Practice and Predictors of self-medication among urban and rural adults in Sri Lanka, three decades after Market Economic Reforms Dr. Pushpa Ranjan Wijesinghe MD- Rostov (General Medicine) MSc, MD-Colombo (Community Medicine) MPH-New Zealand ( Bio-security)

Background Practice of self-medication in communities in varying degrees Increased private sector involvement in health & pharmaceutical care since 1977 Increased utilization of private health / pharmaceutical care for out patient conditions Competition of the pharmaceutical companies for a larger share of over the counter drug market What is the status of self-medication in settings of contrasting health and pharmacy care infra-structure in this context ?

Objective To describe the current practice and predictors of self-medication in a selected urban and rural area in Sri Lanka Methods Study design A community based cross –sectional study Study Population Adults over 18 years of age, irrespective of sex, permanently residing in the selected districts over a period of 1 year

8 Urban Council areas 30 GN divisions PSU 30 Households per a GN division 1 individual per house (900) 7 Regional Council (PS ) areas PPS Voters list Kish Table 30 GN divisions PSU 30 Households per a GN division 1 individual per house (900) n= 900 Stratification Urban district Rural district n= 900

Study Instruments Interviewer administered questionnaire (IAQ) Validated Likert scale to assess the Perceived satisfaction with available pharmacy services – Access, Continuity, General Satisfaction of services – Availability, Affordability, Efficacy of drugs – Inter-personal explanation, Considerateness Validated Likert scale to assess the perceived access to allopathic medical care – Availability of services, – Regularity and acceptability of services – Affordability of services – Concern for clients

Medication use Predisposing factors Enabling factors Need variables ACCESS FACTORS SOCIO DEMOGRAPHIC FACTORS BELIEFS & ATTITUDES ACTUAL OR PERCEIVED MORBIDITY Anderson and Newman’s health services utilization model

Urban (n=863) Rural (n=846) Prevalence of medication use (95% confidence interval ) 33.9% (30.7%-37.1 %) 35.3% (32. 1%-38.5%) Urban (n =293)Rural (n=299) Only allopathic medicine users91.4%84.6% Only traditional medicine users3.8%12.4% Both allopathic and traditional medicine users 4.8%3.0% Urban (n=863) Rural (n=846) Prevalence of self medication * (95% confidence interval ) 12.2% (10.0% -14.4%) 7.9% (6.1%-9.7%) Self medication as a proportion of medication use * 37.2%25.6% Practice of medication use * P < 0.05

Practice of self-medication Urban Rural Conditions of Acute onset and short duration58%67% Perceived non-severity of the condition for physician consultations 55%64% Previous satisfactory response of the same drug to a similar condition 53%60% Self-medication without any symptom09%12% Using previous prescriptions for self medication for purchasing drugs 37%- Using labels/blister packs of previously used drugs for purchasing drugs -45% Self-medication with one drug49%73% Self-medication with 2 drugs28%18%

Predictors of self medication UrbanRural Predisposing variables Adjusted OR ( 95% CI) Household number ≤ 24.3 ( )- Non-affirmation of drugs availability at informal places 0.3 ( )- Need VariablesAdjusted OR ( 95% CI) Symptoms ≤ 27.9 ( ) 2.4 ( ) Enabling VariablesAdjusted OR ( 95% CI) Higher satisfaction with acceptability of medical services 0.96 ( )- Affordability of medical services -0.4 ( ) Technical competence of pharmacy staff -2.8 ( )

Conclusion & recommendations Self-medication is more prevalent in the urban setting Prevalence of self-medication is lower than global estimates Self-medication with 1-2 drugs selected on previous experience is an initial individual response for diseases of acute onset and perceived to be of less severity Lower symptom count is a need variable acting as a proxy measure of perceived severity of the morbidity Self medication is dependent on characteristic access measures unique in the two specific settings Findings should be utilized to – Shape policy changes related to implementation of the CDD act – Design IEC programs for consumers moving towards self-medication – Enhance the capacity of rural pharmacists/assistants as the first contact points in the rural sector

Limitations Less valid data as compared to data collected in a prospective follow up study using a diary method Non-objective measurement of the severity of the condition Social desirability bias due to use of public health midwife for data collection Perceived measures of access to health care and pharmaceutical services reflect general rather than specific context