Prevalence and Predictors of Self-Medication with Antibiotics for Children in Makkah, Saudi Arabia

Self-medication with antibiotics is becoming a very common practice, and it is being practiced globally carrying a significant economic burden and health hazards. This study assesses prevalence and predictors of self-medication with antibiotic for children. A cross-sectional study was carried out on 252 mothers selected randomly from primary health care Centers in Makkah, during the period Jan July 2016. Mothers were interviewed about giving their children antibiotic without prescription using a semi structured questionnaire. Data was analyzed using IBM advanced SPSS statistical package version 23. Logistic regression analysis was done to determine which of the factors are independently associated with self-medication with antibiotic for children. As a result, in total, 252 respondent mothers were interviewed with mean age 36.7±18.4. The prevalence of self-medication with antibiotic for children was 39.3% despite that the majority 82.9% has satisfactory knowledge about proper antibiotic use. Amoxicillin clavulenic is the most self-prescribed antibiotic representing 53.3% followed by amoxicillin 25.6%. The predictors for self-medication were educational level, income, residence and knowledge about antibiotics use. It was concluded that, Self-medication with antibiotics for children is a common practice. Policies and considerable efforts are needed to challenge the self-medication with antibiotics especially increasing the awareness among mothers about the self-medication with antibiotics risks and hazards.


Introduction
Self-medication with antibiotics is an ongoing main global health problem. It is defined as the use of non-prescribed medications by people on their own initiative or on the advice of another individual, without physician consultation [1]. Antimicrobial resistance is one of the world's most persistent public health challenges. Inappropriate and prevalent use of antibiotics could lead to occurrence of antibiotic resistance and treatment failure [2].
In addition, self-medication with antibiotics has economic burden and health hazards due to patients shifting to more than one category of antibiotics as a consequence of the failure of the first line antibiotic [3].
On the other hand, numerous studies conveyed that self-prescription might lead to delay in seeking for health care which results in inconsistent economic loss resulting from failure or delay of diagnosis of underlying illnesses and proper treatment [4,5].
Previously, most studies reported that the frequency of self-prescription with antibiotics is relatively greater in developing countries than in developed countries [6,7]. Regions of Eastern Europe and southern showed much higher prevalence of self-medication than western areas of Europe and northern area [7]. The prevalence has been announced to be approximately 3% in Europe [8]. Conversely, there is an enormous increase in Asia, with the values around 4-75%, which may reach 80.4%in college students [9] or even 92% in Kuwait [10].
Saudi Arabia has a worldwide significance in epidemiology of antimicrobial resistance [6,7]. In addition, Prevalence of self-medication with antibiotics in Saudi Arabia was about 80.6% [11]. At this time the health care system in Saudi Arabia is facing a challenge to reduce selfmedication with antibiotics to decrease bacterial resistance and minimize its burden [12].
Advice from Families, the pharmacist, friends, even continuing previously prescribed medications, or recommendations from an advertisement in widespread magazines and newspapers are the most common sources of self-medications [12].
This study aims to raise awareness about the hazards of using antibiotics without medical prescription, by questioning a number of mothers and comparing the data to other results obtaind from different countries.

Subjects and Methods
A cross-sectional study was carried out on 252 mothers who have children younger than 12 years in Makkah region selected randomly from primary health care Centers in Makkah, during the period Jan -July 2016. Sample was collected by using multistage random sample, first 5 primary health care centers were chosen from primary setting in Makkah then about 50 mothers were selected by simple random sample in each selected center. Mothers were interviewed using a semi structured questionnaire. The tool includes three main sections first section about socio demographic data (age, place of housing, education, no of children and health insurance), second section about selfmedication with antibiotics for their children (type of medication, causes for giving antibiotics, source of data about giving antibiotics without medical consultation) and the third section concerning knowledge about proper use of antibiotics (indications, side effects, dose and precautions). satisfactory knowledge was set at 60%. This study was done after getting consent from all interviewed mothers. All data is solely used in the proposed research and confidentiality was assured.

Statistical Analysis
Data was analyzed using IBM advanced SPSS statistical package version 23. Chi-square test was used to examine the relation between qualitative variables. Logistic regression analysis was done to determine which of the factors are independently associated with self-medication with antibiotic for children. P-Value less than 0.05 was considered significant.

Results
In total, 252 respondent mothers were interviewed with mean age 36.7±18.4, 50.4% of them have more than two children less than 12 years, 68.8% have sufficient income and 43.3% have a family member working in the medical field and 51.6% don't have health insurance. Table 1 summarizes the socio demographic characteristics for participants and predisposing factors (age, educational level, residence, occupation, income and number of children less than 12 years).  Figure 1 shows that 39.3% of mothers provide their children with antibiotic without medical consultation. Mothers give their children antibiotics mainly in case of fever 23.8% and sore throat 23%.   The main sources for self-medication in the study participants are shown Figure (3). The vast majority were advised by pharmacist 50.8% followed by friends and relatives 33.7%. According to scoring of respondents' knowledge of antibiotics, majority (82.9%) has satisfactory knowledge. Table 2 shows the correct statements that were discussed with mothers to estimate their knowledge about antibiotic. Approximately 70.2% of mothers correctly believe that antibiotic should not be given to all cases when body temperature rises. Additionally, 53.2% of the respondents knew that antibiotics are used for bacterial infection only. Moreover, 75% reported that inappropriate antibiotic use might lead to microbial resistance while the majority of the respondents (86.9%) correctly identified that antibiotics could cause adverse drug reactions (ADRs). The results of the binary logistic regression analysis including those variables that were significantly different between mothers who practice self-medication and mothers who do not in the univariate analysis are presented in Table 3. The predictors for self-medication were educational level, income, residence and knowledge about antibiotics use.

Discussion
Self-medication with antibiotics might increase the risk of inappropriate use and microbial resistance. In the current study, the results indicate that 39.3% of all mothers provided their children antibiotics without medical prescription. This rate is similar to Jordan study results, which shows that 40.7% of the population used antibiotics without consulting their physicians [13]. Similarly a study was conducted in USA, revealed that the prevalence of self-medication was of 43% [14] and in agreement with the prevalence of selfmedication in china 35.12% [15]. On the contrary, the rate in much lower in Indonesia 7.3% [16]. While it was much higher in UAE's 56.3% [17] the result was inconsistent with the prevalence of self-medication with antibiotic in Eastern Province of Saudi Arabia (80.0%) [18] and 78.7% in Riyadh [19] and 74% in Sudan [20]. It is clear that, self-medication is much higher in developing countries as compared to developed ones which might be related to the cost of physician consultation and low level of satisfaction with general practitioners and the time constraints. On the other hand, it may be related to inefficient high disciplinary regulations. Conversely in developed countries they could afford the cost of medical consultation first and buying the prescribed medications later. Another reason that contributes to the raise of self-medication in developing countries is the existence of antibiotics as OTC medications and can be easily bought from any pharmacy.
The current study revealed that mothers were advised to use self-prescribed antibiotics mainly by pharmacist 50.8% followed by recommendations from friends and relative 33.7%. These results were in agreement to some extent with a study that shows the sources of the non-prescribed antibiotics were pharmacy 53.6% and relatives and friends 10.3% while a previous treatment 36.1% [13].
Amongst the antibiotics given to the participants' children, the most commonly used antibiotics were amoxicillinclavulanic acid 53.3% followed by amoxicillin 25.6%. Our results were in agreement with reported results from different studies in Jordan, Sudan and Greece [13,20,21,22]. On the other hand, amoxicillin was the most commonly selected antibiotic for self-medication [16,19,23,24 ].
In the present study, fever 23.8% and sore throat 23% were the most common reasons for which self-medication with antibiotics were used. This finding matches the common reasons highlighted for self-medication with antibiotics in earlier studies [13,19,20]. However, the common reason was influenza 44.2% in study conducted in UAE's [17].
In the current study, the predictors for self-medication were educational level, income, residence and knowledge about antibiotics which is in agreement with some other studies that revealed age and income are known to be predictors for self-medication [25,26,27].

Conclusion
Self-medication with antibiotics for children is a common practice. Policies and considerable efforts are needed to challenge the self-medication with antibiotics especially increasing the awareness among mothers about the selfmedication with antibiotics risks and hazards.

Recommendations
1. Health education program should be available for the public about self-medication hazards and complications 2. Policy makers should prevent antibiotics to be available as over the counter drugs