Knowledge, attitudes and practice of self-medication among university students in Portugal: A cross-sectional study

Research report Knowledge, attitudes and practice of self-medication among university students in Portugal: A cross-sectional study Regina Ferreira Alves University of Minho, Braga, Portugal Jos´ e Precioso University of Minho, Braga, Portugal Elisardo Becon ˜a University Santiago de Compostela, Corun ˜a, Spain Abstract Aims: To describe the knowledge, attitudes and practices of self-medication in college students and to analyse the predicting factors for the engagement in that behaviour. Design: This is a crosssectional study involving students (n¼840) from a Portuguese university, selected through stratified and proportional sampling. Data were collected using a self-administered questionnaire containing, in addition to sociodemographic issues, a scale measuring knowledge about selfmedication (a¼.488), a scale measuring attitudes towards self-medication (a¼.708) and questions about the patterns of self-medication practices (a¼.445). Differences between outcomes and sociodemographics were analysed through independent t-tests and ANOVA. A generalised linear model was calculated to determine the predictive variables of self-medication. Results: Over half of the respondents ( 54.3%, n¼434) had used some form of self-medication during the preceding year. Students revealed poor knowledge about the referred practice, correctly answering 1.60 (SD ¼0.936) questions in a total of 3, and favourable attitudes towards selfmedication (M¼2.17, SD ¼0.950, range 1–5). Attending engineering sciences (b¼.718, 95% CI: Submitted: 8 January 2020; accepted: 18 September 2020 Corresponding author: Regina Ferreira Alves, CIEC - Research Centre on Child Studies, Universidade do Minho, 4710-057 Braga, Portugal. Email: [email protected] Nordic Studies on Alcohol and Drugs 2021, Vol. 38(1) 50–65 ªThe Author(s) 2020 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/1455072520965017 journals.sagepub.com/home/nad Creative Commons CC BY: This article is distributed under the terms of the Creative Commons Attribution 4.0 License (https://creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 1.373–3.069, p< .001), being female (b¼.866, 95% CI: 1.700–3.327, p<.001)andhaving negative attitudes towards self-medication (b¼.367, 95% CI: 1.227–1.698, p< .001) predict the adoption of those practices. Conclusions: Self-medication is a common practice among university students, the level of self-medication knowledge is low and the low score of the level of attitudes revealed that students tended to have a correct positioning towards self-medication. Therefore, the recommendation to develop campaigns or educational programmes becomes obvious, in order to inform about the adverse effects of the use of non-prescribed medicine. Keywords knowledge, rational use of medicine, self-medication, university students Self-medication is the act by which a person, on their own account or as a result of recommendation from a third party, chooses to administer medicine to themselves in order to prevent, treat or cure a condition whose identity and severity is generally unknown (WHO, 2000a). Self-medication may include using leftover drugs from treatment courses prescribed previously, or drugs obtained from relatives or friends (Ocan et al., 2015), along with “nonprescription” or “over-the-counter” medicine. In some countries, such as Portugal, nonprescription medication is not only available in pharmacies, but also in supermarkets and other outlets (Martins et al., 2016). Self-medication is recommended by the World Health Organization (WHO) to treat self-recognised disorders or symptoms, or to treat chronic or recurring diseases or symptoms, using drugs prescribed by doctors (WHO, 2000a), making it explicitly clear that there is indeed a valid place for self-medication in developed societies. However, it simultaneously points out the need to inform the population about the appropriate use of over-the-counter medications, adopting a more educational approach to health education (WHO, 2000a). This is because the health consequences of this practice are numerous, depending on the type of medication and the varying sensitivity of each individual to them. For example, some of the repercussions for one’s health stemming from this practice include increased resistance to certain types of medication, decreased efficacy of treatments due to inappropriate use, delay of the proper diagnosis, severe medication side effects, toxicity, dangerous drug interactions, drug dependency, hypersensitivity to certain drugs, resistance withdrawal symptoms, and countless other health problems, such as drug overdose or extreme dependence (Bennadi, 2014; Hughes et al., 2001; WHO, 2000b). Nonetheless, the WHO has, however, indicated that responsible self-medication does present the advantage of preventing and treating those diseases which do not require prior medical consultation and has the potential to provide a cheaper alternative for treating common disease (WHO, 2000a). There is an increasing tendency to use medications indiscriminately, making this practice a public health problem (Kasulkar & Gupta, 2015) in the developing countries just as much as in the already developed nations. Globally, with the exception of some North American and Northern European countries (Morgan et al., 2011), selfmedication is a generalised common practice. Although the prevalence of self-medication may vary from country to country, several factors have shown a very consistent association with this practice (Carrasco-Garrido et al., 2014; Martins et al., 2002). Studies show that the main reasons for the practice of self-medication are the following: sufferingfrom a mild illness,havingprevious experience in treating similar illnesses, economic conditions, unavailability of healthcare Alves et al. 51 professionals and generalised excessive accessibility and availability of over-the-counter medications (Hughes et al., 2001), with young age and high educational level being frequent contributing factors for the likelihood of engaging in selfmedication (Martins et al., 2002). Several national (Mendes & Lopes, 2014; Ribeiro et al., 2010) and international (Abay & Amelo, 2010; Adhikary et al., 2014; Al Flaiti et al., 2014; Alshawi et al., 2018; Corrˆea da Silva et al., 2012; Donkor et al., 2012; El-Ezz & Ez-Elarab, 2011; Galato et al., 2012; Garofalo et al., 2015; Gonz´alez-Castillo et al., 2019; Gyawali, 2015; Helal & Abou-Elwafa, 2017; Idris et al., 2016; Klemenc-Ketis et al., 2010; Kumar et al., 2013; L´opez-Cabra et al., 2016; Lukovic et al., 2014; Mustafa & Rohra, 2017; Sawalha, 2008; Skliros et al., 2010; Tuyishimire et al., 2019; Xu et al., 2019) studies from various countries on self-medication practices have focused on college students, identifying an increase and a high prevalence in this particular group (Al Flaiti et al., 2014). This may be relatedtomanyfactorssuchassociodemographic settings, lifestyle, accessibility and availability of medication, increased knowledge, advertisement and high level of education (Martins et al., 2002). In this study, our main aim was to describe the knowledge, attitudes and practices of selfmedication among college students and to analyse the predictive factors for the engagement in that behaviour. Materials and methods Population and sample For the 2018/2019 academic year, 5447 students were registered in the first and third years of integrated bachelor’s and master’s degrees. Excluded from the sample were courses related to health sciences, undergraduate or postgraduate masters and those that did not have classes in the first or third year. Students belonging to the area of health sciences have been excluded from this research because we felt that their knowledge about health in general had the potential to generate some degree of bias in the results of the scales used in the present study, since scientific studies indicate that students in the health area display a higher level of knowledge when compared to those belonging to other areas of study (Xu et al., 2019). In order to carry out this study, the absolute minimum number of students we required was 592 (margin of error ¼5%, confidence level¼99 %, and response distribution¼50%). With the aim of achieving our objective, we carried out a stratified probabilistic sampling of students in the university setting based on the specific academic year they were attending and the specific scientific area of study as well. We chose to divide the several undergraduate and master’s degrees in accordance with a criterion of scientific areas attended (complying with the definition provided and issued by the Foundation for Science and Technology): social and human sciences, judicial and economic sciences, exact and nature sciences and engineering sciences. This cross-sectional research consisting of results obtained from questioning students in the college context (n¼840) attending one university in Portugal has provided us with information gathered by resorting to a validated self-reported questionnaire without biochemical confirmation. The subjects who were part of the study were made up of 464 incoming students (55.2%)and 376 finalist students (44.8%). Regarding the scientific category of studies, 302 students (36.0%) belonged to the area of engineering sciences, 270 (32.1%) to the social and human sciences, 136 (16.2%) to the exact and nature sciences and 132 (15.7%) to the area of judicial and economic sciences. The majority of subjects was female (55.4%,n¼465), at that point not involved in a loving relationship (58.3%,n¼ 486), displaced from their usual residence (64.9%,n¼537), full-time students ( 88.8%, n¼739) and had a body mass index (BMI) corresponding to what is unanimously scientifically considered to be normal weight ( 73.1%,n¼599). The average age of the 52 Nordic Studies on Alcohol and Drugs 38(1) students who took part in this study was 20.78 years (SD ¼4.221), with a minimum of 18 years old and a maximum of 54 years. Instrument Currently, several scientific instruments exist to analyse the prevalence of self-medicating practices among young adults, such as the Youth Risk Behavior Surveillance System (YRBSS) (CDC, 2017b), the National Survey on the Use of Psychoactive Substances in the General Population (Balsa et al., 2017), the European School Survey Project on Alcohol and Other Drugs (ESPAD) (Hibell et al., 2012), the Behavioral Risk Factor Surveillance System (BRFSS) (CDC, 2017a) and the National Survey on Drug Use and Health (SAMHSA, 2017). However, none of the information gathered using the approach taken by any of these surveys entirely met the expectations and intentions behind the decision to carry out the present research. As a result of that, we developed the instruments used and referred to in this research in three different, separate stages – scale construction (first stage); content validity (second stage); and psychometric validity (third stage) – in accordance and compliance with the undertakings defined by Oppenheim (1992) and Bowling (1998). In order to build the scale (first stage) we undertook a review of the existing literature on this topic, so that we understood which specific questions and items were commonly used in order to evaluate the level of knowledge, attitudes and practices of self-medication among students in the university academic context. We have generated an analytical matrix based on the review mentioned directed towards the different and varying dimensions we meant to analyse, and also towards identifying those with the same semantic similarities, which were excluded from the study. For the purpose of completing content validity (second stage), 10 PhD researchers from several Portuguese universities known for the quality of their previous existing work in the area of health education and higher education have been invited to take part in a specific portion of this study. We have considered and went as far as including in the analysis data we gathered from five of the mentioned invited researchers in our final report, while all suggested semantic adaptations were also taken into account. In a similar fashion, the instrument was introduced to 12 university students, using the “thinking aloud” method (Bowling, 1998; Keszei et al., 2010) in order to identify items that might have been confusing, exclude less relevant or redundant ones, and finally to verify that pre-coded response options were sufficient. With the aim of attaining a broader and deeper level of objectivity, we have settled on the following scale as the measure of clarity for each item: 1 ¼confused, 2 ¼unclear, 3 ¼clear. After we received recommendations that pointed out the need to redraft, the preliminary version of the questionnaire survey was presentedto a sample of 32 students who were subsequently excluded from the final sample. Thequestionnaireincludedsociodemographic variables (sex, age, scientific area of study, academic year, weight and height (to calculate BMI), loving relationship, professional situation and current residence) and specific questions to measure the following variables: Prevalence of self-medication – “In the last 12 months, how many times have you consumed any of the following psychoactive substances as listed (without prescription): antidepressants/sedatives/ soothing/tranquilisers; analgesics/antiinflammatory medication; vitamins/food supplements”. Possible answers: never; 1–2 times; 3–5 times; 6–9 times; 10 or more times, with 1 point being assigned to each behaviour that was practiced at least once. Self-medication patterns were analysed according to the classification: Yes (having self-medicated at least once in the last 12 months) and No (having not self-medicated in the last 12 months). The scale’s confidence index (Cronbach’s alpha) was .445. Alves et al. 53 Self-medication knowledge – three-item scale (“Excessive use of paracetamol causes liver toxicity”; “Changing the schedules for taking medication does not pose any danger”; “Food supplements can be taken without medical prescription because they do not cause any negative effects on the organism”). Answer options: true, false, don’t know. One point was assigned to each correct answer, while providing an incorrect answer or responding “I don’t know” resulted in 0 points. The sum of all items was calculated, hence higher scores correspond to a higher level of knowledge. Cronbach’s alpha in the sample was .488. Attitudes towards self-medication – two items on a five-point Likert scale (1 ¼ strongly disagree, 5 ¼fully agree) (“It is acceptable to use non-prescription drugs for a short time”, and “It is acceptable to use previously prescribed medications to treat the same symptoms”). The results obtained in this scale show the following dynamics: the higher the average of the scale, the more negative the attitudes of university students toward self-medication were, ranging from 1 to 5. Cronbach’s alpha for the scale calculated with the sample of this study was acceptable (a¼.708). Procedure and statistical analysis The application of the instrument was carried out in the classroom context and in paper-and-pencil format for all students in the sample, after acquiring informed consent. A total number of 873 questionnaires was administered to subjects, and that number reflects the total number of students who were simultaneously present in the classroom and had accepted to take part in the study. We excluded 33 questionnaires from our final examination and results, given the fact that they were poorly filled in or given back unanswered (or answered in incomplete terms). The rate of response was 96.2%(95%CI 94.8–97.6). All ethical research procedures with humans referred to by Christensen et al. (2015) were fulfilled and the study was approved by the university ethics committee. Data were analysed using IBM Statistical Package for the Social Sciences (SPSS), version 26.0 (Armonk, NY, USA). Descriptive analyses were performed for the demographic variables and practice questions. In order to analyse the psychometric characteristics of the scales, we have studied their reliability resorting to Cronbach’s alpha calculation (a). Regarding the topic of knowledge about self-medication and attitudes towards self-medication, the mean scores were calculated and then compared among different subgroups of respondents, using appropriate statistical tests. An independent samples t-test was used for dichotomous variables and analysis of variance (ANOVA) for others, with Bonferroni used for multiple comparison procedures. We calculated the connections and interactions between the results of the study resorting to Pearson’s correlation. Finally, we calculated a generalised linear model with the purpose of defining and identifying the predictive variables and factors involved in the likelihood ofengaging in selfmedication practices. In order to calculate this this model, we have used the sociodemographic variables which presented and showed statistically significant differences when it came to the specific matter of self-medicating practices. Betas (b)andtherespective95%confidence intervals (95%CI) are presented. A p-value of .05 orless was considered statistically significant, with the exception of multiple comparisons between groups, for which the Bonferroni correction was applied. Results The findings showed that self-medication was a common practice among university students, since over half of the respondents ( 54.3%,n¼ 434) had used some form of self-medication during the preceding year. Analgesics/antiinflammatories ( 40.8%,n¼326) were commonly used for self-medication, followed by vitamins/food supplements ( 26.4%,n¼211) 54 Nordic Studies on Alcohol and Drugs 38(1) and antidepressants/sedatives/soothing/tranquilisers ( 13.9%,n¼111) (Table 1). The results indicate that self-medication was more common among female students (62.0%, n¼269, w 2 (1) ¼18.348, p¼.000) compared to male students (38.0%,n¼131) (Table 2). We found that girls use more analgesics/antiinflammatory medication (47.7%,n¼210) and antidepressants/sedatives/soothing/tranquilisers (19.0%,n¼84) than boys (32.2%,n¼116 (w 2 (1) ¼19.715, p¼.000) and 7.5%,n¼84 (w 2 (1) ¼22.140, p¼.000), respectively). Vitamins/ food supplement consumption was higher in engineering science students compared to the other science areas (w 2 (3) ¼13.652, p¼.003). The level of knowledge about selfmedication was 1.60 +0.936 (out of 3). In Table 3, it is observable that students in the natural and exact sciences and in the judicial and economic sciences have a higher level of knowledge about self-medication compared to students in the engineering sciences (F(3, 833) ¼5.812, p¼.001),andalsothatfemaleshad a higher level of knowledge than male students (t(835) ¼–3.699, p¼.000). The level or type of attitudes towards selfmedication is 2.17 +0.950, a minimum of 1 and a maximum of 5, with the highest value corresponding to more negative attitudes. It means that students showed favourable attitudes towards self-medication, because the majority of respondents disagreed or strongly disagreed with the items (“It is acceptable to use non-prescription drugs for a short time” – 65.1%and “It is acceptable to use previously prescribed medications to treat the same symptoms” – 60.0%). As shown in Table 4, there were significant differences based on practices of self-medication. Students who had self-medicated in the past year are those who exhibit more favourable attitudes toward self-medication practices (t(788) ¼– 4.739, p¼.000). This was also due to the type of medication used without supervision, i.e., regardless of the type of medication taken in the last 12 months, attitudes are always more favourable to analgesics/anti-inflammatory medication (t(789) ¼–3.830, p¼.000), antidepressants/sedatives/soothing/tranquilisers (t(790) ¼–3.175, p¼.002) and vitamins/food supplements (t(788) ¼–3.469, p¼.001). There was no statistically significant correlation between the level of knowledge and the level of attitudes (r¼–.064, p>.05). Table 1. Self-medication-related characteristics. f% Self-medication No 365 45.7 Yes 434 54.3 Last 12 months Antidepressants/sedatives/soothing/tranquilisers (without prescription) Never 690 86.1 1–2 times 62 7.7 3–5 times 19 2.4 6–9 times 8 1.0 10 or more times 22 2.7 Analgesics/anti-inflammatory medication (without prescription) Never 474 59.3 1–2 times 139 17.4 3–5 times 94 11.8 6–9 times 47 5.9 10 or more times 46 5.8 Vitamins/food supplements (without prescription) Never 588 73.6 1–2 times 95 11.9 3–5 times 41 5.1 6–9 times 19 2.4 10 or more times 56 7.0 Alves et al. 55 Table 2. Frequencies and chi-square test for sociodemographic variables and self-medication and type of self-medication practices. General self-medication (Yes) Self-medication of analgesics/ anti-inflammatories (Yes) Self-medication of antidepressants/ sedatives/ soothing/ tranquilisers (Yes) Self-medication of vitamins/food supplements n(%) w 2 n(%) w 2 n(%) w 2 n(%) w 2 Year of Frequency First year 243 (55.4) 0.421 185 (42.1) 0.780 68 (15.5) 0.915 110 (25.1) 2.085 Third year 191 (53.1) 141 (39.1) 43 (11.9) 101 (28.1) Scientific area Engineering sciences 163 (56.6) 2.725 116 (40.3) 1.301 29 (10.0) 9.353* 98 (34.0) 13.652* * Exact and natural sciences 77 (56.6) 58 (42.6) 27 (19.9) 29 (21.3) Judicial and economic sciences 63 (55.3) 41 (44.3) 13 (11.3) 27 (23.7) Social and human sciences 131 (50.2) 101 (38.7) 42 (16.1) 57 (21.8) Sex Male 165 (46.0) 18.348* ** 116 (32.2) 19.715* ** 27 (7.5) 22.140* ** 92 (25.6) 0.205 Female 269 (61.1) 210 (47.7) 84 (19.0) 119 (27.0) Age < 20 years 181 (53.9) 0.047 139 (41.4) 0.092 46 (13.6) 0.021 76 (22.6) 4.283* 20 years 253 (54.6) 187 (40.3) 65 (14.0) 135 (29.2) Loving relationship Yes 186 (53.6) 0.190 142 (41.2) 0.020 40 (11.5) 2.795 95 (27.4) 0.254 No 246 (55.2) 182 (40.7) 70 (15.7) 115 (25.8) Current residence Displaced 157 (56.5) 0.758 112 (40.3) 0.059 46 (16.5) 2.969 71 (25.5) 0.129 Not displaced 271 (53.2) 210 (41.2) 62 (12.1) 136 (26.7) Professional situation Full-time student 381 (54.2) 0.024 286 (40.6) 0.140 96 (13.6) 0.296 179 (25.5) 3.559 Worker / student 49 (55.1) 38 (42.7) 14 (15.7) 31 (34.8) BMI Low weight 34 (60.7) 1.055 24 (42.9) 3.748 15 (26.8) 8.750* 15 (26.8) 0.093 Normal weight 306 (53.7) 222 (38.9) 78 (13.6) 151 (26.5) Overweight 85 (55.2) 73 (40.8) 17 (11.0) 39 (26.3) Note. Bold indicates statistically significant difference after applying the Bonferroni correction. BMI ¼body mass index. *p< .05. ** p< .01. *** p< .001. 56 Results from the generalised linear model indicated that the scientific area of study, sex of students and the attitudes towards selfmedication had a statistically significant effect in the measure of self-medication practices. Thus, attending engineering sciences (b¼.718, 95% CI: 1.373–3.069, p< .001), being female (b¼ .866, 95%CI: 1.700–3.327, p<.001)andhaving negative attitudes towards self-medication (b¼ .367, 95%CI: 1.227–1.698, p< .001) predict the adoption of those practices (Table 5). Discussion In our study, more than half of college students reported self-medication practices in the last 12 months. This corroborates the findings of a study conducted in 2014 in Portugal, where it Table 3. Mean, one-way ANOVA and t-test for sociodemographic variables and knowledge about selfmedication. Knowledge about self-medication ANOVA Mean (SD)Zp Scientific area Engineering sciences 1.43 (0.940) 5.812 .001 Exact and natural sciences 1.72 (0.849) Judicial and economic sciences 1.77 (0.970) Social and human sciences 1.64 (0.933) BMI Low weight 1.74 (0.849) 1.873 .154 Normal weight 1.63 (0.930) Overweight 1.50 (0.970) t-student tp Self-medication Yes 1.66 (0.896) –2.279 .023 No 1.51 (0.966) Self-medication of analgesics/ anti-inflammatory medication Yes 1.70 (0.901) –2.589 .010 No 1.52 (0.946) Self-medication of antidepressants/sedatives/ soothing/tranquilisers Yes 1.77 (0.839) –2.223 .027 No 1.56 (0.944) Self-medication of vitamins/food supplements Yes 1.61 (0.935) 0.868 .386 No 1.55 (0.923) Year of frequency First year 1.66 (0.922) 2.117 .035 Third year 1.52 (0.950) Sex Male 1.47 (0.955) –3.699 .000 Female 1.70 (0.908) Age < 20 years 1.63 (0.920) 0.875 .382 20 years 1.57 (0.948) Loving relationship Yes 1.59 (0.954) –0.367 .714 No 1.61 (0.915) Current residence Displaced 1.66 (0.888) 1.371 .171 Not displaced 1.57 (0.956) Professional situation Full-time student 1.59 (0.927) –1.279 .201 Worker/student 1.72 (0.993) Total 1.60 (0.936) Note. Bold indicates statistically significant difference after applying the Bonferroni correction. BMI ¼body mass index. Alves et al. 57 was found that 58.7%of incoming students self-medicated (Mendes & Lopes, 2014). The prevalence of consumption of medicines without prescription in highereducation varies by geographical area, so in previous studies in the Middle East region it was shown that university students engaged more frequently in selfmedicating behaviour than the subjects analysed in our study (Palestine – 98%, Sawalha, 2008; Kuwait – 70.4%, Mitra et al., 2019; New Delhi –85.4%, Adhikary et al., 2014; Saudi Arabia – 73%, Alshawi et al., 2018 and 65.58%,Mustafa & Rohra, 2017; India – 84.0%,Kumaretal., 2013; Nepal – 83.3%, Karmacharya et al., 2018 and 81.9%, Gyawali, 2015). In this region studies were conducted in some countries which also identified a similar prevalence of this behaviour when compared to Portuguese university students (Egypt – 55%, El-Ezz & Ez-Elarab, 2011; Bangladesh – 54.5%, Idris et al., 2016; Kingdom of Table 4. Mean, one-way ANOVA and t-test for sociodemographic variables and attitudes towards selfmedication. Attitudes towards self-medication ANOVA Mean (SD)Zp Scientific area Engineering sciences 2.25 (0.923) 1.378 .248 Exact and natural sciences 2.10 (0.919) Judicial and economic sciences 2.16 (1.048) Social and human sciences 2.11 (0.945) BMI Low weight 2.23 (0.834) 0.363 .696 Normal weight 2.16 (0.925) Overweight 2.22 (1.046) t-student tp Self-medication Yes 2.31 (0.919) –4.739 .000 No 1.99 (0.952) Self-medication of analgesics/ anti-inflammatory medication Yes 2.32 (0.913) –3.830 .000 No 2.06 (0.956) Self-medication of antidepressants/sedatives/ soothing/tranquilisers Yes 2.44 (0.887) –3.175 .002 No 2.13 (0.950) Self-medication of vitamins/food supplements Yes 2.36 (0.937) –3.469 .001 No 2.10 (0.942) Year of frequency First year 2.11 (0.929) –1.785 .075 Third year 2.23 (0.973) Sex Male 2.18 (0.967) 0.424 .672 Female 2.15 (0.937) Age < 20 years 2.11 (0.910) –1.433 .152 20 years 2.21 (0.977) Loving relationship Yes 2.18 (0.974) 0.426 .671 No 2.15 (0.933) Current residence Displaced 2.17 (0.983) 0.252 .801 Not displaced 2.15 (0.920) Professional situation Full-time student 2.18 (0.947) 1.101 .271 Worker/student 2.07 (0.949) Total 2.17 (0.950) Note. Bold indicates statistically significant difference after applying the Bonferroni correction. BMI ¼body mass index. 58 Nordic Studies on Alcohol and Drugs 38(1) medical students. Asian Journal of Medical Sciences,7(6), 63. https://doi.org/10.3126/ajms. v7i6.15246 Skliros, E., Merkouris, P., Papazafiropoulou, A., Gikas, A., Matzouranis, G., Papafragos, C., Tsakanikas, I., Zarbala, I., Vasibosis, A., Stamataki, P., & Sotiropoulos, A. (2010). Selfmedication with antibiotics in rural population in Greece: A cross-sectional multicenter study. BMC Family Practice,11. https://doi.org/10. 1186/1471-2296-11-58 Tuyishimire, J., Okoya, F., Adebayo, A. Y., Humura, F., & Lucero-Prisno, D. E. (2019). Assessment of self-medication practices with antibiotics among undergraduate university students in Rwanda. Pan African Medical Journal,33. https://doi.org/10.11604/pamj. 2019.33.307.18139 WHO. (2000a). Guidelines for the regulatory assessment of medicinal products for use in self-medication. WHO Drug Information,14. https://apps.who.int/iris/handle/10665/66154 WHO. (2000b). The benefits and risks of selfmedication: General policy issues. WHO Drug Information,14(1), 1–2. https://apps.who.int/ iris/handle/10665/57617 Xu, R., Mu, T., Wang, G., Shi, J., Wang, X., & Ni, X. (2019). Self-medication with antibiotics among university students in LMIC: A systematic review and meta-analysis. The Journal of Infection in Developing Countries,13(08), 678–689. https:// doi.org/10.3855/jidc.11359 Alves et al. 65