Role of Sensitization and Awareness Program on Knowledge, Attitude, Views, and Practice of Self-Medication Among MBBS Students in a Medical College of Bihar

Aims Self-medication is an essential component of self-care; however, its use has significantly increased. Its practice has many risks such as wrong diagnosis, adverse drug reactions, antimicrobial resistance, etc. Being future doctors, self-medication has a special impact on MBBS students. Henceforth, the present study was undertaken to sensitize MBBS students in a medical college in Bihar and to analyze its role in different aspects of self-medication. Methods and material This was a cross-sectional, questionnaire-based study. The questionnaire was circulated to MBBS students of all the phases. After collecting the responses, scoring and grading was done and then a sensitization and awareness program was conducted through different modes and medium. After three months the same questionnaire was distributed, and their response was again collected. Statistical analysis used With an expected 40% prevalence, the minimum sample size needed to attain a power of 95% and an alpha value of 0.05 was calculated to be 201. Statistical Package for Social Sciences version 16 was used for data analysis. The chi-square test was used to see the association in responses obtained, before and after sensitization. A P-value with ≤0.05 was considered statistically significant. Results The questionnaires were circulated among 439 students. On comparing the grades, we found that phase III students comparatively had better knowledge regarding different aspects of self-medication. On analyzing different aspects of self-medication, we found that there was a significant improvement in many aspects post-sensitization. Conclusions MBBS students are future doctors, hence they should be more educated about the pros and cons of self-medication. This study showed that the perception of participants improved after our educational activities. We hope that after becoming aware, these young budding doctors will spread awareness, which, in turn, will benefit society. Additionally, we hope that this study will have an impact on students from different medical colleges and even healthcare providers, promoting responsible self-medication practices when necessary.


Introduction
Self-medication is defined as the "selection and use of medicines/medicinal products including herbal and traditional products by individuals to treat self-recognized illness or symptoms, or the intermittent or continued use of medication(s) prescribed by the physician for chronic or recurring diseases or symptoms" [1]. It is an essential and pivotal component of self-care; however, with the development and discovery of new drugs, the use of self-care in the form of self-medication has increased which could be attributed to several reasons such as increased availability of drug information on the internet search platforms and social media, suggestions from an advertisement in newspapers, advice given by families, friends, neighbors and the pharmacist, sharing medicines with family members or consuming leftover medicines stored at home [2,3]. Many drugs being used for self-medication are over-the-counter (OTC) drugs [4]. OTC drugs are meant for self-medication and are of proven efficacy and safety. However, their improper use due to insufficient knowledge about their side effects and interactions can have adverse outcomes [5]. The problems due to selfmedication are augmented when non-OTC drugs are also used for self-medication as not all drugs used for self-medication are OTC drugs [5,6]. World Health Organization (WHO) advises the rational practice of selfmedication which can help to prevent and manage ailments that do not require medical consultation and provides a cheaper alternative for treating common illnesses [7,8]. However, it is also known that selfmedication requires information in regard to health conditions and an understanding of disease and medication.
Being future doctors, self-medication has a notable effect on MBBS students. Due to their requirement to study the details of various drugs and diseases, including their administration, side effects, contraindications, and interactions, they are more inclined toward self-medication, facilitated by their convenient and comprehensive access to drug information. This differentiation from the general population is a significant aspect. While some MBBS students become more cautious in practicing self-medication, recognizing the potential harm of irrational and inappropriate drug use, they prefer consulting qualified doctors even for minor illnesses. However, certain students, bolstered by their textbook knowledge, may become confident and initiate self-medication. Consequently, they may experience success and be encouraged to continue this approach, even providing advice to fellow medical students. On the other hand, adverse outcomes can occur, leading to detrimental health or a diseased state. Proper sensitization and awareness about self-medication among MBBS students can help mitigate these unforeseeable situations. Therefore, the present study was conducted to sensitize and raise awareness among MBBS students, examining its influence on their knowledge, attitude, views, and self-medication practices.

Materials And Methods
This was a cross-sectional, questionnaire-based study that was completed in six months (June-November 2022). This study was conducted on MBBS students at an Autonomous Medical College in Bihar after obtaining permission from the ethics committee of the Institute (vide letter no. 1491/IEC/IGIMS). A selfdesigned, pre-validated questionnaire consisting of close-ended questions was used which was divided into the following parts: Part A -Demographic details of the participants (Appendix: Figure 2), Part B -Knowledge of participants on self-medication (Appendix: Figure 3), Part C -Attitude of participants on selfmedication (Appendix: Figure 4, Table 1), Part D -Views of participants on self-medication (Appendix: Figure 4, Table 2) and Part E -Practice of participants on self-medication (Appendix: Figure 5).
All the students were made aware of this study and students who were willing to participate were included. Students who were not willing were excluded. The study was conducted on Phase I (first year) and Phase II (second year) students during their scheduled lecture/practical class and Phase III (third and fourth year) students were involved through online platforms (WhatsApp Group, Google Forms, and Zoom Cloud Meeting) to conduct this study. A brief description of the nature of the study, its purpose, and the procedure of completing and submitting the questionnaire was explained to the participants through their respective mediums. Written informed consent was obtained from every student before filling the questionnaire and confidentiality was ensured to them. The questionnaire was then circulated to the participating students and their responses were collected/recorded. The incompletely filled-up questionnaires were excluded and finally, 267 responses were used for data interpretation scores were given to each student on the basis of their response submitted in "knowledge aspect of self-medication." On the basis of this score, each student was given a grade ( Table 1).  After collecting the responses, a proper sensitization and awareness program was conducted for these participating students through interactive lectures, group dynamics activities along with role play and seminars using audio-visual aids through the respective medium. After three months of educational activities the same questionnaire (Parts B, C, and D) was distributed again among the participating students, and later on, their responses were collected. With an expected 40% prevalence of self-medication in a total of 439 students, the minimum sample size needed to attain a power of 95% and an alpha value of 0.05 was calculated to be 201. Statistical Package for Social Sciences (SPSS) version 16 was used for data analysis. The survey was descriptive and qualitative data were described as numbers and percentages. The age of participants was assessed in terms of mean and standard deviation (SD). The chi-square test was used to see the association in responses obtained, before and after sensitization. A p-value with ≤0.05 was considered statistically significant.

Results
The questionnaires were circulated among 439 students, out of which 314 responses were obtained. However, 47 of these responses were excluded due to its incompleteness, resulting in 267 valid responses for data interpretation. Among these 267 responses, 158 (59.1%) were from male participants, while 109 (40.8%) were from female participants. The mean age of the participants was 22.23 ± 2.37 years, as shown in Table 2.

TABLE 2: Demographic variables
Scoring was done for each participating students on the basis of their response regarding knowledge about self-medication before conducting educational activity. On the basis of scoring, grades were given to different phases of students as shown in Figure 1.

TABLE 3: Knowledge of participants on self-medication before and after educational activities
The grades obtained by students based on scores given to them in knowledge aspect was compared as shown in Table 4.

Grade Before educational activities After educational activities P-value (Chi-Square)
Grade A (Score 8-10) 157 207 <0.0001 Grade B (Score 5-7) 39 33 Grade C (Score 3-4) 48 21 Grade B (Score 0-2) 23 6 On analyzing the attitude aspect, we noted that good number of students agreed that self-medication is acceptable for medical students however after carrying the educational activity they disagreed to this aspect as shown in Table 5.

TABLE 5: Attitude of participants on self-medication before and after educational activities
On looking into the view aspect, it was noted that participants had view that self-medication can lead to adverse reactions. This view was more pronounced after carrying the educational activity as shown in Table  6.

TABLE 6: View of participants on self-medication before and after educational activities
The practice aspect showed that an important reasons in "for" of self-medication were that it is easy and convenient, economy of time and money and no need to see a doctor for minor illness as shown in Table 7.

Discussion
Several studies have previously been conducted on self-medication, but no studies have been conducted in India to analyze the role of sensitization and awareness programs on the knowledge, attitude, views, and practice of self-medication among MBBS students. Hence, this study was conducted to examine the impact of educational activities on the perception of self-medication. Participation in this study was voluntary and included MBBS students from all three phases (first year to fourth year). All the participants were adolescents, and a male preponderance was observed. Studies on self-medication have reported various prevalence figures, ranging from 43.2% to 91% [9][10][11][12]. This variation may be attributed to the diverse demography, socioeconomic status, and availability of non-prescription drugs over the counter. In our study, 87.6% of the participants had a history of self-medication. On proportional analysis, it was observed that out of 158 male participants, 104 (65.8%) had a history of self-medication, while out of 109 female participants, 91 (83.4%) had a history of self-medication. Other studies have also reported a higher number of females engaging in self-medication compared to males [13,14].
Scoring was done for each participating student on the basis of their response regarding knowledge about self-medication before conducting the educational activity. On the basis of scoring, grades were given to different phases of students which were then compared. In comparison, we found that the phase 3 students (third and fourth year) comparatively had better knowledge regarding different aspects of self-medication. This may be due to their more academic knowledge and clinical exposure in contrast to students of phases 1 and 2. There is a correlation between the year of study and the level of knowledge about self-medication, which can be interpreted that "knowledge increases with the level of education" as also reported by Gyawali et al. and Shankar et al. [15,16].
On analyzing the knowledge aspect, we found that a good number of students were aware of responsible self-medication definition and this awareness increased after conducting educational activities which was statistically found to be highly significant. In addition, we also found that the majority of participants had the perception that "basic knowledge about drug action is required for self-medication." However, after sensitization through educational activities, this perception changed which was statistically found to be significant. Further, it was seen that participants had the knowledge that "if they experience any unwanted effects of self-medication" then they should "discontinue the current medication for its cure." This knowledge changed to "consulting physician" after conducting educational activity which was statistically found to be highly significant.
On analyzing the attitude aspect, we noted that a good number of students agreed that self-medication is acceptable for medical students; however, after carrying out the educational activity they disagreed with this aspect which was statistically significant. In addition, the majority of participants agreed that a "pharmacist is a good source of advice/information about minor medical problems" which has also been reported by Mehta et al. and Wajantri et al. [17,18]. However, post-sensitization they strongly disagreed with this, and the difference was found to be highly significant.
Upon examining the viewpoint, it was observed that participants held the belief that self-medication can result in adverse reactions. This perspective became more prominent after conducting the educational activity, which was statistically highly significant.
Further, the practice aspect was analyzed under different parameters. The important reasons "for" selfmedication were that it is easy and convenient, the economy of time and money, and no need to see a doctor for minor illnesses. These perceptions are akin to those outlined by WHO that self-medication provides a cheaper and more convenient alternative for treating common minor illnesses [7]. In addition, similar reasons had been reported by other studies also [19][20][21][22]. Similarly, important reasons "against" selfmedication were the risk of misdiagnosing and adverse effects which has been previously reported by James et al. and Hughes et al. [14,19]. This may be due to the knowledge about adverse drug reactions among the participants. On further analysis, it was seen that fever followed by headache were the most common causes of self-medication, and drugs relieving fever (antipyretic-analgesic) were the most common group of drugs used. A similar pattern of self-medication had been reported by other studies also [23][24][25][26][27].
The place of obtaining drugs showed that the majority of participants opted pharmacy shop and this can be co-related to their previous response which showed that the majority of participants had the attitude that "pharmacist is a good source of advice/information about minor medical problems." This reason was followed by obtaining drugs from family/friends as procuring becomes easy if any family member/ friend is a doctor which has been also acclaimed by Gyawali et al. [15]. Upon experiencing adverse effects followed by self-medication majority of the participants had practice of stopping the medication followed by consulting the physician. This practice can be validated as it is consistent with their response given before sensitization in the knowledge aspect.
There are certain limitations of the present study. Although the respondents were requested to complete the questionnaire independently, the mutual influence between the students could not be entirely ruled out. We could not analyze the practice aspect after educational activities. This could be done in the future with a longer duration of study. The results of the study would have been more generalized per se if it could involve students from other medical colleges in Bihar. The strength of our study was its method, as we tried to spread awareness regarding different aspects of self-medication, and we also analyzed its impact statistically. To the best of our knowledge, no studies have been done in India in this context which has been a demand from previous studies [15,27]. In addition, a good sample size was also the strength of our study as 71.5% of MBBS students from our institute turned up voluntarily to participation. The response rate and its completeness were apt as it was found to be 85%.

Conclusions
Healthcare providers, who possess knowledge about diseases and medications, are more susceptible to selfmedication, which can even influence the non-medical population. MBBS students, as future doctors, should be well-informed about the pros and cons of self-medication. This study demonstrated that participating students' perceptions regarding various aspects of self-medication significantly improved after our educational activities. We anticipate that these young aspiring doctors, once aware, will disseminate this knowledge to benefit society. Additionally, we hope that this study will have an impact on students from different medical colleges and even healthcare providers, promoting responsible self-medication practices when necessary.