Open Access | Peer-reviewed | Research Article
Department of anesthesia and intensive care, faculty of medical technology, university of Tripoli, Libya.
Published: June 09, 2020 | DOI : 10.5281/zenodo.3912021
In Libya, prescription medicines can easily be dispensed without a prescription, as self-medication with the subsequent of potential misuse and unnecessary risk for patients. This systematic review and meta-analysis explored the prevalence of self-medication among citizens in Libya. A systematic search was performed in PubMed, ISI Web of Knowledge, EMBASE, Medline, Scopus, google scholar and ResearchGate databases for studies published in Libya reporting the prevalence of non-prescription use of medicines in community pharmacies, targeting studies published from Jan 2008 until Dec 2019. A random effects meta-analysis was conducted to calculate pooled estimates of non-prescription use of medicines. Out of 63 articles identified, a total of 13 papers from 7 cities were met the inclusion criteria and involved a total of 4741 subjects. The overall pooled proportion of self-medication of drugs was 53.6% (95% CI: 0.93% – 1.08%), with low heterogeneity and the P-value of the entire population sampled was found to be = 1.000 (df = 12). Seven out of the 13 studies reported data on self-medication for antibiotics without prescription. The records ranged from 15.3% (95% CI 0.61–1.65) in Misurata to 76.6% (95% CI 0.80–1.25) in Tripoli. Self-medication use of medicines among Libyan population is a common phenomenon involving a high proportion use of antibiotics. This misuse of medications could enhance the development and spread of antibiotic resistance.
Keywords: Self-medication, medicine dispensing, drug, prescription, misuse, Libya.
|Citation: Ahmed Atia. (2020) Epidemiology of self-medication practice among Libyans: A systematic review and meta-analysis. Journal of PeerScientist 3(1): e1000020.|
|Received: May 08, 2020; Accepted June 26, 2020; Published June 29, 2020.|
|Copyright: © 2020 Ahmed Atia. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.|
|Data Availability: All relevant data are within the paper and its Supporting Information files.|
|Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.|
|Competing interests: The authors have declared that no competing interests exist.|
|*E-mail: firstname.lastname@example.org | Phone: +218921132362|
Practices of self-medication is commonly seen phenomenon and known to cause a global public health issues . The term self-medication, as described by WHO, represents to the utilization of medication without medical prescription to treat self-diagnosed illnesses or to promote health . Many patients may treat themselves and self-medicate, using either over-the-counter (OTC) medication or prescribed medicines without prescription, including antibiotics . In many cases, sources of self-medication are relatives, colleagues or friends, who share both the drugs and the information about how to use. This practice encourages of acquisition of new drug without referring to doctor to identify if the active principle is proper . Nevertheless, numerous factors such as lack of trust on physician, lack of time and access to health care, and physician fees have been shown to affect self-medication behavior [5-6]. OTC drugs are remedies that are approved for self-medication because of their indication is simply known by patients and generally considered as safe and effective medicines. Paracetamol and other NSAIDs used to relief pain are among these OTC medicines. Nevertheless, self-medication is not restricted to OTC drugs, and patients using prescription medications as self-medication . These drugs maybe left over from a previous treatment, or purchased straightforward from the community pharmacies without a prescription . In some countries, patients encouraged for self-medication in order to treat minor illnesses .
This self-practice is perceived by their authorities as a prospect to held responsibility for maintaining their own health. On the other hand, some nations have implemented rigorous policies to prevent the drug misuse, targeting to upsurge patient’s self-alertness and to diminish unsuitable self-medication that causes depletion of resources, increase of chance of bacterial resistance and drug adverse reactions .
Self- medication is a major public health concern and is practiced worldwide, with a reported prevalence ranging from low prevalence in developed countries and much higher in developing and undeveloped countries [11-14]. In addition, the few studies conducted in Libya stated a high prevalence of self-medication. Prevalence extending from 15.3% in Misurata city  to 46% among non-medical students from the Benghazi University  to 56.19% in the city of Tripoli  have been reported.
In Libya, prescription medications can easily be dispensed without prescription from community pharmacies, resulting in potential drug misuse and health hazard . Further, some patients urged doctors to prescribe antimicrobials for them in believing of the effectiveness of antibiotics treatment . The concern of self-medication among population in Libya signifies an emerging area in the scientific exploration. Hence, combination of all available information could be valuable in order to attain a single quantitative assessment and to obtain precious conclusions than those reported from separate studies. For this purpose, a systematic review and meta-analysis were performed in order to explore the occurrence of self-medication practice among the Libyan population. To the best of our knowledge, this is the first systematic review to examine drug self-medication in Libya.
Results and Discussion
The database search recruited 63 publications for assessment. A number of 42 publications were excluded during searching process that did not met the inclusion criteria. The results retrieved from the search were analyzed separately yielding 21 articles met the inclusion criteria and retrieved for detailed search. Through this phase, 10 more articles were excluded, with reasons: 2 were excluded since related to testing prescription knowledge, 3 editorials, 1 opinion piece, 2 reviews, 1 article with data included with other studies, and 1 not peer reviewed. However, additional two studies included after references screening, with a final of 13 studies included (Figure 1).
Figure 1: Flow diagram of article selection progression.
The 13 studies were conducted in 6 cities and involved 4741 population. The majority of the studies (7 out of 13) included in this review were conducted in Tripoli city. Almost all (12 out of 13) of the included studies were of prospective cross-sectional design (Table 1). Around 9 of the 13 studies included questioner-based studies. The remaining 4 studies were based on; 3 studies were prescription analysis, and one study used simulated patient method.
Table 1: Details regarding characteristics of the included studies:
This is the first study to provide pooled estimates of the level of drug dispensing without prescription in Libya. Even with regional variations, providing drugs without prescription remains high worldwide . The prevalence of self-medication of drugs in the Libyan community ranging from 25% to 88.6% in Tripoli [20-21], 46% to 88.3% in Benghazi [16,22], 39.5% in Misurata , and 41.7% in Al-Asaba . On the other hand, medication without prescription was given to 8.5% children in Messellata , mostly consisting of penicillins. In addition, 15.3% of the women self-medicated during pregnancy .
The overall pooled estimation of self-medication of drugs was 53.6% (95% CI: 0.93% – 1.08%), and there was a low heterogeneity and the P-value of the entire population sampled was found to be = 1.000 (df = 12) (Figure 2). This local estimate was similar to earlier estimate reported in Egypt (65%, 95% CI 56–74) and Bosnia (58%, 95% CI 49–66) [26-27]. However, it was lower than estimates in India (66%, 95% CI 60–72) and Brazil (74% 95% CI 65–82) [28-29]. In general, self-medication with non-prescription drugs was more common in previous studies in Saudi Arabia (81% 95% CI 73–89) , Syria (87%, 95% CI 82–91) , and Ethiopia (77% 95% CI 62–92) .
Figure 2: Results of proportion meta-analysis: Subgroup analysis of studies describing the incidence of self-medication gathered by geographical distribution.
Outcomes of this study also highlight some concerns about the safe dispensing use of antibiotics. Seven out of the 13 studies reported data on self-medication for antibiotics without prescription. The records ranged from 15.3% (95% CI 0.61–1.65) in Misurata  to 76.6% (95% CI 0.80–1.25) in Tripoli . The pooled estimate was 49.3%. Similarly, in previous study, the proportion of non-prescription supply of antibiotics based on pharmacy staff recommendation was 58% (95% CI 48–68) . This finding has a significant effect on public health safety, mostly for the risk of emerging of microbial resistance.
Reports from earlier studies have stated that there were several causative factors to the prevalent phenomenon of self-medication in countries such as Libya: lack of access to healthcare services, easy access of medicines without prescription, and the rising behaviors of dispensing drugs to control nervousness or other mental disorders . In addition, we found some studies stated low incidence of self-medication, conceivably this might be due to the occurrence of more distinct and specific enclosure criteria to choose subjects.
The current study has some limitations that should be stated. Firstly, our study was limited by a lack of data from many cities in the country. In addition, in cities where data were available, a small sample size were used which may not necessarily reflect the extent of non-prescription use of medicines across the country. Thus, our results may have over or underrepresented the concrete range of non-prescription supply of medicines. Furthermore, the findings of our study did not consider the impact of any local regulatory policies targeted at diminishing the supply of drugs without prescription or self-medication, which was implemented after the publication of the included articles and has caused decreasing of self-medication of non-prescribed medications.
Regardless of socio-demographic characteristics of the study participants, we attempted to analyze 13 original studies addressing self-medication practice in Libya. From this, 4741 participants were included for pooled estimation of primary outcome measures. Since self-medication is a common phenomenon in low-income countries like Libya where resources are often scarce, we tried to include all eligible studies for better power of estimation and ease of subgroup analyses.
Based on our findings, it’s clearly conveyed that medicines are repeatedly dispensed without prescription in many cities around the country. This misuse of medicines, particularly antibiotics, could harm patient safety and increase the chance of development and spread of antibiotic resistance. Considerable attention on this drug-practice concern is advisable with the emphasize on enforce laws and policies that could limit the self-use of drugs without prescription. In addition, implementing governmental initiatives that enhance physician education of appropriate medication use, and to increase the awareness of citizens to the risks related to this issue is needed.
Materials and Methods
A systematic search of literature was done in order to identify publications from EMBASE, Medline, ISI Web of science, Google scholar and ResearchGate that reported the following keywords: ‘Libya’, ‘self-medication’, ‘self-prescription’, ‘over the counter medication’, ‘dispensing practice’, “antibiotics’ and ‘self-administration’ from January 2008 until December 2019. All manuscripts written in English or Arabic were considered. Exclusion criteria were data from included publications, review articles, and study on animal models.
Initially, the results retrieved from the search were analyzed separately to explore possibly eligible criteria. The publications were arranged by title and abstracts and only entitled studies were selected for full text assessment. Through this phase, all unrelated publications (lack of relevance, studies on animals, data present in other publications, case reports, and review articles) were considered as exclusion criteria. Publications in non-English or Arabic language were also excluded. Finally, only articles with eligible criteria were selected and analyzed.
The full articles were reviewed and screened to extract self-medication practices details. For each study, the following details were extracted; author, year of publication, place and study design, prevalence of self-medication or consumption rate, and drugs most commonly consumed or prescribed.
Statistical analyses were performed using the software Review Man 5.3, for Windows. Percentage meta-analyses were conducted to analyze pooled proportions (with 95% confidence interval) of drug self-medication for all included studies. The chi-squared test and the I2 were used to estimate the degree of heterogeneity across studies.
- Rodrigues, Carla F. “Self-medication with antibiotics in Maputo, Mozambique: practices, rationales and relationships.” Palgrave Communications1 (2020): 1-12.
- World Health Organization. The Role of the pharmacist in self-care and self-medication: report of the 4th WHO Consultative Group on the Role of the Pharmacist, The Hague, The Netherlands, 26-28 August 1998. No. WHO/DAP/98.13. World Health Organization, 1998.
- Tesfamariam, Sirak, et al. “Self-medication with over the counter drugs, prevalence of risky practice and its associated factors in pharmacy outlets of Asmara, Eritrea.” BMC public health1 (2019): 159.
- Khalifeh, Malak M., Nicholas D. Moore, and Pascale R. Salameh. “Self‐medication misuse in the Middle East: a systematic literature review.” Pharmacology research & perspectives4 (2017).
- Gualano, Maria R., et al. “Use of self-medication among adolescents: a systematic review and meta-analysis.” The European Journal of Public Health3 (2015): 444-450.
- Sharma, Ajitha, et al. “Perceptions and practices of self-medication in healthcare and nonhealthcare university students in South India.” Journal of basic and clinical physiology and pharmacology6 (2015): 633-640.
- Sarganas, Giselle, et al. “Prevalence, trends, patterns and associations of analgesic use in Germany.” BMC Pharmacology and Toxicology1 (2015): 28.
- Sisay, Mekonnen, Getnet Mengistu, and Dumessa Edessa. “Epidemiology of self-medication in Ethiopia: a systematic review and meta-analysis of observational studies.” BMC Pharmacology and Toxicology1 (2018): 56.
- Bennadi, Darshana. “Self-medication: A current challenge.” Journal of basic and clinical pharmacy1 (2013): 19.
- World Health Organization: Report of the WHO Expert Committee on National Drug Policies. 1995. [Last accessed on 30-3-2020]. Available from: http://www.who.int/medicines/library/dap/who-dap-95-9/who-dap-95-9.shtml
- Shehnaz, Syed Ilyas, Anoop Kumar Agarwal, and Nelofer Khan. “A systematic review of self-medication practices among adolescents.” Journal of adolescent health4 (2014): 467-483.
- Shafie, Mensur, et al. “Prevalence and determinants of self-medication practice among selected households in Addis Ababa community.” PloS one3 (2018): e0194122.
- Oshikoya, Kazeem A., Idowu O. Senbanjo, and Olisamedua F. Njokanma. “Self-medication for infants with colic in Lagos, Nigeria.” BMC pediatrics1 (2009): 9.
- Grigoryan, Larissa, et al. “Self-medication with antimicrobial drugs in Europe.” Emerging infectious diseases3 (2006): 452.
- Elmadani, Bashir. “ANTIBIOTIC MISUSE AMONG PREGNANT WOMEN IN MISURATA CITY.” 3.2(2016): 28-33.
- Ghaieth, Mohamed F., et al. “Antibiotics self-medication among medical and nonmedical students at two prominent Universities in Benghazi City, Libya.” Journal of pharmacy & bioallied sciences2 (2015): 109.
- Atia, Ahmed. “Monitoring the Level of antibiotic purchase without a prescription among Libyan young adults.” Indian Journal of Pharmacy Practice4 (2018): 209.
- Atia, Ahmed E., and Ahmed N. Abired. “Antibiotic prescribing for upper respiratory tract infections by Libyan community pharmacists and medical practitioners: An observational study.” Libyan Journal of Medical Sciences2 (2017): 31.
- Atia A. Utilization of Antibiotic among University Medical Students from Tripoli, Libya. J Antibiotics Res. 2.2: 2018b: 1-5.
- Sherif, Fathi Mohamed. “An evaluation of the prescribing patterns of rugs in Libya.” JMJ3 (2008).203-206.
- Agha M, Zagwan N, Alkhboli W, Mokhtar M, Elouzi A. Evaluation of Self-Medication with over the Counter (OTC) Analgesics Among Tripoli University Students. Adv Res Chem & App Sci. 1.1: 2019:24-28.
- Aljarari, Nouh MH, et al. “Prescribing patterns of gastrointestinal drugs in private clinics in Benghazi-Libya.” International Journal of Basic & Clinical Pharmacology1 (2017): 113.
- El-Nimr, Nessrin A., et al. “Impact of a Mass Media Campaign on Adults’ Knowledge and Attitudes towards Antibiotic Use.” Journal of High Institute of Public Health2 (2019): 97-105.
- arbi A, Abired A, Atia A. Prescribing pattern of anti-diabetic drugs in Libyan diabetics patients. A cross sectional survey. Pharmacological and Pharmaceutical Reports. 1.2 (2018):24-30.
- Domma, A. M., M. A. B. Gamal, and B. Sangar. “Common antibiotics prescribed for acute respiratory tract infected children in Libya.” IOSR J Pharm8 (2015): 19-22.
- Amin, Mohamed E., Amira Amine, and Mohammad Shoukry Newegy. “Injudicious provision of subtherapeutic doses of antibiotics in community pharmacies.” INNOVATIONS in pharmacy1 (2017).18.
- Marković-Peković, Vanda, et al. “Initiatives to reduce nonprescription sales and dispensing of antibiotics: findings and implications.” Journal of research in pharmacy practice2 (2017): 120-125.
- Shet, Anita, Suba Sundaresan, and Birger C. Forsberg. “Pharmacy-based dispensing of antimicrobial agents without prescription in India: appropriateness and cost burden in the private sector.” Antimicrobial resistance and infection control1 (2015): 55.
- Volpato, Dalton Espíndola, et al. “Use of antibiotics without medical prescription.” Brazilian Journal of Infectious Diseases4 (2005): 288-291.
- Al-Ghamdi, Mastour S. “Empirical treatment of uncomplicated urinary tract infection by community pharmacist in the Eastern province of Saudi Arabia.” Saudi medical journal12 (2001): 1105-1108.
- Al-Faham, Zaid, Ghaith Habboub, and Farah Takriti. “The sale of antibiotics without prescription in pharmacies in Damascus, Syria.” The Journal of Infection in Developing Countries05 (2011): 396-399.
- Erku, Daniel Asfaw, et al. “Extent of dispensing prescription-only medications without a prescription in community drug retail outlets in Addis Ababa, Ethiopia: a simulated-patient study.” Drug, healthcare and patient safety8 (2016): 65.
- Auta, Asa, et al. “Global access to antibiotics without prescription in community pharmacies: A systematic review and meta-analysis.” Journal of Infection1 (2019): 8-18.
- Atia, Ahmed E. “Prescribing errors and the need for prescription separation in Libya.” Libyan Journal of Medical Sciences 2.1 (2018): 1-2.