ORIGINAL RESEARCH

published: 09 March 2022

doi: 10.3389/fpubh.2022.803937

Self-Medication Practices in Medical

Students During the COVID-19
Pandemic: A Cross-Sectional
Analysis
Farah Yasmin 1 , Muhammad Sohaib Asghar 2*, Unaiza Naeem 1 , Hala Najeeb 1 ,
Hamza Nauman 1 , Muhammad Nadeem Ahsan 3 and Abdullah Khan Khattak 4
1
Department of Internal Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan, 2 Department
of Internal Medicine, Dow University of Health Sciences–Ojha Campus, Karachi, Pakistan, 3 Department of Nephrology, Dow
University of Health Sciences–Ojha Campus, Karachi, Pakistan, 4 Department of Internal Medicine, Aga Khan University
Hospital, Karachi, Pakistan

Background and Objectives: During the pandemic, the growing influence of social
Edited by: media, accessibility of over-the-counter medications, and fear of contracting the virus
Chantal M. Morel, may have led to self-medication practices among the general public. Medical students
Université de Genève, Switzerland
are prone to such practices due to relevant background knowledge, and access to drugs.
Reviewed by:
Hashaam Akhtar,
This study was carried out to determine and analyze the prevalence of self-medication
Yusra Institute of Pharmaceutical practices among medical students in Pakistan.
Sciences Islamabad, Pakistan
Sarosh Iqbal, Materials and Methods: This descriptive, cross-sectional study was conducted
University of the Punjab, Pakistan online in which the participants were asked about the general demographics, their self-
Ali Hassan Gillani,
Xi’an Jiaotong University, China
medication practices and the reasons to use. All participants were currently enrolled
Amal Akour, in a medical college pursuing medical or pharmacy degree. Non-probability sampling
The University of Jordan, Jordan technique was used to recruit participants.
*Correspondence:
Muhammad Sohaib Asghar Results: A total of 489 respondents were included in the final analysis. The response
[email protected] rate was 61%. Majority of the respondents were females and 18–20 years of age. Self-
medication was quite prevalent in our study population with 406 out of 489 individuals
Specialty section:
This article was submitted to
(83.0%) were using any of the drugs since the start of pandemic. The most commonly
Infectious Diseases – Surveillance, utilized medications were Paracetamol (65.2%) and multivitamins (56.0%). The reasons
Prevention and Treatment,
reported for usage of these medications included cold/flu, or preventive measures
a section of the journal
Frontiers in Public Health for COVID-19. The common symptoms reported for self-medication included fever
Received: 28 October 2021 (67.9%), muscle pain (54.0%), fatigue (51.7%), sore throat (46.6%), and cough (44.4%).
Accepted: 07 February 2022 Paracetamol was the most commonly used drug for all symptoms. Female gender, being
Published: 09 March 2022
in 3rd year of medical studies, and individuals with good self-reported health were found
Citation:
Yasmin F, Asghar MS, Naeem U,
more frequent users of self-medication practices.
Najeeb H, Nauman H, Ahsan MN and Conclusion: Our study revealed common self-medication practices among medical
Khattak AK (2022) Self-Medication
Practices in Medical Students During and pharmacy students. It is a significant health issue especially during the pandemic
the COVID-19 Pandemic: A times, with high consumption reported as a prevention or treating symptoms
Cross-Sectional Analysis.
of COVID-19.
Front. Public Health 10:803937.
doi: 10.3389/fpubh.2022.803937 Keywords: self-medication, medical students, COVID-19, pandemic, public health, Pakistan

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Yasmin et al. Self-Medication Practices Among Medical Students

INTRODUCTION study reports the prevalence of self-medication in the highly

affected medical student population in Pakistan—the future of
The Coronavirus 2019 (COVID-19) was declared a pandemic by the healthcare system. It is important to assess self-medication
the World Health Organization on January 30th, 2020 (1). As practices among medical students, because they have relevant
of October 22nd, 2021, the global crisis has affected 242 million knowledge, and are more likely to access to prescription as well
individuals and claimed over 4.9 million lives (2). as OTC drugs. Low tendency to consult health professionals,
With clinical trials of multiple drugs in the pipeline, there reliance on the internet for information on background medical
are no definitive treatments with confirmed evidence against the knowledge, and treating self-diagnosed illnesses could be factors
severe acute respiratory syndrome-coronavirus-2 (SARS-CoV- that promotes self-medication practice among medical students.
2). Anti-malarial drugs, hydroxychloroquine, and chloroquine The primary objective was to determine and analyze the
received emergency approval to treat prophylaxis in COVID-19 prevalence of self-medication practices among medical students
when a small non-randomized trial was initially promising (3). for respiratory symptoms, from the onset of first COVID-19
It was soon labeled controversial as randomized studies depicted symptom or in case of being positively tested for COVID-
an increased risk-to-benefit ratio (4). However, rapid medical 19. We further assessed the self-medicated drugs used for
research has developed, and massively rolled out COVID- respiratory problems during the pandemic. A secondary aim
19 vaccines prevented the adverse effects from symptoms of was to evaluate the factors associated with self-medication of
the disease in affected individuals (5). It is envisaged that various drugs among medical students during the COVID-19
vaccine advent and procurement by developed countries will pandemic in Pakistan. This will allow the health ministries and
soon create global inequity as middle-to-low income nations educational administrations alike to undertake measures and
struggle to vaccinate healthcare workers and the older population address the gap of health negligence that can result from self-
(6). Economic recession in developing countries, like Pakistan medication practices.
has only managed to fully vaccinate less than half of its
population (7).
MATERIALS AND METHODS
The third wave of coronavirus had peaked, yet Pakistan’s
overburdened healthcare system reached a 90% occupancy of Study Design
ventilators and hospital beds (8). Travel restrictions, oxygen This descriptive, cross-sectional study was conducted online
shortage, and the risk of contracting the virus from crowded from January 25th to February 20th, 2021. The design of
clinics and hospitals have inculcated fear in the public, allowing the study and sample size was modified according to the
a nation prone to self-medication to rely more heavily on pilot study carried out from December 11th to December
self-diagnosis (9, 10). Self-medication is the administering of 15th, 2020, under the expertise of professors and doctors. The
medicines to treat self-recognized symptoms, psychological questionnaire was developed in English, on Google survey, and
ailments, and first aid based on prior knowledge, without distributed through social media platforms. The online survey
consulting a physician (11). The growing influence of social questions were obtained after a thorough literature search and
media has let individuals explore COVID-related symptoms, pain assessing the validity and reliability (16, 17). The responses
keywords, and treatments worldwide, as well as in Pakistan, were made anonymous to maintain confidentiality and reliability.
as revealed by an infodemiological study on Google trends Each participant received an email of their response to avoid
(12). Adding to this is the availability of over the counter duplication of data. Clarification of the contents and the purpose
(OTC) drugs in pharmacies across Pakistan which has been the of the study were explained at the start of the survey followed
highest contributor to a self-medicating prevalence of 81% in the by an informed consent. Data was anonymized and only the lead
populous Karachi. Easily accessible drugs in pharmacies across investigator had access to the responses.
Pakistan range from analgesics, antibiotics, anti-diarrheal agents,
antihistamines, antipyretics, cough-suppressants, vitamins to Development of Survey Questionnaire and
herbal medicines and homeopathy (10, 13). Though the primary Operationalization of Variables
reason was affordability, the greatest driver (47.8%) of self- The questionnaire included a total of 11 questions. Seven
medication was the belief that the illness was insignificant. This questions were dedicated to the general demographics including
stems from poor health literacy amongst the general public which the city of residence, gender, age, marital status, level of
is easily influenced by the media (10). It is also well noted that education/medical, and comorbid conditions. The next 4
preference for self-medication is cultural practice in Pakistan. questions were based on self-medication of drugs for prevention
The positive and negative effects of self-medication of Sanna and treatment of respiratory symptoms: drug selection, reasoning
Makki, a herbal laxative, which was widely used as a COVID-19 for self-medication, symptoms they were looking to improve,
cure after mass-circulation on WhatsApp was a well-publicized and if any of the drugs improved those symptoms. The
example (14). The risks attached to self-medicated drugs include participants were asked if they consulted any physician
incorrect and improper dosage, and antibiotic abuse leading to before starting these medications, were they been using these
drug resistance (15). medications before COVID-19 pandemic, and do they have
A trending worldwide practice of self-medication does not any comorbid conditions that warrant the use of these
have enough literature on an ongoing pandemic, except studies medications. All these questions if answered as a No have
conducted in Peru and Saudi Arabia (16, 17). However, no been considered as self-medication during the pandemic. The

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Yasmin et al. Self-Medication Practices Among Medical Students

drugs listed in the survey included acetaminophen, ibuprofen, region, presence of comorbid conditions, and self-reported
azithromycin, hydroxychloroquine, ivermectin, doxycycline, health as control variables. Categorical variables were assessed
antivirals (lopinavir, ritonavir, remdesivir, and others), cetirizine, using frequencies and percentages, through univariate analysis.
multivitamin compounds or any other drug (open question) for Analytical statistics were performed with 95% confidence
respiratory symptoms. All drugs were classified according to the intervals (CI) and odds ratios (OR), which were obtained using
Anatomical Therapeutic Chemical (ATC) (18). This selection logistic regression.
of drugs was based on the existing literature, and reports
from the local media. COVID-19 can present with a range
of symptoms. Frequently reported symptoms were obtained RESULTS
from CDC’s guidelines (19). The list of symptoms included
fever, fatigue, cough, muscle ache, nasal congestion, sore throat, A total of 374 medical and 115 pharmacy students were included
headache, breathing difficulty, no symptom, and other symptom in the final analysis. The response rate was 61%. Majority of the
(open question). Anosmia was omitted as being controversial at respondents were of 18–20 years of age (58.5%). More than three-
the time of inception of this study (16). To assess the reason for fourths were females. 34.0% of medical students were in first year,
drug use, participants had seven options listed as cold/flu, no 20.6% in second year, 20.3% in third year, 13.9% in fourth year,
symptoms, COVID-19 prevention, had COVID-19 symptoms, and 11.2% were in final year of their medical education. Most
COVID-19 positive, consume the drug regularly, other reason respondents were from province Sindh and Punjab (combined
(open question). The following 5-point Likert scale was used to 85.7%). Only 4.5% reported previous comorbid conditions, while
identify and list the improvement in symptoms if any: improved majority (60.5%) were in good state of self-reported health. While
all symptoms, improved most of the symptoms, improved a few reporting the risk of acquiring COVID-19 infection, 43.8% were
of the symptoms, improved only one symptom, did not alleviate unbothered. Another 38.0% admitted mild risk while only 2.9%
any of the symptoms. reported severe risk. 15.3% of participants were already infected
with the virus. The socio-demographic characteristics of the
Sample Size/Sampling Technique participants are described in Table 1.
The sample size of the survey was obtained from the pilot study Self-medication was prevalent in our study population with
determined using the power analysis. The minimum sample size 316 out of 374 medical students (84.5%) and 90 out of 115
was 385, with a statistical power of 80% and a confidence interval pharmacy students (78.3%) were using any of the drugs since the
of 95%. We hypothesized that at least 50% of the participants start of pandemic. The most commonly utilized medications were
would practice self-medication, with a 5% margin of error. Paracetamol (65.2%), multivitamins (56.0%), Ibuprofen (29.0%),
The formula for sample size estimation was n = N ×/((N- Cetirizine (27.8%), and Azithromycin (25.6%) among others.
1) E2 + x), where N is the population size and n is sample The reasons reported for usage of these medications included
size estimation. A non-probability sampling technique was used cold/flu (71.4%), as preventive measures for COVID-19 (43.3%),
to recruit participants from social media platforms, including or a self-medication for COVID-19 symptoms (34.1%). However,
WhatsApp, Facebook, and Messenger. 35.2% reported taking these medications without any reason
or symptoms, while another 40.1% consumed them regularly
Inclusion/Exclusion Criteria for other reasons. The symptoms reported for self-medication
Inclusion criteria included completed responses, and the included fever (67.9%), fatigue (51.7%), cough (44.4%), sneezing
respondent i.e., male or a female medical student pursuing MBBS (40.7%), muscle pain/body aches (54.0%), nasal congestion
or Pharm D degree from a medical college in Pakistan, having (42.1%), sore throat (46.6%) anosmia (23.1%), and breathing
the ability to understand English, and being technologically adept difficulty (24.5%) as shown in Table 1. Paracetamol was the most
and have access to Internet. While exclusion criteria included commonly used drug for all symptoms including fever, fatigue,
respondents from other than the medical field. cough, sneezing, myalgia, nasal congestion, sore throat, anosmia,
and shortness of breath. Figure 1 demonstrates the relative
Ethical Approval proportions of drug use for each specific symptomatology.
The study received ethical approval from the Institution’s Paracetamol use was common in individuals >21 years,
Ethics Committee of the Dow University Ojha Hospital. Each final year medical students, those already infected with
participant had the right to withdraw from the study at any time. COVID-19, and having flu, fever, and fatigue. 45.4% shown
The possible risks and the purpose of the survey were thoroughly all or most symptoms resolved with its use as shown
explained. Participants had to provide consent before filling out in Table 2. Azithromycin use was common in age >21
the questionnaire. years, 5th year medical students, inhabitants of Khyber
Pakhtunkhwa/Balochistan, as well as those already infected
Data Analysis with COVID-19. Cetirizine use was frequent among pharmacy
Microsoft Excel 2016 was used for data collection and assembled students, final year medical students and those with self-reported
in to Statistical Package for Social Sciences (SPSS) version 25.0 risk of COVID-19 infection. Use of antivirals was prevalent
for data analysis. A multivariate analysis estimated the preference among males of above 21 years of age. Use of multivitamins
of self-medication for the surveyed drugs using the baseline was also common in individuals >21 years, females, residents
demographics i.e., sex, age, marital status, educational status, of Khyber Pakhtunkhwa/Balochistan and those either already

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Yasmin et al. Self-Medication Practices Among Medical Students

TABLE 1 | Sociodemographic characteristic of medical students during the TABLE 1 | Continued

COVID-19 lockdown (n = 489).
Variables N (%)
Variables N (%)
Fatigue 253 (51.7)
Age 18–20 years 286 (58.5) Cough 217 (44.4)
21–25 years 192 (39.3) Sneezing 199 (40.7)
>25 years 11 (2.2) Muscle pain/Body aches 264 (54.0)
Gender Male 108 (22.1)
Nasal congestion 206 (42.1)
Female 381 (77.9)
Sore throat 228 (46.6)
Student Medical 374 (76.5)
Anosmia (loss of smell) 113 (23.1)
Pharmacy 115 (23.5)
Breathing difficulty 120 (24.5)
Medical year (n = 374)* 1st year 127 (34.0)
Used it even though I had 173 (35.4)
2nd year 77 (20.6)
none of the above
3rd year 76 (20.3) symptoms
4th year 52 (13.9) Reporting of symptom Alleviated ALL the 106 (21.7)
5th year 42 (11.2) improvement after medicine symptoms
State Sindh 237 (48.5) use
Punjab 182 (37.2) Alleviated MOST of the 109 (22.3)
Khyber Pakhtunkhwa 61 (12.5) symptoms
Balochistan 9 (1.8) Alleviated A FEW of the 91 (18.6)
Comorbidities Present 22 (4.5) symptoms

Absent 467 (95.5) Alleviated only ONE 85 (17.4)

symptom
Self-reported health Excellent 114 (23.3)
Alleviated NONE of the 98 (20.0)
Good 296 (60.5)
symptoms
Fair 72 (14.7)
Poor 7 (1.4) Data presented as frequency and percentage.
*Data retrieved for medical students only (n = 374).
Self-reported risk of No risk 214 (43.8)
acquiring COVID-19
Already infected 75 (15.3)
Mild risk 186 (38.0) infected with COVID-19 or reported mild to severe risk of
Severe risk 14 (2.9) acquiring infection. Individuals from province Punjab were more
Use of medications Paracetamol 319 (65.2) likely to use ivermectin and less likely to use cetirizine as self-
Ibuprofen 142 (29.0) medication. Doxycycline use was found prevalent in males. Use
Azithromycin 125 (25.6) of ivermectin was not shown to improve any of the self -reported
Hydroxychloroquine 43 (8.8) symptoms. Other medications were more common among those
Ivermectin 22 (4.5) having comorbid conditions and self-reported as fair/poor. All
Doxycycline 19 (3.9) these factors showed significant association when conducted on a
Cetirizine 136 (27.8) logistic regression model with reported odds ratios and p-values
Antivirals 35 (7.2) as shown in Table 3.
Multivitamins 274 (56.0)
The following variables were significantly associated
Others 56 (11.4)
with self-medication practice in logistic regression
Reason for use Cold/Flu 349 (71.4)
(Supplementary Figure 1; Table 4): female sex (p < 0.001),
Used it without having any 172 (35.2)
third-year medical students (p = 0.022), self-reported health as
symptoms good (p = 0.029), and those previously infected with COVID-19
Used it for prevention of 212 (43.3) (p = 0.050). In multivariate analysis, female gender (<0.001),
COVID-19 infection those in third year of medical studies (p = 0.031) and those
Had COVID-19 symptoms 167 (34.1) students who perceived their self-reported health as “good” were
and I self-medicated more likely to adopt self-medication practices (p = 0.032).
Had confirmed positive 129 (26.4)
COVID-19 infection and I
self-medicated DISCUSSION
Consumed regularly for 196 (40.1)
other reasons
Self-medication is often considered as an ambiguous
Others 155 (31.7)
phenomenon and the practice is commonplace in developed
Symptomatology reported Fever 332 (67.9)
and developing countries alike. However, it has not been
for medicine use extensively qualitatively or quantitatively studied, especially
in Pakistan (20). Self-medication with antibiotics rates were
(Continued) generally low in middle income countries, according to a

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Yasmin et al. Self-Medication Practices Among Medical Students

FIGURE 1 | Relative proportions of drug use on specific symptomatology.

2020 review, however, among affected countries, Pakistan had is the first of its kind within the current pool of literature
one of the highest prevalence of 81.23%, with only 7.3% in available, that has evaluated self-medication among medical
Indonesia and 26.9% in Bangladesh (21). A study conducted by students in the context of COVID-19, encompassing most
the Aga Khan University, Karachi in 2008 revealed 76% self- provinces of Pakistan.
medication rates among the medical and non-medical university The incidence of self-medication revealed in our results is
students surveyed (22), while another survey from pre-COVID around 83%, a finding that is comparable to self-medication
times, consisting of a small segment of medical students in occurrence rates during COVID-19 reported in studies
Pakistan found 99% of them to be engaged in practicing conducted abroad. Among the nursing undergraduates in Saudi
self-medication (23). To the best of our knowledge, our study Arabia, self-medication practice with antibiotics and analgesics

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Yasmin et al.
TABLE 2 | Factors associated with self-medication of various drugs among medical students during the COVID-19 lockdown (n = 489).

Factor Parace-tamol Ibuprofen Azithro-mycin HCQ Iver-mectin Doxy- Cetirizine N Antiviral Multi-vitamin Other
N = 319 N = 142 N = 125 N = 43 N = 22 cycline = 136 N = 35 N = 274 N = 56
N = 19

Age (years)
18–20 155 (48.6) 76 (53.5) 50 (40.0) 26 (60.4) 11 (50.0) 12 (63.2) 65 (47.8) 12 (34.3) 140 (51.1) 32 (57.1)
21–25 and above 164 (51.4) 66 (46.5) 75 (60.0) 17 (39.5) 11 (50.0) 7 (36.8) 71 (52.2) 23 (65.7) 134 (48.9) 24 (42.9)
Gender
Female 251 (78.7) 114 (80.3) 92 (73.6) 34 (79.1) 18 (81.8) 11 (57.9) 100 (73.5) 20 (57.1) 233 (85.0) 43 (76.8)
Male 68 (21.3) 28 (19.7) 33 (26.4) 9 (20.9) 4 (18.2) 8 (42.1) 36 (26.5) 15 (42.9) 41 (15.0) 13 (23.2)
Student
Medical 244 (76.5) 109 (76.8) 95 (76.0) 34 (79.1) 17 (77.3) 15 (78.9) 95 (69.8) 27 (77.1) 209 (76.3) 44 (78.6)
Pharmacy 75 (23.5) 33 (23.2) 30 (24.0) 9 (20.9) 5 (22.7) 4 (21.1) 41 (30.1) 8 (22.9) 65 (23.7) 12 (21.4)
Medical year
1st year 65 (26.6) 28 (25.7) 24 (25.3) 15 (44.1) 5 (29.4) 3 (20.0) 21 (21.6) 6 (22.2) 69 (33.0) 19 (43.2)
2nd year 49 (20.1) 22 (20.2) 15 (15.8) 6 (17.6) 2 (11.8) 3 (20.0) 24 (24.7) 4 (14.8) 40 (19.1) 13 (29.5)
3rd year 56 (23.0) 28 (25.7) 24 (25.3) 7 (20.6) 7 (41.2) 6 (40.0) 22 (22.7) 9 (33.3) 43 (20.6) 5 (11.4)
4th year 40 (16.4) 20 (18.3) 14 (14.7) 2 (5.9) 3 (17.6) 3 (20.0) 15 (15.5) 5 (18.5) 31 (14.8) 5 (11.4)
5th year 34 (13.9) 11 (10.1) 18 (18.9) 4 (11.8) 0 (0.0) 0 (0.0) 15 (15.5) 3 (11.1) 26 (12.4) 2 (4.5)
State
6

Sindh 154 (48.2) 76 (53.5) 43 (34.4) 19 (44.2) 5 (22.7) 6 (31.6) 71 (52.2) 17 (48.6) 129 (47.1) 26 (46.4)
Punjab 120 (37.6) 45 (31.7) 44 (35.2) 14 (32.6) 13 (59.1) 8 (42.1) 38 (27.9) 9 (25.7) 96 (35.0) 18 (32.1)
KPK and Balochistan 45 (14.1) 21 (14.8) 38 (30.4) 10 (23.2) 4 (18.2) 5 (26.3) 27 (19.9) 8 (22.6) 49 (17.9) 12 (21.4)
Comorbidities
Present 13 (4.1) 6 (4.2) 5 (4.0) 3 (7.0) 2 (9.1) 1 (5.3) 6 (4.4) 2 (5.7) 11 (4.0) 10 (17.9)
Absent 306 (95.9) 136 (95.8) 120 (96.0) 40 (93.0) 20 (90.9) 18 (94.7) 130 (95.6) 33 (94.3) 263 (96.0) 46 (82.1)
Self-reported health
Excellent 63 (19.7) 33 (23.2) 24 (19.2) 11 (25.6) 2 (9.1) 3 (15.8) 24 (17.6) 8 (22.9) 53 (19.3) 7 (12.5)
Good 204 (63.9) 87 (61.3) 79 (63.2) 24 (55.8) 15 (68.2) 10 (52.6) 83 (61.0) 15 (42.9) 176 (64.2) 35 (62.5)

Self-Medication Practices Among Medical Students

Fair/Poor 52 (16.3) 22 (15.5) 22 (17.6) 8 (18.6) 5 (22.7) 6 (31.6) 29 (21.3) 12 (34.3) 45 (16.4) 14 (25.0)
COVID-19 risk
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No risk 111 (34.8) 57 (40.1) 44 (35.2) 15 (34.9) 13 (59.1) 11 (57.9) 44 (32.3) 16 (45.7) 92 (33.6) 18 (32.1)
Already infected 63 (19.7) 19 (13.4) 36 (28.8) 7 (16.3) 2 (9.1) 1 (5.3) 22 (16.2) 2 (5.7) 68 (24.8) 11 (19.6)
Mild/Severe 145 (45.4) 66 (46.8) 45 (36.0) 21 (48.8) 7 (31.8) 7 (36.8) 70 (51.5) 17 (48.6) 114 (41.6) 27 (48.2)
Reason
Cold/Flu 263 (82.4) 53 (37.3) 31 (24.8) 10 (23.2) 5 (22.7) 1 (5.3) 53 (39.0) 10 (28.6) 18 (6.6) 27 (48.2)
No symptoms 90 (28.2) 28 (19.7) 16 (12.8) 11 (25.6) 7 (31.8) 1 (5.3) 10 (7.3) 1 (2.8) 81 (29.6) 2 (3.5)
COVID-19 prevention 79 (24.8) 24 (16.9) 21 (16.8) 12 (27.9) 6 (27.2) 2 (10.5) 6 (4.4) 1 (2.8) 71 (25.9) 6 (10.7)
COVID-19 symptoms 104 (32.6) 29 (20.4) 28 (22.4) 7 (16.3) 4 (18.2) 1 (5.3) 7 (5.1) 9 (25.7) 31 (11.3) 13 (23.2)

(Continued)
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Yasmin et al.
TABLE 2 | Continued

Factor Parace-tamol Ibuprofen Azithro-mycin HCQ Iver-mectin Doxy- Cetirizine Antiviral Multi-vitamin Other
N = 319 N = 142 N = 125 N = 43 N = 22 cycline N = 136 N = 35 N = 274 N = 56
N = 19

COVID-19 positivity 92 (28.8) 23 (16.2) 38 (30.4) 6 (13.9) 6 (27.3) 2 (10.5) 5 (3.7) 6 (17.1) 60 (21.9) 16 (28.6)
Regular use 97 (30.4) 21 (14.8) 15 (12.0) 5 (11.6) 4 (18.2) 2 (10.5) 19 (14.0) 5 (14.3) 57 (20.8) 19 (33.9)
Others 105 (32.9) 45 (31.7) 17 (13.6) 12 (27.9) 10 (45.4) 3 (15.8) 15 (11.0) 4 (11.4) 16 (5.8) 9 (16.1)
Symptoms
Fever 303 (95.0) 73 (51.4) 32 (25.6) 8 (18.6) 3 (13.6) 2 (10.5) 3 (2.2) 4 (11.4) 12 (4.3) 13 (23.2)
Fatigue 189 (59.2) 43 (30.3) 14 (11.2) 6 (13.9) 4 (18.2) 1 (5.3) 1 (0.7) 2 (5.7) 69 (25.2) 12 (21.4)
Cough 112 (35.1) 30 (21.1) 46 (36.8) 7 (16.3) 3 (13.6) 1 (5.3) 27 (19.8) 3 (8.6) 1 (0.3) 23 (41.1)
Sneezing 96 (30.1) 18 (12.7) 15 (12.0) 8 (18.6) 3 (13.6) 1 (5.3) 73 (53.7) 4 (11.4) 4 (1.5) 14 (25.0)
Muscle pain 196 (61.4) 42 (29.6) 15 (12.0) 9 (20.9) 2 (9.1) 2 (10.5) 4 (2.9) 1 (2.9) 24 (8.8) 11 (19.6)
Nasal congestion 97 (30.4) 26 (18.3) 23 (18.4) 6 (13.9) 1 (4.5) 4 (21.1) 52 (38.2) 2 (5.7) 3 (1.1) 20 (35.7)
Sore throat 98 (30.7) 25 (17.6) 58 (46.4) 5 (11.6) 3 (13.6) 2 (10.5) 19 (14.0) 1 (2.9) 5 (1.8) 21 (37.5)
Anosmia 56 (17.5) 19 (13.4) 17 (13.6) 4 (9.3) 2 (9.1) 0 (0.0) 5 (3.7) 2 (5.7) 11 (4.0) 12 (21.4)
Breathing difficulty 63 (19.7) 21 (14.8) 15 (12.0) 6 (13.9) 4 (18.2) 3 (15.8) 4 (2.9) 3 (8.6) 15 (5.5) 9 (16.1)
No symptoms 110 (34.5) 31 (21.8) 9 (7.2) 9 (20.9) 6 (27.3) 2 (10.5) 8 (5.9) 6 (17.1) 81 (29.6) 6 (10.7)
Alleviated symptoms
All of them 76 (23.8) 30 (21.1) 24 (19.2) 9 (20.9) 2 (9.1) 3 (15.8) 28 (20.6) 8 (22.6) 59 (21.5) 12 (21.4)
Most of them 69 (21.6) 32 (22.5) 29 (23.2) 9 (20.9) 3 (13.6) 4 (21.1) 30 (22.0) 6 (17.1) 56 (20.4) 9 (16.1)
7

Few of them 58 (18.2) 26 (18.3) 19 (15.2) 7 (16.3) 2 (9.1) 4 (21.1) 24 (17.6) 7 (20.0) 54 (19.7) 12 (21.4)
One of them 55 (17.2) 25 (17.6) 25 (20.0) 8 (18.6) 3 (13.6) 3 (15.8) 25 (18.4) 5 (14.3) 50 (18.2) 13 (23.2)
None of them 61 (19.1) 29 (20.4) 28 (22.4) 10 (23.2) 12 (54.5) 5 (26.3) 29 (21.3) 9 (25.7) 55 (20.1) 10 (17.9)

Bold values signify significant p-value (<0.05) by either chi-square or Fisher’s exact test.
Data presented as frequency and percentage.
HCQ, hydroxychloroquine; KPK, Khyber Pakhtunkhwa.

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Yasmin et al. Self-Medication Practices Among Medical Students

TABLE 3 | Bivariate analysis of the factors associated with the self-medication of various drugs during the COVID-19 lockdown among medical students (n = 489).

Variable Parace-tamol Ibuprofen Azithro-mycin HCQ Iver-mectin Doxy-cycline Cetirizine Antiviral Multi-vitamin Other

Age (years)
18–20 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000
21–25 and above 3.554* 1.331 2.766* 0.931 1.432 0.815 1.829* 2.918* 2.025* 1.172
Gender
Female 1.136 1.220 0.723 1.078 1.289 0.321* 0.712 0.343* 2.573* 0.930
Male 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000
Student
Medical 1.001 1.022 0.965 1.078 1.048 1.159 0.636* 1.041 0.974 1.144
Pharmacy 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000
Medical year
1st year 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000
2nd year 1.669 1.414 1.038 0.631 0.651 1.676 2.286* 1.105 0.909 1.155
3rd year 2.671* 2.063* 1.981* 0.757 2.475 3.543 2.056* 2.709 1.095 0.400
4th year 3.179* 2.210* 1.581 0.299 1.494 2.531 2.046 2.145 1.214 0.605
5th year 4.054* 1.255 3.219* 0.786 – – 2.804* 1.551 1.366 0.284
State
Sindh 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000
Punjab 1.043 0.696 1.438 0.912 3.569* 1.770 0.617* 0.633 0.935 0.891
KPK/Balochistan 0.970 0.908 5.358* 1.564 2.812 2.962 1.468 1.570 1.953* 1.679
Comorbidities
Present 0.760 0.913 0.850 0.761 2.235 1.188 0.972 1.315 0.776 7.627*
Absent 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000
Self-reported health
Excellent 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000
Good 1.795* 1.022 1.365 0.826 2.989 1.294 1.299 0.294* 1.688* 2.143
Fair/Poor 1.559 0.947 1.447 1.055 3.784 3.041 1.611 0.512 1.523 3.524*
COVID risk
No risk 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000
Already infected 4.872* 0.935 5.795* 1.366 0.424 0.249 1.604 0.339 12.882* 0.888
Mild/Severe 2.446* 1.357 0.848 1.556 0.561 0.669 2.080* 1.150 1.758* 0.505*

The dependent variable corresponds to the drug used while the reported p-values were obtained by logistic regression model, with the crude odds ratios reported.
P-values <0.05 have a *sign that indicates significant association with the dependent variable. Positive association implies to odds ratio >1.0 and negative association implies to odds
ratio <1.0.
HCQ: hydroxychloroquine; KPK: Khyber Pakhtunkhwa.

was found to be 87% (5) while In Kenya, health care self- Paracetamol was the highest used drug in our study,
medication prevalence was 60.4% among healthcare workers, respondents 21–25 years and above, 5th year medical students,
indicating an increase from pre pandemic results (24). Another those already infected with COVID-19, and stating symptoms
study assessing self-medication prevalence in the Nigerian of cold/flu, fever and fatigue showed significant use. High
population during the pandemic reported a finding of 41% (25). use of Paracetamol aligns with results from the nursing
In Togo, 34.1 % of the participants that belonged to healthcare, undergraduates in Saudi Arabia (17) and from the Peru adult
air transport, police, road transport and informal sectors population (16) where it was also the most consumed drug.
reported to self-medicate and healthcare division had the highest As a widely used first line pharmacotherapy analgesic for
of 51.9% against all sectors (26). Conversely, in Peru, the number tackling pain disorders and different pyrexia, Paracetamol use
of responders not engaging in self-medication was higher than is widely reported in studies comprising of medical students.
those that did, for all drugs including Acetaminophen, Ibuprofen, Health science major students in Nigeria commonly used
Azithromycin, Hydroxychloroquine, Penicillin, Antiretrovirals, it as a pain reliever (25), while medical students in Iran
which were evaluated (16). Multivariate logistic regression model were also frequent users of this drug (27). An Indian study
showed that being female gender, medical school year 3rd, having found medical students to be more likely to self-medicate
been already infected with COVID-19 or having already infected than paramedical students and for this purpose, Paracetamol
with COVID-19 were factors that were associated respondents was consumed mostly (28). Paracetamol has been known to
expected to self-medicate the most. have negligible anti-inflammatory action (28) and guidelines

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Yasmin et al. Self-Medication Practices Among Medical Students

TABLE 4 | Multivariate analysis of the factors associated with the self-medication practice during the COVID-19 lockdown among medical students (n = 489).

Factors OR 95% CI p-value aOR 95% CI p-value

Age (years)
18–20 1.000 - - 1.000 - -
21–25 and above 1.091 0.674–1.767 0.722 1.106 0.656–1.865 0.706
Gender
Female 2.547 1.531–4.239 <0.001* 2.810 1.630–4.843 <0.001*
Male 1.000 - - 1.000 - -
Student
Medical 1.513 0.896–2.556 0.121 1.590 0.914–2.766 0.101
Pharmacy 1.000 - - 1.000 - -
Medical year
1st year 1.000 - - 1.000 - -
2nd year 1.545 0.715–3.337 0.269 1.383 0.588–3.254 0.457
3rd year 3.003 1.175–7.677 0.022* 3.591 1.127–11.444 0.031*
4th year 1.655 0.669–4.093 0.276 1.517 0.435–5.289 0.513
5th year 1.094 0.453–2.644 0.842 1.034 0.278–3.849 0.960
State
Sindh 1.000 - - 1.000 - -
Punjab 0.796 0.485–1.306 0.366 0.685 0.402–1.168 0.164
KPK and Balochistan 2.166 0.878–5.344 0.094 1.862 0.737–4.705 0.189
Comorbidities
Present 0.526 0.200–1.388 0.195 0.567 0.202–1.590 0.281
Absent 1.000 - - 1.000 - -
Self-reported health
Excellent 1.000 - - 1.000 - -
Good 1.826 1.065–3.132 0.029* 1.853 1.053–3.261 0.032*
Fair/Poor 1.576 0.756–3.286 0.225 1.530 0.710–3.299 0.278
COVID risk
No risk 1.000 - - 1.000 - -
Already infected 2.230 0.999–4.980 0.050* 1.904 0.832–4.356 0.127
Mild/Severe 1.509 0.907–2.509 0.113 1.304 0.765–2.223 0.329

*Indicates significant association with the dependent variable (P < 0.05).

KPK, Khyber Pakhtunkhwa; COVID, coronavirus disease.

issued during the initial months of the pandemic state that Multivitamins were the second highest consumed drug in our
it can be used for treating mild COVID-19 symptoms when study, which have also been the drug of choice as divulged in
managing patients at home (29) or for self-medication, especially a population-based survey during COVID-19 in Nigeria with
for fever or headache (30). This is consistent with our 51.8% reporting to use this group of medicine (25). In Togo,
results corresponding to Paracetamol use as it was greatly 27.6% used Vitamin C when self-medicating (26), while in Egypt,
used to treat “fever” in our study population, and its use 27% used vitamin C and 17.7% used vitamin D (31). A study
also showed improvement in all or most of the symptoms from 2015 involving healthcare and non-healthcare university
experienced by the responders who employed Paracetamol. students from South India found multivitamins to be among
However, some instances report the drug to be exacerbating the most commonly self-medicated drugs (32). Multivitamins
COVID-19 symptoms, likely due to activation of prothrombotic include multiple vitamins and minerals, trace elements all of
mechanisms which is known as one of the leading pathogenic which possess antioxidant properties and have a crucial role in
causes of COVID-19 (29). Single or repeated high Paracetamol regulating immune function and can reduce risk of respiratory
dose, or chronic ingestion above therapeutic doses can result infection (33). A large observational study conducted in US,
in hepatotoxicity (17). Hepatotoxicity from intentional or non- UK, and Sweden during first waves of COVID-19 demonstrated
intentional Paracetamol overdose is the most common cause a modest protective effect among those taking multivitamin
of drug-induced liver injury and is a global issue (17). The supplements with a reduced risk for testing positive for SARS-
medicine’s toxic dosage effects must be known to students CoV-2 (33). Hence, these might explain the significant use of
utilizing it. multivitamins by females and participants 21–25 years and above.

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Yasmin et al. Self-Medication Practices Among Medical Students

Additionally, individuals with COVID-19 can experience weight fear and stigma, knowledge and access to prescription-only
loss; having adequate amounts of vitamins and minerals can medicines while trying to keep one’s health status, especially
prevent this unintended reduction in weight (34). Moreover, if infected with COVID-19, could be accounted for self-
a deficiency in certain micronutrients such as Vitamin A, medication rates among the medical students’ community (26).
Vitamin D, Zinc can be deleterious during viral infections (33). Furthermore, practicing self-medication allowed the students
These factors might elucidate why those infected with COVID- to exercise freedom in managing their health and wellbeing
19 in our research resorted to a significantly high rate of instilling a sense of independence (24). The overall high self-
multivitamin use. medication rate throughout all year groups can be ascribed to
Ibuprofen was the third highest self-medicated drug in the extensive educational load upon these students and stressful
our population. Previously, it has been reported to be the circumstances which results in distress and compels them to
most preferred NSAID for analgesic purposes among nursing seek OTC drugs (45). Another study conducted in Poland
undergraduates in Saudi Arabia (20%) (17). As a non- highlighted such behaviors increased during lockdown (46).
steroidal anti-inflammatory drug (NSAID), it is well tolerated According to a study from Jordan, factors such as female gender,
and effective during pain and inflammation and has minor working in the medical field, and history of COVID-19 infection
side effects (17). Alongside Paracetamol, it is one of the were reportedly associated with self-medication similar to our
most extensively used antipyretic (35). Since the start of findings (47).
the pandemic, Ibuprofen use has been subject to debate While the high self-medication percentage suggests medical
(36). Initially discouraged for use as it was suspected to students’ confidence while self-prescribing, the possibility
aggravate infections (37), such claims were later rejected. A that students’ knowledge about drug pharmacology, cultural
study analyzing data from ISARIC Clinical Characterization prevalence, and limited experience at the current student level
Protocol UK cohort found NSAIDS use not disposing to can make them susceptible to unfavorable outcomes, must not
any poor COVID-19 outcome (38). A 2021 systematic review be undermined (28). Drug addiction and drug dependence
and meta-analysis reiterated similar findings and revealed (29) can also be induced by repeated self-medication, which
no negative association between use of NSAIDS, including students must be aware of. Lockdown and isolation guidelines
Ibuprofen, with SARS-CoV-2 infection or its outcomes (39). have prevented the population from visiting hospitals and
Ibuprofen has been known to have a better analgesic response clinics and have altered health-seeking behavior. As different
in men while higher threshold and greater tolerance for SARS-CoV-2 variants keep emerging, people are likely to self-
electrically induced pain, responded significantly to ibuprofen medicate (48). Medical students are also probable to keep self-
in contrast to women (40). Nevertheless, the high use of medicating, which could be helpful in obtaining benefits of
this drug during COVID-19 can be linked to its efficacy in self-care, and alleviating burden on the healthcare system of
relieving fever, infection (35). However, users must be wary that the country by reducing number of physician visits (49). By
disproportionate use of the drug can cause adverse drug reactions practicing self-medication wisely themselves, staying mindful of
(ADRs) (17). the pharmacological and taxological risks of improper drug use
Hydroxychloroquine and ivermectin, the sales of which (25), they could facilitate the lay population to treat themselves
escalated globally in wake of COVID-19 were found to be for minor ailments which could further relieve pressure on health
consumed in low amounts in our study (41). Other frequently care setups.
used drugs were Cetirizine and Azithromycin. Azithromycin has The study is important as questions specific to the drug
been popular amongst antibiotics that have been used for self- trends in the local population were incorporated, and responses
medication in Pakistan (21) and has also been an alternative for from all parts of the country were received. However, as
self-medication in other countries such as Saudi Arabia (17) and online platforms were used for disseminating the questionnaire,
Peru (16). Using antibiotics during self-medication is the leading students in remote areas with no access to the internet
cause of antimicrobial resistance (42) thus its intake must be could not be a part of the survey. Other limitation included
regulated, its appropriate use and disposal ensured especially by non-random sampling method and generalizability of study
medical students. results. Besides, due to recall bias, some responders might have
The most common reason for use of the respective drug answered incorrectly.
was “cold/flu”, consistent with results from studies of including
medical students from Iran (29, 43) and Brazil (44). “Fever”,
one of the most common COVID-19 symptom (19), followed CONCLUSION
by “Muscle Pain” were the highest symptomologies reported
for medicine use. Analgesic use for muscular pain at any site Our study revealed common self-medication practices among
was also highly common among undergraduate medical and medical and pharmacy students. It is a significant health issue
paramedical students in India (28). Studies evaluating medical especially during the pandemic times, with high consumption
students’ attitudes toward self-medication delineate sufficient reported as a prevention or treating symptoms of COVID-
knowledge, familiarity with disease, and time constraints which 19. Further measures are needed to improve healthcare
can also be cited as motives for self-medication among our policies regarding awareness and sensitization about the
participants in this pandemic scenario (17). In the early days risks of self-medication. Future studies should also assess
of SARS-CoV-2 outbreak, when the disease was a source of students’ attitude toward self-medication, their knowledge

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Yasmin et al. Self-Medication Practices Among Medical Students

regarding drug dosage and potential side effects, and the AUTHOR CONTRIBUTIONS
role of medical colleges to better ascertain their approach
toward self-medication. FY: conceptualization. UN, HNaj, HNau, and AK: data curation.
MSA: formal analysis. FY and MNA: funding acquisition. FY, UN,
and HNaj: investigation. MSA and AK: methodology. FY, UN,
DATA AVAILABILITY STATEMENT
and AK: project administration. UN, HNaj, and HNau: resources.
The raw data supporting the conclusions of this article will be MSA and HNau: software. MSA, HNau, and AK: validation.
made available by the authors, without undue reservation. HNaj and HNau: visualization. UN and HNau: writing—original
draft. FY, MSA, MNA, and AK: writing—review and editing. All
authors approved the final version of the manuscript.
ETHICS STATEMENT
The studies involving human participants were reviewed and SUPPLEMENTARY MATERIAL
approved by Ethics Approval was taken in this study from
Institutional Review Board of Dow University Ojha Hospital The Supplementary Material for this article can be found
(Approval No. IRB (DUH)-2020/174/021), and content to online at: https://www.frontiersin.org/articles/10.3389/fpubh.
participate was obtained from all the individuals through 2022.803937/full#supplementary-material
online platform. The patients/participants provided their written Supplementary Figure 1 | Crude and Adjusted level analysis of factors
informed consent to participate in this study. associated with self-medication among medical students.

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Frontiers in Public Health | www.frontiersin.org 12 March 2022 | Volume 10 | Article 803937