Exploring Self-medication Behavior among Clients of Pharmacies in Kerman Province of Iran

1. INTRODUCTION

Health has always been one of the most important concerns of human societies, and health systems have always tried to improve the overall level of community health. This goal is realized through a set of factors in which medication plays an important role [1]. Although medication is an inevitable factor in the treatment of diseases [2], it acts like a double-edged blade. One edge, cures the disease, and the other edge endangers human life due to unwanted side effects and a lack of knowledge about the correct consumption of medication [3]. The social view has always taken the harmless and healing aspect of the medication [4], resulting in overuse of medication and self-medication, which are the biggest problems of health systems all around the world [5].

Self-treatment, which is different from the concept of self-care, is a behavior by which a person tries to take action to treat a disease or solve a health problem without the help and advice of experts [6]. Arbitrary use of medication is one of these actions that includes taking an industrial or homemade medication, obtaining medication without a physician’s prescription, using previously prescribed medication for similar conditions, using medications that exist at home, and refusing to use prescribed drugs whether through additional consumption without physician's prescription or not taking the drug completely [4, 7].

The process of selling drugs in pharmacies takes one of these two forms: a) delivery of medicines that require a physician's prescription, and b) delivery of medicines without a doctor’s prescription. Group a) is called Prescription Only Medicine (POM), which patients are not allowed to use on their own without a doctor's prescription. Group b) is called non-prescription or over-the-counter (OTC) drugs, which can be obtained without a doctor's prescription, according to the opinion of a pharmacist. Basically, some drugs are recognized as safe and healthy for non-prescription use. These medicines, after being used for a long time all around the world and also after being reviewed and analyzed in terms of possible side effects by authoritative authorities, have been considered safe to use without a physician prescription [8].

Due to the significant advances that have been made in various scientific fields, more people have gained access to various medications. However, this easy access to medication has become a harmful social phenomenon, which is referred to as arbitrary drug use or self-medication [9]. Since in most of the less developed countries, almost every drug on the market can be sold without a prescription, a wide range of POM drugs can be consumed without a doctor's prescription [10]. This problem itself causes many problems, such as inappropriate and indiscriminate use of medicine [8], lack of optimal treatment of the disease, long-term side effects of medication, unwanted poisoning, death, possible delay in the treatment of a serious illness, hidden symptoms of severe diseases and interaction with other drugs [5].

Studies conducted in this field have indicated irrational use of drugs and a high prevalence of self-medication in many countries, including Iran [11]. According to the statistics of the World Health Organization, Iran is one of the top 20 countries in the world in terms of drug consumption [12]. Every Iranian consumes 390 medications a year and uses 10-15% of the country's medications arbitrarily without consulting a doctor. It has been estimated that 83.3% of Iranians self-medicate, and painkillers, antibiotics, anti-cough and cold medications are the most commonly used drugs in self-medication [13]. According to these statistics and the culture of drug use in Iran, it can be said that the irrational use of drugs in Iran is much more critical than in countries, such as Bangladesh, Tanzania, Nigeria, Nepal, India, Jordan, Ethiopia, and Saudi Arabia, where the total self-medication rate is about 56, 81, 75, 63, 69, 42.5, 39 and 35 percent, respectively [14-18].

What is clear is that arbitrary drug use and self-medication are some of the worst behaviors in drug administration, and the responsibility of rationalizing prescription and drug use is on the healthcare providers [10]. In this regard, the first step is to identify the causes of arbitrary drug use among patients, and by identifying these causes, we can take effective measures to correct such behaviors. Therefore, this study was conducted to investigate the causes of arbitrary drug use among the clients of pharmacies in Kerman province. It is expected that the results of this study will help to make effective plans to eliminate or reduce arbitrary drug use among people.

2. METHODOLOGY

In this qualitative study, using the exit poll survey method, the researcher interviewed people who bought medication without a doctor's prescription outside the pharmacy. The interviews were semi-structured and lasted for 15-20 minutes. At the beginning of each interview, the objectives of the study were explained to the participants and with their permission, the interview process was recorded, and field notes were taken. We reached data saturation at the 32^nd interview, which was the point in the process of the present research where we collected enough data to draw the necessary conclusions, i.e., further data collection would not yield additional insights of value.

To ensure the reliability of study findings, the Lincoln and Guba approach was taken. Four criteria of credibility, dependability, transferability, and confirmability were used to check the data's trustworthiness [19]. To ensure credibility, the interview text and extracted codes were given to some participants to find out whether they could confirm them or not. They were also asked to make any comment or suggestion that they wanted, and their corrective comments were applied. It should be noted that the extracted codes were reviewed and discussed in several meetings with the members of the research team until a consensus was reached and the codes were finalized. To ensure the dependability of the study, enough time was allocated to data collection and communication with the participants. Also, field notes were taken while recording the interviews. To ensure the confirmability of the study, a complete description of the study process and stages, including data collection as well as code extraction and analysis, was provided to several readers and research colleagues to confirm the accuracy of the findings. In order to ensure transferability, a clear description of the sampling process, characteristics of the participants, and data collection and analysis was provided to the research team so that they could judge the application of the findings in other contexts.

To analyze the data, Colaizzi’s seven-step method was used. These steps include: 1) Reading all the descriptions provided by the participants (in other words, the protocol) to get familiar with them. 2) Extracting important sentences from the protocol. 3) Formulating the meanings of each of the important sentences in the previous step. 4) Repeating the previous steps for each protocol identified in the first step and classifying related meanings in a set of themes (categories). 5) Combining the results in the form of a comprehensive description of the study topic. 6) Formulating a comprehensive description of the phenomenon under study in the form of an explicit and clear statement about the basic structure of the phenomenon under the title of the inherent structure of the phenomenon. 7) Validating the findings by referring back to each of the participants [20]. For this purpose, in the first stage, the recorded conversations were reviewed several times to get a general understanding of the concepts and meanings of statements made by the participants. Then, each interview was reviewed in the second stage and phrases or sentences that were directly related to the desired phenomenon were identified. In the third step, a special concept was considered for each of the extracted sentences. Then, level two codes or sub-categories were obtained by merging the related codes at level one. In the fifth stage of analysis, a comprehensive description of the investigated topics and main categories was created. In the sixth stage, a comprehensive description of the phenomenon was created, and then the results were presented.

3. RESULTS

The information obtained from the semi-structured interviews, after coding and analysis, were categorized into three main categories: patient-related factors, physician-related factors, and pharmacy-related factors. Each of these categories represents the main causes of arbitrary drug use among pharmacy clients. These categories also had several subcategories. In total, 9 subcategories and three main categories were created (Table 1).

4. DISCUSSION

In the present study, the causes of self-medication among the clients of pharmacies in Kerman were explored. Improper use of drugs has long-term side effects for patients and imposes a heavy cost on society, insurance companies, and the government. For this reason, it is important to identify and analyze the causes of self-medication. As the results of this study showed, several factors have an effect on self-medication, which can be considered in the three main categories of patient-related factors, physician-related factors, and pharmacy-related factors.

Previous use of medication and improvement of symptoms, making sure that the medication is safe, recommendation of other people, recognizing the disease, and considering it harmless and easy to access were found to be the main causes of self-medication in this study. However, in other studies, such as the study of Jalilian et al., the previous use of drugs was known as the most important cause of self-medication from the perspective of participants [21]. This result is in line with the findings of the present study. In another study by Baghani-Moghadam and his colleagues, the student's attitude toward the reasons for self-medication was evaluated, and among the variables studied, the variable of considering the drugs harmless obtained the highest mean score [22]. In another study, the effect of this issue on the self-administration of drugs was highlighted in such a way that among the 428 people participating in the study, 12 considered the harmlessness of drugs as a reason for self-medication [13]. These two studies confirm the results of the present study. Moreover, according to studies conducted in other countries, reasons including busy schedule, desire for quick relief, ease and convenience, the influence of advertisements, cheapness, unawareness of side effects, and lack of access to healthcare were determined as the factors behind self-medication [23-27].

In Jalilian et al.'s study, the advice of non-specialists on the therapeutic benefits of drugs was identified as one of the reasons for self-medication [13]. This issue has also been investigated in Amani et al.'s study, which investigated the attitude of students in Ardabil City toward self-medication. The results of this study showed that students’ positive attitude towards self-medication was one of the main reasons for arbitrary drug use [28]. The recommendation of other people to take medication, as the third sub-category found in the present study, as well as the results of previous studies, confirm this issue as one of the causes of arbitrary drug use. Two studies by Jalilian et al. and Sharifirad et al. have identified the minor symptoms and the lack of need to visit a doctor as the causes of arbitrary drug use. In the study of Sharifirad and his colleagues, among the 295 elderly people who participated in the study, 75 considered the minor symptoms of the disease and not visiting the doctor as the most important reasons for self-medication [29]. These studies confirm the result of the present study regarding recognizing the disease and considering it harmless.

Easy access to drugs was found in the present study as one of the causes of arbitrary drug use. This issue has been investigated as one of the most important causes of self-medication in many studies. For instance, Karimi and colleagues in a study showed that 60.5% of the participants referred to the availability of drugs as one of the most obvious causes of self-medication [30]. Considering the causes of self-medication found in the present study, it seems necessary to recognize and address this basic issue as the most important cause of arbitrary drug use among people. Therefore, improving public awareness about the harms and side effects of arbitrary drug use by using new methods, such as storytelling, effective advertising, and using informative and exciting games, can be considered as one of the effective measures that we can take to increase people's resistance toward self-medication.

Another cause of self-medication found in this study was physician-related factors, which also had a sub-category of “lack of trust in doctors for diagnosis and treatment”. Other studies have also highlighted this factor as one of the reasons for self-medication. For instance, the studies of Karimi et al., Amani et al., and Mohammadi et al. have considered a lack of trust in doctor's treatment as one of the reasons that encourage self-administration of drugs [28, 30, 31]. In this regard, we can refer to factors, such as improving the relationship between physician and patient, improving the performance of the referral system, and increasing patient participation in the decision-making and treatment process as factors that increase people’s trust in physicians.

The “pharmacy-related factor” was the last cause of arbitrary drug use found in this study. This category had three sub-categories “ease of buying medication from the pharmacy”, “providing advice by pharmacy technicians,” and “technical fee of prescription”. These factors have also been considered in many studies. For example, in the study of Baghani Moghadam and the study of Aghakhani and colleagues, selling medication without a doctor's prescription was considered as one of the reasons for self-medication [22, 27]. Mohammadi et al.'s study refers to the “recommendation of self-medication in the pharmacy” as one of the causes of arbitrary drug use [31]. Concerning the subcategory of “technical fee of prescription”, the literature review could not find any study in this field, but in many studies, such as Mohammadi et al.'s study, Amani et al.'s study, and Karimi et al.’ study, high cost of the prescription was referred to as contributing factor in the arbitrary use of drugs [28, 30, 32]. In this regard, increasing the price of non-prescription drugs, reducing the technical fee of prescriptions, and increasing the public's awareness about the role and responsibility of pharmacy technicians as drug suppliers can be considered as effective solutions to the problem of arbitrary drug use.

CONCLUSION

Results of the present study showed that there are many challenges regarding self-medication or arbitrary drug use at the community level; the challenges are felt more by patients, doctors, and pharmacies. Despite their special position in the country's health system, pharmacies play an important role in self-medication and arbitrary drug use by facilitating easy access to medications. At first glance, the cause of this problem may be related to the absence or weakness of competent bodies that monitor and supervise the activities of pharmacies and even the pharmacies’ specialists. But as the results of this study show, the misplaced and wrong culture of the society plays a major role in this regard, and correcting such culture is beyond the capability of a single organization. Therefore, raising public awareness about the prescription and consumption of drugs, reforming the medical education system, correcting the public culture regarding the consumption of drugs, improving the infrastructure of the pharmaceutical system, and strengthening health insurance to cover all medications have significant roles in improving the consumption and prescription of drugs. Also, monitoring the performance of pharmacies and convincing people not to take medicine without a doctor's prescription can make a significant contribution to reducing self-medication and improving drug consumption behavior.

AUTHORS' CONTRIBUTIONS

M. Aliramezany and M.Iranmanesh conceived the presented idea. M.Iranmanesh developed the theory and conducted the interviews. M. Aliramezany and M.H. Iranmanesh verified the analytical methods. F. Yousefi encouraged M.Iranmanesh to investigate [a specific aspect] and supervised the findings of this work. All authors discussed the results and contributed to the final manuscript.

REFERENCES