A Systematic Review Of The Literature To Assess Self-medication Practices
Original ArticleArticleA Systematic Review of the Literature to Assess Selfmedication PracticesDnyanesh Limaye1,2,3*, Vaidehi Limaye3, Gerard Krause1, 2, Gerhard Fortwengel3Department of Epidemiology, Helmholtz Centre for Infection Research, Braunschweig, Germany, 2Hannover Medical School,Hannover, Germany, 3Faculty III, Hochschule Hannover, University of Applied Sciences and Arts, Germany1Corresponding author:Dnyanesh Limaye. “PhD Programme”“Epidemiology“, Helmholtz Centrefor Infection Research, GmbH,Braunschweig” Braunschweig,Germany.Tel: 4951192962585;Email: dnyanesh.limaye@hs-hannover.deAbstractBackground: Self-medication, practiced globally is an important public health problem.Research studies have indicated inappropriate self‐medication results in adverse drugreactions, disease masking, and inaccurate diagnosis of disease, increased morbidity, druginteractions, antibiotic resistance and wastage of healthcare resources. Rationale: Severalself-medication systematic reviews have been written for specific population like adolescents,elderly population and medical students, etc. or for particular country or for specific disease.As the issue of self-medication and associated antibiotic resistance presents an importantglobal public health problem with a reported worldwide increase in self-medication practicesin the last decade, an integration of available global self-medication data could be useful toget a comprehensive yet comparative understanding about associated problems, antibioticresistance, reaching stronger conclusions and planning future intervention than those drawnfrom reviews on specific target diseases or populations. We therefore intended to systematicallyreview the existing literature on global self-medication practices in order to gain comprehensiveinformation regarding prevalence, sample populations, medications used, target disease andreasons for self-medication. Methods: We conducted a systematic review of the literature onself-medication practices by searching, PubMed Medline and Web of Science database usingthe following combination of keywords - self-medication, self-prescription, non-prescription.Truncation was used to ensure retrieval of all possible variations of search terms. The searchwas limited to articles published between 1st January 2000 and 31st December 2016, humanstudies and English language. Duplicate and irrelevant studies were excluded from the finalreview. Results: A total of 140 studies covering 189279 subjects from children, adults, to geriatricpopulation, with the overall prevalence of SM ranging from 0.1% to 100%, were included inthe review. Studies were from diverse geographical locations. Majority of the studies werefrom Brazil (12; 9%), followed by 9 (6%) each from India (9; 6%) and Pakistan and 8 (6%) fromNigeria. Most of the studies (44; 31%) were done to find antibiotic SM prevalence, and 75 (54%)studies were done without any specific therapy area focus. Antibiotics (82; 59%), followed byNSAID’s (43.31%), and cough and cold medicines (13.9%) were the most widely self-medicateddrugs. Cough and cold (61.43%), body pain (45; 32%), gastrointestinal complaints (44. 31%)were the top reported health complaints in the studies and pharmacy (80.57%), relatives &friends (45.32%), left overs (31; 22%), were the most common sources of self-medication.Conclusion: Self-medication was seen as a widespread phenomenon along with antibiotics asmost widely self- medicated drugs. The World Health Organization reported alarming levelsof resistance to antibiotics in member countries. The misuse of antibiotics poses a serious riskto infectious disease control and public health in general. Lack of knowledge in lay peopleand lack of attention of the public health researchers regarding not only self-medication butassociated important problem like antibiotic resistance and potential adverse events deservesimmediate implementation public health programs for increasing awareness and importanceof this issue. At the same time, while implementing the rules and regulations governmentsshould improve on providing adequate and affordable access to health care services. Furthercross sectional studies with a standardized methodological approach are needed to gain bettercomparative understanding of global SM prevalence and practices.Keywords: Self-medication; Self-prescription; Non-prescription; Antibiotic resistanceIntroductionQuest for recovery from diseases and having wellness is a naturalhealth seeking behaviour. In response, self-medication is themost commonly seen phenomenon [1]. The term self-medication(SM) refers to the use of drugs to treat self-diagnosed disordersor symptoms, or the intermittent or continued use of a prescribeddrug for chronic or recurrent disease or symptoms [2,3]. Mainsources of self-medication are relatives, friends, pharmacists1This is an open access article distributed under the terms of the Creative CommonsAttribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix,tweak, and build upon the work non‑commercially, as long as the author is creditedand the new creations are licensed under the identical terms.How to Cite this Article: Dnyanesh Limaye. A Systematic Review of theLiterature to Assess Self-medication Practices. Ann Med Health Sci Res.2017; 7: 1-15 2017 Annals of Medical and Health Sciences Research
Limaye D et al.: Literature to assess Self-medication Practiceswho not only provide medicines but also the information aboutdrug’s use [4,5]. At the same time several factors like lack ofaccess to health care, physician fees, time constraint, lack oftrust on physician, inadequate implementation of drug lawshave been shown to influence self-medication behavior [5-7].Guidance a search strategy for PubMed Medline and Web ofSciences is presented here in Figure 1 [30].Self- medication is an important public health problem and ispracticed globally [3,7-9]. with a reported prevalence of 21% inLithuania [10]. 19.8% in Romania [10]. 15.2% in Spain [10]. 21%in Portugal [8]. 31% in Czech Republic [11] among Europeancountries. In developing countries reported prevalence rates aremuch higher, with 79% in India [12]. 84% in Pakistan [3]. 78% inSaudi Arabia [13]. 67% in Nigeria [14].Several studies have indicated that inappropriate self-medicationresults in adverse drug reactions, disease masking, inaccuratediagnosis of disease, increased morbidity, drug interactions,antibiotic resistance and wastage of healthcare resources [7,15-18].RationaleIn the past several years, several systematic reviews on selfmedication have been written for specific population likeadolescents [5,19] elderly population [20] physician and medicalstudents [21] for particular countries [22,23]. or for specific disease [2426].As self-medication has a substantial impact on public healthwith growing practice [27-29]. it is helpful to have the issue of selfmedication presents an important public health issue, it maynot only be a problem but could also offer advantages in manysituations. There has been reported increase in self-medicationpractices in the last decade worldwide [27-29]. As self-medicationhas a substantial impact on public health with growingpractice, it is helpful to integrate global self-medication data.It would give comprehensive yet comparative understanding,reaching stronger conclusions and planning future interventionthan those drawn from reviews on specific target diseases orpopulations. As a part of the background for this effort, existingliterature on self-medication was reviewed. This reviewprovides an overview of global self-medication practices. Itgives comprehensive information regarding prevalence, samplepopulations, medications used, target disease and reasons forself-medication.MethodSearch strategyAuthors conducted a systematic review of the literature on selfmedication practices. Preferred Reporting Items for SystematicReviews and Meta-Analysis (PRISMA) flow diagram andguidance set out by the Centre for Reviews & Disseminationwas followed for this review [30,31]. understanding of diseases andhealth, growth in information technology, number of availablemedications, and drug information have been identified as keyfactors contributing to increase in self-medication practicesin the last decade [27-29]. Based on this, PubMed Medline andWeb of Science database were searched for papers publishedbetween 1st January 2000 and 31st December 2016. Title/abstract search was conducted with a combination of key words:self-medication, self-prescription, non-prescription. Truncationwas used to ensure retrieval of all possible variations of searchterms. As per Centre for Review and Dissemination (CRD)Figure 1: Literature search strategy.Screening and eligibility criteriaPairs of reviewers (four - eyes principle) - independentlyscreened the resultant literature from PubMed and Web ofScience by reviewing their titles and abstracts. Search waslimited to articles in English language and available as full textpublication. Eligible studies for full text review were selectedby excluding duplicate studies. Studies which were opinions,critiques of previous studies, letters to editors, were excludedand only those explicitly referring to self-medication practiceswere included for full text review. Two reviewers appraised thefull text of each study independently. Any discrepancies betweentwo reviewers were resolved through discussion, or involving athird reviewer as arbiter, if necessary. Finally, a third reviewer- checked all the excluded and included studies to validate thefinal selection of publications. Limiting the search to these twodatabases may not provide access to all self-medication studiesand may influence the results, authors are aware of this as astudy limitation.Data extractionTwo reviewers screened all the full text articles to look for selfmedication practices details. Based on the results, a databasewas designed to enlist the self-mediation components addressedby them. Following self-medication component details wereextracted from each study: year of publication, country of origin,population sampled, self-medication therapy area if any, selfmedication definition, study objective, socioeconomic details,health insurance, reasons, sources, medical conditions treated,antibiotic resistance awareness, patient leaflet use, adverseevents checks, place and survey method, recall period, ethicalapproval for study, and pilot study information.ResultsLiterature search resultsThe literature search as shown in Figure 1 generated a total1663 studies from PubMed Medline and Web of Science. Titleand abstract review was done to remove duplicate (342) andirrelevant studies (1181). (We defined irrelevant studies as –publications not based on own studies conducted by authorsto investigate self-medication or which are giving opinion orcritique of previous studies, or with a focus on drug dependency,Annals of Medical and Health Sciences Research September 2017 Vol 7 Special Issue 1 2
Limaye D et al.: Literature to assess Self-medication Practicessubstance abuse, safety database, pharmacist views, mooddisorders, medical ethics and emotional socialization). Finally140 studies were included in the systematic review. The studydetails are presented in Table 1 [32-154].Study characteristicsThe studies in the 140 publications differed in sample size,therapy areas, self-medication prevalence, recall period, andTable 1: Self-Medication Prevalence From Various Countries.CountrySample size176-379Argentina (2)[100,101]134-141Bahrain (2)[15,17]500-1300Bangladesh (2)[18,116]772Brazil meroon (1) [1]30-1459China (6) [32,86,90,112,130,149]414Colombia (1) [125]287-389Croatia (2) [ 41,111]979Czech Republic (1) [11]251Congo (1) [127]1959Denmark (1) [44]1100Egypt (1) [147]270-1257Ehiopia (4) [17,148,121,133]1705Euro-Mediterranean region (1) [66]1090-15548Europe (4) [9,10,49,55]857Finland (1) [42]100-3027France (2) [107,155]600Ghana (1) [91]150-1139Greece (2) [73,128]418Guatemala (1) [134]100-1928India (9) [6,12,54,87,99,139,146,151,153]25Indonesia (1) [135]180-500Iran (6) [7,47,73,106,129,140]467Israel (1) [38]1269Italy (3) [93,102,141]819Jordan (4) [60,63,144,152]100-1110Kuwait (3) [43,56,136]500Lao (1) [45]319Lebanon (1) [114]1005Lithuania (1) [138]314Malaysia (1) [29]245Mexico (1) [70]142Nepal (1) [35]Study Therapy AreaOphthalmology, PsoriasisNSAntibiotics, NSNSDentalAntibiotics, NSNSAnalgesic, NSNSNSAntibioticsNSAntibiotics, NSAntibioticsAntibioticsNSSteroids, NSAntibioticsAntibiotics, NSAntibioticsDentistry, NSAntibioticsMigraine, AntibioticsAntibioticsAntibiotics, NSAntibiotics, NSDiabetes, Antibiotics, ics,Malaria, Colic, Menstrual210-4128Nigeria (8) [14,40,50,75,81,82,83,93]Disease, Dentistry, ENT, Antimalarial, NS150-1850Antibiotics, NSPakistan (9) e (2) [61,104]609-891AntibioticsPoland (2) [103,137]1192-3198Antibiotics, NSPortugal (3) [8,48,117]461NSAIDRomania (1) [110]504NSAID, AntibioticsSaudi Arabia (3) [13,131,142]383-1296NSSerbia (2) [124,143]410-1294NSSlovenia (4) [77,78,79,88]190-20738Antibiotics, NSSpain (4) [34,46,76,95]175AntibioticsSri Lanka (1) [132]1000-1750Antibiotics And Anti-malarialsSudan (3) [16,39,51]690AntibioticsSweden (1) [37]93MalariaTanzania (1) [119]400-3720NSThailand (2) [53,71]602-3521Antibiotics, NSTurkey (4) [33,36,64,154]860AntibioticsUAE (1) [67]884AntibioticsUganda (1) [115]19-691Antibiotics, NSUSA (3) [62,65,74,97]160NSVietnam (1) [145]1200AntibioticsYemen, Saudi Arabia, and Uzbekistan (1) [118]NS Non-specific; ENT Ear, Nose, Throat, NSAID Non-steroidal anti-inflammatory drugsAnnals of Medical and Health Sciences Research September 2017 Vol 7 Special Issue 1 Self-medication 01 to 370.1 to 9220-7710073-820.3NS86-9219-58567531-10039783
Limaye D et al.: Literature to assess Self-medication Practiceslocation. These studies covered 189279 subjects from children,adults, to geriatric population. Sample size ranged from 19 to20738. The articles reviewing self-medication prevalence ratesoriginated from different countries (Table 1).Six studies were multinational in nature and investigated crossnational prevalence of SM among adults from Yemen, SaudiArabia, and Uzbekistan [118]. Euro-Mediterranean - Cyprus,Egypt, Jordan, Lebanon, Libya, Tunisia and Turkey [66] andEurope [9,10,49,55]. Majority of the studies were from Brazil (12;9%) [52,58,68,69,80,85,89,98,105,109,120,123]. followed by 9 (6%) each fromIndia (9; 6%) [6,12,54,87,99,139,146,151,153]. and Pakistan [3,59,84,96,108,113,122,125,150].and 8 (6%) from Nigeria [14,40,50,75,81,82,83,93].Majority of the studies used face to face interview method(98.70%) for data collection, while self-administeredquestionnaire technique was used for remaining 42 (30%)studies. Seventy-five (54) studies were done without any focuson specific therapy area for self-medication, whereas 44 (31%)studies investigated self-medication prevalence of antibiotics,rest of the studies were in other therapy areas for example:malaria, analgesic, diabetes, menstrual symptoms etc.Results based on specific self-medication aspectsDefinition of self-medication: The phrasing of self-medicationdefinition was inconsistent across studies. Twenty-six (18%)studies failed to report definition of SM. However the mostcommon themes used in definition were as follows: use of drugswithout consultation of healthcare professional (57; 40%), useof drugs without prescription (27; 19%), use of the drugs withown initiative (24; 17%). Remaining 8 (6%) studies used varieddefinitions of self-medication such as – using the drug withlay advice, at the recommendation of family/friends, use afterdemanding from pharmacist etc.Performance characteristics of SM: After a review of 140publications, it was seen that only 93(66%) publications reportedthat they had obtained ethical approval for conducting the researchstudy. Reported recall period varied from - on that day to ever inlife. Before conducing the main study only 63(45%) publicationsreported piloting before initiation of the study. Response ratesvaried from as low as 2% for a web-based platform study and 18%to as high as 100% in face to face interview studies (Table 2) [155-172].Prevalence rates and associated factorsThe overall prevalence of SM ranged from 0.1% to 100% and 3studies did not report SM prevalence (Table 2) [62,86,119]. Thirtyseven studies had low (less than 36% i.e. below 25th percentile),63 studies had medium (between 36% to 77% i.e., 25th to 75thpercentile), whereas 40 studies had high prevalence (more than77% i.e., above 75th percentile) of SM.Most of the studies (44.31%) were done to find antibiotic SMprevalence, some other therapy areas studied were analgesics,malaria, and psoriasis etc., whereas 75 (54%) studies were donewithout any specific therapy area focus.Antibiotics SM prevalence varied from 1% to 100%. Seventeenstudies had low, 21 studies had medium, whereas 7 studies hadhigh prevalence of SM. High antibiotic prevalence was reportedfrom studies done in the developing countries like Indonesia,Sri Lanka, Nigeria, Sudan, Guatemala etc. Greece was the onlycountry belonging to developed nations which showed a highantibiotic SM prevalence 77% [72].A cross national study done in 19 European countries showedhigh prevalence rates of self-medication with antimicrobialdrugs in eastern and southern Europe and low in northernand Western Europe [10]. Younger age, higher education, andpresence of a chronic disease were associated with higherrates of self-medication. Another cross national study done in12 European countries indicated that higher gross domesticproduct (wealth) and exact dispensation of prescribed tabletquantities by pharmacies were independently associated withlower likelihood of antibiotic self-medication [55]. A study inEuro-Mediterranean region revealed that prevalence of selfmedication with antibiotics varied from 0.1% in Cyprus to 37%in Lebanon [66]. Rates of self-medication rose with increasingage in Lebanon [66]. A study done in Yemen, Saudi Arabia,and Uzbekistan documented self-medication prevalence ofantibiotics varied from 48% in Saudi Arabia to 78% in Yemenand Uzbekistan [148]. In Yemen and Saudi Arabia younger womenand respondents with a lower level of education were morelikely to self-medicate with antibiotics [118]. A descriptive, crosssectional study reported SM prevalence of 20% among 20738Spanish adult populations [76]. The prevalence of self-medicationwas 17% for women and 14% for men (p 0.05). The variablesthat were independently and significantly associated with agreater probability of self-medicated consumption in womenwere: lower age; consumption of alcohol; smoking habit.Among men, self-medication was associated with nationality(immigrants were more likely to self-medicate), income, andalcohol consumption [76]. A cross-sectional study done with3,720 undergraduate students in the Northern part of Thailandshowed that 86% participants used self-medication. Femaleshad significantly higher SM prevalence than males [53].Socioeconomics and health insuranceIncome, education and health insurance aspects were lookedinto 51(36%), 115(82%), and 28(20%) studies respectively.Participants with higher income [39,85] and higher education level[32,63,64,69,151]and having insurance [32,63,64]. were reported to bemore likely to use SM.Antibiotic resistance, prescribing information, adverseeventsKnowledge about antibiotic resistance, prescribing informationreading, and adverse events awareness among participants werereported in 12(9%), 18(13%), and 49(35%) studies respectively.On the backdrop of overall lack of attention of the public healthresearchers on the important problems related to self-medication,concerns about antimicrobial resistance, and potential adverseeffects were reported as disadvantages of self-medication withantibiotics in the urban population of Yogyakarta, Indonesia [135].Lack of antibiotic resistance knowledge was seen amongparticipants from Kuwait, over half of participants did not agreeon the statements: ‘the unnecessarily use of antibiotics canAnnals of Medical and Health Sciences Research September 2017 Vol 7 Special Issue 1 4
Limaye D et al.: Literature to assess Self-medication PracticesTable 2: Summary of results.VariablesOverall prevalence of SMAntibiotic SM prevalenceSample sizeRecall periodResponse rateTotal participant populationParticipants self-medicatedVariablesEthical approvalPilot studyIncomeEducationHealth insuranceAntibiotic resistancePrescribing information readingAdverse event awarenessDrugs used for self-medication Antibiotics 9,150,151,152,13,154,156]Range0.1% to 100 %1 to 100%19 to 20738point of time to lifetime use2 % to 100 %18927981665 (43%)Number of studies (%)91 (65 %)63 (45 %)51 (36%)115 (82%)28 (20%)12 (9%)18 (13%)49 (35%)82 (59%)43 (31%) NSAID13 (9%) Cough & cold medications [7,8,12,85,57,61,68,100,105,125,130,154,156]5 (4%) Antimalarial [39,40,51,94,120]Sources of self-medication 9,10180 ,143,144,145,148,154] friends and relatives 20,126,137,138,139,140,147,150,151,153,154,156]45 (32%)31 (22%) left overs11 (8%) home pharmacy [6,7,11,18,41,59,66,103,120,125,126]8 (6%) previous prescriptions [6,17,54,55,63,90,119,124]Reasons for self-medication time constraint 105,107,109,113,114,115,116,117,118,59 ,143,144,147,148, 149,150,154,156] cost constraint 136,141,146,149,150,151,152,153] mild disease Have knowledge ,116,118,127,139,140,141,152,153,154] past experience 4,117,122,132,136,145,149,150] no trust in physician 151,157] convenience [13,59,63,71,91,113,135,151,152] previous prescription [12,92,109,126,129,142,148]Self-medicated health complaints Cough and cold 54,156] Body ,155]GI diseases 7,128,129,133,134,135,137,141,144,146,53 (38%)28 (20%)25 (18%)24 (17%)16 (11%)9 (6%)7 (5%)61 (43%)45 (32%)147,148,155,157]44 (31%)FeverInfection ,153,155]Headache 2,123,124,126,129,132,147,149,154]Menstrual problems [6,43,45,53,57,76,99,112,119,124,132]Skin disease [13,32,43,53,71,74,76,115,129,133]Malaria [39,40,51,94,120,128]40 (29%)32 (23%)24 (17%)11 (8%)10 (7%)6 ,133,135,139,143,147,149,152,154,155,156]increase the resistance of bacteria to them’ (51%), ‘resistance toantibiotics is a worldwide problem’ (53%) [136].Another study among non-medical students from Karachi,Pakistan reported that while 63% participants denied havingany knowledge about antibiotic resistance, only 20% correctlyknew that indiscriminate use of antibiotics can lead to increasedantibiotic resistance [113]. A study from Central Saudi Arabiainvestigating attitudes towards SM found that 44% participantsindicated that they always read the medication pamphlet, and29% believed that buying medication without prescription isnot safe practice [142]. A study evaluating the knowledge, attitudeand practice of SM among medical students from Arabian GulfUniversity, Bahrain found that 45% of the participants practicedAnnals of Medical and Health Sciences Research September 2017 Vol 7 Special Issue 1 5
Limaye D et al.: Literature to assess Self-medication PracticesSM, 72% read the package insert, and 33% reported risk ofadverse reactions as a reason against SM [15].Self-medicated drugsThe most widely self-medicated drugs were antibiotics (82;59%), followed by NSAID’s (43; 31%), and cough and coldmedicines (13; 9%). 5(4%) Studies done in Sudan,[39,51]. Nigeria[40,93].and Tanzania [119]. reported SM of antimalarial drugs asshown in Table 2.AntibioticsAntibiotic SM varied from 1 to 100% as shown in Table 2.Penicillins were the most commonly used medicines for SMand participants of younger age, higher education, and havinga chronic disease were associated with higher prevalence ofself-medication [10]. Authors also reported that, respondents’self-diagnosed disorders were self-limiting and antimicrobialdrugs would not have been indicated [10]. Seventy percentof the university students from Accra, Ghana indicated thatthey practiced SM with antibiotics. The most commonly usedantibiotic was amoxicillin (23.9%). Thirty five percent of thestudents who practiced self-medication indicated that theirtreatments were not successful, and among these 77% continuedwith SM but changed the antibiotic. Forty six percent of thestudents did not complete the full course of antibiotics, while51% of the respondents were aware that SM could cause adversehealth effects such as antibiotic resistance [91].A study done in Bahir Dar City, Ethiopia reported 18%prevalence of SM with amoxicillin (64.4%) as most commonlyused antibiotic. Individuals with lower educational status,younger age groups, and those unable to read and write weremore likely to use SM with antibiotics. Authors also reportedthat in Ethiopia, amoxicillin is the most commonly prescribedantibiotic from which its common use in community couldhave arisen [133]. Twenty six percent antibiotic SM prevalencewas reported among participants from Bangladesh andmetronidazole (50%) was the most frequently self-medicatedantibiotic. Diarrhea, dysentery and food poisoning werethe main indications for self-medication, revealing the poorhygienic food intake of the Bangladeshi people as pointed outin the study. Forty one percent participants reported excellentdisease recovery and of them 7% reported side effects for theSM of antibiotics [116].NSAIDsFollowed by antibiotics (82; 58%), NSAIDs (43; 30%) were thesecond most self-medicated drugs, as shown in Table 2. A studydone to find influence of medical training on self-medicationby students in Bahrain showed NSAIDs (81%) were the mostcommonly used drugs for SM. This correlated well with highincidence of headache, mostly stress-related among medicalstudents as a very common indication for self-medication [57].Similarly a study done in Tabriz, Iran showed NSAIDs (21%)were the most commonly used drugs for SM among the clientsof drug stores. Administrative employees consistently requestedfewer SM drugs than blue-collar workers [7]. A study done toinvestigate the contents of home medicine chests and theirrelationship with self-medication in children and adolescents inBrazil, showed that NSAIDs (27%) were most commonly storeddrugs [58]. Many of these had past their expiry date (12%) andwere missing (33%) their original patient information leafletsor labels. Medicines were stored in kitchen or bathroom, whichcould lead to physical or chemical changes due to exposureto heat, cold, humidity and sunlight, in addition to the risk ofcontamination by chemical and sanitary products. Furthermore,in this study it was observed that storing medicines in thebathroom was a risk factor for self-medication, perhaps becausethe products are more easily accessed and more likely to benoticed there [58]. A study in dental patients from Karnataka,India showed that NSAIDs (42.5%) were the most commonlyused drugs for SM with a high prevalence among females. Thismay be due to lower threshold towards pain in females andgreater fear of dental treatments among them [139]. A study inRomania did not find significant difference in self-medicationwith NSAIDs among urban (92%) and rural (81%) participants.There were no significant differences based on education, orgender among the participants [110].Anti-malarialsAntimalarial self-medication prevalence varied from 4.4% to50% [39,51,40,93,119]. A study done in Khartoum, Sudan reported43.4% prevalence of SM with anti-malarials. A Higherprevalence was seen in males, younger age group of 40years, middle income earners and less educated respondents[39].Thirty nine percent of the respondents who self-medicatedwith antimalarials reported
literature on self-medication was reviewed. This review provides an overview of global self-medication practices. It gives comprehensive information regarding prevalence, sample populations, medications used, target disease and reasons for self-medication. Method Search strategy Authors conducted a systematic review of the literature on self-
May 02, 2018 · D. Program Evaluation ͟The organization has provided a description of the framework for how each program will be evaluated. The framework should include all the elements below: ͟The evaluation methods are cost-effective for the organization ͟Quantitative and qualitative data is being collected (at Basics tier, data collection must have begun)
Silat is a combative art of self-defense and survival rooted from Matay archipelago. It was traced at thé early of Langkasuka Kingdom (2nd century CE) till thé reign of Melaka (Malaysia) Sultanate era (13th century). Silat has now evolved to become part of social culture and tradition with thé appearance of a fine physical and spiritual .
On an exceptional basis, Member States may request UNESCO to provide thé candidates with access to thé platform so they can complète thé form by themselves. Thèse requests must be addressed to esd rize unesco. or by 15 A ril 2021 UNESCO will provide thé nomineewith accessto thé platform via their émail address.
̶The leading indicator of employee engagement is based on the quality of the relationship between employee and supervisor Empower your managers! ̶Help them understand the impact on the organization ̶Share important changes, plan options, tasks, and deadlines ̶Provide key messages and talking points ̶Prepare them to answer employee questions
Dr. Sunita Bharatwal** Dr. Pawan Garga*** Abstract Customer satisfaction is derived from thè functionalities and values, a product or Service can provide. The current study aims to segregate thè dimensions of ordine Service quality and gather insights on its impact on web shopping. The trends of purchases have
Chính Văn.- Còn đức Thế tôn thì tuệ giác cực kỳ trong sạch 8: hiện hành bất nhị 9, đạt đến vô tướng 10, đứng vào chỗ đứng của các đức Thế tôn 11, thể hiện tính bình đẳng của các Ngài, đến chỗ không còn chướng ngại 12, giáo pháp không thể khuynh đảo, tâm thức không bị cản trở, cái được
Le genou de Lucy. Odile Jacob. 1999. Coppens Y. Pré-textes. L’homme préhistorique en morceaux. Eds Odile Jacob. 2011. Costentin J., Delaveau P. Café, thé, chocolat, les bons effets sur le cerveau et pour le corps. Editions Odile Jacob. 2010. Crawford M., Marsh D. The driving force : food in human evolution and the future.
Le genou de Lucy. Odile Jacob. 1999. Coppens Y. Pré-textes. L’homme préhistorique en morceaux. Eds Odile Jacob. 2011. Costentin J., Delaveau P. Café, thé, chocolat, les bons effets sur le cerveau et pour le corps. Editions Odile Jacob. 2010. 3 Crawford M., Marsh D. The driving force : food in human evolution and the future.
