Self-medication with oral antibiotics among University students in United Arab Emirates

Purpose: To investigate the prevalence of antibiotic use without prescriptions and to identify factors associated with this behavior among university students using oral non-prescription drugs (ONPD). Methods: A cross-sectional study was conducted among the students of major universities in UAE. A multistage sampling technique was used in the present study. Results: Out of 2875 students, only 2355 (81.9 %) questionnaire were fully answered and included. Of 2355, more than half (1348; 57.2 %) of the participants reported using ONPD. More than one-third (484, 35.9 %) of 1348 participants used antibiotics without a prescription during the 90 days prior to the present study. Binary logistic regression identified nine statistically significant variables: nationality (OR = 0.471, 95 % CI: 0.326 - 0.681, p < 0.001); cost-influence behavior (OR = 1.716, 95 % CI: 1.175 -2.508, p < 0.005); belief in ONPD effectiveness (OR = 0.332, 95 % CI: 0 .135 - 0.815, p < 0.05); year of study (OR = 0.310, 95 %, CI: 0.141 - 0.681, p < 0.004); medication knowledge (OR = 0.619, 95 % CI: 0.443 - 0.866, p < 0.005); self-care orientation (OR=1.878, 95 % CI: 1.304 - 2.706, p < 0.001); using ONPD helps to save money (OR=1.665, 95 % CI: 1.047-2.649, p<0.04); and urgency of use (OR = 1.644, 95 %, CI: 1.144 - 2.363, p < 0.007); as well as being healthcare students (OR = 1.465, 95 %, CI: 1.012 - 2.120, p < 0.05). Conclusion: There is a need for educational intervention to improve students’ knowledge, attitude, and awareness regarding the risk of using antibiotics without prescriptions. International, Open-J-Gate and Pharmacy Abstracts


INTRODUCTION
Bacteria have specific genetic characteristics, which enable the microorganisms to develop resistance to antibiotics. Irrational and overuse of antibiotics can increase the speed of this process [1]. Consequently, lack of awareness of rational antibiotic use and self-medication with these medications has been identified as a major factor for the development of antibiotic resistance [2]. Nevertheless, antibiotic use is highly prevalent, with statistics [3]  antibiotic use. Purchase of antibiotics without a prescription is estimated to account for 50 % worldwide [4]. This implies that users are selfmedicating and are likely to misuse these products.
Such irresponsible use of nonprescribed antibiotics is a major global public health problem [5]. Self-medication has been identified as a key cause for increased antimicrobial resistance [2] and this trend constitutes a global public health concern. This again is of particular interest in developing countries [3,6] as it contributes to the spread of antimicrobial resistance, cross-resistance and treatment failure on a global level [7]. Selfmedication of antibiotics has been reported to be high among university students, with the highest (77 and 80 %) prevalence reported among Pakistani students and Sudanese general public respectively [8][9]. On the other hand, lower (about 40%) prevalence rates were reported for students in Palestine, Iran and UAE [10][11][12]. Antibiotics are sold with and without a prescription in the UAE [13,14]. It has been argued that the prevalence rates of antibiotic use without prescriptions in UAE are considered high and are due to the lack of enforcement of laws and regulations, which would otherwise prohibit this practice [12]. Therefore, the aim of this study is to measure the present prevalence of using antibiotic without prescription and identify the risk factors associated with this behaviour among university students in UAE.

Study design
A cross sectional study was conducted among the students of major universities in UAE. A multistage sampling technique was used in the present study. In step 1, three out of five UAE universities that offer medical and non-medical programs were randomly selected. In step 2, three medical and non-medical colleges from each university were selected by stratifying on medical and non-medical colleges and then a simple random sampling technique was used to select three colleges including one medical and two non-medical colleges within each university. In step 3, random sample from each year of program were selected using simple random table.

Study population
Specified precision method was used to determine the sample size as described previously [15] where the desired level of confidence was set at 95% and the desired level of precision was set at 0.03 on either side, such that the estimated proportion of inappropriate use was within 3%.
In the present study, the questionnaire was distributed to 3346 students and identified 2875 eligible students, giving a response rate of 85.9%. A total of 471 students were excluded, as they have had no prior experience ever with the use of ONPD. Furthermore, 356 students were unwilling to participate in the study and only 2,519 students were identified as both ONPD user and non-user in the past 90 days before the study. Of 2,519 participants, 164 questionnaires were excluded due to incomplete status or the fact that most outcomes variables were not answered. Of 2,355 completed surveys, 1,007 respondents reported that that they have not used ONPD during the past 90 days before conducting the study. The remaining 1,348 ONPD users in the past 90 days were collected and analyzed throughout the study period.

Questionnaire development
A self-administered questionnaire was used in this study. The questionnaire was constructed and developed based on Andersen behavioral model that guided the present study [16]. The questionnaire comprised three types of questions that were divided into three categories: predisposing factors, enabling factors and need factors, accordingly, the survey ended up with more than 25 explanatory variables. Independent variables were grouped into predisposing factors (three demographic characteristics, one social structural characteristic and fifteen health belief characteristics), enabling factors (colleges, year of study, medication knowledge, source(s) of ONPD-information [17], income and employment) and need factors (self-care orientation and perceived-health).The survey was completed in a paper-and-pencil survey instead of an online form. The researcher provided a personal introduction and briefing of the study, informing the students of the nature of the study, the purpose of the study, and the expected time to complete the questionnaire. Appropriate drug use was assessed based on five assessment criterion namely self-diagnosis, self-selection of ONPD, dose, frequency of use and food-drug administration [15]. For the purpose of this study, participants were asked whether they used oral antibiotics without prescription in the past 90 days before conducting the study.

Data analysis
The data were analyzed using Statistical Package for the Social Sciences (SPSS, version 20, Chicago, IL, USA). Descriptive statistics was used to describe the study variables using frequencies and percentages. Binary Logistic Regression (BLR) was conducted to identify the risk factors of using antibiotics without prescription using enter method.

Ethics
The present study was conducted after the approval of the Institutional Ethics Committees (approval no. DFCM/08/01/14/739, University of Sharjah) in UAE and Gloucestershire University, UK, approval no. REC.4113).

RESULTS
A total of 2875 students were approached from different universities in UAE for the survey of utilization of non-prescription drugs. Only 2355 questionnaire were fully answered, returned and included in the present study. Among these, majority were females (1797; 76.3 %), single (2151; 91.3 %), and not employed during the study period (2190; 93%). Majority of the responders (2158; 91.6 %) were in the age group of 18-23 years as shown in Table 1. More than half of them (1348; 57.2 %) reported using ONPD in the past 90 days before conducting the study and were asked to complete the survey. Among the 1348 users of ONPD, more than one third (484, 35.9 %) of the ONPD users reported using antibiotics without a prescription during the 90 days prior to the present study. Healthcare students accounted for 492 (36.5 %) of participants with more than a third (181, 36.8 %) of them reporting using antibiotics without a prescription. On the other hand, of the total nonhealthcare (856, 63.5 %) respondents, 303 (35.4 %) were using the antibiotics without a prescription. Hence, the difference between healthcare and non-healthcare respondents was statistically not significant (p = 0.608).
A binomial logistic regression was performed to ascertain the effects of 41 potential predicators on the likelihood that participants will use antibiotics without prescriptions. The logistic regression model was not statistically significant, χ 2 (8) = 5.637, p = 0 .688. The model explained 25 % (Nagelkerke R 2 ) of the variance in using antibiotics without prescriptions and correctly classified 71.4 % of cases. Sensitivity was 52.2 %, specificity was 83.4 %, positive predictive value was 66.5 % and negative predictive value was 73.4 %. Of the 41 predictor variables only 9 were statistically significant: nationality, costinfluence behaviour, the belief in ONPDeffectiveness, year of study, medication knowledge, self-care orientation cutting costs, emergency use, as well as being healthcare students. Being a Healthcare participant was a significant variable for using antibiotics without a prescription. Healthcare participants had 1.4 times higher odds of using antibiotics without prescription compared to non-healthcare participants (OR = 1.465, 95 %, CI: 1.012 -2.120, p < 0.05). Therefore being a healthcare participant might be a risk factor for misusing antibiotics without prescription.
Urgency of the health situation and financial reasons were also significant predictors. Participants who frequently used ONPD in order to save money had 1.6 times higher odds of using antibiotics without a prescription compared to participants who did not (OR = 1.665, 95 % CI: 1.047 -2.649, p < 0.04). Furthermore, participants who use ONPD because of urgent heath situation had 1.6 times higher odds of using antibiotics without prescription compared to those who did (OR = 1.644, 95 %, CI: 1.144 -2.363, p < 0.007). Therefore, urgency of situation and financial reasons might be risk factors for misusing antibiotics without prescription. Participants with a high self-care orientation had significantly 1.8 times higher odds of using antibiotics without prescription compared to a low self-care orientation's participants and this result was statistically significant (OR = 1.878, 95 % CI: 1.304-2.706, p<0.001). Therefore, high level of self-care orientation might be a risk factor for using antibiotics without prescription. Logistic regression model for associations with antibiotic's use without prescription is summarized in Table 2.

DISCUSSION
In the present study, more than one third of users reported misusing antibiotics without a prescription during the 90 days prior to the study. It might be possible that such trend is due to easy access to antibiotics in UAE and the economic status of participants who find medical consultation rather expensive (saving money). Another possible reason is a false sense of confidence in self-diagnosis and self-treatment among participants who use antibiotics without prescription and this speculation is consistent with that of Pan et al [18] who concluded that a false sense of confidence in self-treatment and easy access to antibiotics without prescription had encouraged Chinese students to selfmedicate with antibiotics without medical consultation.
One of the associated factors of concern was nationality, which was connected with medical insurance. UAE nationals had lower odds of using antibiotics without prescription compared to expatriates. This data was retrieved from information provided by Zaghloul et al [19] arguing that non-UAE nationals have limited or no health insurance in comparison to UAE nationals who have access to premium health care. Our study indicated that non-UAE students had statistically significant increased odds of using antibiotics without prescription. . Again, participants who were influenced by the cost of drugs had a higher probability of using antibiotics without a prescription than those who were not influenced. This can be attributed to the belief that more expensive drugs are more effective because higher cost signals higher quality. Microbial infections were perceived by participants as a serious health condition and they may buy more expensive antibiotics with the misconception that these are more effective than their cheaper alternatives. We also observed that participants who believed that ONPDs had moderate to no effect were less likely to take antibiotics without a prescription. This belief is attributed to the availability of oral nonprescription drugs and ease of gaining access to antibiotics without prescription in the UAE [14]. As no other study has engaged with these variables it is not possible to compare our findings with those of other researches and it is recommended that future research should explore this gap. Participants with poor-tomoderate medication knowledge had a lower probability of using antibiotics without a prescription than participants with good medication knowledge of ONPD. This finding could be attributed to a false sense of confidence among university students with good medication knowledge, such that they misused antibiotics at a higher prevalence than students with poor-tomoderate medication knowledge. This finding supports previous research that showed that a false sense of confidence in self-treatment and easy access to antibiotics without a prescription had encouraged Chinese students to use antibiotics without a prescription [18].
Nevertheless, the Chinese study also reported that "prior" medication knowledge of the university students was a risk factor for using antibiotics without a prescription [18]. This inconsistency with the final findings between our study and the Chinese study might be attributed to the differences in the method of measuring, classifying and coding the medication knowledge variable. Furthermore, the number and the types of predictors which entered the multivariate statistical analysis in our study are larger and broader than that of Pan et al [18]. Therefore, there is a need for further studies to more fully investigate the relationship between knowledge and antibiotic misuse among students in the UAE.
The year of study of the students was associated with the risk of taking antibiotics without prescription. Students in the first year of study were more likely to take antibiotics without prescription as compared with students in the fourth, fifth and sixth year of study. Senior students might have higher awareness in using antibiotics without a prescription compared to junior students. These findings agree with a study that showed that self-medication with antibiotics was lower among fourth year than second year medical students in Bahrain [20].
There is a distinct difference between awareness and knowledge; awareness is being conscious of the risks attributed to misuse of antibiotics rather than acquiring information to pass examinations and do the job better. Therefore, we need high awareness and right information [21]. Money saving behavior seemed to act as a motivating factor for taking antibiotics without prescription. As stipulated by Zaghloul et al [19] participants who had to pay for consultations would renounce this practice and engage in self-medication, including taking antibiotics without prescription. This was also true for the population in our study.
Participants who did not use ONPD for an urgent heath situation had a higher probability of using antibiotics without prescription than those who did. This finding might be explained in the context of health-seeking behavior, which differs from person to person depending on the severity of the illness (low versus high) as shown by Biswas et al [22]. It might be possible that participants who perceived their illness as an urgent (e.g. getting a fever at night) would use an ONPD immediately. However, if they get a more severe illness, they would visit a physician to ask for a prescription. This might also suggest that participants with a high perception of the severity of an illness do not have misconceptions about the use of antibiotics without a prescription. Our observation is in line with earlier descriptive findings, which demonstrated that nonprescription drugs are used in emergency situation among university students [23]. As far as we are aware this is the first time that urgency of drug use is investigated as associated variable for misusing antibiotics without a prescription in the literature. Participants who had a high perception of self-care were more likely to take antibiotics without a prescription as compared to participants of low self-care perception. This is similar to the observation in Palestinian students with high self-care orientation who were found to be more confident in self-medication across a variety of drug categories including antibiotics [11].
In summary, only 9 out of 41 predictor variables were significantly associated with use of ONPDs including antibiotics.
These factors include; nationality, cost-influence behavior, the belief in ONPD-effectiveness, year of study, medication knowledge, self-care orientation, saving money, and the emergency of use as well as being healthcare students.

Limitations of the study
A major limitation of this study is the collection of retrospective data about use of medications that may be under-reported by the participants leading to the possibility of a reported lower prevalence rate in this study. Another limitation is that no attempt was made to investigate the influence of the insurance status of participants on the prevalence of self-medication with oral antibiotics.

CONCLUSION
The prevalence of misuse of antibiotics is high among university students in UAE. There is an urgent need for educational intervention to improve students' knowledge of, attitude to, and awareness of the risks of using antibiotics without prescription. In addition, the introduction of a national day on rational use of antibiotics would certainly increase public awareness of such an important health issue.