A hospital-based cross-sectional study on parental self‑medication among children in a tertiary care hospital in Kolkata

Introduction: Self-medication / self-prescription, the practice of using measures to treat and handle diseases, without consulting appropriate authority, has been significantly inculcated in modern society. Parental self-medication is today a significant paediatric public health problem contributing to global rise of antimicrobial resistance. Objectives: To assess the magnitude and determinants of parental self-medication among children attending a tertiary care hospital in Kolkata. Method: This cross-sectional study was conducted on parents of 105 children attending the paediatric clinic of a tertiary care hospital in Kolkata. Universal sampling was employed. Parents were surveyed by face-to-face interview using a pre-tested semi-structured interview schedule validated by subject experts. Information on pattern, reasons, and perception of parental self-medication were elicited from the schedule. Microsoft Excel and STATA MP16 were used for statistical analysis. Results: Mean ages of the parents and their children were 31.79±5.6 years, and 5.3±2.9 years respectively. Prevalence of parental self-medication was 78.1% (95%CI: 69-85%). Analgesic-antipyretics were the most common type of medicine used during self-medication (77.1%), whereas prior experience in dealing with similar illness was the most common reason (42%) for practising self-medication. Higher educational level of respondent parent and increased age of child (>3 years) were significantly associated with the practice of self-medication in bivariate analysis. Conclusions: Prevalence of parental self-medication was 78.1%. Analgesic-antipyretics were used during self-medication in 77.1% cases. Prior experience in dealing


Introduction
Self-medication or self-prescription is a common practice in many developing countries, where without consulting a doctor or pharmacist, a significant proportion of individuals use medicines to handle or treat illnesses.Self-medication makes an individual vulnerable to various health issues like risks of drug interactions, drug resistance, adverse drug reactions, inappropriate drug choice and augmented polypharmacy.The health hazards (short-term or long-term) due to intake of non-prescribed medications are greater in children 1 .Parents prefer to treat their children with various medications along with self-medication.The rise in the occurrence of 'mixopathy' (trend of simultaneous administration of allopathic, homeopathic, or ayurvedic treatments) is also responsible for the magnitude of self-medication.According to a study in China, one-third of the child population had parental self-medication of antibiotics 2 .Principal medicines used were analgesics, antibiotics, anti-allergic drugs and cough syrups 3 .
Antibiotics are widely misused in low-resource settings, and self-medication of antibiotics are contributing to the rapidly growing global phenomenon of antimicrobial resistance (AMR) 4 .Self-prescription often arises from self-diagnosed health issues, or information regarding any signs or symptoms and their remedies.This information usually derives from old prescriptions for similar symptomatology, frequent suggestions by relatives or friends, and/or mass media and social media advertisements 1,5,6 .
Parental protective behaviour, which establishes itself as a common cultural denominator, might be attributable to the higher magnitude of self-prescription among children who belong to higher socioeconomic strata.Easy accessibility of multiple treatment outlets, improper distribution of non-prescription drugs by community pharmacists, their profit-seeking behaviour, in addition to lack of proper knowledge and attitude of parents /caregivers regarding indication of various drugs (antibiotics) catalyse the phenomenon of parental selfmedication 7,8 .An Indian study reported that mismanagement of leftover drugs from previous prescriptions was the commonest reason for selfmedication among children 9 .Though parental selfmedication is an emerging public health problem with major implication, its prevalence has not been estimated in East India, especially among children availing of paediatric treatment in the tertiary healthcare setup.

Objectives
To assess the pattern of parental self-medication and its contributing factors in children attending the paediatric department of a tertiary care hospital in Kolkata and to find the sources of knowledge and pattern of medicines used in parental self-medication.

Method
An observational cross-sectional study was conducted on parents of children attending the paediatric department (both outdoor and indoor clinic) of ESI-PGIMSR and ESIC Medical College and Hospital Joka, a tertiary care hospital of Kolkata, India, in September 2021.

Inclusion and exclusion criteria:
Parents/ caregivers of children who were under twelve years old at the time of data collection were selected for the study.Parents of critically-ill patients were excluded from the study.

Sample size:
This was estimated to be 105 using Cochran's formula, considering prevalence of parental self-medication among paediatric age group as 61% from a recent Indian study 10 done at a similar setting, 10% absolute error of precision, 5% ɑ-error, and 10% nonresponders.
Complete enumeration method was implemented during sampling, wherein data were collected from all eligible study participants present in the paediatric department during the time of data collection.After rapport building, parents were surveyed by face-to-face interview using a pre-tested semi-structured interview schedule adapted from a previous study 11 .
The study tool was face and content validated by public health experts.Apart from socio-demographic characteristics, data were elicited on pattern of selfmedication, reasons for parental self-medication, observation of effect of self-medication, and perception of parents about self-medication.In the sub-section for pattern of self-medication, the participants were surveyed on the discipline and type of medicines used for selfmedication, symptomatology of paediatric age group for which parental self-medication took place, and the duration of self-medication.The sub-section of reasons for parental self-medication also included the question about the sources of knowledge about the treatment of self-medication.
Ethical issues: Approval for study was obtained from the Institutional Ethics Committee of ESI-PGIMSR & ESIC Medical College and Hospital Joka, Kolkata (No. ESI/114/IEC(JOKA)/2022) dated 14.11.2022, and due care was taken so that confidentiality of study participants was maintained.Written informed consent was obtained from the parents/guardians of the participating children.

Statistical analysis:
Data collected were compiled in Microsoft Excel and analysed using appropriate statistical technique.STATA MP16 was used for data analysis.Categorical data were expressed in frequencies and percentages and continuous data by mean, median, standard deviation and inter-quartile range.Appropriate statistical tests of significance were performed to estimate association of various factors with the dependent variable of parental self-medication.For all tests a p-value <0.05 was considered statistically significant.
Perception of guardians of the paediatric age group regarding self-medication was found to be worrisometwo-third of the study participants did not consider visiting a doctor as a necessary step whenever their child became ill.Around 70% of the parents perceived selfmedication as a completely safe process.
The common sources of knowledge about the treatments (or medicines) for self-medication were family and friends (51%) and doctor's previous prescription (47%).The primary reasons for parental self-medication among the study participants are demonstrated in Figure -2.
The effectiveness of self-medication was elicited through observation of parents of direct adverse effects after administration of self-prescribed medicines.Forty three out of the 82 participants who performed parental selfmedication reported occurrence of side effects and subsequent transport of the child to nearest healthcare facility.Among these incidents, children were suffering from severe adverse effects 15 times.Table 2 demonstrates the association of parental selfmedication with various socio-demographic characteristics through bivariate analysis.Increasing age of the child and higher educational level of the parent were positively associated with occurrence of selfmedication which was statistically significant.According to results of the current study, pre-school children (aged 0-3 years) were less self-medicated by their parents than school-going children.

Discussion
The current study shows a 78.1% prevalence of parental self-medication among the children (82 of 105 participants) indicating a significant public health problem.A nation-wide online survey in China reported only 24.2% self-medication among children aged 12 years or younger 3 .Similarly, a study by Naaraayan SA, et al 13 showed a 32% prevalence of self-medication among children attending out-patient department of a tertiary care hospital in South India.Prevalence of family self-medication among children in a tertiary hospital of North-east India was 56% 9 .However, recent studies in Romania and Italy reveal a trend of increasing selfmedication rates (70% and 69.2% respectively) among parents of children 14,15 .The disproportionately high prevalence in the current study might be because most study participants were selected from in-patient facilities of the hospital, and the possibility of parental selfmedication before subsequent admission due to adverse effect thus came into effect.
In the current study, children above three years of age were more likely to be self-medicated by their parents than those below three years.A study by Yu M, et al 16 found independent association between increasing age of children and parents' self-medicating behaviour in rural areas of China.Another study in China showed that children aged three years or more were more likely to be self-medicated by their caregivers than children aged 0-2 years, in both rural and urban areas 17 .
Parent's educational level was also significantly associated with their self-medicating practices.This is contrary to findings of other contemporary studies where the higher the mother's educational attainment, the less the chances of children being self-medicated 18,19 .The probable reason could be the attitude of educated parents regarding minor illness and confidence over their own prior experience of similar illness, as demonstrated in the Peruvian multi-centre study by Paredes JL, et.al 20 .In current study, no significant differences in prevalence of parental self-medication were found across gender and birth order categories.
The reasons for parental self-medication in the current study are multifactorial.Prior experience in dealing with similar ailment was the commonest cause for the practice among parents in our study, which is consistent with findings of recent studies in Iraq 21 and Mongolia 22 .Perception of mildness of illness was also prominent in the present study, which resonates with results from the study by Tarciuc P, et al 14 where the likelihood of parental self-medication was higher in children whose parents perceived that self-medication was not harmful in minor ailments.Metlo M, et al 6 , in their evaluation of reasons for self-medication among educated parents in Pakistan, found consideration of the ailment as mild to be the chief reason.A hospital-based study in Congo reported the main reason for parental self-medication in children was avoidance of formalities and cost in the treatment 23 .
In the current study, the commonest drugs used for selfmedication were antipyretic analgesics like paracetamol, which is in line with the existing literature of facilitybased studies on parental self-medication 9.24-26 .The main sources of knowledge of the treatment (or medicines) were family, friends, and doctors' previous prescription.A study in Central India by Rathor P, et al 27 reported pharmacists and internet as the chief sources of knowledge for self-medication.Around one-third of selfmedicated children in the present study was administered antibiotics.This could add to the pool of antimicrobial resistance from early ages.As per clinic-based study in China, children with parental self-medication with antibiotics were more likely to be subsequently prescribed antibiotics with doctors resulting in a vicious cycle of dangerously inappropriate antibiotic use behaviour 28 .Practice of self-medication with Ayurvedic medication, and mixed pathies was a finding consistent with other Indian studies 27,29 .
The present study has a few limitations.The sample size is not optimal to generalize its findings of patterns of self-medication in children to a large-scale population.Due to the cross-sectional design, longitudinal effect of self-medication in children cannot be properly elicited.Moreover, lack of probabilistic sampling technique impairs the external validity of the findings.Notwithstanding methodological limitation, this study determined the burden of parental self-medication of children in a tertiary care setting in Eastern India, where there is a scarcity of research on the topic.
There are many adverse health implications of inadvertent self-medication including adverse drug reaction, drug-drug interaction, loss of efficiency in medicines, incidence of resistance in subsequent administration etc. Proper education of parents regarding ill-effects of self-medication must be implemented from the physician level.Accessibility of basic paediatric healthcare facilities should be increased, and strict legislation should be ensured to stop pharmacists providing medicines without proper prescription.Future research, preferably longitudinal in design, is needed to determine the association between hypothesized risk factors and parental self-medication.Studies in the community covering a larger population should be conducted to depict the appropriate burden in society.Preventive strategies should include public awareness and strengthening of regulatory mechanisms towards drug marketing.

Conclusions
Prevalence of parental self-medication was 78.1%.Analgesic-antipyretics were used during self-medication in 77.1% cases.Prior experience in dealing with similar illness was the reason for practising self-medication in 42% cases.Higher educational level of the respondent parent and increased age of child (>3 years) were significantly associated with the practice of selfmedication.