Self-medication and related health complaints among expatriate highschool students in the United Arab Emirates

Introduction

Self-medication is defined as obtaining and consuming drugs without the advice of aphysician to treat self-recognized illnesses or symptoms.1,2 Generally involvingover-the-counter (OTC) medications but also associated with prescription-onlymedicines (POM)3,4, self-medication forms a part of the concept of self-care andmay be guided by a community pharmacist.2Pharmacists can advise patients on drug choice and the “responsible” use of approvedOTC drugs.1,2

Adolescence is a key period in which an individual takes first steps towardsself-care and self-medication.3,5,6,7,8,9,10 Thehealth care habits adopted during adolescence may be carried over into adulthood.Moreover, adolescents may indulge in autonomous health behaviors, use medicineirrationally without adult guidance6,7,8,11 and also misuse OTC and prescription drugsto get “high”.12 Additionally, a familialpractice of SM has been reported to encourage SM during adolescence.10 The United Arab Emirates (UAE) is a MiddleEastern country of the Gulf Cooperation Council (GCC). An average 53.43% of thepopulation of GCC countries (total population: 45.9 million13) consists of expatriates.14 In the UAE, the expatriates constitute about 83% of the totalpopulation15 and those who live with their family are educated, professionalqualified and belong to the middle/ higher income group.15 These expatriates may have access to a wide range of OTCmedication (or even POM) in their home countries in addition to the OTC medicinesavailable in UAE community pharmacies. Moreover, differences in accessibility to thepublic healthcare system between the local Emirati and expatriate population mayalso influence self-medication practices in the latter.

Though globalization and migration have become a common phenomenon, published data onself-medication practices in this large population (expatriates) are lacking andstudies on the use of medicines by adolescents’ (whether local or expatriate) fromthe Middle Eastern countries are scarce.8 Asno previous study on medicine use by adolescents in the UAE could be identified, wefelt it was worthwhile to explore the prevalence and practices of self-medication inthis population.

The aims of the study were to explore the prevalence of self-medication with both POMand OTC medications, the health complaints related to self-medication, sources ofdrug procurement and sources of drug recommendation and to investigate any genderdifferences related to self-medication among expatriate high school students ofUAE.

Methods

A cross-sectional survey was carried out among a convenience sample of expatriatehigh school students (grades 9 to 12) in four private schools in the UAE, afterobtaining Institutional Ethics Committee approval. The minimum sample size,calculated by considering the prevalence of self-medication as 75% (based on averageof prevalence rates of previous studies)8,7 and marginal error as 5%, was 300.Taking into account a non-response rate of 10%, the questionnaires were distributedto the 330 students present on the day of the survey. The response rate was 98.2%with 324 students returning the completed questionnaires.

Male and female students majoring in natural sciences, commerce and arts wereconsidered to obtain a representative sample from all three streams of study. Thefour participating schools had nearly equal distribution of gender in the classeswhich was reflected in our study sample. The teachers were briefed about the studyobjectives and the instructions for filling the questionnaires were given to, whothen conveyed the information to their students. Voluntary participation wasstressed upon, confidentiality of data was assured and informed consent was obtainedfrom the participating students.

Results

The socio-demographic characteristics of the 324 participating students appear inTable 1. All the students wereexpatriates from multi-ethnic backgrounds and almost equally distributed by gender.The majority were residing in the UAE for more than three years, aged 16 to 17 yearswith parents having college degrees.

The period prevalence rate of self-medication in the past year among the participantswas 89.2%, which did not vary with age, gender, ethnicity or educational level ofthe parents (Table 1). The majority of therespondents had started self-medicating after the age of 13 years (58.6%) but somealso indicated 10-13 years (32.5%) and even 7-10 years (8.9%) as the age ofcommencing self-medication.

The most common sources of the medicines among the self-medicating students (n=289)were community pharmacies (71.3%) and stocks kept at home (20.4%) (Figure 1). Parents (68.9%) and pharmacists (46%)were the most common source of drug recommendation (Figure 2). There were no significant gender differences with regard toboth these factors.

Figure 1

Figure 1. Sources of drug procurement (Males=134; Females=142).

Figure 2

Figure 2. Sources of drug recommendation (Males=134; Females=142).

Headache, fever and flu symptoms were the common self- reported conditions in theprevious year. About half of the students also reported allergies and sleepproblems. Females suffered significantly more often with inability to sleep, skin,eye and ear diseases and constipation than the males (Table 2).

In concordance with the health complaints reported, antipyretics, analgesics andantibiotics were the medications used most commonly used during the past year. Asignificant female preponderance was observed for the use of vitamins/ nutritionalsupplements and sedative/hypnotics in the previous year (Table 3)

As with self-medication during the previous year, analgesics and antipyretics weremost commonly used during the past two weeks too. Statistically significant genderdifferences were observed with the use of analgesics, sedative/hypnotics (higher infemales) and anti-allergic, herbal/homeopathic medicines (higher in males) in thepast two weeks (Table 4).

On sub-analysis of the data, the majority of self-medicating students (71.3%)reported experiencing at least one health problem in a month, with significantdifferences (p<0.01) observed among males (64.2%) and females (78.2%). Similarsignificant gender differences (p<0.001) were also observed in self-medication atleast once in a month (Males: 38.8%; Females: 58.4%). A small fraction of students(22.1%) reported at least one health complaint and 15.2% were partaking at least onedrug on a daily basis. There were no gender differences in the health complaintssuffered daily and daily use of drugs.

The students had experienced an average of 7.9 (SD=4.2) health complaints in the pastyear. They had self-medicated with one to twelve drugs during the past year and withone to seven drugs during the past two weeks. The average number of drugsself-medicated during the past year and the past two weeks were 4.5 (SD=3.6) and 2(SD=1.5) respectively. There was a statistically significant positive correlationbetween the number of health complaints and number of medicines self-medicated forboth boys (r=0.557; p<0.001) and girls (r=0.648; p<0.001).

Discussion

Our study is the first that examined the self-medication practices among theadolescent expatriate population in UAE. The high prevalence of self-medication,which illustrates autonomous health behavior in this population, is quite alarming.Recent research has also revealed that prescription and OTC drug abuse is anemerging trend12,20 and the use of medicines in adolescents is being regarded aspart of a cluster of risk behaviors.21Additionally, as most lifestyle habits are acquired during adolescence and asadolescents have inadequate knowledge about drugs7,22 this group is at high riskfor irrational drug use.

Although other studies have used different recall periods, which limits comparison,the prevalence of self-medication in our sample is comparable to that reported inKuwaiti (92%)8 or Maltese (90.3%)16 adolescents and higher than that observed inGerman (57%)7 or Brazilianadolescents(56.6%3, 52.6%23, 50%10). Though self-medication is reported to increase with age amongDanish5, Kuwaiti8, Saudi adolescents24; more common in German7, Norwegian9,Brazilian10 females6 and associated with maternal educational level in Brazil10, no such associations were observed in ourstudy.

Our data is concordant with literature16,25 that show pharmacies as the most commonsources of medicines. Studies had also reported that adolescents had access to thehome medicine cabinet26 or obtained theirmedicines from their parents.5 Moreover,parents and pharmacists can probably influence adolescents on the appropriate use ofdrugs as the majority of our students reported to be self-medicating on theirrecommendation. Other studies have likewise identified mothers3,10 and pharmacists3,23 asbeing responsible for advising adolescents. Interestingly, only 5.2% of the cases ofself-medication in our study were influenced by the media (including internet),analogous to that reported elsewhere.3

The high proportion of our students suffering from headache, fever and flu (asobserved in other studies3,7,11,17) indicates the associationof self-medication with symptomatic treatment of these conditions. The highprevalence of self-reported allergies and sleeping problems is also notable as alower prevalence of allergic rhinitis (36%)27and insomnia (20%11, 15%7) had been reported elsewhere. Our data also confirms theadolescents’ self-rated health as a predictor of medicine use because a positivecorrelation was found between the self-reported health complaints and medicineconsumption for both genders.

The female excess observed for certain self-reported health complaints is alsoobserved in other studies.28 Some researchershave explained these gender differences due to the differences in biology,psychological stresses, self-image, fixation with physical appearance, etc.29 The latter two reasons may contribute to thegreater prevalence of skin and eye diseases reported by our female students. Thehigher proportion of females experiencing health complaints at least once a month(78.2%) may also be attributed to the high prevalence of menstrual pain (59.9%). Thehigh monthly morbidity reported by females is also corroborated by theirsignificantly higher use of analgesics in the preceding two weeks (Table 4).

As reported in other studies3,5,7,8,9,10, analgesics and antipyretics were themedicines most commonly used. Many of our students were also taking nutritionalsupplements (43%), indicating their awareness of health-related issues. The use ofanti-allergics (32.5%) is almost similar to that reported by Kuwaiti adolescents(40%).8 This high use of anti-allergicsand nasal decongestants along with the high prevalence of self-reported allergies inour sample may suggest the need for further research on the regional prevalence ofthese disorders. The use of herbal/homeopathic medicine by a third of the sampleindicates their acceptance of these alternative healthcare systems.

The one year prevalence rate of self-medication did not show any difference withregard to gender in our study. Nevertheless, on analyzing the practice ofself-medication with respect to use of specific drug groups, a female excess wasobserved. Analogous to our study, female predominance of self-medication has alsobeen reported for pain (especially headache, stomach-ache)5,6,8,9 and sleepingdifficulties5 (Tables 3 and 4). However,in contrast to the female excess observed with respect to vitamins/nutritionalsupplements in our study (Table 3), the useof vitamins was higher among male Kuwaiti adolescents.8 Moreover, unlike the significant male excess observed in the use ofanti-allergics over the past two weeks (Table4), no such gender differences were reported in other studies.8,9

The high prevalence of self-medication with antibiotics (54%) during the past year isalarming even though it is similar to that encountered among Indian adolescents(58%).25 In contrast, Maltese (19%)16, and Brazilian adolescents (8.6%)3 seemed to be using antibiotics less often. Thegeneral population of UAE is also reported to be self-medicating frequently withantibiotics acquired from community pharmacies without prescriptions30,31,though the OTC dispensing of antibiotic is illegal.18

Studies have indicated that immigrants were more likely to self-medicate32 and their prior experiences in countrieswith easy access to antibiotics influenced their acquisition of antibiotics withouta prescription.33 The majority of expatriatesresiding in UAE come from developing countries where pharmacists often dispenseantibiotics without prescriptions.4,34 Consequently, as many of our expatriateadolescents appeared to be successful in obtaining antibiotics, it may be due toeasy accessibility to stocks at home16,25,26(bought from their own home countries or from community pharmacies in UAE30,31)or “leftover” antibiotics from previous prescriptions.26 Inappropriate self-medication with antibiotics and theoverall volume of antibiotic consumption in the community have serious implicationsin the development of antibiotic resistance.

The use of sedatives/hypnotics by about one fourth of our sample is also noteworthy.Being a prescription drug in UAE, the sources for this may also be the same as thosefor antibiotics. Literature indicates a low prevalence of use of this drug(6.4%6, 15%7). Furthermore, a female excess for sedatives/hypnotics was observed,which has also been reported by the Danish study5 but not confirmed by otherstudies.6,9

The self-medication pattern observed in our respondents is similar to the practicesadopted by adults. Analogous to our results, the use of analgesics/antipyretics andantibiotics is also commonly encountered among the adult population.4,35

The high overall use of medicines indicates that adolescents are takingresponsibility for their own health but also exposes them to risks of misdiagnosis,inappropriate use, drug interactions and polypharmacy. Health care providers,educators and parents can play a vital role in making the transition to self-caresuccessful in adolescents.36 A robustpharmacovigilance system is also advocated, with the community pharmacists providingadvice to adolescents on responsible self-medication under adult guidance.2 This extended role should be also taken intoaccount in the education, training and practice of community pharmacists. Educationand awareness campaigns can also be undertaken to promote the role of the pharmacistand enhance opportunities for adolescents communicating with pharmacists. Morein-depth studies identifying and tackling the raison d'être of the use ofantibiotics, sedatives, or hypnotics and education campaigns dealing with theeffects of their inappropriate use directed at parents, adolescents and pharmacistscan be advocated. Strict regulatory strategies should be enforced to limit theimport of POM and their sale without prescription. OTC medicines may be dispensed toadolescents in limited numbers for the relief of mild illnesses.

We acknowledge the limitations of this standardized survey, particularly theself-reported nature of data and the likelihood of mutual influence between students.However, adolescents appear to report health risk behaviors and medicine usereliably over time.37 We are also aware thatthere could have been an overlap of use of Acetaminophen and Non-SteroidalAnti-Inflammatory Drugs (NSAIDs) for the relief of pain and fever. Moreover, in viewof the inclusion of schools with English as the medium of instruction (withoutrepresentation from schools using Arabic or other languages), the small sample sizeand the non-probability sampling design, it may not be possible to generalize theresults to the whole of UAE. Nevertheless, given the paucity of previous research,we consider that our study contributes to increasing the knowledge of medicine usein this population.

Conclusions

This is the first study to explore the self-medication practices among adolescentstudents in UAE and provides baseline data critical in creating awareness about therisks and benefits of self-medication. The prevalence of self-medication among thehigh school students in UAE was high, with no variation based on age, gender,ethnicity or parents’ educational level. A high incidence of self-reported healthcomplaints and a female preponderance of medicine use for certain health complaintswere also discerned. As pharmacies were the most common source of self-medicateddrugs and pharmacists were one of the common sources of drug recommendation, thecommunity pharmacists have an important role as qualified public health educators inadvising adolescents both on the choice of medicines and their safe and effectiveuse. The extensive use of antibiotics and sedative/hypnotics indicates a necessityfor educational health programs emphasizing the risks associated with theirirrational use and strict enforcement of UAE Federal Laws regarding the dispensingof these drugs. Additional studies on local Emiratis adolescents and otherexpatriate ethnicities are directions for our future research. Health careproviders, pharmacists, educators and parents should be actively involved in earlyhealth education strategies for establishing responsible use of medicines in thisage group.