Golnesa Kazemioula1Shayan Golestani2Seyed Mohammad Amin Alavi3Forough Taheri4
Reza Ghanei Gheshlagh5
Mohammad Hassan Lotfalizadeh6*- 1Department of Medical Genetics, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
- 2Department of Oral and Maxillofacial Surgery, Dental School, Islamic Azad University, Isfahan, Iran
- 3Faculty of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
- 4Department of Medical Genetics, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- 5Social Determinants of Health Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran
- 6Board Certificate Oral and Maxillofacial Radiologist, North Khorasan University of Medical Sciences (NKUMS), Bojnurd, Iran
Background: The COVID-19 pandemic and restrictions on travel and quarantine measures made people turn to self-medication (SM) to control the symptoms of their diseases. Different studies were conducted worldwide on different populations, and their results were different. Therefore, this global systematic review and meta-analysis was conducted to estimate the pooled prevalence of self-medication.
Methods: In this systematic review and meta-analysis, databases of Scopus, PubMed, Embase, and Web of Science were searched without a time limit. All eligible observational articles that reported self-medication during the COVID-19 pandemic were analyzed. Heterogeneity among the studies was assessed using Cochran's Q test and I2 statistics. A random-effects model was used to estimate the pooled prevalence of self-medication. The methodological quality of the articles was evaluated with the Newcastle-Ottawa Scale.
Results: Fifty-six eligible studies were reviewed. The pooled prevalence of self-medication was 48.6% (95% CI: 42.8–54.3). The highest and lowest prevalence of self-medication was in Asia (53%; 95% CI: 45–61) and Europe (40.8%; 95% CI: 35–46.8). Also, the highest and lowest prevalence of self-medication was related to students (54.5; 95% CI: 40.8–68.3) and healthcare workers (32.5%; 16–49). The prevalence of self-medication in the general population (48.8%; 40.6–57) and in patients with COVID-19 (41.7%; 25.5–58). The prevalence of self-medication was higher in studies that collected data in 2021 than in 2020 (51.2 vs. 48%). Publication bias was not significant (p = 0.320).
Conclusion: During the COVID-19 pandemic, self-medication was highly prevalent, so nearly half of the people self-medicated. Therefore, it seems necessary to provide public education to control the consequences of self-medication.
Introduction
On January 30, 2020, the World Health Organization (WHO) declared a state of public health emergency due to the emergence of COVID-19 disease. Six months later, ~20 million cases and 700,000 deaths were reported worldwide (1). People resorted to self-medication (SM) due to the fear of contracting COVID-19, misinformation, and low access to health services. With people confined to their homes, the Internet was the only source of information they had access to. Also, when the hospitals were filled with patients, people were afraid to go to the hospitals and started self-medication (2).
Self-medication refers to choosing and using drugs to treat self-diagnosed symptoms and diseases without consulting a doctor (3). Self-medication includes the purchase and use of over-the-counter (OTC) medications, prescription-only medications (POMs), and leftover medication out of recommended (4). Self-medication leads to resource waste, increased pathogens resistance, and antibiotic resistance (3, 5). Also, self-medication is associated with incorrect dosage, incorrect route of administration, long-term use, improper storage, drug interactions, polypharmacy, and the risk of dependence and abuse, so it has become a serious public health problem worldwide (6, 7). In most cases, the feeling of the mildness of the disease and no need to consult a doctor, previous pleasant experiences with self-treatment, the feeling of being able to self-care, and the lack of availability of a doctor increase self-treatment (4). Furthermore, socio-economic factors, lifestyle, sources of medical information, access to medicines, and the potential of managing some diseases through self-care are related to the continuous increase of self-treatment worldwide (7, 8). On the other hand, self-treatment reduces the economic burden on patients, the high cost of hospital treatments, and the pressure on health care systems, limiting the number of hospital visits (6, 9). Because self-treatment starts with self-diagnosis, the probability of its being incorrect is high, and even a correct diagnosis can be associated with the wrong treatment choice. Also, the average consumers do not know if they are in a particular group with significant side effects of medicine or not; they are unaware of drug contraindications. Sometimes, the patients take the same active ingredient with a different name, and there is a risk of double medication or harmful interactions. Sometimes there is a risk of the wrong prescription (e.g., intravenous instead of intramuscular) (10).
Different studies that have investigated the prevalence of self-medication in the COVID-19 pandemic around the world have reported different results. Knowing the prevalence of self-medication in this pandemic can provide health policymakers and researchers with helpful information. Therefore, the present study was conducted to estimate the overall prevalence of self-medication in the COVID-19 pandemic.
Methods
This systematic review and meta-analysis, which sought to estimate the pooled prevalence of self-medication in endemic COVID-19 globally, was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (11). The PRISMA checklist is attached as a Supplementary File 1. The protocol of this systematic review was not registered in Cochrane and PROSPERO.
Search strategy
We searched PubMed, Scopus, Web of Science, and Embase databases from January 2020 to May 2022 using the following terms: (“Self Medication” OR “Self Medicat*” OR “SelfMedicat*”) AND (“COVID-19” OR “SARS-CoV-2” OR “COVID 19” OR “2019-nCoV” OR “Coronavirus Disease-19” OR “SARS CoV 2” OR “2019 Novel Coronavirus” OR “Wuhan Coronavirus” OR “SARS Coronavirus 2” OR “Wuhan Seafood Market Pneumonia Virus”). Databases were searched in June 2022. To access more articles, the reference list of selected articles was reviewed. Further details are provided in Table 1.
Table 1. The search strategy.
Selection of studies and data extraction
The inclusion criteria were: observational studies reporting data on the prevalence or frequency of self-medication during the COVID-19 pandemic and published in English. Exclusion criteria included unrelated studies, interventional studies, review articles, theses, case reports, and repeated articles. According to the inclusion and exclusion criteria, the authors independently read the title and abstract of all articles and separated the relevant ones. In the next step, the authors reviewed the full text of these articles, and essential information such as the first author's name, year of publication, sample size, type of study, country, target group, mean age, and time of data collection were recorded in a pre-prepared form. Any disagreement was resolved by consultation and discussion.
Quality assessment
We used the Newcastle-Ottawa scale to check the methodological quality and assess the bias of the articles, which included seven items and three dimensions of selection, comparison, and result. These dimensions were assigned 5, 2, and 3 stars, respectively. The selection dimension with four items evaluates the target population, sample size estimation, non-response rate, and measurement tool. The first three items can be assigned up to one star and the fourth item up to two stars. The comparable dimension evaluates the use of the control group and can get up to two stars. The result dimension has two items evaluating the result (two stars) and statistical tests (one star). High-quality articles were defined as ≥4 stars (12). The bias assessment was checked by two authors independently, and any disagreements were resolved through consultation.
Meta-analysis
STATA version 16 software was used for data analysis. We used the binomial distribution to combine the selected studies. To show the general prevalence of self-medication from the Forest plot and to examine the heterogeneity among the selected studies, we used the I2 index and Cochran's Q test. We considered the I2 level >75% as high heterogeneity. Because the I2 index in this study was more than 75% and Cochran's Q test was significant, the random effects model was used to combine the selected studies. Subgroup analysis was performed based on the continent, target population, and year of data collection. Also, a meta-regression test was used to investigate the relationship between the prevalence of self-medication and the mean age of the participants. The publication bias of the studies was evaluated using a funnel plot based on Egger's regression.
Results
In the initial search, 674 articles were retrieved, of which 359 were removed due to duplication. Then, the authors independently reviewed the remaining articles' titles and abstracts. After screening the articles based on the inclusion and exclusion criteria, 186 articles were excluded. The full text of six articles could not be retrieved. The full text of the remaining 123 articles was reviewed. Sixty-seven articles were excluded due to not reporting the prevalence of self-medication or incomplete reports. Finally, 56 articles with a sample size of 56,063 subjects were included in the analysis (Figure 1).
Figure 1. The process of screening and selecting the articles based on the PRISMA guidelines.
In terms of quality, 32 articles had moderate quality, and 24 studies had excellent quality (Supplementary File 2). Twenty-six studies were published in 2022, 24 in 2021, and 6 in 2020. Twelve articles published in 2022, 14 published in 2021, and two published in 2020 were high quality. Most of the studies were conducted in the Asian continent (n = 31) and on the general population (n = 29). Also, the data of 31 studies were collected in 2020. Most studies were conducted in three countries: India (n = 11), Saudi Arabia (6 studies), and Nigeria (6 studies) (Table 2). The pooled prevalence of self-medication in these three countries was 45% (95% CI: 35–55), 57% (95% CI: 43–71), and 43.5% (95% CI: 26.5–60.5), respectively.
Table 2. The characteristics of included studies.
The pooled prevalence of self-medication was 49% (95% CI: 43–54). Also, the findings by continent showed that the highest and lowest prevalence of self-medication was in Asia (53%, 95% CI: 45–61) and Europe (40.8%, 95% CI: 35–46.8), respectively. The prevalence of self-medication in America (47.8%, 95% CI: 33.6–62) was higher than in Africa (41.5%, 95% CI: 29.5–53.5). By dividing the target population, the findings showed that the highest and lowest prevalence of self-treatment was related to students (54.5%, 95% CI: 40.8–68.3) and healthcare workers (35.5%, 95% CI: 16–49). The prevalence of self-medication in the general population was 49% (95% CI: 41–57) (Figure 2).
Figure 2. Prevalence of self-medication in the general population during the COVID-19 pandemic.
Also, the prevalence of self-medication in studies collected in 2021 (51.2%, 95% CI: 40.5–61.8) was higher than in studies collected in 2020 (48%, 95% CI: 40.3–55.7). The results of the subgroup analysis are presented in Table 3, the meta-regression results showed that the prevalence of self-medication was not related to the study sample size (p = 0.629), and the mean age of participants (p = 0.170). Publication bias was also not significant (p = 0.363) (Figure 3).
Table 3. Prevalence of self-medication during the COVID-19 pandemic by continent, target population, time of data collection.
Figure 3. Publication bias.
Discussion
This study, which was conducted to estimate the cumulative prevalence of self-medication in the COVID-19 pandemic, showed that nearly half of the people have self-medicated. The results of a previous meta-analysis conducted on 14 relevant studies published between April 1, 2020, and March 31, 2022, showed that the pooled prevalence of self-medication was 44.9% (65). In addition to updating that study, we reported the results of 56 eligible studies by continent, target population, and time of data collection in the present study. James et al. (66) noted that people worldwide practice self-care practices, which in many cases are done through self-medication.
If self-treatment is done correctly, it can be beneficial for one's health. The WHO also recognizes correct self-medication as a type of self-medication (67). Mir et al. (48) mentioned that self-medication encourages patients to rely on themselves in making decisions for the management of minor illnesses.
The highest prevalence of self-medication was related to students. A recent meta-analysis showed that the prevalence of self-medication in students (before the COVID-19 pandemic) was 49.5% (68). The prevalence of self-medication among college students seems to have increased during this pandemic. This finding can be attributed to their higher education level compared to the general population. The lowest prevalence of self-medication was related to healthcare workers. This finding may be due to their familiarity with the consequences of self-medication. The low prevalence of self-medication in the European continent can be due to clear instructions regarding the distribution and provision of medicine and the general knowledge of the people of that region. The prevalence of self-medication was higher in studies that collected data in 2021. The reason for this finding can be the reduction of people's extreme fear of the COVID-19 virus and everyone's familiarity with this disease. False information at the beginning of the disease and the health measures applied by the governments had led to psychological distress and significant fear in the people, so in some countries, people bought and stored toilet paper, face masks and staple foods and even armed (69).
Although the high prevalence of self-medication can indicate people's self-care behavior, it can also lead to serious risks, especially for the elderly, children, pregnant women, and people with underlying diseases. Due to the fact that in the future, it is possible that other waves of the COVID-19 pandemic or other pandemics may occur, it is necessary to prepare and present instructions and guidelines to separate safe self-medication from high-risk ones so that the risks of self-medication are minimized.
Limitations
One of the limitations of this study was that gray texts were not included in the analysis. The reason was the lack of access to the databases that provided these documents. Another limitation of this study was that in this systematic review and meta-analysis, only articles published in English were analyzed.
Conclusion
This study showed that self-medication during the COVID-19 pandemic was highly prevalent, so nearly half of the people had self-medicated at this time. The prevalence of self-medication in students was higher than in other groups. Also, with increasing age, the prevalence of self-medication had an almost downward trend. Considering the consequences of self-medication, it seems necessary to educate the general population through the media to increase drug information and improve their health literacy. Awareness of drug risks can reduce the practice of self-medication now and even in pandemics that may occur in the future.
Data availability statement
The original contributions presented in the study are included in the article/Supplementary material, further inquiries can be directed to the corresponding author.
Author contributions
GK and FT contributed to designing and performing this systematic review. RG and GK checked the data and conducted data analyses. SA and ML contributed to writing and editing the paper. All authors read and confirmed the final version of the manuscript.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
Supplementary material
The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpubh.2022.1041695/full#supplementary-material
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Keywords: self-medication, prevalence, systematic review, COVID-19, meta-analysis
Citation: Kazemioula G, Golestani S, Alavi SMA, Taheri F, Gheshlagh RG and Lotfalizadeh MH (2022) Prevalence of self-medication during COVID-19 pandemic: A systematic review and meta-analysis. Front. Public Health 10:1041695. doi: 10.3389/fpubh.2022.1041695
Received: 11 September 2022; Accepted: 17 October 2022;
Published: 03 November 2022.
Edited by:
Yusra Habib Khan, Jouf University, Saudi ArabiaReviewed by:
Sukrit Kanchanasurakit, University of Phayao, ThailandMohammed Gumaa, TRUST Research Center, Egypt
Copyright © 2022 Kazemioula, Golestani, Alavi, Taheri, Gheshlagh and Lotfalizadeh. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Mohammad Hassan Lotfalizadeh, dr.mohamadhassanlotfizadeh@gmail.com