Practice and Prevalence of Antibiotic Self-Medication among Undergraduate Students at Kilimanjaro Christian Medical University College, Tanzania

Background: Antibiotic self-medication has been on the rise in different parts of the world. Antibiotic self-medication causes excessive antibiotic exposure to humans which is associated with many health risks including antibiotic resistance. The objective of this study was to assess practice and determine the prevalence of antibiotic self-medication among undergraduate students. Methodology: This was a descriptive cross-sectional study conducted at Kilimanjaro Christian Medical University College. A self-administered questionnaire was used to assess the practice and knowledge of antibiotic self-medication among undergraduate students. A total of 300 undergraduate students were purposively sampled. The association between categorical predictors and antibiotic self-medication waspresented as Odds Ratios (OR) with 95% Confidence Intervals (95% CIs) using logistic regression. Result: The prevalence of antibiotic self-medication among undergraduate students is 191(63.7%) with amoxicillin 103(53.9%) being the most used antibiotic for treatment of respiratory disorders 109(57.1%) and gastrointestinal disorders 50(26.2%). Pharmacy is the major source of antibiotics used for self-medication 165(86.4%). Delayed/queue in seeking hospitals services was the main reason for practicing antibiotic self-medication 74(38.7%). Conclusion: The study observed a high prevalence of antibiotic self-medication among undergraduate students. This calls for immediate implementation of public health programs aimed at increasing awareness of consequences that may results from antibiotic self-medication. At the policy-making level, there is an urgent need to legislate and enforce laws restricting access to antibiotics in Tanzania.


INTRODUCTION
S elf-medication with antibiotics is frequently practiced in many parts of the world and has been one of the major factors contributing to the development of antibiotic resistance.World Health Organization (WHO) defines self-medication as self-care based on the selection and use of antibiotics by individuals to treat self-recognised symptoms or illnesses. 1Antibiotic self-medication has negative consequences as incorrect diagnosis with inappropriate treatment can lead to disease progression, life-threatening conditions 2 , and increased emergence of resistant bacteria that would be challenging to eliminate. 3dergraduate students in universities or colleges, who are the future health care workers, play a pivotal role in educating the community or patients on the advantages and disadvantages of self-medication. 4ifferent studies have reported prevalence of East African Science 2022 | Volume 4 | Number 1 d in health facilities) and accredited drug dispensing outlets (ADDO).Antibiotics are more available to communities in the drug-specific retailers through the prescription and over-the-counter dispensing mechanisms. 22,23veral studies have been conducted elsewhere to highlight the problem of antibiotic self-medication in the general community 22,24,25 , students 26,27 and children through their parents/caretakers. 28,29There is limited data on antibiotic self-medication practices among undergraduate students in Tanzania.Therefore, there was a need to conduct this study to determine the prevalence of the problem and emphasise more knowledge and practice on antibiotic self-medication as it threatens public health.Hence, findings from this study will provide baseline findings that would help in formulating strategies for control of antibiotic consumption in the medical and non-medical communities.

Study Area, Design and Population
A descriptive,cross-sectional study was conducted at Kilimanjaro Christian Medical University College (KCMUCo) from April to May 2017.KCMUCo is a private medical institution which is a constituent college of Tumaini University-Makumira located in Kilimanjaro, Tanzania.The main campus is located in the urban area of Moshi district.The study included both male and female medical students from Year 1 to Year 3. The study excluded year 4 and year 5 students because they were in their clinical rotations/ practice and thus were not readily available.

Sampling Method and Data Collection Tool Questionnaire
The questionnaire was adopted from Araia et al., 30 .Nonprobability (purposive) sampling technique was used to get the sample of 300 students.The students were approached during class hours and the questionnaires were self-administered.The questionnaire was set in English language and it composed of closed-ended questions.The questions were structured into subsections that guided data analysis and interpretation.The questionnaire was composed of 3 sections.Section 1 composed of sociodemographic information such as; sex, gender and year of study.
Section 2 composed of 12 questions.Participants were asked questions regarding their knowledge on selfmedication.The following questions were asked; "Can self-medication be practiced in all illnesses?Do you think that self-medication is better than medical consultation?Can the same prescription be shared between two people having different complaints?Do you think that selfmedication can result in harmful consequences,Do you think that self-medication can delay seeking medical advice?Do you think that antibiotic resistance is an outcome of self-medication without prescription and can self-medication lead to emerging of a new problem like new complaint?".Section 3 composed of 14 questions regarding selfmedication practice with antibiotics.Participants were asked which medical condition (s) assessment prompted them to self-medicate with antibiotics, what were the reasons for self-medication and the sources of the antibi-otic they use(d).
Validity of the Questionnaire To maximise validity, the questionnaire was pretested on relevant respondents before distribution.10 students filled the questionnaire as a pilot study, and in-depth cognitive interviews were carried out to examine how the students understood and responded to the questions.In addition, 2 experts in the field of survey design approved the quality of the questionnaire.After the pretest, adjustments in phrasings were made so as to make the questionnaire simple to answer and yet give accurate and credible data.

Data Analysis Plan
Data was analysed using IBM SPSS Statistics for Windows, Version 22.0 (IBM Corp, Armonk, NY, USA).Descriptive statistics were used to summarise the data.The association between categorical predictors (sex, mode of entry, year of study and course) and antibiotic selfmedication was presented as odds ratios (OR) with 95% Confidence Intervals (95% CIs) using logistic regression.Only one predictor was significantly associated with self-medication in the bivariate analysis (set to p <.1).Therefore, multivariate analyses were not performed.A p<.05 was significant.

Ethical Considerations
Ethical approval to conduct this study was obtained from KCMUCo ethical committee, Certificate Number 2473.Before administration of the questionnaire, written consent was sought from the participants.All measures to protect privacy and confidentiality were considered.Neither names nor students' registration number were mentioned during data collection and final publication.

Knowledge of Antibiotic Use Based On Antibiotic Self-Medication
Over 90% of the respondents were aware that selfmedication should not be practiced in any illnesses and that seeking for medical consultation is the best treatment practice.Majority of the respondents knew that the same prescription cannot be shared between two people with different complaints.As expected, majority reported that antibiotic use for self-medication can lead to antibiotic resistance.Few respondents 16(5.3%) reported that selfmedication can be practiced in all illnesses, 20(6.7%) reported that self-medication is better than seeking for medical consultation, and 19(6.3%) reported "no" to a statement that self-medication can result in harmful consequence.Only 6(2.0%) reported "no" to a statement that self-medication can cause a delay in seeking medical advice, Table 2.All respondents 300(100.0%)had heard about antibiotics.
Regarding the source of information/antibiotics for self-medication, 165(86.4%)got an opinion from a pharmacist, 11(5.8%) got an opinion from a friend, 6(3.1) called a doctor by phone satisfaction with the previous prescription and 5 (2.6) used leftover treatment from a previous illness, Table 3.Among those who practiced antibiotic self-medication (191), when they were asked about the outcome of self-medication, 143(74.9%)reported that their condition improved while 2(1.0%) reported that their condition got worse.13(6.8%) reported adverse reactions such as vomiting, dizziness and headache.

Association of Self-Medication with Socio-Demographic Characteristics
In the univariate analysis of predictors for self-medication, only one variable qualified for further analysis.Respondents in their 2 nd year of study were more likely to self-medicate themselves with antibiotics as compared to 3 rd -year students (OR = 2.68; 95% CI: 1.42 -5.04).Since only one variable qualified for further analysis, the multivariable analysis was not performed, Table 4.

DISCUSSION
Currently, there are increasing reports of antibiotic resistance in different parts of the world 31 , its prevalence is increasing and among the major drivers of resistance is antibiotic self-medication. 32Equally, Self-medication is reported to be an increasing problem among medical and non-medical students. 33ough the inappropriate use of antibiotics as a result of self-medication is common worldwide, developing countries are most affected due to the higher prevalence of diseases and limited resources. 34In this study, more than half of the respondents who practicedself-medication preferred amoxicillin 53.9%.Amoxicillin is from the penicillin group of antibiotics.The choice of antibiotics used by majority of the respondents demonstrates that these groups of antibiotics are more prone to misuse since they are readily available and at low cost.A big percentage of the respondents got their medicines from pharmacies 86.4%, more importantly, these antibiotics are the most used and prescribed by clinicians in the region. 35A study conducted in Nigeria reported that antibiotic is the most frequently mis-useddrug among undergraduate students 17 , specifically amoxicillin, which has been reported to be used for self-medication elsewhere. 18,35ue to inappropriate treatment, there is probable risk of antimicrobial resistance as well as adverse events for individuals.Resistance to amoxicillin has been reported in the setting. 36,37The inappropriate use of antibiotics in the area resulted in the observed resistance to antibiotics.
The prevalence of antibiotic self-medication in thisstudy (63.7%) is lower than that observed in a study conducted in the Democratic Republic of Congo which reported a prevalence of 73.4%. 38Moreover, studies conducted in Sudan (79.5%) 2 , Pakistan 76% 4 , Palestine 98% 39 and Eritrea 79.2% 30 found that the prevalence of antibiotic self-medication among undergraduate students was considerably higher as compared to results from the present study.This could be attributed to their high knowledge aboutmedications and, consequently, think that their knowledge is adequate to practice self-medication 40 , and that they do not need medical consultation. 41In areas where self-medication is common among the general population, also undergraduate students have the same behaviours.In Tanzania, a prevalence of 58% was reported among the general population. 24Therefore, the prevalence is generally similar.In Ethiopia, a study conducted among households showed the prevalence of self-medication to be at 50.2%. 42In other settings such as Saudi Arabia, Ras Al-Khaimah, India and Pakistan, the prevalence was reported to be 35.4%,[45][46] The practice of self-medication is common among both the general population and students.Undergraduate students attempt to practice their acquired knowledge of pharmacology and related subjects and this has resulted

Clinical Features and Self-Medication
The main reasons for self-medication reported by respondents in this study were delayed/queue in seeking in a higher prevalence of self-medication among undergraduate students of up to 98% in Kuwait 20 and 99% in Pakistan. 4Reasons for delayed/queue in seeking hospitals services could be due to the small number of health workers employed at the hospitals, late coming among the hospital employees, and corruption among health workers where these workers are bribed by well-off patients andplace their appointment cards before others. 47Similar findings were observed in studies conducted in Ethiopia 5,48 and Pakistan. 4 this study, the most common health problems which lead to self-medication among undergraduate students were respiratory and gastrointestinal disorders at 57.1% and 37.1% respectively.0][51] This study observed that respiratory disorders such as flu and cold were the most common ailment that provoked self-medication among the respondents.Consequences of illnesses such as; cold, flu and fever could be due to viral infections, and thus these conditions are usually wrongly treated using antibiotics. 52This indicates inappropriate antibiotic use as treatment of viral infections.Such inappropriate antibiotic use leads to development of resistant microbes, increased treatment cost and adverse reactions.The rational use of antibiotics is thus of utmost importance to limit the increase in bacterial resistance.
Association of Self-Medication with Socio-Demographic Characteristics Self-medication with antibiotics was observed with no significant association with socio-demographic characteristics variables such as sex as well as the mode of entry.Results show that students in year 2 were more likely to practice self-medication as compared to students in year 3 of study.There is no direct explanation as to why the second-year undergraduate students were more likely to self-medicate, this may have happened by chance.Otherwise, we expected that third-year students could have practiced self-medication more as compared to others because they are more exposed to the field as compared to the second-and first-year students.In other studies, conducted in Tanzania, an association of Self-medication with antibiotics with socio-demographic characteristics was reported. 24,25However, these findings were in the general population.

Limitation of the study
The main limitation of this study is that the data collected was self-reported.This may introduce some bias in the behaviour of the respondents studied.Prevalence of selfmedication was studied for one month only, results could have been different in other periods as well as in different seasons.The study population was only undergraduate students of year 1 to year 3, other students were not included because the time of data collection coincided with the time of their clinical rotation in peripheral hospitals.The inclusion of other undergraduate students could have presented differences in analysed data.However, this has no effect on the validity of the results observed concerning the parameters assessed in this study.Some variables were not stretched enough to provide multiple responses, this could also have provided a different perspective on antibiotic self-medication among undergraduate students.

CONCLUSION
The study observed a high prevalence of antibiotic selfmedication among undergraduate students.This calls for immediate implementation of public health programs aimed at increasing awareness of consequences that may results fromantibiotic self-medication.There is need for review of educational programs especially in the teaching of clinical pharmacology to include modules on selfmedication and rational use of medicines.At the policymaking level, there is an urgent need to legislate and enforce laws restricting access to antibiotics in Tanzania.More importantly, a national commitment forsolving the problem of antibiotic misuse in Tanzania is urgently required.

FIGURE 1 :
FIGURE 1: Common Antibiotic Used for Self-Medication

TABLE 2 :
Knowledge of Self-Medication (N=300) Bolded responses are correct unless indicated otherwise

TABLE 4 :
Association of Self-Medication with Antibiotics and Socio-Demographic Characteristics COR: Crude odds ratio

TABLE 3 :
Practice Regarding Self-Medication of Antibiotics among Undergraduate Students (n=191)