In a study conducted on University students from Mansoura, Egypt, the two main reasons for self-medication were no need to visit the doctor for a minor disease (73.9%) and the knowledge of previous experience (71.4%) [2].
In the present study, participants have a high percentage of knowledge of the possible side effects of the purchased medication which was about 76%, only a minor number of participants have experienced side effect (9.39%), and majority of those who experienced side effect have stopped taking the medication (58.125%) or went to hospital (25.6%). Lack of information about the medication can lead to unwanted side effects which may in turn harm the patient requiring hospitalization, and this will increase severity of the disease, and waste patients' time and money. As for the Health problems that provoked self-medication, in our study headache was the main health problem (58.83%), followed by fever (26.88%), cough (24.4%), runny nose (22.9%), dental pain (21.99%), and menstrual problems (19.17%). In two studies that were conducted in Bahrain and Jordan, headache was the major problem that provoked practicing selfmedication [8]. Another study that was conducted in a rural population in South-Western Saudi Arabia, indicated that pain (38.3%), Influenza (26.3%), Cough (24%), and Allergy (11.4%) were the main health problems that provoked selfmedication [9]. There was a surge in the use of analgesics as our study which reports a prevalence of 80.26%, which is quite high. The most commonly used analgesics are paracetamol and NSAIDs. A study from Saudi Arabia indicated that the top utilized medication class in Saudi Arabia was analgesics, specifically diclofenac. This class represents 67% of the top used drugs in Saudi Arabia [14], followed by antipyretics which are the second most used medicine (48.3%). It is very high percent as compared with percent of people who do not have kids. Usually, antipyretic drugs are used to decrease fever that is associated with factors like vaccinations which is the most common reason for fever itself. So, parents usually use antipyretics without prescription but with instructions. Third high prevalence is eye drops (24.8%). These could be dangerous sometimes because there are many types of drops that not only contains saline. So, the patient should be careful about which kind of eye drops are needed. Cough syrup (20.11%) with the fourth highest prevalence, is used for the temporary relief of cough due to the common cold, hay fever or other upper respiratory allergies. Some of the cough syrup products contain a nonnarcotic cough suppressant. It acts centrally on the cough centre thereby suppressing the cough reflex. This product might lead to addiction if it not uses as recommending. In comparison, a cross-sectional study in Saudi Arabia found that the top 4 classes of self-medicated drugs used by the population surveyed are, analgesics (84.1%), antipyretics (70.9%), anti-tussive syrups (46.9%) and antibiotics (37.3%) [12]. This study has nearly similar findings to our study. In the current study, the prevalence of self-medication with antibiotics (12%) was relatively low in comparison to the findings of other studies. A cross-sectional study in Saudi Arabia reported that the percentage of antibiotic use was 37.30% [12]. Another study in central Saudi Arabia reported that the percentage of antibiotic use was 22.3% [11]. Highest prevalence of using antibiotic in self-medication was in Jordan with percentage of 59.8% [7]. Antibiotic use without proper indication, diagnosis of the disease might lead to increasing morbidity among the population and may lead to multiple resistant strains of the causative organisms which are difficult and costly to treat, especially in immune compromised individuals [10].
Finally, the inappropriate use, indication, diagnosis of drug should not only be blamed on the patients alone as the healthcare providers and physicians in particular have a significant role to play by providing health education on selfprescription. Our study had several limitations such as recall bias, which was minimized by adapting a well formatted, simple, and easy-tounderstand questionnaire by translating it to the Arabic language because the study is about prevalence of self-medication practice in the Eastern Province, Saudi Arabia.

CONCLUSION
In conclusion, our findings demonstrated that frequency of taking self-medication in the Eastern province, Saudi Arabia is alarmingly high. Most common medications being used without a prescription are analgesics. The common health problems that provoke selfmedication are headache, fever, and cough. The reason for using self-medication in being knowledge or previous experience, mild severity of illness and in order to save time. So, it's very important to increase the cognizance among the population about the risks associated with this practice and how to practice self-medication more responsibly to avoid unwanted outcomes.

DISCLAIMER
The products used for this research are commonly and predominantly use products in our area of research and country. There is absolutely no conflict of interest between the authors and producers of the products because we do not intend to use these products as an avenue for any litigation but for the advancement of knowledge. Also, the research was not funded by the producing company rather it was funded by personal efforts of the authors.

CONSENT
Consent is given for participants to agree to take part in survey.

ETHICAL APPROVAL
It is not applicable.