self medication of antibiotics

Research Report on Self-Medication of Antibiotics in M.P. State, India

CHRIST UNIVERSITY INSTITUTE OF MANAGEMENT

BANGALORE

A STUDY ON PREVALENCE OF THE Practise OF

Self-medication of ANTIBIOTICS IN

M.P. State, INDIA

SUBMITTED TO:

PROF. VENKATESHA BHAGAVATH

CUIM, BANGALORE

SUBMITTED BY:

KINSHOO SHAH

1st yr, MBA (IB), CUIM

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CERTIFICATE OF THE GUIDE

This is to certify that the Project Work titled “A STUDY ON PREVALENCE OF THE

PRACTISE OF SELF-MEDICATION OF ANTIBIOTICS IN M.P. STATE, INDIA” is a

bonafide work of the researcher KINSHOO SHAH carried out in partial fulfillment for the award

of degree of MBA in International Business from Christ University Institute of

Management under my guidance. This project work is original and not submitted earlier for the

award of any degree diploma or associate ship of any other University / Institution.

Name of Guide in charge, Signature of the Guide in charge,

Prof. Venkatesh Bhagavath

Place: Bangalore

Date: 27th April 2010

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ACKNOWLEDGEMENT

We owe thanks to a great many people who helped and supported us during the course of this

project work.

We express our deepest gratitude to our lecturer, Prof. Venkatesh Bhagavath the Guide of the

project for guiding and correcting various documents of ours with attention and care. He has

taken pain to go through the project and make necessary correction as and when needed. He has

been a constant source of encouragement, guidance and support from the initial to the final level

enabled us to develop an understanding of the subject.

We are over helmed in all humbleness and gratefulness to acknowledge our depth to all those

who have helped us to put these ideas, well above the level of simplicity and into something

concrete.

We would also thank our institution and my faculty members without whom this project would

be a distant reality.

Our deep sense of gratitude to the people, pharmacists/chemists/druggists and doctors for the

support and guidance.

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ABSTRACT

The project was undertaken as a part of our MBA in IB course curriculum at Christ University

Institute of Management.

The recent trends reveal a surprising fact that the tendency of self-medication if growing in people with the advent of internet and more detailed health books, ignoring the bitter truth that self-medication can be dangerous.

It is very unfortunate to see people blindly consuming Antibiotic without even realising what harm they can do to their body. There are people who are addicted to antibiotics, for every silly disease they advice to take antibiotics without consulting doctor.

From sore throat to body pain, people use antibiotics. Fever, cold, cough, constipation or indigestion is among the usual cases of self-medication. The mostly misused drugs are analgesics or pain relievers. For some it works, but for others it’s not always good news.

It is also seen that usually for some common ailments like fever & indigestion; people often don’t prefer to consult a physician. Instead they either utilize their own knowledge through reading of health books, articles or internet; or refer a pharmacist/chemist/druggist and ask them to give some medicines, who often think of themselves as half doctor.

However, the important questions are”

“Is the practise of self-medication still prevalent in India?”

“Is this practice fair on the pharmacists’/chemists’/druggists’ part to dispense Antibiotics without doctor’s prescription?”

“How far is it justified to take risk with the health of the patients?”

Through this research project we analyzed the various facets involved to study the results of dispensing Antibiotics over the counter in India and how far is this practice justified concerning patients life. For this we conducted the study based on a few pharmacist/chemist shops, doctors and some people in the vicinity.

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STATEMENT OF AUTHENTICITY

We hereby declare that the project work entitled “A STUDY ON PREVALENCE OF THE

PRACTISE OF SELF-MEDICATION OF ANTIBIOTICS IN M.P. STATE, INDIA”

submitted to the Christ University Institute Of Management, is a record of an original work

done by us under the guidance of Prof. Venkatesh Bhagavath, Faculty Member and this project

work has not performed the basis for the award of any Degree or diploma/ associate

ship/fellowship and similar project if any.

Research Person:

KINSHOO SHAH, 1st yr, MBA (IB), CUIM

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CONTENTS

CHAPTER 1: INTRODUCTION.............................................................................................10

Health Definitions......................................................................................................................10

Over The Counter Drugs....................................................................................................................11

Chemist & Pharmacist- Roles & Responsibilities……………………………………...….......11

About Antibiotics- Side Effects& Allergy................................................................................................13

Self-Medication...................................................................................................................................16

Factors That Influence The Tendency of Self-Medication.............................................................16

Problem Statement..............................................................................................................................17

Research Objectives............................................................................................................................17

CHAPTER 2: LITERATURE REVIEW..................................................................................19

Studies Exploring Antibiotic Misuse..........................................................................................19

Antibiotics Use Linked to Ashtma..............................................................................................19

Socioeconomis & Behavioral Factors.......................................................................................20

Antibiotics as Cause of Resistance...........................................................................................20

Self-Medication with Antibiotics.................................................................................................21

Self-Medication in India.................................................................................................................23

Social Factors Leading to Self-Medication in India..............................................................25

Statistics............................................................................................................................................27

CHAPTER 3: STUDY DESIGN & METHODOLOGY........................................28

Data Collection Method.................................................................................................................28

Data Sources....................................................................................................................................28

Research Instruments...................................................................................................................28

Sampling Design.............................................................................................................................28

Period Covered By The Study.....................................................................................................29

Sampling Unit...................................................................................................................................29

Sample Size.......................................................................................................................................29

Survey Method.................................................................................................................................29

Experiment Method........................................................................................................................30

Action Plan Followed......................................................................................................................31

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CHAPTER 4: PRESENTATION & ANALYSIS OF DATA..................................32

Software Used..................................................................................................................................32

Main Hypothesis:.............................................................................................................................33

Data Characteristics.......................................................................................................................33

Percentage of Antibiotic USers...................................................................................................34

Hypothesis 1.....................................................................................................................................34

Frequency of Usage of Antibiotics............................................................................................35

Hypothesis 2.....................................................................................................................................35

Patient Awareness - Further Analysis......................................................................................36

Hypothesis 3.....................................................................................................................................36

Hypothesis4......................................................................................................................................40

Education as a Factor of Self-Medication...............................................................................42

Hypothesis 5.....................................................................................................................................42

Ailments Commonly Subjected to Self-Medication.............................................................43

Pharmacist/Chemists Responsiveness....................................................................................45

Hypothesis 6.....................................................................................................................................45

Hypothesis 7.....................................................................................................................................48

Doctor’s Point of View...................................................................................................................51

Hypothesis 8.....................................................................................................................................51

CHAPTER: 5 DISCUSSION & INTERPRETATION OF FINDINGS.....................53

Main Hypothesis:.............................................................................................................................53

Hypothesis 1.....................................................................................................................................53

Hypothesis 2.....................................................................................................................................53

Hypothesis 3.....................................................................................................................................54

Hypothesis 4.....................................................................................................................................55

Hypothesis 5.....................................................................................................................................56

Hypothesis 6.....................................................................................................................................56

Hypothesis 7.....................................................................................................................................57

Hypothesis 8.....................................................................................................................................57

CHAPTER: 6 CONCLUSION, IMPLICATION & RECOMMENDATION................59

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Benefits Of This Research............................................................................................................59

Limitations:........................................................................................................................................60

Recommendation:...........................................................................................................................60

Conclusion:........................................................................................................................................61

REFERENCES........................................................................................62

Websites & Sources.......................................................................................................................62

Bibliography......................................................................................................................................62

LIST OF TABLES AND FIGURES

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S. No List of Tables Page No. S. No List of Tables Page No.

1.1 Table 1 23 1.11 Table 11 45

1.2 Table 2 24 1.12 Table 12 45

1.3 Table 3 37 1.13 Table 13 46

1.4 Table 4 37 1.14 Table 14 47

1.5 Table 5 38 1.15 Table 15 48

1.6 Table 6 38 1.16 Table 16 49

1.7 Table 7 39 1.17 Table 17 50

1.8 Table 8 40 1.18 Table 18 51

1.9 Table 9 42 1.19 Table 19 52

1.10 Table 10 43

S. No List of Figures Page No.S. No List of Pie Charts Page

No.

2.1 Figure 1 32 5.1 Pie-Chart: 1 34

2.2 Figure 2 33 5.2 Pie-Chart: 2 34

3.1 Flowchart 1 31 5.3 Pie-Chart: 3 35

4.1 Bar-Chart: 1 37 5.4 Pie-Chart: 4 35





5.9 Pie-Chart: 9 50

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CHAPTER 1: INTRODUCTION

“Mens sana in corpore sano”

~ Juvenal

(Your prayer must be for a sound mind in a sound body.)

HEALTH is the general condition of a person in all aspects. It is also a level of functional and/or metabolic efficiency of an organism, often implicitly human.

At the time of the creation of the World Health Organization (WHO), in 1948, health was defined as being "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity". [Ref 1]

Achieving and maintaining health is an ongoing process. Effective strategies for staying healthy and improving one's health include the following elements:

Observation of daily living. Social Activity. Hygiene. Stress Management. Health Care.

Overall health is achieved through a combination of physical, mental, emotional, and social well-being, which, together is commonly referred to as the Health Triangle.

The LaLonde report suggests that there are four general determinants of health including

human biology, environment, lifestyle and Healthcare services.

Thus, health is maintained and improved not only through the advancement and application of health science, but also through the efforts and intelligent lifestyle choices of the individual and society.

A major environmental factor is water quality, especially for the health of infants and children in developing countries.

A common saying about health:

“Health is not valued till sickness comes”.

~ Dr. Thomas Fuller

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http://en.wikipedia.org/wiki/Developing_country

http://en.wikipedia.org/wiki/Health_science

http://en.wikipedia.org/wiki/Healthcare

http://en.wikipedia.org/wiki/Lifestyle_(sociology)

http://en.wikipedia.org/wiki/Environment_(biophysical)

http://en.wikipedia.org/wiki/Human


OVER-THE-COUNTER (OTC) DRUGS are medicines that may be sold directly to a consumer without a prescription from a health care professional, as compared to prescription drugs, which may only be sold to consumers possessing a valid prescription. [Ref 2]

In many countries, OTC drugs are selected by a regulatory agency to ensure that they are ingredients that are safe and effective when used without a physician's care.

OTC drugs enable people to relieve many annoying symptoms and to cure some diseases simply and without the cost of seeing a doctor. However, safe use of these drugs requires knowledge, common sense, and responsibility.

In addition to the substances such as aspirin and acetaminophen that people typically think of as OTC drugs, many other commonly available products are considered OTC drugs by the federal Food and Drug Administration (FDA). Some toothpastes, some mouthwashes, some types of eye drops, wart removers, first aid creams and ointments that contain antibiotics, and even dandruff shampoos are considered OTC drugs.

Some OTC drugs were originally available only by prescription. After many years of use under prescription regulation, drugs with excellent safety records may be approved by the FDA for over-the-counter sale. The analgesic ibuprofen and the indigestion remedy famotidine are examples of such drugs. Often, the OTC version has a substantially lower amount of active ingredient in each tablet, capsule, or caplet than does the prescription drug. When establishing appropriate doses of OTC drugs, manufacturers and the FDA try to balance safety and effectiveness.

Safety ConsiderationsSafety is a major concern when the FDA considers reclassifying a prescription drug as OTC. Most OTC drugs—unlike health foods, dietary supplements (including medicinal herbs) and complementary therapies —have been studied scientifically and extensively. However, all drugs have benefits and risks, and some degree of risk has to be tolerated if people are to receive a drug's benefits.

Safety depends on using a drug properly. For OTC drugs, proper use often relies on consumer self-diagnosis, which leaves room for error. For example, most headaches are not dangerous, but in rare cases, a headache is an early warning of a brain tumor or hemorrhage.

People who purchase OTC drugs should read and follow the instructions carefully. Because different formulations—such as immediate-release and controlled-release (slow-release) formulations—may have the same brand name, the label should be checked each time a product is purchased, and the dosage should be noted.

Often, the labels of OTC drugs do not list the full range of possible side effects. As a result, many people assume that these drugs have few, if any, side effects. For example, the package insert for one analgesic cautions people not to take the drug for more than 10 days for pain. However, the possible serious side effects that can occur with long-term use (such as life-threatening bleeding from the digestive tract) are not mentioned—not on the box, bottle, or

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package insert. Consequently, people with chronic pain or inflammation may take the drug for a long time without realizing that such use could lead to serious problems.

Considerations in Reclassifying a Drug as Over-The-Counter: [Ref 3]

Safety

Has the drug been used for a long enough time so that any harmful effects are fully understood?

What harmful effects (including those form misuse) may the drug produce? Is the drug habit forming? Do the benefits of OTC status outweigh the risks?

Ease of Diagnosis & Treatment

Can the average person self-diagnose the condition that calls for the drugs? Can the average person treat the condition without help of a doctor or other health care

practitioner?

Labelling

Can adequate directions for use be written? Can warnings against unsafe use be written? Can the average person understand the information on the label?

CHEMISTS & PHARMACISTS

Pharmacists are health professionals who practice the science of pharmacy. In their traditional role, pharmacists typically take a request for medicines from a prescribing health care provider in the form of a medical prescription, evaluate the appropriateness of the prescription, dispense the medication to the patient and counsel them on the proper use and adverse effects of that medication. [Ref 4]

At present there are around 14 lakhs chemists/pharmacists in India and in the coming years the industry is expected to generate an annual turnover of more than $11 billion in India. The major players in Indian pharmacy retail sector are Reliance (R-ADAG), Hong Kong-based Zuellig Pharma, US-based Cardinal Health, Apollo Health, Fortis Healthworld, Subiksha, Manipal Cure & Care and Medicine shoppe.

Roles & Responsibilities:

Pharmacists/druggists/chemists act as a learned intermediary between physicians and patients and thus ensure the safe and effective use of medications.

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http://en.wikipedia.org/wiki/Health_profession


Pharmacists/druggists/chemists also participate in disease-state management, where they optimize and monitor drug therapy or interpret medical laboratory results – in collaboration with physicians and/or other health professionals.

One of the most important roles that pharmacists are currently taking on is one of pharmaceutical care. Pharmaceutical care involves taking direct responsibility for patients and their disease states, medications, and the management of each in order to improve the outcome for each individual patient. Pharmaceutical care has many benefits that include but are not limited to:

Decreased medication errors Increased patient compliance in medication regimen Better chronic disease state management Strong pharmacist-patient relationship Decreased long-term costs of medical care

About ANTIBIOTICS

An Antibiotic is substance or compound that kills or inhibits the growth of bacteria. Antibiotics belong to the broader group of antimicrobial compounds, used to treat infections caused by microorganisms, including fungi and protozoa. [Ref 5]

Oral antibiotics are simply ingested, while intravenous antibiotics are used in more serious cases, such as deep-seated systemic infections. Antibiotics may also sometimes be administered topically, as with eye drops or ointments.

Few antibiotics: Penicillin, Cephalosporins, Macrolides, Quinolones, Carbapenems, and Other Antibiotics (Aminoglycosides, Tetracyclines, Sulfonamides, Mupirocin, Glycopeptides, Synercid, and Oxazolidinones.

Few manufactures of Antibiotics: Abbott Laboratories, Advancis Pharmaceutical Corp., Bayer HealthCare AG, Bristol-Myers Squibb Co., Cubist Pharmaceuticals, Inc., Daiichi Sankyo Company, Limited, Eli Lilly and Co., GlaxoSmithKline Plc, Johnson & Johnson, Kyorin Pharmaceutical Co., Ltd., LG Life Sciences Limited, Novartis AG, Pfizer Inc., Pliva d.d., Ranbaxy Laboratories Ltd, Roche, Sanofi-Aventis SA, Takeda Pharmaceutical Company, Ltd., Toyama Chemical Co., Ltd., and Wyeth Pharmaceuticals, Inc.

Side effects

Although antibiotics are generally considered safe and well tolerated, they have been associated with a wide range of adverse effects. Side effects are many, varied and can be very serious

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depending on the antibiotics used and the microbial organisms targeted. The safety profiles of newer medications may not be as well established as those that have been in use for many years.

“The first rule of antibiotics is try not to use them, and the second rule is try not to use too many of them”.

~ Paul L. Marino, The ICU Book

Adverse effects may include:

Fever Nausea Photo dermatitis Anaphylaxis Diarrhoea &/or Dehydration Abdominal Pain Prolonged or incorrect use of antibiotics can cause an individual to become weak and

more susceptible to outside infections. Colitis, the inflammation of the colon is a rare effect. More serious side effects include the formation of kidney stones with the sulphonamides,

abnormal blood clotting with some of the cephalosporin, increased sensitivity to the sun with the tetracycline, blood disorders with trimethoprim, and deafness with erythromycin and the amino glycoside.

In case of overdose, there is a chance of increasing the risk of cancer. Other side effects can result from interaction with other drugs (called drug-drug

interaction), such as elevated risk of tendon damage from administration of a quinolone antibiotic with a systemic corticosteroid.

Inappropriate antibiotic treatment and overuse of antibiotics have been a contributing factor to the emergence of resistant bacteria.

It is widely believed that human malpractices such as inadequate dosing, incomplete courses and indiscriminate drug use have contributed to the emergence and spread of antimicrobial resistance.

“Did God who gave us flowers and trees,Also provide the allergies?”

~ E.Y. Harburg

Allergy is a disorder of the immune system often also referred to as atopy. Allergic reactions occur to normally harmless environmental substances known as allergens. [Ref 6]

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An allergic reaction occurs when the immune system begins to recognize a drug as something "foreign". Antibiotics, especially the penicillin and sulphonamides, account for a large proportion of allergic drug reactions. Allergic reactions commonly have the following symptoms:

Shortness of breath

Hives

Itching

Swelling of your lips, face, or tongue

Fainting

Several different symptoms can indicate that a person is allergic to penicillin. These include: [Ref 7]

Hives (raised, intensely itchy spots that come and go over hours) Angioedema (swelling of the tissue under the skin, commonly around the face), Wheezing and coughing from asthma-like reactions (narrowing of the airways into the

lungs).

Serious allergies to penicillin are common, with about 10 percent of people reporting an allergy. This is also one of the reasons why self-medication should be avoided.

“The appearance of a disease is swift as an arrow; its disappearance slow, like a thread”.

~ Chinese Proverb

This impatience is the main reason why patients often don’t complete their course of Antibiotics. They are unaware of the fact that by not completing their course of Antibiotics, they are imposing a danger to their health & the illness can occur again. It is essential to completely render the causative organism inactive so that it does not reproduce or show effects again by following the course of Antibiotics along with proper instructions & precautions.

SELF- MEDICATION

“Every patient carries her or his own doctor inside”. ~ Albert Schweitzer

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Self-medication can be defined as the use of drugs to treat self-diagnosed disorders or symptoms, or the intermittent or continued use of a prescribed drug for chronic or recurrent disease or symptoms. It is usually selected by consumers for symptoms that they regard as troublesome to require drug therapy but not to justify the consultation of a prescriber. In developing countries, most illnesses are treated by self-medication.

It has been noticed that people often practice self-medication and consume medicines on the basis of their knowledge, which they think is sufficient, or by just referring a chemist/druggist. They either consult a chemist and obtain a medicine from his shelf, or may consult a neighbour who may be having some tablets left over from his previous illness, and readily spares them. They don’t prefer to consult a physician, due to many reasons. This practice may be harmful to the patient.

Fever, cold, cough, constipation or indigestion is among the usual cases of self-medication. The mostly misused drugs are analgesics or pain relievers.

A major shortfall of self-medication is the lack of clinical evaluation of the condition by a trained medical professional, which could result in missed diagnosis and delays in appropriate treatments.

A major problem with self-medication with antimicrobials is the emergence of human pathogens resistance. Self-medication with antibiotics may increase the risk of inappropriate use and the selection of resistant bacteria. One of the triggers for using self-medication may be past experience with antibiotics prescribed by health professionals.

Safety issues include concerns relating to age of the user, pregnancy, underlying disease and the potential for drug interactions.

Factors That Influence the Tendency of Self-Medication

Patient education, socio-economic status, gender and age appear the major factors associated with self-prescription of the medicines.

The availability of antimicrobial agents for self-medication may increase and could include antibacterial agents for oral or topical use.

Changed regulation from Prescription-Only Medicine (POM) to Pharmacy (P) medicine of selected agents with indications for short-term use in specific minor infections and illness is likely to have advantages to the user. However, safeguards to their use would need to be included in the Patient Information Leaflet (PIL).

“If your body's not right, the rest of your day will go all wrong. Take care of yourself.”

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~ Terri Guillemets

PROBLEM STATEMENT

Recent trends reveal an exponential increase in the practise of self-medication being followed in India still, especially in the case of Antibiotics.

This practice is followed by the chemists/druggists/pharmacists to earn more profits and reduce wastage of time & labour.

The patients take Antibiotics without referring to any physician so as to save money & time. Also in some cases they feel that the doctors waste their money by prescribing too many medicines, some of which they consider are unnecessary. Some other socioeconomic & environmental factors are also seems to be influencing the practise of self-medication in India.

However, the important questions are”

“Is this practice of self-medication still prevalent in India?”

“Is this practice fair on the chemists’/druggists’/pharmacists’ part?”

“How far is it justified to take risk with the health of the patients?”

This project intends to do a comparative research to address this by analyzing the various facets involved.

RESEARCH OBJECTIVES

The Objective of this research is to study the prevalence of practise of self-medication of Antibiotics in M.P. State, India.

The Scope of this research includes:

Analyzing the current scenario.

Testing the knowledge & perceptions of patients regarding Antibiotics.

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Knowing the Doctor’s point of view in this case.

Understanding the chemists’/druggists’/pharmacists’ behaviour.

Analysis of the measures needed to be taken.

The Limitations of this research includes:

Responses may be subjected to bias.

Cannot get full access to customer thoughts.

Lack of respondent willingness to follow instructions.

Busy schedules of the doctors due to which many responses may not be attained.

Respondents may hide actual habits & practices.

Ignorance of patients.

CHAPTER 2: LITERATURE REVIEW

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“If a runny nose and congested chest have you thinking of antibiotics, think again.”

~ ScienceDaily (Jan. 18, 2005)

STUDIES EXPLORING ANTIBIOTIC MISUSE

“For uncomplicated colds, zero are necessary; bronchitis, less than 10 percent are necessary; sore throats, maybe up to 10 to 15 percent of these patients need an antibiotic,” - Dr. Jim Wilde, paediatric emergency medicine and infectious disease physician at the Medical College of Georgia. [Ref 7]

“Ninety to 95 percent of all infections are viral or low-acuity bacterial infections such as ear infections or sinus infections,” - Dr. Wilde. Yet studies show that more than half of patients in the United States are taking bacteria-destroying antibiotics for colds, flu and bronchitis, all caused by viruses - Dr. Wilde.

Scientists & doctors believe that without big change, antibiotics - needed to treat life-threatening conditions such as meningitis and pneumonia - may be useless within 50 years.

Third-world countries, where severe physician shortages preclude prescriptions for antibiotics, already are living the nightmare of common infections that no longer have a treatment.

Antibiotics Use Linked To Asthma

A study was conducted by Dr. Kozyrskyj and colleagues from the University of Manitoba and McGill, University in Montreal on “Antibiotics Use in Infants Linked To Asthma” to study the linkages of asthma occurrence to antibiotic usage in infants. [Ref 8]

The reason for antibiotic use was categorized by lower respiratory tract infection (bronchitis, pneumonia), upper respiratory tract infection (otitis media, sinusitis), and nonrespiratory tract infection (urinary infections, impetigo). Risk and protective factors also were noted, including gender, urban or rural location, neighbourhood income, number of siblings at age 7, maternal history of asthma, and pets reported living in the home.

Results showed that antibiotic use in the first year was significantly associated with greater odds of asthma at age 7. This likelihood increased with the number of antibiotic courses, with children receiving more than four courses of antibiotics having 1.5 times the risk of asthma compared with children not receiving antibiotics.

When researchers compared the reason for antibiotic use, their analysis indicated that asthma at age 7 was almost twice as likely in children receiving an antibiotic for nonrespiratory tract infections compared with children who did not receive antibiotics.

Maternal asthma and presence of a dog during the first year of life were both associated with asthma risk.

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Children who received multiple antibiotic courses and who were born to women without a history of asthma were twice as likely to develop asthma as those not receiving antibiotics.

Furthermore, absence of a dog during the birth-year doubled asthma risk among children taking multiple courses of antibiotics.

Socioeconomic and Behavioral Factors

A study conducted by Iruka N. Okeke, Adebayo Lamikanra, and Robert Edelman; Obafemi Awolowo University, Ile-Ife, Nigeria; and .University of Maryland School of Medicine, Baltimore, Maryland, USA on “Socioeconomic and Behavioral Factors Leading to Acquired Bacterial Resistance to Antibiotics in Developing Countries”. [Ref 9]

In developing countries, acquired bacterial resistance to antimicrobial agents is common in isolates from healthy persons and from persons with community-acquired infections. Complex socioeconomic and behavioral factors associated with antibiotic resistance, particularly regarding diarrheal and respiratory pathogens, in developing tropical countries, include:

Misuse of antibiotics by health professionals, unskilled practitioners, and laypersons; Poor drug quality & lack of quality compliance and monitoring;

Degraded antibiotics Expired antibiotics Counterfeit antibiotics Adulterated antibiotics

Unhygienic conditions accounting for spread of resistant bacteria; Inadequate Hospital Infection Control Practices; and Inadequate surveillance.

Misuse of Antibiotic as Cause of Resistance

The perception that antibiotic resistance is primarily the undesirable consequence of antibiotic abuse or misuse is a view that is simplistic and inaccurate, according to a recent report by the American Academy of Microbiology on “Misuse Of Antibiotic Not the Only Cause of Resistance”. [Ref 10]

The reasons behind the spread of resistance are much more complex, including appropriate antibiotic use, lack of proper sanitation and hygiene, and even the environment.

Antibiotic resistance is an international pandemic that compromises the treatment of all infectious diseases. At the present time, resistance essentially is uncontrollable. The reasons behind the establishment and spread of resistance are complex, mostly multi-factorial, and mostly unknown.

Resistance is often portrayed as simply an undesirable consequence of antibiotic abuse or misuse, but the rate of antibiotic resistance emergence is related to all uses of drugs, not just

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misuse, and the total amount of antibiotics used and the environment also play roles. The main driving factor behind resistance may actually be a lack of adequate hygiene and sanitation, which enables rapid proliferation and spread of pathogens.

SELF-MEDICATION WITH ANTIBIOTICS

Self-medication with antibiotics may increase the risk of inappropriate use and the selection of resistant bacteria. One of the triggers for using self-medication may be past experience with antibiotics prescribed by health professionals. We examined the association between prescribed use and self-medication with antibiotics

Is Self-Medication With Antibiotics In Europe Driven By Prescribed Use?

A study shows that source of self-medication is leftover antibiotics bought on prescription for specific disease/symptom. The result of the study: [Ref 11]

The association between prescribed use and self-medication was modified by source of self-medication, region in Europe and education.

This association was consistently stronger for self-medication from leftovers than from other sources, primarily directly from a pharmacy.

It was stronger also for respondents from Northern/Western Europe than respondents from Eastern Europe and Southern Europe and those with low education.

Prescribed use for URTIs (minor ailments such as throat symptom, influenza, etc.) increased the likelihood of self-medication with leftover antibiotics for these symptoms/diseases in all European regions.

Prevalence of Self-Medication in STD Patients

A research was conducted by Centers for Disease Control and Prevention, National Center for Prevention Services, Atlanta, Georgia to ascertain the prevalence of self-medication with antimicrobial agents among patients attending a clinic for treatment of sexually transmitted diseases (STDs). [Ref 12]

For this the researchers collected a urine specimen for antimicrobial testing from 551 patients before treatment. They defined self-medication as an antimicrobial agent taken on the patient's own initiative by self-report during the week before the visit to the clinic or a positive urine assay for antimicrobial agents at the time of the clinic visit.

Results of the study are:

A total of 75 (14%) of the 551 participants were self-medicators, 19 reported antimicrobial use and had a positive urine test, 27 reported antimicrobial use but had a negative urine test, and 29 denied antimicrobial use but had a positive urine test.

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Thus, 29 (60%) of the 48 patients with antimicrobial agents detected in their urine at the time of the clinic visit denied self-medication.

Self-medicators acquired their antibiotics either from their medicine cabinet (44%) or from a family member or friend (56%).

Self-medication was associated with self-report of prior use of unprescribed antimicrobial agents (P < .0001).

They concluded that use of unprescribed antimicrobial agents (usually beta-lactam agents or tetracyclines) among STD clinic attendees in the study was common and that self-reporting was not a reliable method of screening for self-medicators.

International Journal of STD & AIDS:

One of the health education messages given in sexually transmitted disease (STD) control is patients' adopting appropriate health seeking behaviour. This includes reporting to health facilities for appropriate diagnosis and treatment. In parts of the world where STD etiologic agents have assumed resistance to commonly used antimicrobials, this is important. [Ref 13]

Results of the study:

The antimicrobial self medication practices of 764 patients attending an STD clinic in a developing country were studied.

Seventy-four and a half per cent admitted to self medication before reporting to the clinic. The antibiotics taken in inappropriate dosages were purchased over the counter, given by

friends or were 'left-overs' from previous medications.

In the fight to control STD spread as a means of reducing the incidence of HIV/AIDS, indiscriminate use of antimicrobials needs to be guarded against.

SELF-MEDICATION IN INDIA

A survey to study self-medication practise in India was conducted by Department of Prev. & Social Medicine, Govt. Medical College, Nagpur, India, according to Indian Journal of Medical Sciences. [Ref 14]

Some of the findings are:

Out of 323 persons visiting the 3 medical shops, 104 (31%) per sons purchased the drugs without prescription.

Amongst the persons buying the drugs without prescription, 32(30.8%) were aged 41-50 years while 28(26.9%) were aged 31-40 years.

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Literacy status of persons practising self medication was mainly illiterate (23.1%) and graduate or above (26%). 27 persons (26%) buying drugs without prescription were of labour class while 20 (19.3%) were businessmen.

Cough and cold was the most common complaints for self medication (22.2%) followed by fever (17.4%), boils (7.6%), acidity (6.8%), joint pain (6.8%) etc.

Analgesics and antipyretics were most commonly sold drugs on self prescription (30.9%) followed by tonics or vitamin preparation (16.1%), antibiotics (10.7%), antacids (6.8%) and cough syrup (5.4%). [Table 1]

Total 149 categories of drugs were used for medication of 144 complaints in 104 persons. Out of 104 self medicating per sons 32(30.8%) got the information about drugs from

friends or neighbours, 24(23.1%) from chemist while 19(18.3%) bought the drugs because it was once prescribed by doctor. [Table 2]

Out of 104 persons only 2 knew the action and side effects of the drug while 72 persons were also using some other drugs themselves. Out of these 104, 90 persons felt that self medication is wrong but still were practising it.

Table 1: Distribution of Drugs Sold On Self-Prescription

S. No. Complaints Number Percentage

1. Analgesics 46 30.9

2. Tonics/Vitamins/Antipyretics 24 16.1

3. Antibiotics 16 10.7

4. Antacids 10 6.8

5. Cough Syrup 8 5.4

6. Eye Drops 6 4.0

7. Anti-diarrhoeal 6 4.0

8. Anti-allergic 5 3.4

9. Anti-spasmodic 4 2.7

10. Anti-amoebic 4 2.7

11. Nasal Decongestant 4 2.7

12. Anti-hypertensive 4 2.7

13. Anti-malarial 3 2.0

14. Anti-fungal 3 2.0

23

http://www.indianjmedsci.org/article.asp?issn=0019-5359;year=1997;volume=51;issue=3;spage=93;epage=96;aulast=Deshpande


15. Anti-helmenthic 2 1.3

16. Purgatives 2 1.3

17. Sedatives 2 1.3

Table 2: Source of Information about the Drug

S. No. Source Number Percentage

1. Once Prescribed 19 18.3

2. Mass Media 12 11.5

3. Friends/Neighbours 32 30.8

4. Family members 17 16.3

5. Chemist 24 23.1

Social Factors Leading To Self-Medication in India

A research was conducted by researchers from Clinical Epidemiology Unit, Medical College, Trivandrum, Kerala, India; Centre for Clinical Epidemiology and Biostatistics, The University of Newcastle, Callagham, Australia and Department of Anthropology, University of Arizona, USA to study the “Social factors influencing the acquisition of antibiotics without prescription in Kerala State, South India”. [Ref 15]

The research included survey by random sampling of 400 households in one primary health centre area near Trivandrum.

Results of the research are:

69.3% (95% CI=64.8–73.8) of households had at least one person using a pharmaceutical product during the two-week recall period; antibiotics formed almost 11% of the medicines consumed.

24


Pharmacy based interview and observation data were collected from 405 antibiotic purchasers sampled from 11 out of the 12 private pharmacies in the area. Seventy-three of these 405 customers purchased antibiotics without a prescription (18%; 95%).

By combining the household survey and pharmacy observations, it was estimated that almost half of 1% (0.41%; 95%) of the population, or four people per 1000, is engaged in self-medication using antibiotics in Kerala in any two-week period.

The data show that people least likely to follow this practice are

from higher income families, Having more education and higher status occupations and Receiving the benefits of medical insurance.

Conversely, logistic regression analysis indicated that risk of buying antibiotics without a script was associated with education at secondary level or below, the perception that it is expensive to consult a doctor and low satisfaction with medical practitioners. Keralites' self-medication patterns are interpreted broadly using social, cultural, historical and economic perspectives.

Drug Prescription and Self-Medication in India

A study was conducted by a researcher from UK regarding study of self-medication in India. [Ref 16]

This report included a study of the prescribing and dispensing of drugs in India. The drugs supplied to 2400 patients by the public and private medical sectors and by private pharmacies (over the counter dispensing) were recorded, and were analyzed with respect to the patient's presenting complaint and diagnosis.

The main findings are:

Large numbers of drugs are prescribed by doctors in the private sector. Combination preparations containing ‘hidden’ classes of drug are often given. Anti-infective are widely and often inappropriately used.

Potentially dangerous drugs are sold over the counter and prescribed for trivial or bizarre indications. Drugs which have been withdrawn as dangerous in the West remain popular first line drugs in India.

Food supplements and tonics of dubious nutritional and pharmacological value make up a high proportion of the total drugs bill.

It is concluded that a rational drugs policy and/or an essential drugs list will be useless unless accompanied by intensive efforts to improve the education and updating of doctors and pharmacists and to reduce the commercial pressures on doctors to prescribe unnecessary drugs.

Pharmacies, Self-Medication and Pharmaceutical Marketing in Bombay, India

25


A research conducted by researchers from Department of Anthropology, Emory University, , Atlanta, USA and Department of Anthropology, University of Arizona, AZ, USA to study the practice of self-medication being encouraged by pharmacies in India. [Ref 17]

Studies of pharmaceutical practice have called attention to the role played by pharmacists and pharmacy attendants in fostering self-medication and medicine experimentation among the public. Left undocumented is the extent to which clients passively follow the advice of pharmacy personnel or question their motive or expertise.

While research has focused on pharmacists and pharmacy attendants as agents encouraging self-medication and medicine experimentation, adequate attention has not been paid to pharmacist–client interactions that are sensitive to the social, cultural, and economic context in which medicine sales and advice occur. This paper highlights the context in which pharmacy attendants engage in “prescribing medicines” to the public in Bombay, India.

An ethnographic description of pharmacies and pharmaceutical-related behaviour in Bombay is provided to demonstrate how reciprocal relationships between pharmacy owners, medicine wholesalers and pharmaceutical sales representatives (MRs) influence the actions of pharmacy staff. Attention is focused on the role of the medicine marketing and distribution system in fostering prescription practice, pharmacy “counter-pushing” and self-medication.

In documenting the profit motives of different players located on the drug sales continuum, it is argued that the economic rationale and the symbiotic relations that exist between doctors, MRs, medicine wholesalers and retailers, need to be more closely scrutinized by those advocating “rational drug use”.

STATISTICS

• Currently, the pharmaceutical industry in India is a $ 10 billion industry, growing at a rate of around 10% annually.

• Indian pharmaceutical industry ranks 4th in terms of volume and 13th in terms of value.• Around 8% of the world’s drugs are manufactured in India.• India has 300 pharmaceutical companies of large and moderate size and another 10,000

small and tiny firms.• But 70% of the production is by the top 100 larger companies.• The industry is highly fragmented, with the largest formulation players having a market

share of less than 6%. • The industry manufactures about 400 bulk drugs and almost the entire range of

formulations.

26


CHAPTER 3: STUDY DESIGN & METHODOLOGY

DATA COLLECTION METHOD

Primary DataFor my research purpose, I have used the questionnaire survey method to conduct the analysis. Questionnaires are of three categories such as structured, un-structured, disguised and undisguised. The appropriate category was chosen for designing the final questionnaire.

Pretesting Of QuestionnaireA pilot study was conducted by distributing a model questionnaire to a small sample group. Based on the doubts raised by the respondents, the questionnaire was modified accordingly.

Secondary Data Secondary data collection was done through the use of websites and health journals.

DATA SOURCES

Primary Data Source: Collected using questionnaires, direct interviews and web/e-mail surveys.

Secondary Data Source: Literature reviews.

27


RESEARCH INSTRUMENTS

Close ended questionnaires to obtain primary data. Online Research Face to face Interview Observation Experience Surveys

SAMPLING DESIGN

Simple Random Sampling & Cluster Sampling

PERIOD COVERED BY THE STUDY

From April 5th to April 20th, 2010.

SAMPLING UNIT For sampling, the Sampling Unit selected was Saugor (M.P.), Bhopal (M.P.), and Indore (M.P.) to ensure availability of data from a diverse group. The sampling unit would include

People of various occupation, income groups & education standards who are the patients visiting chemist shops or doctors.

Chemists/druggists/pharmacists owning or employed in retail chemist/drug/pharma shops.

Doctors & medical students of various medical course.

SAMPLE SIZE

A sample size of 100 in case of patients & pharmacists would be the focus of study.

A sample size of 50 in case of doctors & medical students would be the focus of study.

SURVEY METHOD

28


The survey is a non-experimental, descriptive research method. Surveys can be useful when a researcher wants to collect data on phenomena that cannot be directly observed (such as opinions on medical services). Surveys are used extensively in library and information science to assess attitudes and characteristics of a wide range of subjects, from the quality of user-system interfaces to library user reading habits.

TYPES OF SURVEYS

Data are usually collected through the use of questionnaires, although sometimes researchers directly interview subjects. Surveys can use qualitative (e.g. ask open-ended questions) or quantitative (e.g. use forced-choice questions) measures. There are two basic types of surveys: cross-sectional surveys and longitudinal surveys.

Cross-Sectional SurveysCross-sectional surveys are used to gather information on a population at a single point in time. An example of a cross sectional survey would be a questionnaire that collects data on how parents feel about Internet filtering, as of March of 1999. A different cross-sectional survey questionnaire might try to determine the relationship between two factors, like religiousness of parents and views on Internet filtering.

Longitudinal SurveysLongitudinal surveys gather data over a period of time. The researcher may then analyze changes in the population and attempt to describe and/or explain them. The three main types of longitudinal surveys are trend studies, cohort studies, and panel studies.

Trend StudiesTrend studies focus on a particular population, which is sampled and scrutinized repeatedly. While samples are of the same population, they are typically not composed of the same people. Trend studies, since they may be conducted over a long period of time, do not have to be conducted by just one researcher or research project. A researcher may combine data from several studies of the same population in order to show a trend.

Cohort StudiesCohort studies also focus on a particular population, sampled and studied more than once. But cohort studies have a different focus.

Panel StudiesPanel studies allow the researcher to find out why changes in the population are occurring, since they use the same sample of people every time. That sample is called a panel.

EXPERIMENT METHOD

29


The experimental method involves manipulating one variable to determine if changes in one variable cause changes in another variable. This method relies on controlled methods, random assignment and the manipulation of variables to test a hypothesis. An experiment is a study of cause and effect.

The Field ExperimentSometimes it is possible to carry out experiments in a more natural setting, i.e. in ‘the field ’. A famous example of this is the series of studies carried out by Piliavin et al (1969) in which they arranged for a person to collapse on an underground train and waited to see how long it was before the person was helped. One of the independent variables they used was the appearance of the ‘victim’: whether he was carrying a walking stick or whether he appeared to be drunk.

As with the laboratory experiment, the independent variable is still deliberately manipulated by the researcher. However it is not possible to have such tight control over variables in the field, but it does have the advantage of being far less artificial than the laboratory.

ACTION PLAN FOLLOWED

FLOWCHART: 1

30

Prepare a Draft

Literature Review

Finalizing the parts of city

Take permission from retail pharma

Data Collection

Questionnaires Survey

Interviews

Report Preparation


CHAPTER 4: PRESENTATION & ANALYSIS OF DATA

SOFTWARE USED

The Software SPSS Statistics 17.0 was by our team to analyze the data collected from the surveys conducted as part of the study. The latest version of this software application is IBM SPSS Statistics 18

FIGURE: 1

SPSS provides the tools you need to speed through every stage of your statistical research and reach accurate results, even if you work with complex or difficult data. The various features available are:-

Features for Data Preparation

Data validation rules and/or Automatic Data Preparation help you validate complex data more easily.

Multiple imputation procedures allow you to develop reliable estimates for missing data and create more accurate models.

Data transformations prepare your data for advanced analyses.

Features for Analysis

31


Optimal binning. Nonlinear and multivariate analysis. Survival analysis algorithms.

General linear models with repeated measures.

Features for Reporting

Create custom tables that present results clearly.

Use new post-compute feature to create additional categories even after your data has been tabulated.

FIGURE: 2

MAIN HYPOTHESIS: Prevalence of the practise of self-medication of Antibiotics in M.P. State, India.

DATA CHARACTERISTICS

Findings & Interpretation: The respondents are majorly professionals (27.3%). Home makers (18.2%), students (18.2) and businessmen (18.2%) constitute a significant & equal portion of the sample, while freelancer is the least (9.1). Hence from the chart it is clear that the majority of the respondents to the survey conducted were professionals. [Pie Chart 1]

32


PIE CHART: 1

PERCENTAGE OF ANTIBIOTICS USERS

Hypothesis 1: There is a rising trend towards usage of Antibiotics with or without prescription.

Findings & Interpretation: All of the respondents- patients, pharmacists as well as doctors- have consumed Antibiotics in their life (100 % Yes). This probably reflects the increased usage of Antibiotics for general or specific ailments, with or without prescription, among all sections of society in M.P. State of India. [Pie Chart 2]

PIE CHART: 2

33


FREQUENCY OF USAGE OF ANTIBIOTICS

Hypothesis 2: The frequency of usage of Antibiotics with or without prescription has been increased.

Findings & Interpretation: Majority of the respondents- patients, pharmacists & doctors use Antibiotics often. While responses of never before were neglible.

Among patients- responses for often use antibiotics were the maximum (54.5%), while that of very often & sometimes were equal (18.2% each). But responses for never used were not received. [Pie Chart 3]

PIE CHART: 3

Among pharmacists- responses for often use antibiotics were the maximum (52%), while that of sometimes (27 %) and very often (12 %) were found. But responses for never before (9%) were the least received among pharmacist. [Pie Chart 4]

PIE CHART: 4

34


Among doctors- responses for often use antibiotics were the maximum (50%), while that of very often (30 %) & sometimes (20 %) were found. But responses for never used were not received among doctors too. [Pie Chart 5]

PIE CHART: 5

PATIENT AWARENESS – Further Analysis

Hypothesis 3: Effect of awareness among patients about side-effects & allergies of antibiotics on their behaviour of referring a doctor before taking antibiotics.

Findings & Interpretation: [Table 3, 4, 5 & 6]

From Table 3, it can be inferred that out of those people who have used antibiotics in their life, 60% have referred a doctor before taking antibiotics. While 40% of them had taken antibiotics without consulting a doctor. [Bar Chart: 1]

From Table 4, it is seen that 83.3% of patients who consulted a doctor knew the side-effects caused by antibiotics & that explains why they referred doctor before consuming antibiotics. While 16.7 % of them didn’t know that antibiotics cause side-effects but referred a doctor before consuming antibiotics.

But 25% of the patients who didn’t consulted doctor knew that antibiotics cause side-effects, still they didn’t refer doctor before consuming antibiotics.

While 75% of them didn’t know any side-effects of antibiotics and that can probably explain the reason why they didn’t refer a doctor before taking antibiotics.

From Table 5, it can be inferred that most of the people don’t consult a doctor before taking antibiotics since it has highest mean value (2.000).

From Table 6, it can said that there is no significant difference of means of knowledge of side-effects of antibiotics in the referring to a doctor before taking antibiotics (p>0.05).

35


TABLE: 3Crosstabulation

Have you ever taken antibiotics? * Have you referred a doctor before taking antibiotics?

hvureferddoctorb4tkingAB

TotalYes No

hvuevertakenantibiotics Yes Count 60 40 100

% within

hvuevertakenantibiotics

60.0% 40.0% 100.0%

% within


100.0% 100.0% 100.0%

% of Total 60.0% 40.0% 100.0%

Std. Residual .0 .0

Total Count 60 40 100

% within

hvuevertakenantibiotics

60.0% 40.0% 100.0%

% within


100.0% 100.0% 100.0%

% of Total 60.0% 40.0% 100.0%

BAR CHART: 1

36



Have you referred a doctor before taking Antibiotics? * Do you know any side-effects of Antibiotics?

douknwanysideeffctsofAB

TotalYes No Don't Know

hvureferddoctorb4tkingAB Yes Count 50 0 10 60

% within


83.3% .0% 16.7% 100.0%

No Count 10 30 0 40

% within


25.0% 75.0% .0% 100.0%

Total Count 60 30 10 100

% within


60.0% 30.0% 10.0% 100.0%

TABLE: 5

Descriptives

Have you referred a doctor before taking Antibiotics?

N Mean Std. Deviation Std. Error

95% Confidence Interval for Mean

Minimum MaximumLower Bound Upper Bound

Yes 6 1.1667 .40825 .16667 .7382 1.5951 1.00 2.00

No 3 2.0000 .00000 .00000 2.0000 2.0000 2.00 2.00

Don't

Know

1 1.0000 . . . . 1.00 1.00

Total 10 1.4000 .51640 .16330 1.0306 1.7694 1.00 2.00

37


TABLE:6ANOVA

Have you referred a doctor before taking Antibiotics?

Sum of Squares df Mean Square F Sig.

Between Groups (Combined) .433 2 .217 .771 .498

L

i

n

e

a

r

T

e

r

m

Unweighted .408 1 .408 1.453 .267

Weighted .426 1 .426 1.517 .258

Deviation .007 1 .007 .025 .879

Within Groups 1.967 7 .281

Total 2.400 9

38


Findings & Interpretation: [Table 7]

It is observed that 66.7% of the patients who referred a doctor before consuming antibiotics have some allergy from any antibiotics. 16.7 % of them didn’t know if they have any or not, while rest 16.7% didn’t know that antibiotics even cause allergy.

25% of the patients who didn’t refer a doctor have some kind of allergy from antibiotics; still they didn’t consult a doctor before consuming antibiotics. 25% of them didn’t know any allergies caused by antibiotics while rest 50% didn’t even know that antibiotics cause allergy which probably explains the reason of their behaviour.


Have you referred a doctor before taking antibiotics? * Do you have allergy from antibiotics?

douhvallergyofAB


hvureferddoctorb4tkingAB Yes Count 40 10 10 60

% within hvureferddoctorb4tkingAB

66.7% 16.7% 16.7% 100.0%

No Count 10 10 20 40


25.0% 25.0% 50.0% 100.0%



50.0% 20.0% 30.0% 100.0%

Hypothesis 4: The awareness among patients about correct practise to be followed in case of antibiotics on their behaviour of referring a doctor before its consumption.


It is seen that out of people who think it’s correct to take antibiotics from a chemist without doctor’s prescription, 60% referred a doctor before taking antibiotics while rest 40% didn’t. [Bar Chart: 2]

Similar percentage is found among people who think it is not correct. Thus we can say that 40% of people in spite of knowing that it is wrong took antibiotics without consulting a doctor.

TABLE: 8

Crosstabulation

Is it correct to take antibiotics without prescription? * Have you referred a doctor before taking antibiotics?

39



TotalYes No

correcttotkABfrmchemistwtho

utpresc

Yes Count 30 20 50

% within


utpresc

60.0% 40.0% 100.0%

% within


50.0% 50.0% 50.0%

% of Total 30.0% 20.0% 50.0%

Std. Residual .0 .0

No Count 30 20 50

% within


utpresc

60.0% 40.0% 100.0%

% within


50.0% 50.0% 50.0%

% of Total 30.0% 20.0% 50.0%

Std. Residual .0 .0


% within


utpresc

60.0% 40.0% 100.0%

% within


100.0% 100.0% 100.0%

% of Total 60.0% 40.0% 100.0%

BAR CHART: 2

40



It can be inferred that out of those people who said that they always finish their course of antibiotics, 66.7% knew that antibiotic resistant bacteria is likely to reoccur if patient doesn’t complete his course of antibiotics. While 33.3% of them said that reoccurrence of disease doesn’t depend on finishing of course, but still finished their course may be following doctor’s instruction.

Out of people who often finish their antibiotics course, 40% didn’t know about reoccurrence of antibiotics resistant bacteria. While 60% of them said that reoccurrence of disease doesn’t depend on finishing of course.

Out of those who sometimes complete their antibiotics course, 50% knew about antibiotic resistant bacteria being the reason of reoccurrence of disease. While rest 50% didn’t know about bacteria, probably explaining the reason why they don’t finish their course of antibiotics.

TABLE: 9

Crosstabulation

41


Do you finish your course of antibiotics? * Antibiotic resistant bacteria likely to occur if people don’t finish their course of antibiotics?

ABresbaclikelytooccureifppldntfinishcourse


doufinishurcourseofAB Always Count 20 10 0 30

% within

doufinishurcourseofAB

66.7% 33.3% .0% 100.0%

Often Count 0 30 20 50

% within


.0% 60.0% 40.0% 100.0%

Sometimes Count 10 0 10 20

% within


50.0% .0% 50.0% 100.0%


% within


30.0% 40.0% 30.0% 100.0%

EDUCATION AS A FACTOR OF SELF-MEDICATION

Hypothesis 5: To find whether education is a factor influencing behavior towards misuse & self-medication of antibiotics.


It can be inferred from the table that out of the people whose highest level of education was undergraduate, 100% didn’t refer a doctor before taking antibiotics. This clearly explains the reason of their behavior & increasing cases of misuse of antibiotics.

Out of people with highest education as graduation, 53.4% didn’t refer a doctor before taking antibiotics.

Out of post-graduated people, only 14.3% consumed antibiotics without consulting a doctor.

Out of people who have done doctorate, 87.5% didn’t refer a doctor before taking antibiotics. Here the reason may be attributed as their own knowledge about medicines.


Highest level of education? * Have you referred a doctor before taking antibiotics?

hvureferddoctorb4tkingAB Total

42


Yes No

Highestlevelofeducation Undergraduate Count 0 6 6

% within

Highestlevelofeducation

.0% 100.0% 100.0%

Graduate Count 27 31 58

% within


46.6% 53.4% 100.0%

Post Graduate Count 24 4 28

% within


85.7% 14.3% 100.0%

Doctorate Count 1 7 8

% within


12.5% 87.5% 100.0%


% within


52.0% 48.0% 100.0%

Ailments Commonly Subjected To Self-Medication:

According to people/patients, the ailments for which they take antibiotics without referring a doctor or a pharmacist are headache (36.4%), body ache (27.3%) while fever, tonsillitis & abdominal disorder all had equal percent (9.1). [Pie Chart 6]

According to people/patients, the ailments for which they take antibiotics without referring a doctor by just seeking a pharmacist’s/chemist’s advice are fever (27.3%), body ache & abdominal disorder (18.2%) while body ache, tonsillitis & any other all had equal percent (9.1). [Pie Chart 7]

PIE CHART: 6

43


PIE CHART: 7

PHARMACIST/CHEMIST RESPONSIVENESS

Hypothesis 6: The attitude of pharmacists/chemists towards self-administration of antibiotics.

44


Findings & Interpretation:

Out of the responses received from the chemists/pharmacists, 88% have taken antibiotics in their life, 8% haven’t while 4% didn’t know about it. [Table 11]

40.9% among those who have taken antibiotics in their life have referred a doctor before taking antibiotics while 59.1% didn’t consult one. [Table 12]

58.3% of those who consume antibiotics very often don’t refer a doctor before taking them while 59.1% of those who often take antibiotics don’t refer a doctor. 77.8% of those consume only sometimes don’t refer a doctor.[Table 13]

TABLE: 11

Have you ever taken antibiotics?

Frequency Percent Valid Percent

Cumulative

Percent

Valid Yes 88 88.0 88.0 88.0

No 8 8.0 8.0 96.0

Don't Know 4 4.0 4.0 100.0

Total 100 100.0 100.0


Have you ever taken antibiotics? * Have you referred a doctor before taking antibiotics?


TotalYes No

hvuevertakenantibiotics Yes Count 36 52 88

% within hvuevertakenantibiotics

40.9% 59.1% 100.0%

No Count 1 7 8


12.5% 87.5% 100.0%

Don't Know Count 0 4 4


.0% 100.0% 100.0%



37.0% 63.0% 100.0%

BAR CHART: 3

45



How often do you take antibiotics?* Have you referred a doctor before taking antibiotics?


TotalYes No

hwoftendoutkantibiotics Very Often Count 5 7 12

% within

hwoftendoutkantibiotics

41.7% 58.3% 100.0%

Often Count 25 27 52

% within


48.1% 51.9% 100.0%

Sometimes Count 6 21 27

% within


22.2% 77.8% 100.0%

Never Before Count 1 8 9

% within


11.1% 88.9% 100.0%


% within


37.0% 63.0% 100.0%

BAR CHART: 4

46


Hypothesis 7: Sense of morality among chemists/pharmacists towards dispensing of antibiotics

without doctor’s prescription.

Findings & Interpretation:

66% of chemists/pharmacists agree & 6% strongly agree that there should be a strict law

against dispensing antibiotics over the counter without checking doctor’s prescription

while 25% disagree & 3% strongly disagree with that. [Table 14]

62.5% of the pharmacists/chemists who think it’s not fair on chemist’s part to dispense

antibiotics without doctor’s prescription provide antibiotics strictly on prescription only,

while 37.5% of those think it’s fair. [Table 15]TABLE: 14

There should be a strict law against prescribing antibiotics without prescription?


Cumulative

Percent

Valid Stronlgy Agree 6 6.0 6.0 6.0

Agree 66 66.0 66.0 72.0

Disagree 25 25.0 25.0 97.0

Strongly disagree 3 3.0 3.0 100.0

Total 100 100.0 100.0

TABLE: 15

47


Crosstabulation

Do you strictly provide antibiotics only on prescription? * Is it fair on chemist’s part to dispense antibiotics without doctor’s prescription?

faironchemistparttogvABwthoutpresc


doustrictlyprovABondocpresc Always Count 3 5 0 8

% within

doustrictlyprovABondocpresc

37.5% 62.5% .0% 100.0%

Often Count 8 61 16 85

% within


9.4% 71.8% 18.8% 100.0%

Sometimes Count 0 6 1 7

% within


.0% 85.7% 14.3% 100.0%


% within


11.0% 72.0% 17.0% 100.0%

BAR CHART: 5

Ailments Commonly Subjected To Self-Medication:

48


According to the chemists/pharmacists, headache (43%), body ache (29%), fever (15%), abdominal disorder (7%), tonsillitis (5%) & eye infection (1%) are the ailments commonly subjected to self-medication by patients. [Table 16 & Pie Chart 8]

According to chemists’/pharmacists, headache (36%), body ache (26%), fever (19%), abdominal disorder (8%), tonsillitis (6%), eye infection (3%) and any other (2%) are the ailments commonly used by patients on suggestions or advise from chemists’/pharmacists. [Table 17& Pie Chart 9]

TABLE: 16

For which ailments patients take antibiotics on the own?


Cumulative

Percent

Valid Fever 15 15.0 15.0 15.0

Headache 43 43.0 43.0 58.0

Bodyache 29 29.0 29.0 87.0

Tonsilitis 5 5.0 5.0 92.0

Abdominal Disorder 7 7.0 7.0 99.0

Eye Infection 1 1.0 1.0 100.0

Total 100 100.0 100.0

PIE CHART: 8

TABLE: 17

49


For which ailments do you dispense antibiotics without doctor’s prescription?


Cumulative

Percent

Valid Fever 19 19.0 19.0 19.0

Headache 36 36.0 36.0 55.0

Bodyache 26 26.0 26.0 81.0

Tonsilitis 6 6.0 6.0 87.0

Abdominal Disorder 8 8.0 8.0 95.0

Eye Infection 3 3.0 3.0 98.0

Any Other 2 2.0 2.0 100.0

Total 100 100.0 100.0

PIE CHART: 9

50


DOCTOR’S POINT OF VIEW

Hypothesis 8: To find out whether doctors advise their patients not to consume antibiotics without referring a doctor & thus think its doctor’s or chemist’s duty to guide them.

Findings & Interpretations:

Out of the doctors who always advise their patients not to take antibiotics without consulting a doctor, 70% think that it is doctor’s duty to give patients such advice. While 61.5% of those who often advise their patients think it is doctor’s duty.[Table 18]

Out of the doctors who always advise their patients not to take antibiotics without consulting a doctor, 70% think that it is chemist’s duty to give patients antibiotics only on doctor’s prescription. While 61.5% of those who often advise their patients think it is chemist’s duty.[Table 19]


Do you advise patients not to take antibiotics on their own? * Is it doctor’s duty to advise patients not to take antibiotics without consulting doctor?

isitdoctorsdutytoadvicepatients

TotalYes No

douadvicepatientsnottotkAB

withtrefdoc

Always Count 21 9 30

% within


withtrefdoc

70.0% 30.0% 100.0%

Often Count 8 5 13

% within


withtrefdoc

61.5% 38.5% 100.0%


% within


withtrefdoc

57.1% 42.9% 100.0%


% within


withtrefdoc

66.0% 34.0% 100.0%

51


TABLE: 19

Crosstabulation

Do you advise patients not to take antibiotics on their own? * Is it chemist’s duty to give antibiotics only on doctor’s prescription?

isitchemistsdutytochkdocpresc

TotalYes No


withtrefdoc

Always Count 21 9 30

% within


withtrefdoc

70.0% 30.0% 100.0%

Often Count 9 4 13

% within


withtrefdoc

69.2% 30.8% 100.0%


% within


withtrefdoc

100.0% .0% 100.0%


% within


withtrefdoc

74.0% 26.0% 100.0%

52


CHAPTER: 5 DISCUSSION & INTERPRETATION OF FINDINGS

Main Hypothesis: Prevalence of the practise of self-medication of Antibiotics in M.P. State, India. From PIE-CHART: 1

Interpretation and Findings:

The respondents are majorly professionals (27.3%). Home makers (18.2%), students (18.2) and businessmen (18.2%) constitute a significant & equal portion of the sample, while freelancer is the least (9.1). Hence from the chart it is clear that the majority of the respondents to the survey conducted were professionals.

PERCENTAGE OF ANTIBIOTICS USERS

Hypothesis 1: There is a rising trend towards usage of Antibiotics with or without prescription.

From PIE-CHART: 2

Findings & Interpretation: All of the respondents- patients, pharmacists as well as doctors- have consumed Antibiotics in their life (100 % Yes). This probably reflects the increased usage of Antibiotics for general or specific ailments, with or without prescription, among all sections of society in M.P. State of India.

FREQUENCY OF USAGE OF ANTIBIOTICS

Hypothesis 2: The frequency of usage of Antibiotics with or without prescription has been increased.

Findings: Majority of the respondents- patients, pharmacists & doctors use Antibiotics often. While responses of never before were negligible.

Among patients- responses for often use antibiotics were the maximum (54.5%), while that of very often & sometimes were equal (18.2% each). But responses for never used were not received. [Pie Chart 3]

Among pharmacists- responses for often use antibiotics were the maximum (52%), while that of sometimes (27 %) and very often (12 %) were found. But responses for never before (9%) were the least received among pharmacist. [Pie Chart 4]

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Among doctors- responses for often use antibiotics were the maximum (50%), while that of very often (30 %) & sometimes (20 %) were found. But responses for never used were not received among doctors too. [Pie Chart 5]

Interpretation:

It can be inferred that the frequency of antibiotics usage has been increased among all the sections of the society including chemists/pharmacists & doctors.

PATIENT AWARENESS – Further Analysis

Hypothesis 3: Effect of awareness among patients about side-effects & allergies of antibiotics on their behaviour of referring a doctor before taking antibiotics.

Findings: [Table 3, 4, 5, 6 & 7]

From Table 3, it can be inferred that out of those people who have used antibiotics in their life, 60% have referred a doctor before taking antibiotics. While 40% of them had taken antibiotics without consulting a doctor. [Bar Chart: 1]

From Table 4, it is seen that 83.3% of patients who consulted a doctor knew the side-effects caused by antibiotics & that explains why they referred doctor before consuming antibiotics. While 16.7 % of them didn’t know that antibiotics cause side-effects but referred a doctor before consuming antibiotics.

But 25% of the patients who didn’t consulted doctor knew that antibiotics cause side-effects, still they didn’t refer doctor before consuming antibiotics.

While 75% of them didn’t know any side-effects of antibiotics and that can probably explain the reason why they didn’t refer a doctor before taking antibiotics.

From Table 5, it can be inferred that most of the people don’t consult a doctor before taking antibiotics since it has highest mean value (2.000).

From Table 6, it can said that there is no significant difference of means of knowledge of side-effects of antibiotics in the referring to a doctor before taking antibiotics (p>0.05).

From Table 7, it is observed that 66.7% of the patients who referred a doctor before consuming antibiotics have some allergy from any antibiotics. 16.7 % of them didn’t know if they have any or not, while rest 16.7% didn’t know that antibiotics can even cause allergy.

25% of the patients who didn’t refer a doctor have some kind of allergy from antibiotics; still they didn’t consult a doctor before consuming antibiotics. 25% of them didn’t know any allergies caused by antibiotics while rest 50% didn’t even know that antibiotics cause allergy which probably explains the reason of their behaviour.

Interpretation:

It can be inferred from the data that most of the people consuming antibiotics use them without referring a doctor.

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In spite of knowing the side-effects of antibiotics, patients don’t consult doctors while still a major part of population doesn’t know that antibiotics do cause side-effects.

It can be inferred that wither are not aware of the fact that antibiotics can cause allergies or even on knowing this, they don’t bother to consult doctor before consuming antibiotics.

Hypothesis 4: The awareness among patients about correct practise to be followed in case of antibiotics on their behaviour of referring a doctor before its consumption.

Findings: [Table 8]

It is seen that out of people who think it’s correct to take antibiotics from a chemist without doctor’s prescription, 60% referred a doctor before taking antibiotics while rest 40% didn’t. [Bar Chart: 2]

Similar percentage is found among people who think it is not correct. Thus we can say that 40% of people in spite of knowing that it is wrong took antibiotics without consulting a doctor.

Findings: [Table 9]

It can be inferred that out of those people who said that they always finish their course of antibiotics, 66.7% knew that antibiotic resistant bacteria is likely to reoccur if patient doesn’t complete his course of antibiotics. While 33.3% of them said that reoccurrence of disease doesn’t depend on finishing of course, but still finished their course may be following doctor’s instruction.

Out of people who often finish their antibiotics course, 40% didn’t know about reoccurrence of antibiotics resistant bacteria. While 60% of them said that reoccurrence of disease doesn’t depend on finishing of course.

Out of those who sometimes complete their antibiotics course, 50% knew about antibiotic resistant bacteria being the reason of reoccurrence of disease. While rest 50% didn’t know about bacteria, probably explaining the reason why they don’t finish their course of antibiotics.

Interpretation:

Most of the people think it is correct to take antibiotics from a chemist/pharmacist without consulting a doctor whereas some in spite of knowing it is not correct take antibiotics without referring a doctor.

A major part of population is still unaware about antibiotic resistant bacteria & the fact that disease reoccurs if a patients doesn’t complete his course of antibiotics.

In spite of knowing that disease may reoccur is they don’t complete the course of antibiotic, patients don’t bother to finish their antibiotic course.

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EDUCATION AS A FACTOR OF SELF-MEDICATION

Hypothesis 5: To find whether education is a factor influencing behavior towards misuse & self-medication of antibiotics.

Findings: [Table 10]

It can be inferred from the table that out of the people whose highest level of education was undergraduate, 100% didn’t refer a doctor before taking antibiotics.

Out of people with highest education as graduation, 53.4% didn’t refer a doctor before taking antibiotics.

Out of post-graduated people, only 14.3% consumed antibiotics without consulting a doctor.

Out of people who have done doctorate, 87.5% didn’t refer a doctor before taking antibiotics. Here the reason may be attributed as their own knowledge about medicines.

Interpretation:

In can be said that low levels of education in M.P. State in India are one of the factors leading to increasing trends of self-medication.

This clearly explains the reason of their behavior & increasing cases of misuse of antibiotics.

But it’s surprising to know that some of well educated people also don’t refer a doctor before consuming antibiotics. The reasons for this may b many, but still it is unsafe to use antibiotics without doctor’s consultation as a disease may appear something else, but actually might be something else.

PHARMACIST/CHEMIST RESPONSIVENESS

Hypothesis 6: The attitude of pharmacists/chemists towards self-administration of antibiotics.

Findings:

Out of the responses received from the chemists/pharmacists, 88% have taken antibiotics in their life, 8% haven’t while 4% didn’t know about it. [Table 11]

40.9% among those who have taken antibiotics in their life have referred a doctor before taking antibiotics while 59.1% didn’t consult one. [Table 12]

58.3% of those who consume antibiotics very often don’t refer a doctor before taking them while 59.1% of those who often take antibiotics don’t refer a doctor. 77.8% of those consume only sometimes don’t refer a doctor. [Table 13]

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Interpretation:

It can be inferred that among the chemists/pharmacists, most of them have taken antibiotics and more than half amongst them didn’t consult a doctor consuming them.

Among the pharmacists, those who take antibiotics very often & often didn’t consult doctor before consuming them.

In this case, the reason can be stated as since they are dealing with medicines & have a fair knowledge about them know the usage. But in the case of antibiotics, doctor’s prescription is a necessity as they have many side-effects & may cause allergies.

Hypothesis 7: Sense of morality among chemists/pharmacists towards dispensing of antibiotics

without doctor’s prescription.

Findings:

66% of chemists/pharmacists agree & 6% strongly agree that there should be a strict law

against dispensing antibiotics over the counter without checking doctor’s prescription

while 25% disagree & 3% strongly disagree with that. [Table 14]

62.5% of the pharmacists/chemists who think it’s not fair on chemist’s part to dispense

antibiotics without doctor’s prescription provide antibiotics strictly on prescription only,

while 37.5% of those think it’s fair. [Table 15]

Interpretation:

It can be observed that most of the chemists/pharmacists agree % believe that there should be strict laws against dispensing of antibiotics without doctor’s prescription.

Most of them who believe it’s not fair on chemist’s part to dispense antibiotics without prescription provide antibiotics to patients only on prescription.

DOCTOR’S POINT OF VIEW

Hypothesis 8: To find out whether doctors advise their patients not to consume antibiotics without referring a doctor & thus think its doctor’s or chemist’s duty to guide them.

Findings:

Out of the doctors who always advise their patients not to take antibiotics without consulting a doctor, 70% think that it is doctor’s duty to give patients such advice. While 61.5% of those who often advise their patients think it is doctor’s duty. [Table 18]

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Out of the doctors who always advise their patients not to take antibiotics without consulting a doctor, 70% think that it is chemist’s duty to give patients antibiotics only on doctor’s prescription. While 61.5% of those who often advise their patients think it is chemist’s duty.[Table 19]

Interpretations:

It can be inferred that most of the doctors who advise their patients about misuse of antibiotics & that they should be consumed only after consulting a doctor think it is doctor’s duty as well as chemist’s duty to advise patients. The chemist’s should themselves not dispense antibiotics without a doctor’s prescription. The chemists should also advise such patients coming to them for self-prescribed drugs to refer a doctor and then only give them the drugs.

“From all the above it can be inferred that the practise of self-medication of antibiotics in M.P. State, India is still prevalent & being followed.”

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CHAPTER: 6 CONCLUSION, IMPLICATION & RECOMMENDATION

BENEFITS OF THIS RESEARCH

Proper practices being followed by chemists/pharmacists/druggists, as per the guidelines, ensure:

Health of the people.

No misuse of potent & hazardous drugs.

No illegal activity performed.

Helps stop anti-social activities.

Public awareness.

Since this study involves people from all sections of the society in M.P. State, India, it helps:

Understand the prevalence of the practise of self-medication of antibiotics properly.

It helps understand the patients’ behaviour towards consumption of antibiotics.

It also helps realize whether the chemists/pharmacists perform their jobs honestly and

follow the rules & guidelines or not.

It enables the govt. authorities to realize the condition of self-medication.

It helps doctor’s understand their patients’ tendency & their behaviour.

BENEFITS FOR THE STUDENTS

To understand the Indian Pharmaceutical Market.

To understand the factors that influence self-medication in M.P. State, India.

To understand the influence of education & awareness among patients in self-medication.

To get a glimpse of the patient perception.

To understands the recent trends in the antibiotic market.

LIMITATIONS:

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1. The reason behind patients’ perception towards antibiotics is difficult as it may include

various factors.

2. It may not be possible to cover the whole population so the sample size

selected maybe small.

3. Prone to

o Non response error

o Unconscious misinterpretation

o Deliberate falsification

o Acquiescence Bias

o Extremity Bias and

o Interviewer bias

o Respondents may not actively participate in the process of giving information.

RECOMMENDATIONS:

Antibiotics are potent drugs which cause side-effects and may cause allergy too. There are various rules & norms laid down by the FDA which needs to be strictly followed.

For this to happen, I would recommend:

Chemists/pharmacists/druggists need to understand their responsibilities & realize their

importance in the society.

The doctors also need to be more assertive in making sure their patients don’t use the

once-prescribed again for similar kind of disorder either for themselves or for any other

person.

The rules against selling of antibiotics without prescription need to be more vigilant.

Though there have been issues about making some categories as OTC Drugs, still until

govt. takes any concerned step, it should not be permitted, rather completely prohibited.

Proper database regarding sale of antibiotics should be maintained.

Strict actions should be taken against such chemists.

Some measure to educate population & make them aware regarding self-medication need

to be taken by the govt.

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Some Recommendations/ Precautions For Patients/People:

The patients need to understand that self-medication, especially in the case of antibiotics

can be hazardous as it causes side-effects & allergies too. Thus it is recommended to use

antibiotics only after consulting a doctor.

The patients should realize that dispensing antibiotics over the counter without asking for

doctor’s prescription is illegal and not permitted by the govt. thus, even if they notice

some chemist performing such activity, they should inform concerned authority.

The people should not follow such practices by themselves and should also guide others

regarding this.

CONCLUSION:

The research project helped me to study about the prevalence of practise of self-medication in M.P. State, India. I came to realize the increasing need of assertive & solid measures to be taken by the govt. soon to stop this misuse of drugs. I also understood the patients’ perceptions towards antibiotics & their behaviour towards their administration.

The research projects enabled me to get a clear picture about the malpractices followed by the chemists/pharmacists. It also helped me to understand some of the factors influencing the practice of self-medication of antibiotics and their misuse.

I also realized the chemists’ behaviour & perception towards dispensing antibiotics as over the counter without seeking the doctor’s prescription.

Thus, as a conclusion, it can be stated that there is an urgent to take some solid steps to stop this practise of self-medication of may be hazardous antibiotics among the people of M.P. State, India.

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REFERENCES

WEBSITES & SOURCES

1. http://en.wikipedia.org/wiki/Health2. http://en.wikipedia.org/wiki/Over-the-counter_drug3. http://www.merck.com/mmhe/sec02/ch018/ch018a.html4. http://en.wikipedia.org/wiki/Pharmacist5. http://en.wikipedia.org/wiki/Antibiotic6. http://en.wikipedia.org/wiki/Allergy7. http://www.utdol.com/patients/content/topic.do?topicKey=~BGPByYTXv9Rb9I8. http://www.sciencedaily.com/releases/2005/01/050111162856.htm9. http://www.sciencedaily.com/releases/2007/06/070611185240.htm10. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2627681/pdf/10081668.pdf11. http://www.sciencedaily.com/releases/2009/10/091015163557.htm12. http://jac.oxfordjournals.org/cgi/content/abstract/59/1/15213. http://www.ncbi.nlm.nih.gov/pubmed/821869014. http://ijsa.rsmjournals.com/cgi/content/abstract/8/7/45615. http://www.indianjmedsci.org/article.asp?16. http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6VBF-46FPT417. http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6VBF-466KJ4518. www.sciencedirect.com

19. www.spss.com

BIBLIOGRAPHY

TRIPATHI, K.D., “Essentials of Medical Pharmacology”, 5th Edition, Jaypee Publications, New Delhi.

KOTHARI, C.R (1990), “Research Methodology methods and techniques”, New Delhi,

New Age International (p) Ltd.

SA WAKSMAN (1947). "What Is an Antibiotic or an Antibiotic Substance? DAVIES, JULIAN, “Antibiotic Resistance: A Growing Health Threat, in Forum for

Applied Research and Public Policy.

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http://en.wikipedia.org/wiki/Allergy

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