Self-medication during COVID-19 outbreak: a cross sectional online survey in Dhaka city

Abstract

Background: Self-medication is a common practice in Bangladesh as it provides a low-cost alternative for people, which involves inappropriate and injudicious use of medicines treat self-recognized symptoms by the people.Methods: A cross sectional online survey was conducted on 626 citizens by structured questionnaires during COVID-19 outbreak from April to May 2020 in Dhaka city, to observe the prevalence, pattern and sources of self-medication among the respondents with high socio-economic standings and education.Results: The prevalence of self-medication amid the outbreak of COVID-19 was 88.33% and only 179 (28.59%) took medication with doctors’ advice and remaining 447 (71.40%) respondents took the drugs as “self-medication” by other sources. The most frequently used prescription-only drug during the outbreak were ivermectin (77.15%), azithromycin (54.15%), doxycycline (40.25%). The common symptoms for which the respondent took self-medications were fever, throat pain, dry-cough and total 105 (16.77%) respondents took medications without having any symptoms. Almost 355 (85.33%) had taken medication without doing any test for COVID-19. This could be due to unusual distress, caused by high self-awareness of their health and buying capacity of medication.Conclusions: The study revealed the causes of self-medication as news of spread, effects and remedies in media channels, internet; mental stress of lockdown and isolation, insecurity and panic about scarcity of drug and healthcare support. High risks of developing antibiotic resistance, adverse drug reactions and financial loss was predictable with absence of strict regulatory enforcement to protect people and proper utilization resources during COVID-19 outbreak in Dhaka city.

Full text

International Journal of Basic & Clinical Pharmacology | September 2020 | Vol 9 | Issue 9 Page 1
International Journal of Basic & Clinical Pharmacology
Nasir M et al. Int J Basic Clin Pharmacol. 2020 Sep;9(9):xxx-xxx
http://www.ijbcp.com
pISSN 2319-2003 | eISSN 2279-0780
Original Research Article
Self-medication during COVID-19 outbreak: a cross sectional
online survey in Dhaka city
Morshed Nasir*, A. S. M. Salauddin Chowdhury, Tahmina Zahan
INTRODUCTION
The practice of self-medication is prevalent in most parts
of Bangladesh regardless of socio-economic status and
level of education. While this is indisputable, the
incidence of self- medication is may be higher in the low
or middle-income countries without consulting with
qualified health professionals.1 Although the WHO
stressed that rational self-medication practice helps in the
prevention and treatment of some minor pathological
conditions at affordable cost, but otherwise it may cause
wastage of resources, resistance to pathogens and serious
health hazards with adverse drug reactions and prolonged
morbidity.2,3 In a developing country like Bangladesh, the
practice of self-medication may provide an alternative for
people as low-cost to avoid high cost of clinical services
and many drugs dispensed over the counter (OTC)
without prescription.4 But it is gone beyond the OTC
drugs and sometimes prescription-only drugs like
antimicrobials, sedatives, hypnotics and strong NSAIDs
also reported to be dispensed without prescription in few
cases.
DOI: http://dx.doi.org/10.18203/2319-2003.ijbcp20203522
Department of Pharmacology and Therapeutics, Holy Family Red Crescent Medical College, Dhaka, Bangladesh
Received: 16 July 2020
Revised: 02 August 2020
Accepted: 03 August 2020
*Correspondence:
Dr. Morshed Nasir,
Email: morshednasir@hotmail.com
Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Background: Self-medication is a common practice in Bangladesh as it provides a low-cost alternative for people,
which involves inappropriate and injudicious use of medicines treat self-recognized symptoms by the people.
Methods: A cross sectional online survey was conducted on 626 citizens by structured questionnaires during
COVID-19 outbreak from April to May 2020 in Dhaka city, to observe the prevalence, pattern and sources of self-
medication among the respondents with high socio-economic standings and education.
Results: The prevalence of self-medication amid the outbreak of COVID-19 was 88.33% and only 179 (28.59%) took
medication with doctors’ advice and remaining 447 (71.40%) respondents took the drugs as “self-medication” by
other sources. The most frequently used prescription-only drug during the outbreak were ivermectin (77.15%),
azithromycin (54.15%), doxycycline (40.25%). The common symptoms for which the respondent took self-
medications were fever, throat pain, dry-cough and total 105 (16.77%) respondents took medications without having
any symptoms. Almost 355 (85.33%) had taken medication without doing any test for COVID-19. This could be due
to unusual distress, caused by high self-awareness of their health and buying capacity of medication.
Conclusions: The study revealed the causes of self-medication as news of spread, effects and remedies in media
channels, internet; mental stress of lockdown and isolation, insecurity and panic about scarcity of drug and healthcare
support. High risks of developing antibiotic resistance, adverse drug reactions and financial loss was predictable with
absence of strict regulatory enforcement to protect people and proper utilization resources during COVID-19 outbreak
in Dhaka city.
Keywords: COVID-19, Self-medication, Drug dispensing, Rational use of drug

Nasir M et al. Int J Basic Clin Pharmacol. 2020 Sep;9(9):xxx-xxx
International Journal of Basic & Clinical Pharmacology | September 2020 | Vol 9 | Issue 9 Page 2
According to the World Health Organization (WHO),
self-medication is explained as “the selection and use of
medicines by individuals (or a member of the individual’s
family) to treat self-recognized or self-diagnosed
conditions or symptoms. Reasons commonly adducted
for indulgence in self-medication includes delayed access
to healthcare centers, socio cultural belief, relatively high
cost of hospital treatment, previous experience of
treatment of same symptoms, easy availability of drugs,
poor regulatory practice, urgency of feeling relieved,
advice from friends and media. Moreover, the ratio
between doctor and patient in Bangladesh is currently as
low that places the country at second position from the
bottom, among the South Asian countries, according to
the WHO.5 Besides, some individuals practice out of
ignorance, poverty and generalized hypes.
Dhaka, being the capital and the major economic-hub of
the country; it lags behind in the ratio between healthcare
workers compared to other neighboring countries, thus
hampering proper, and timely healthcare. So, practice of
self-medication is almost inevitable as the country has
only 6 doctors, nurses, and midwives for every 10,000
populations, according to the report of health bulletin
published yearly by the health ministry.6 Some studies on
general tendency and pattern of self-medication practice
of prescription-only drugs among students and people
with or without medical knowledge showed alarming
scenario in Dhaka city.7
The outbreak of coronavirus disease 2019 is putting a
massive strain on vulnerable healthcare system in low
and middle-income countries like Bangladesh.
Inequitable access to healthcare is further widened by the
socio-economic gap and sense of insecurity during this
pandemic since the beginning of 2020.8 Besides, the
population of higher socio-economic standings are more
potential to have access to better health information,
medications and affordability that may lead to self-
medication practice in mass. Similarly, people with
higher education are reported to have much distress,
probably due to high self-awareness and access to mass
information network.9
The combat against COVID-19 is still continuing in
Bangladesh, with the highest incidence rate in Dhaka
city. The available data by WHO revealed that the highest
AR was observed to continue in the Dhaka
(2321.7/1,000,000) and was highest (9422.1/1,000,000)
during April to June 2020.10 As there is no approved cure
for COVID-19 or a vaccine against SARS-CoV-2, the
aim of treatment is focused to manage and reduce
symptoms until clinical recovery. Most people (around
80%) are asymptomatic or mild infection that can be
treated at home. In this case, one should be self-isolated
for at least two weeks until recovered. Almost one in
every five people infected with COVID-19 will require
hospital support. Around 15% of cases suffering severe
infection require oxygen supplement for respiratory
symptoms and 5% experience critical infections,
requiring ventilation. Patients at a higher risk of severe or
critical infections include older people, comorbid with
underlying health conditions.
As stated in the National Guideline on case management
of COVID-19 in Bangladesh, there is no precise effective
treatment for COVID-19, the mainstay of management is
early diagnosis and supportive care of symptoms and
optimum support for organ function in severe illness. No
drug is yet recommended as chemoprophylaxis as there is
no quality evidence of efficacy and safety in COVID-19.
Though patients should be managed in hospital setting;
however, proper home care may also be advised with
mild illness unless rapid deterioration or inability to avail
hospital if necessary.11 But lack of rapid response,
scarcity of hospital beds, absence of private practice,
inadequate capacity of testing (RT-PCR), spread of un-
authenticated treatment protocols are putting the citizens
in dilemma of choosing medical advices. Lot of
prescription-only drugs like antimicrobials (azithromycin,
doxycycline), anti-parasitic (ivermectin), anti-malarial
(hydroxychloroquine) along with leukotrienes inhibitor
(montelukast), vitamin D, zinc, calcium and paracetamol
are reported to become shortage in the dispensary and
peripheral supply chain throughout the city. Because of
commonly occurring symptoms of soreness or pain in
throat, dry cough, fever, body ache, breathlessness;
people started to take medicines without being diagnosed
or tested for COVID-19. Besides the risk of misuse or
overuse of these drugs may lead to immediate or delayed
complications including adverse drug reactions
(hypersensitivity, anaphylaxis), drug interactions,
malfunction or destruction of vital organs such as liver,
kidney; the practice of self-medication gives a deceitful
sense of security and masking the correct diagnosis.
Many countries are using different drugs but they are not
using those as the guidelines and should only be used
under the supervision of physicians on a case-by-case
basis, not as a general recommendation.12
In view of this high prevalence of self-medication of
prescription-only drugs in Bangladesh and its associated
adverse socio-economic impact on individual and the
healthcare service system, supply chain at large. This
study is therefore done to evaluate the awareness, pattern
and attitude towards self-medication among the high
socio-economic and educated citizens in Dhaka during
the outbreak of COVID-19 without testing, diagnose and
prescription.
METHODS
This cross-sectional online survey adopted a descriptive
non-experimental research design to investigate the
awareness and practice of self-medication conducted
from April to June 2020, the period during the nationwide
lockdown and up surging of number of positive COVID-
19 cases. Because it was not feasible to do a community-
based sampling survey during this outbreak period, we
decided to collect data online by convenience sampling.

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International Journal of Basic & Clinical Pharmacology | September 2020 | Vol 9 | Issue 9 Page 3
Using and relying on the authors’ network with people
living in Dhaka city, a structured questionnaire was
circulated to complete via clicking the link, connected to
Google form. The questionnaire contained brief
introduction on the background, objective, procedure,
voluntary nature of participation, declaration of
anonymity and confidentiality, and notes for filling in the
online questionnaire.
The inclusion criteria were set as, the adult citizens living
in Dhaka city, aged 25 years or more, with education
level of graduation or above, non-medical professionals,
having email address, agreed to participate voluntarily.
Respondents having involvement or knowledge on
medical background (medical graduates, medical
practitioners, nurses, medical researchers) were excluded
to find out the public perceptions and their responses to
take medications without prescription during COVID-19
outbreak. The frequencies of response were recorded in
datasheet and observed according to demographic
characteristics, sources of information, clinical symptoms
and status of COVID-19 test results.
The questionnaire was developed and validated through
face and content validity techniques. The face validity
was achieved by giving the draft questionnaire to a few of
the citizens with inclusion criteria at Dhaka city, to assess
whether the response looks meaningful, well designed
and/or a good measure of the construct to an innocent
bystander. Information gathered from this exercise was
used to refine and modify the questionnaire further. The
content validity was done by giving the resultant
questionnaire to two independent scholars from the fields
of public health, pharmacology and social statistics to
assess its appropriateness, clarity, coverage and relevance
to the study. The incorporated draft questionnaire was
recast for ambiguity and repetitive questions were struck
off.
The reliability of the validated questionnaire was
ascertained by test retest method. The questionnaire was
administered twice at two weeks’ interval on ten
respondents from Dhaka city who practiced self-
medication during COVID-19 outbreak. The responses
were compared and the reliability coefficient determined
(r=0.83).
RESULTS
Total 639 participants completed the online survey
questionnaire and submitted with e-mail verification.
After excluding 13 respondents, of whom 10 were
doctors by profession and 3 were below the minimum age
limit (25 years); the final sample consisted of 626 valid
participants. Among the final sample, 316 (50.47%)
respondents were from the age group of 45-54 years, 346
(55.27%) were women, 312 (49.84%) held a bachelor
degree and 230 (36.74%) engaged in non-civil services.
Other demographic characteristics are shown in (Table
1).
Table 1: Frequency distribution of respondents by
their socio-demographic features.
Variables
Frequency
Percentage
Gender
Male
282
45.04
Female
346
55.27
Age in years
25-34
96
15.33
35-44
156
24.92
45-54
316
50.47
55+
58
9.26
Education level
Undergraduate
110
17.57
Bachelor degree
312
49.84
Master degree
178
28.43
Doctoral and
advanced
26
4.15
Work status
Students
84
13.41
Civil service
13
2.06
Non-civil service
230
36.74
Self-
employed/business
184
29.39
Retired
38
6.07
Unemployed
77
12.30
Out of 626 respondents, only 73 (11.66%) did not take
any medication during the survey period as 12 (1.91%)
were negative by rRT-PCR test for COVID-19 and 61
(9.74%) did not test. Remaining 132 respondents
(21.08%) was found positive test result for COVID-19.
The most frequently used prescription-only drug among
the respondents were ivermectin (77.15%), azithromycin
(54.15%), montelukast (43.13%), calcium supplements
(41.37%), doxycycline (40.25%) and hydroxychloroquine
(20.44%) respectively. The frequency of taking the
prescription-only drugs among the respondents who were
not even the diagnosed by rRT-PCR positive result, were
reported higher with ivermectin (76.68%) and
azithromycin (50.0%) as shown in Table 2.
Figure 1: Distribution of respondents taken
medication according to source of advices.
Doctor
29%
Pharmacy
24%
Friends
20%
Media
27%

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International Journal of Basic & Clinical Pharmacology | September 2020 | Vol 9 | Issue 9 Page 4
Table 2: Frequency distribution of respondents by use of prescription only drugs.
Variables
No. of
respondents
Azithromycin
Doxycycline
Hydroxy-
chloroquine
Ivermectin
Montelukast
Zinc
Calcium
Vit-D
No
medication
RT-
PCR
test
Positive
132
111
93
84
109
62
103
81
44
0
Negative
78
20
31
0
55
10
21
69
41
12
Not done
416
208
128
44
319
198
0
109
0
61
Total
626
339
252
128
483
270
124
259
85
73
Figure 2: Distribution of respondents taken
medication according to symptoms.
Among the respondents, only 179 (28.59%) took
medication with doctors’ advice and remaining 447
(71.40%) respondents took the drugs as “self-medication”
by other sources like friends/family, pharmacy/dispensary
and media/internet as shown in (Figure 1).
Total 105 (16.77%) respondents took medications
without having any symptoms. Among the remaining 521
respondents, common symptoms for which the
respondents took medications were fever (37.61%), throat
pain (28.79%), dry-cough (14.20%), loss of smell
(9.21%), loss of taste (3.45%), body ache (4.99%) and
rarely diarrhea (1.72%) respectively as shown in (Figure
2).
DISCUSSION
To the best of our knowledge, this is the first online
survey in Dhaka city evaluating the pattern and frequency
of self-medication practice of prescription-only drugs in
COVID-19 outbreak (April to June 2020) in Bangladesh.
As the survey population was well-educated adults from
different working status, the respondents’ participation
was expected to represent the sincerest and accurate
scenario of the defined survey population.
Almost similar proportion of male and female
participated in the study and most of them (50.47%)
belonged to the age group of 45-54 years. Highest
number of respondents (49.84%) were graduates
(Bachelor degree) and lowest with doctoral degree
(4.15%). Only 2.06% respondents were from civil service
and most of the rest were from non-civil service
(36.74%), self-employed or business (29.39%) living in
Dhaka city at the time of COVID-19 pandemic.
Among 626 survey population in Dhaka city who had
taken medication for COVID-19, only 132 (21.08%)
were documented as positive and 78 (12.45%) as
negative by RT-PCR test. The rest of 416 (66.45%) had
never done the test, but almost 355 (85.33%) had taken
medication without doing any test for COVID-19. This
finding could be due to having additional distress due to
high self-awareness of their health as reported by Roberts
et al among people with higher educational status.9
Having self-medication without detecting COVID-19
among a large number of respondents could also be due
to feeling of insecurity influenced by availability of local
medical resources, efficiency of public health system, and
prevention and control measures taken in pandemic
situation.17
The rate of self-medication of antimicrobial agents like
azithromycin (54.15%), doxycycline (40.25%) were
found much higher during the outbreak of COVID-19
comparing to 21% and 25% for azithromycin and
doxycycline before the pandemic as reported by
Chowdhury et al.13 Azithromycin was the fifth highest
percentage of people with self-medication throughout the
previous years, whereas it became most common
antibiotic during the present pandemic. On the other
hand, ivermectin being the anti-parasitic agent was self-
medicated by 77.15% of the respondents. This might be
due to the nationwide broadcast of an experience by a
team of Bangladeshi physicians and Bangladesh Medical
College Hospital (BMCH) claimed as “outstanding
results” in 60 patients with COVID-19 patients all of
whom recovered in combination of ivermectin and
doxycycline.12 This attempt was made on the outcome of
an in-vitro study reported as a single treatment by
ivermectin is capable of ~5000 folds reduction of viral
, 37.61
, 28.79
, 14.2
, 9.21
, 3.45
, 4.99
, 1.72
, 16.77
0 10 20 30 40
Fever
Throat pain
Dry cough
Loss of smell
Loss of taste
Body ache
Diarrhea
No symptom

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International Journal of Basic & Clinical Pharmacology | September 2020 | Vol 9 | Issue 9 Page 5
load at 48 hours in cell culture.14 Self-medication of this
drug was found highest (483/626) among the respondents
irrespective of test results by RT-PCR. Though the drugs
like chloroquine, hydroxychloroquine and azithromycin,
was recommended in the treatment protocol of COVID-
19 patients in Bangladesh, according to the “National
Guidelines on Clinical Management of Coronavirus
Disease 2019” published in the health directorate’s
website; hydroxychloroquine was used much less
(20.44%) than any other antimicrobials without
prescription.11 This could be due to mass publicity and
sharing of news in national and international news and
social media as the drug can cause hazardous
abnormalities in cardiac rhythm in COVID-19 patients,
and should be limited only in clinical trials or hospitals
with adequate facilities to monitor any cardiac
complications, warned by FDA in a safety
communication briefing globally.12 The overall the
prevalence and dominance of self- medication of
antimicrobials in low and middle income countries were
reported around 39% in previous studies before COVID-
19 pandemic; but was outrageously higher (88.33%) in
Dhaka city during the pandemic.15,16
Considering the sources or advice for medication, only
179 (28.59%) respondents followed or consulted with
doctors and rest by media or internet (27.15%), pharmacy
or dispensary (24.44%) and friends or family (19.8%).
This finding was very much similar to the previous
studies that reported the high prevalence of self-
medication (including antimicrobials) since people could
obtain any drugs from the pharmacies without
prescription even in the distant areas of the country.18
Moreover, during pandemic, people struggle to cope with
constant news of the spread and effects of COVID-19 on
news-media, social-media, internet without having
adequate forms of social support and access to doctors as
a result of lockdowns and self-isolation.8,19 Most of the
respondents (37.61%) took antibiotic as self-medication
for fever during COVID-19 outbreak, followed by throat
pain (28.79%), dry cough (14.20%); whereas almost
16.77% respondents had no symptoms whatsoever.
Having inappropriate antimicrobials and supplementary
medications (zinc, calcium, vitamin-D) without
prescription is associated with the risk of drug
interactions, masking symptoms of underlying diseases
and most importantly, the development of anti-microbial
resistance.20,21
Although there is no approved specific medication to
prevent or treat COVID-19, this online survey among the
educated adults with high socio-economic standings
revealed that high prevalence of self-medication of
prescription only drugs was persistent during the outbreak
in Dhaka city. Unsolicited news of spread, effects and
remedies in media channels, internet; mental stress of
lockdown and isolation, insecurity and panic about
scarcity of drug and healthcare support might have
triggered up the practice self-medication. Psychological
distress levels were also influenced by availability of local
medical resources, prevention and control measures.22
There is sufficient evidence of increasing resistance to
antibiotics in the Bangladesh resulting from irrational and
misuse of antibiotics, where sales of antibiotics are not
restricted at any level.23 Unopposed access to buy
antibiotics and its injudicious use might provoke a long-
term burden of drug-resistant strains with problems of
under and over-dosage, treatment failure and severe
adverse effects to vital organs. It also results in delay in
care seeking, which results in paradoxical economic loss
due to delayed diagnosis and irrational treatment.24
Bangladesh is already in the burden of lower ratio of
healthcare workers and supply support system, with high
rate of community-transmission of COVID-19 and require
effective and efficient enforcement of regulation against
free display and sales of drugs without prescription and
individuals duly authorized. Immediate acceleration of
health education campaigns, strict legislations on
dispensing drugs and increasing the quality and access to
healthcare are the important interventions that might
change the people’s health seeking behavior.25
CONCLUSION
The pattern of medication, including self-medication is an
important health indicator, which reflect the degree of
supply utilization and regulatory enforcement of
healthcare services within a community. Pandemic
situation of COVID-19 is likely to sustain for years and
will have huge socio-economic and psycho-social impact
on people’s lifestyle and behavior, as predicted by the
WHO and epidemiologists from different regions.
Therefore, a vast nationwide survey and surveillance
should be done on self-medication of mass population to
protect them from the potential risks, overuse shortage
and irrational financial involvement during the COVID-
19 outbreak.
ACKNOWLEDGEMENTS
We gratefully acknowledge all the respondents for their
spontaneous participation in the study. We also extend
our gratitude and thanks to Dr. Rawshan Ara Perveen for
logistic and software support.
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: The study was approved by the
Institutional Ethics Committee
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