
==== Front
Antimicrob Resist Infect Control
Antimicrob Resist Infect Control
Antimicrobial Resistance and Infection Control
2047-2994
BioMed Central London

39300551
1466
10.1186/s13756-024-01466-6
Research
Prevalence of self-medication practices with antibiotics and associated factors among students in five colleges in Eritrea: a cross-sectional study
Gebregziabher Nahom Kiros nahomkiros21@gmail.com

12
Netsereab Tesfit Brhane 13
Franchesko Bethiel Tekie 4
Ghebreamlak Hanna Habte 4
Yihdego Natnael Mulugeta 4
1 Department of Community Medicine, Orotta College of Medicine and Health Sciences, Asmara, Eritrea
2 https://ror.org/02mh8wx89 grid.265021.2 0000 0000 9792 1228 Department of Epidemiology & Biostatistics, School of Public Health, Tianjin Medical University, Tianjin, China
3 https://ror.org/00f1zfq44 grid.216417.7 0000 0001 0379 7164 Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, Hunan China
4 Ministry of Health, Asmara, Eritrea
19 9 2024
19 9 2024
2024
13 1068 4 2024
14 9 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Background

Despite their significant contribution to reducing mortality and morbidity from infectious diseases, antibiotics face challenges due to their inappropriate use, one of which is self-medication. This study assessed the prevalence of|| self-medication with antibiotics among Eritrean college students and its associated factors.

Methods

An analytical cross-sectional study evaluated the prevalence of self-medication with antibiotics among students from five colleges from September 2019 to February 2020. Participants were selected through simple random sampling, and each participant completed a structured questionnaire covering socio-demographic characteristics, knowledge and attitudes toward antibiotics, and self-medication practices. Logistic regression analysis was employed to identify factors associated with self-medication with antibiotics.

Results

The study distributed 380 questionnaires, with 375 returned, yielding a response rate of 98.68%. Findings revealed that 80.3% of participants were familiar with antibiotics. Additionally, 18.8% agreed with non-prescription antibiotic use for simple ailments. Of the 252 respondents who answered, 67.1% reported self-medication with antibiotics. Within the preceding six months, the prevalence of such self-medication was 34.3%. Factors associated with self-medication included college affiliation, with participants from the College of Science (COS) exhibiting lower odds (AOR = 0.38, 95% CI: 0.16–0.91, p = 0.03) compared to the College of Business and Social Sciences (CBSS) students. Those living in dormitories had 2.4 times higher odds (AOR = 2.42, 95% CI: 1.7–5.02, p = 0.017) to self-medicate compared to those living with family. Moreover, individuals unaware of antibiotic resistance had higher odds (AOR = 2.41, 95% CI: 1.24–4.7, p = 0.009) of self-medication. Attitude score was also significantly associated with self-medication (AOR = 0.88, 95% CI: 0.8–0.98, p = 0.027).

Conclusions

These results highlight the necessity for tailored educational programs to advocate for appropriate antibiotic utilization and mitigate the prevalent misuse of antibiotics among college students. Initiatives focused on increasing knowledge about the dangers linked with self-medication and advocating for conscientious antibiotic usage are essential in combating the escalating challenge of antibiotic resistance and safeguarding public health.

Keywords

Self-medication
Irrational antibiotic use
Antibiotics
Eritrea
College students
issue-copyright-statement© BioMed Central Ltd., part of Springer Nature 2024
==== Body
pmcBackground

Antibiotic medications have been crucial in reducing mortality and morbidity from infectious diseases, but their inappropriate use has greatly diminished these benefits. Despite growing public awareness and concerns among healthcare providers, the global trend of antibiotic misuse continues to rise at an alarming rate [1, 2]. This misuse leads to the emergence of antibiotic-resistant microorganisms, which is a growing public health threat [3, 4]. It is estimated that 700,000 lives are lost annually due to antibiotic resistance, and this figure could rise to at least 10 million by 2050 if current trends continue [5]. The economic burden of antibiotic resistance is also substantial, with countries facing increased healthcare costs and lost productivity [6–8]. This issue requires urgent multisectoral attention as the world is on the brink of a post-antibiotic era, where common infections and minor injuries could once again become fatal [9].

In developing countries, antibiotic resistance is driven by surveillance gaps, poor antibiotic quality, clinical misuse, and easy access, while in developed countries, it is fueled by poor hospital regulation and excessive use in food-producing animals [10]. The ease of access to antibiotics in many regions promotes self-medication, which is one of the primary behaviors contributing to antibiotic resistance [4, 11, 12]. Self-medication, as defined by the World Health Organization (WHO), involves the use of medicinal products by the consumer to treat self-diagnosed disorders or symptoms or the inappropriate use of prescribed medications [13]. This behavior includes self-prescription and the improper use of physician-prescribed antibiotics, such as incorrect selection, dosage, and duration [14]. Antibiotics used in self-medication are often obtained through over-the-counter sales, leftover supplies, or drugs shared by family or friends [15, 16]. Globally, it is estimated that more than 50% of antibiotics are purchased without a prescription from formal and informal sectors [17].

The challenge of improper antibiotic use is particularly pronounced in low- and middle-income countries (LMICs), where regulatory frameworks are often lacking or insufficient [18]. In poor regions, self-medication is a common practice for addressing health issues due to limited access to healthcare services [4, 15, 19]. In Sub-Saharan Africa, the combined rate of non-prescription antibiotic requests or consultations resulting in antibiotic supply without a prescription is as high as 69% [20]. Consequently, developing countries report more antimicrobial resistance cases than developed nations [21]. Several factors motivate the use of antibiotics without prescription, including financial and time constraints, social influence, consumer attitudes, and advertisements [14, 19]. Self-medication may offer short-term benefits such as easier access to medication and lower healthcare costs, but it can lead to widespread antibiotic resistance with severe global public health consequences [22].

Studies conducted among college and university students have shown alarmingly high rates of antibiotic misuse. A systematic review and meta-analysis reported a self-medication rate of 70.1% among students [23]. A review focusing on self-medication with antibiotics among university students in LMICs revealed that Africa had the highest combined prevalence at 55.30% [24]. For instance, a survey among university students in Kampala, Uganda, found that nearly 7 out of 10 students had self-medicated with antibiotics [25]. Similarly, a study among undergraduate students in Mekelle, Ethiopia, reported that 44.5% had self-medicated with antibiotics at some point, with 27.5% having done so within the past three months [26]. In China [27], 47.9% of university students reported self-medication with antibiotics, while in the United Arab Emirates [28], a six-month prevalence study showed a rate of 38.2%.

In Eritrea, the Ministry of Health has implemented various initiatives to address this issue, including regulatory policies, public awareness campaigns, and training healthcare providers [29]. However, studies on self-medication in Eritrea are limited to specific areas. One survey among Asmara College of Health Sciences students reported a self-medication prevalence of 79.2% [30]. Another study found that 93.7% of participants in 20 pharmacy outlets in Asmara had practiced self-medication, with 87.6% obtaining antibiotics without a prescription [31]. A community-based study in Asmara reported a self-medication prevalence of 45.5% [32]. These studies highlight the urgent need to address self-medication practices in Eritrea, particularly among college students, as many colleges are located in areas with limited access to comprehensive healthcare services. Understanding the factors associated with self-medication in this group could inform targeted interventions and contribute to broader efforts to combat antibiotic resistance. Therefore, this study aimed to assess the prevalence of self-medication with antibiotics (SMA) among Eritrean college students and identify the associated factors.

Methodology

Study design

This study employed an analytical cross-sectional study design to assess the prevalence of self-medication practice with antibiotics among college students.

Study setting and population

The study was conducted in five colleges of Eritrea, namely, Orotta College of Medicine and Health Sciences (OCMHS), Mai-Nefhi College of Engineering (COE), Mai- Nefhi College of Science (COS), Adi-Keih College of Business and Social Science (CBSS) and Hamelmalo College of Agriculture (HAC). OCMHS is found in Asmara, the capital city of Eritrea. COE and COS are found in the Maekel region, around 25 km southwest of Asmara, whereas CBSS is located at Adi-Keih in the Debub region, 110 km southeast of Asmara. HAC is located in Hamelmalo, a few kilometers outside Keren (in the Anseba region), which is 91 km northwest and far from Asmara. The study was conducted from September 2019 to February 2020. The study population was all degree program students of the above-listed five Eritrea colleges registered for the first semester of the 2019–2020 academic year. The total number of students enrolled in these colleges during the data collection time was 3394.

Inclusion and exclusion criteria

Degree program college students (2nd year and above) who were registered for the first semester in the academic year 2019–2020 and those willing to consent were eligible to participate. Upgrading students and students unavailable during the data collection time were excluded from the study. Upgrading students are government employees with a monthly salary and several years of work experience before returning to college, making them distinct from the typical student population.

Sample size and sampling technique

A single population proportion formula was used to calculate the sample size [n= (Z α/2)2 x P (1-p)/d2]. Where: n1 = Sample size, d = margin of error 5% = 0.05, P = the proportion of self-medication with antibiotics (0.5), Z value for 95% confidence = 1.96. Based on the above parameters, it was 384. Then n2 was calculated using the formula n2= (n1 *N)/( n1 + N). Where N = Size of the study population (total number of students of the five colleges registered for the semester, 3394). This gave a n2=\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\:345$$\end{document}. Finally, we added 10% of n2 for non-response, and the final sample size was 380. The sample was distributed to each college proportional to its total student number. Then, within each college, the allocated sample was divided proportionally among the departments. The same procedure was used to divide the sample among the years of study. Finally, each department was asked to provide a list of names of its students by department and year of study to be used as the sampling frame. Then, the study units were selected using a simple random sampling technique.

Data collection instruments and measurements

The data collection instrument used was a structured self-administered questionnaire with close-ended questions. It was developed by consulting the existing literature and previously conducted similar studies. Experts in the pharmacy department assessed the face and content validity of the questionnaires. The questionnaire consisted of four sections: (1) questions related to participants’ socio-demographic characteristics (college, age, sex, ethnic city, etc.); (2) questions related to knowledge on antibiotics; (3) questions related to attitude towards antibiotic use; (4) questions related to practice assessment concerning self-medication with antibiotic. A pre-test of the questionnaire was conducted among 20 randomly selected students in the College of Education to assess its understandability and ease of administration. Based on the results, the questions that the participants did not understand were modified.

Knowledge

Knowledge questions contain 20 items, which could be responded to using two options, i.e., “Yes” or “No.” The responses for the items were stated as correct when the right and wrong answers were answered as “Yes” and “No,” respectively. Every single correct answer was scored using one point. To estimate the performance of overall knowledge, a cumulative correct response of knowledge items was calculated, i.e., the sum of scores of the 20 items. Then, the cumulative correct responses (i.e., ranging from 0 to 20 points) were divided into three categories based on the median score. The results were categorized as “poor” for the scores below the median line, “moderate” for those at the median line, and “adequate” for those above the line.

Attitude

The procedure for data analysis of the attitude-related questions was similar to the knowledge section. The criteria were formed to assess respondents’ attitudes towards self-medication: First, the numbers 1, 2, 3, 4, and 5 were assigned to represent strongly disagree, disagree, neutral, agree, and strongly agree, respectively. The performance of overall attitudes was estimated by calculating the scores of the five attitude items, the sum of scores of A1 to A5, in which the potential range of the cumulative attitudes score could be 5–25. The attitude performance was then also categorized into three, based on the median score as “appropriate” for those below the median line, as “moderate” for those at the median line, and as “inappropriate” for those above the median line.

Study variables

The dependent variable in this study was self-medication with antibiotics. The independent variables included socio-demographic characteristics (age, sex, religion, college, year of study, ethnicity, marital status, accommodation, permanent residence, average monthly allowance or income, parent’s level of education and work), knowledge about antibiotics and antibiotic resistance: knowledge score and attitude score.

Data analysis

Data was entered in Microsoft Excel and then imported into Statistical Package for the Social Sciences (SPSS) version 23 for analysis. First, descriptive analysis was performed using frequency and percentage for all study variables. Furthermore, mean, standard deviation or median and interquartile range (IQR) were reported for continuous variables when appropriate. Bivariate and multivariate logistic regression were performed to determine associations and effect sizes between the study variables. Variables found to be significant in the bivariate analysis were included in the multivariate logistic regression analysis. In addition, variables with p < 0.2, found to be substantial in other related literature, were also included in the multivariate logistic analysis. Statistical significance for all analyses was set at p < 0.05.

Results

A total of 380 questionnaires were distributed, out of which 375 were filled and returned, resulting in a response rate of 98.68%. The mean age of the participants was 20.40 (SD ± 1.158), with the majority (54.6%) categorized under the age group of 18–20 years. Of the total respondents, 52.4% were females, and most of the participants belonged to the Christian religion (92.5%). Second-year students comprise the most significant proportion (37.1%) of the participants. Most students (87.4%) permanently reside in urban areas, and 81.2% of the total participants live in dormitories. Regarding the respondents’ parents’ educational level, 40.1% of the mothers had middle-secondary education, while 47.5% of the fathers had tertiary education. Most mothers and fathers work in non-health-related occupations, 89.3% and 70.8%, respectively (Table 1).

Table 1 Socio-demographic characteristics of respondents

Variables	Category	Frequency	%	
College (n = 375)	CBSS	107	28.5	
HAC	63	16.8	
COS	88	23.5	
COE	85	22.7	
OCMHS	32	8.5	
Age category (n = 357)	18–20	195	54.6	
21–24	162	45.4	
Sex (n = 374)	Male	178	47.6	
Female	196	52.4	
Religion (n = 375)	Christian	347	92.5	
Muslim	28	7.5	
Year of study (n = 375)	Second year	139	37.1	
Third year	101	26.9	
Fourth-year	103	27.5	
Fifth year	32	8.5	
Permanent residence (n = 373)	Rural	47	12.6	
Urban	326	87.4	
Accommodation status (n = 372)	With family	69	18.5	
Dormitory	302	81.2	
With relatives	1	0.3	
Mother’s level of education (n = 372)	Illiterate	20	5.4	
Can read and write- elementary	106	28.5	
Middle- Secondary	149	40.1	
College and above- tertiary	94	25.3	
Do not know	3	0.8	
Father’s level of education (n = 366)	Illiterate	8	2.2	
Can read and write- elementary	43	11.7	
Middle- Secondary	135	36.9	
College and above- tertiary	174	47.5	
Do not know	6	1.6	
Mother’s work (n = 373)	Health-related occupations	30	10.7	
Non-health-related occupations	333	89.3	
Father’s work (n = 366)	Health-related occupations	107	29.3	
Non-health-related occupations	259	70.8	
OCMHS: Orotta College of Medicine and Health Sciences, COE: Mai-Nefhi College of Engineering, COS: Mai-NeFhi College of Science, ACBSS: Adi-Keih College of Business and Social Science, HAC: Hamelmalo College of Agriculture

Knowledge of respondents on the use of antibiotics

In this study, most (80.3%) of the participants had ever heard about a drug called antibiotic. When asked about the infections antibiotics are meant to treat, 86.8% said “bacterial infection,” and 5.8% said “viral infections.” However, when asked about diseases treated with antibiotics, 35.5% said “common cold,” 44% said “diarrhea,” and 52.6% said “tuberculosis,” among others. As to the time to stop the antibiotic treatment course, the majority (56.6%) of the respondents said it was “after completion of the treatment,” followed by “after antibiotics run out” (17.4) and “after symptoms disappear” (12.5%) (Table 2).

Table 2 Knowledge of respondents on the use of antibiotics

Variable	Category	Frequency	Percentage	
Ever heard of a drug called antibiotics (n = 375)	Yes	301	80.3	
Antibiotics are medicines used to treat illnesses caused by?	Virus	18	5.8	
Bacteria	269	86.8	
Fungus	2	0.6	
Do not Know	20	6.5	
Which of these diseases do you think are treated with antibiotics?	Common cold	111	35.8	
Diarrhea	137	44.2	
Tuberculosis	164	52.9	
Dengue fever	31	10	
Pneumonia	63	20.3	
Aches and pains	47	15.2	
Malaria	58	18.7	
When do you think people should stop taking antibiotics treatment?	After a few days, regardless of the outcome	7	2.3	
After symptoms disappeared	38	12.5	
A few days after recovery	33	10.9	
After antibiotics ran out	53	17.4	
After the completion of the treatment	172	56.6	

Attitude of respondents on the use of antibiotics

The attitude of participants towards self-medication with antibiotics was assessed using five questions with five-point Likert-type answers (strongly disagree, disagree, neutral, agree, strongly agree). Accordingly, 18.8% agreed that it is okay to use antibiotics without prescriptions if the disease is deemed simple. Just 9.4% of the participants agreed that it is acceptable to share antibiotics with others if their illnesses appear similar. Furthermore, 7.9% indicated that retaining leftover antibiotics for future use with different ailments is permissible. Most respondents (57.5%) believed that leftover antibiotics should be disposed of in regular garbage or flushed down toilets. In contrast, only a small percentage (8.5%) agreed with increasing antibiotic dosage for faster recovery (Table 3).

Table 3 Attitude of respondents on the use of antibiotics

	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree	
People should sometimes use antibiotics without a prescription if they think their illness is simple.	6 (1.9%)	52 (16.9%)	39 (12.7%)	101 (32.8%)	110 (35.7%)	
Sharing antibiotics with family members or friends is okay if your illness looks the same.	4 (1.3%)	25 (8.1%)	21 (6.8%)	118 (38.3%)	140 (45.5%)	
Keeping leftover antibiotics and using them later for other illnesses is okay.	2 (0.7%)	22 (7.2%)	39 (12.7%)	87 (28.3%)	157 (51.1%)	
Leftover antibiotics should be disposed of with regular garbage or flashed at toilets.	70 (22.9%)	106 (34.6)	32 (10.5%)	59 (19.3%)	39 (12.7%)	
People should sometimes increase the dosage of antibiotics during self-treatment for faster recovery.	7 (2.3%)	19 (6.2%)	32 (10.5%)	70 (22.9%)	178 (58.2%)	

Of 311 respondents, 81% were found to have used antibiotics regardless of prescription status. A total of 252 participants gave a response to the question, “Have you ever self-medicated with antibiotics?” Of these, 67.1% (CI: 60.8 − 72.8%) responded positively. In addition, the prevalence of self-medication with antibiotics within the past six months preceding the data collection time was 34.3%. Participants were asked if they had ever stopped taking antibiotics before completing the entire course of treatment, of which 50.3% of the 173 respondents said “Yes.” Almost one-third (32%) of 172 respondents have ever changed the dosage of antibiotics deliberately, and 11.1% have taken antibiotics, although health professionals advised them that it is not necessary. Regarding suggesting antibiotics to others, 57.6% of 170 respondents acknowledged that they have ever advised someone they know to take an antibiotic drug. In the current study, the commonly used antibiotics were Amoxicillin, Cotrimoxazole, Ciprofloxacin, and Metronidazole, in that order (Table 4).

Table 4 Practice of respondents on the use of antibiotics

Variables	Frequency	Percentage	
Ever used antibiotics (n = 311)	252	81	
Ever self-medicated with antibiotics (n = 252)	169	67.1	
Self-medicated with antibiotics within the past six months (n = 169)	58	34.3	
Ever stopped taking antibiotics before completing the entire course of treatment (n = 173)	87	50.3	
Ever changed the dosage of antibiotics deliberately (n = 172)	55	32	
Ever gave or suggested antibiotics to someone (n = 170)	98	57.6	
Ever taken antibiotics against a health professional’s advice (n = 171)	19	11.1	
Commonly used antibiotics for self-medication by respondents (n = 171)	
Amoxicillin	123	71.9	
Cotrimoxazole	9	5.3	
Ciprofloxacin	5	2.9	
Metronidazole	4	2.4	
Benzathine benzylpenicillin	3	1.8	
Amoxicillin + clavulanic acid (Augmentin)	3	1.8	

The most common complaints or symptoms for which antibiotics were used included diarrhea (90.6%), tonsillitis (67.2%), aches and pain (24.6%), and common cold (23.7%). In this study, the participants put forward several reasons why they self-medicate with antibiotics. These include perceiving the disease as not serious (37.4%), previous successful experience (31.4%), quick relief (28.8%), time constraint (18.7%), and knowledge acquired from previous prescriptions (17.3%). The most commonly mentioned sources of antibiotics for self-medication were drug stores or pharmacies (58.3%), followed by friends or family members (28.1%), and health facilities (18.7%). As for stopping antibiotics before the entire course of treatment, 66.3% said “because conditions improved,” and 11.2% said, “got a better medication.” For those who have ever changed the dosage of antibiotic medications, the reasons to do so were improving conditions (45.5%), insufficient drugs (16.4%), reducing adverse reactions (14.5%), and worsening conditions (12.7%). Regarding handling leftover antibiotic medications, 28.7% said they usually don’t have leftovers, 41.3% said they keep them for future use, and 20.4% said they dispose of them in a rubbish bin (Table 5).

Table 5 Characteristics of self-medication practice with antibiotics

Variables	Categories	Frequency	Percentage	
Complaints for which antibiotics were self-medicated (n = 138)	Common cold	33	23.7	
Fever	11	8.0	
Aches and pain	34	24.6	
Diarrhea	125	90.6	
Vomiting	3	2.2	
Skin wound	33	8.8	
Tonsillitis	92	67.2	
Reasons for self-medicating with antibiotics (n = 211)	Health facility far from school or home	6	4.3	
Time constraint	26	18.7	
To save money	14	10.1	
To get quick relief	40	28.8	
Disease not serious	52	37.4	
Knowledge from previous prescriptions	24	17.3	
Previous successful experience	44	31.4	
Source of antibiotics for self-medication (n = 176)	Health facility	26	18.7	
Drug store/pharmacy	81	58.3	
Friends or family members	39	28.1	
From leftovers	11	7.9	
From abroad	10	7.2	
Reason for stopping taking antibiotics before completing the entire course of treatment (n = 89)	The condition didn’t improve	5	5.6	
Condition improved	59	66.3	
Due to adverse effects	7	7.9	
Advised by a friend or family	7	7.9	
I didn’t think it works	1	1.1	
I got better medication	10	11.2	
Motives behind changing the dosage of antibiotics during the course of self-treatment (n = 55)	Improving conditions	25	45.5	
Worsening conditions	7	12.7	
To reduce adverse reactions	8	14.5	
Drug insufficient for complete treatment	9	16.4	
Handling of leftover antibiotics (n = 167)	Usually don’t have leftovers	48	28.7	
Keeping it for future use	69	41.3	
Pour it down in a sink or toilet bowl	15	9	
Dispose of it in a rubbish bin	34	20.4	

Knowledge and attitude scores and their medians were computed for each participant, and the Wilcoxon rank test was used to evaluate the associations between the median score and the socio-demographic characteristics of the study participants. Accordingly, participants from OCMHS had statistically significant higher scores in knowledge (Mdn = 17) than participants from other colleges CBSS (Mdn = 8), HAC (Mdn = 7), COS (Mdn = 8) and COE (Mdn = 8), (P = 0.00; Kruskal–Wallis test). Similarly, participants from OCMHS had statistically significant higher attitude scores (Mdn = 21) than participants from other colleges CBSS (Mdn = 19), HAC (Mdn = 20), COS (Mdn = 20), and COE (Mdn = 19), (P = 0.01; Kruskal–Wallis test). Fifth-year students’ knowledge score was higher (Mdn = 9) as compared to the second (Mdn = 7), third (Mdn = 8), and fourth (Mdn = 8) year students, which was statistically significant (P = 0.00; Kruskal–Wallis test). A statistically significant difference in attitude score was also observed between years of study, second year (Mdn = 19), third-year (Mdn = 20), fourth-year (Mdn = 20), and fifth year (Mdn = 20), (P = 0.02; Kruskal–Wallis test). Respondents whose fathers were illiterate had statistically significant lower attitude scores (Mdn = 16) as compared to those whose fathers had elementary (Mdn = 20), secondary (Mdn = 20), and tertiary (Mdn = 19) levels of education (P = 0.01; Kruskal–Wallis test) (Table 6).

Table 6 Knowledge and attitude scores with sociodemographic characteristics of participants (Wilcoxon rank test results)

Variables	Knowledge score Median (IQR)	p-value	Attitude score Median (IQR)	p-value	
Sex	
 Male	8 (6–9)	0.55 †	20 (17–21)	0.69 †	
 Female	8 (7–10)	19 (17–21)	
College	
 CBSS	7 (6–9)	< 0.00 ‡	19 (17–21)	0.01 ‡	
 HAC	8 (6–10)	20 (18–21)	
 COS	7 (6–9)	20 (17–21)	
 COE	8 (6–9)	19 (17–21)	
 OCMHS	17 (12–19)	21 (19–23)	
Age category	
 18–20	8 (6–9)	0.09 †	20 (17–21)	0.52 †	
 21–24	8 (7–10)	20 (17–21)	
Religion	
 Christian	8 (6–10)	0.33 †	19 (17–21)	0.51 †	
 Muslim	9 (7–9)	19 (17–21)	
Year of Study	
 Second year	7 (6–9)	< 0.00 ‡	19 (17–21)	0.02 ‡	
 Third year	8 (7–9)	20 (18–21)	
 Fourth-year	8 (6–11)	20 (17–21)	
 Fifth year	9 (7–18)	20 (18–23)	
Permanent Residence	
 Rural	8 (6–11)	0.98 †	20 (17–21)	0.87 †	
 Urban	8 (7–10)	19 (17–21)	
Accommodation status	
 With family	8 (6–13)	0.08 †	20 (18–22)	0.30 †	
 Dormitory	8 (7–9)	19 (17–21)	
Mother’s level of education	
 Illiterate	7 (5–9)	0.18 ‡	19 (15–21)	0.30 ‡	
 Can read and write- elementary	8 (6–10)	20 (18–21)	
 Middle- Secondary	8 (6–10)	20 (17–21)	
 College and above- tertiary	8 (7–9)	19 (17–21)	
Father’s level of education	
 Illiterate	6 (6–7)	0.34 ‡	16 (12–18)	0.01 ‡	
 Can read and write- elementary	8 (6–13)	20 (19–21)	
 Middle- Secondary	8 (6–10)	20 (17–21)	
 College and above- tertiary	8 (7–9)	19 (17–21)	
Mother’s work	
 Health-related occupations	8 (6–10)	0.34 †	20 (17–21)	0.33 †	
 Non-health-related occupations	8 (7–10)	19 (17–21)		
Father’s work	
 Health-related occupations	8 (6–9)	0.67 †	19 (17–21)	0.69 †	
 Non-health-related occupations	8 (6–10)	20 (17–21)	
† Mann-Whitney U test, ‡ Kruskal–Wallis test

Factors associated with self-medication with antibiotics

Binary logistic regression was used to assess the association between several background characteristics of the participants and self-medication behavior with antibiotics. On bivariate analysis, five variables achieved significant levels below 0.25, three of which had statistically significant values. As compared to students from CBSS, students from COS and OCMHS had lower odds of self-medication with antibiotics (COR = 0.41, 95% CI: 0.18–0.93, p = 0.033) and (COR = 0.32, 95% CI: 0.12–0.89, p = 0.029), respectively. Those students living in dormitories had 2.9 (COR = 2.91, 95% CI: 1.52–5.57, p = 0.001) times higher odds to self-medicate with antibiotics than those living with their families or relatives. A higher attitude score was also associated with decreased odds of self-medication with antibiotics (COR = 0.89, 95% CI: 0.81–0.98, p = 0.023). Multivariate logistic regression included the three variables with significant p values and two with p values less than 0.25 on bivariate analysis. Accordingly, COS participants had statistically significantly lower odds (AOR = 0.38, 95% CI: 0.16–0.91, p = 0.03) of self-medication compared to those from CBSS. Students living in the dormitory had 2.4 times higher odds (AOR = 2.42, 95% CI: 1.7–5.02, p = 0.017) to self-medicate with antibiotics than those who lived with their families. Those who had never heard about antibiotic resistance were at higher odds (AOR = 2.41, 95% CI: 1.24–4.7, p = 0.009) of self-medication with antibiotics than their counterparts. Finally, participants’ attitude score was also found to have a statistically significant association with self-medication practice with antibiotics (AOR = 0.88, 95% CI: 0.0.8–0.98, p = 0.027). (Table 7)

Table 7 Factors associated with self-medication with antibiotics

Variables	COR [95% CI]	AOR [95% CI]	
College	
 CBSS	1	1	
 HAC	1.3 [0.51–3.28]	1.03 [0.38–2.76]	
 COS	0.41 [0.18–0.93] *	0.38 [0.16–0.91] *	
 COE	0.46 [0.21–1.06]	0.46 [0.19–1.12]	
 OCMHS	0.32 [0.12–0.89] *	0.42 [0.13–1.31]	
Accommodation	
 With Family	1	1	
 Dormitory	2.91 [1.52–5.57] **	2.42 [1.17–5.02] *	
Heard about antibiotic resistance	
 Yes	1	1	
 No	1.62 [0.91–2.87] a	2.41 [1.24–4.7] **	
Know the target pathogens of antibiotics.	
 No	1	1	
 Yes	0.42 [0.15–1.17] b	0.38 [0.12–1.18]	
Attitude score	0.89 [0.81–0.98] *	0.88 [0.8–0.98] *	
*p < 0.05, ** p < 0.01, ap = 0.096, bp = 0.1. OCMHS: Orotta College of Medicine and Health Sciences, COE: Mai-Nefhi College of Engineering, COS: Mai-Nefhi College of Science, ACBSS: Adi-Keih College of Business and Social Science, HAC: Hamelmalo College of Agriculture

Discussion

This research aimed to evaluate the prevalence of SMA among college students in Eritrea and to identify the factors associated with this practice. The study reveals that a significant proportion of the participants possessed knowledge of antibiotics. Specifically, 80.3% of the respondents reported being familiar with antibiotics, a finding consistent with research conducted among Nigerian university students, where 91.4% had prior knowledge of antibiotics [33]. Furthermore, 86.8% of the participants in the current study accurately identified the pathogens targeted by antibiotics. Although this rate is somewhat lower compared to the 99.2% reported among medical students at the University of Zambia [34], it is plausible that the discrepancy is because medical students are more extensively educated about antibiotics through their specialized curriculum.

The most frequently mentioned conditions antibiotics could be used for include the common cold, diarrhea, and tuberculosis. Some have used antibiotics to treat pain, aches, and the common cold. This aligns with findings from various studies that have highlighted the widespread use of antibiotics for flu-like symptoms [35–38]. The prevalence of ever and six-month self-medication with antibiotics was 67.1% and 34.3%, respectively. These figures are comparable to those reported in studies from three universities in Uganda, where the prevalence was 69.4% [39]. In contrast, a study in the United Arab Emirates reported a six-month SMA prevalence of 38.2% [28]. Higher prevalence rates have been observed elsewhere, such as 40.2% in western China [34] and 82% in Qatar [40]. The prevalence observed in the current study also surpasses the 45.1% self-medication rate among the general community in Asmara [32], suggesting that SMA is particularly prevalent among university students.

Half of the respondents in this study admitted to having discontinued their prescribed antibiotic courses prematurely, and one-third reported having intentionally altered the dosage. The primary reasons for discontinuation included improvement in symptoms and switching to alternative medications. These findings are consistent with those of a Qatari study, which noted that 45% of respondents did not complete their last course of antibiotics [40]. Similarly, a survey in Jordan revealed that 65.2% of respondents had interrupted their treatment course, with 59.1% citing feeling better as the reason [41]. A similar trend was observed at Prince Mohammad Bin Fahd University in Saudi Arabia, where 38.4% of students believed that antibiotic courses could be stopped upon feeling improvement [42]. Over 44% of Chinese university students also reported modifying their antibiotic dosages [43]. A potential contributing factor to this behavior could be inadequate information from healthcare providers about the importance of completing the prescribed course. Additionally, students might be influenced by their experiences with other over-the-counter medications, which are often used only as needed. Notably, almost 10% of the students reported using antibiotics against health professionals’ advice. This is reminiscent of a Chinese study where patients successfully pressured doctors for antibiotic prescriptions in 100% of cases [36]. Such behavior could stem from comparison with past symptoms, advice from peers or family, or lack of trust in healthcare providers. This highlights the challenge of curbing irrational antibiotic use, which can undermine efforts to address antibiotic resistance.

Amoxicillin emerged as the most frequently self-medicated antibiotic in this study, a trend corroborated by various other studies [28, 32, 33]. Conversely, studies among university students in Kampala [39] and Lebanon [44] found amoxicillin to be the least commonly used antibiotic, with only 4% and 9% of participants reporting its use, respectively. While the familiarity and availability of amoxicillin may drive its use for self-medication, excessive and irrational use can lead to increased resistance by microorganisms, potentially reducing its effectiveness in future treatments. The frequently cited reasons for SMA by respondents included perceiving the illness as non-serious, previous successful experiences with self-medication, seeking rapid relief, time constraints, and knowledge from past prescriptions. These reasons align with findings from a systematic review and meta-analysis that identified past successful use and the perceived severity of illness as significant determinants of self-medication [15]. Moreover, a substantial proportion of participants reported recommending antibiotic use to acquaintances, emphasizing the potential to propagate this behavior.

Pharmacies were the most common source of antibiotics for self-medication, with 58.3% of participants acquiring antibiotics from these outlets. This finding aligns with previous research conducted in Asmara [32] and is supported by the fact that 87.6% of drug outlets in the country dispensed antibiotics without prescriptions [31]. Similar patterns have been observed in Nigeria [45], China [43], and Qatar [40], where antibiotics were often purchased without prescriptions. Improper disposal or retention of leftover antibiotics is a concerning practice, with many participants either saving them for future use or discarding them improperly. A Jordanian study found that 73.1% of students kept leftover antibiotics, primarily “in case they were needed again” [41]. This behavior suggests that some aspects of self-medication are planned rather than spontaneous.

The study identified several factors associated with self-medication practices. Students from the COE exhibited 81.7% lower odds of SMA than those from the CBSS. This association might be attributed to the proximity of COE to healthcare facilities in Asmara, making access to medical care more convenient compared to the location of CBSS in the outskirts of Adi-Keih Town. Residence of students has been reported to be associated with self-medication with antibiotics in several studies [46, 47]. Those living in dormitories were 2.4 times more likely to engage in SMA. This increased likelihood could be due to time constraints related to academic activities or financial problems to see a doctor, and the practice of sharing medications with roommates. Participants who had never heard of antibiotic resistance were 2.4 times more likely to self-medicate. This finding is consistent with research from Turkish Cypriots [40], Thailand [41], and Bangladesh [42], which also highlighted a relationship between awareness of antibiotic resistance and self-medication practices. Additionally, in line with the findings of previous studies [48, 49], a higher score in attitude correlated with lower odds of self-medication.

Regarding knowledge and attitudes, OCMHS students exhibited significantly higher median scores than those from other colleges. This observation aligns with findings from a systematic review indicating better antibiotic knowledge among health sciences students [44]. However, a study of medical students in Malaysia revealed differences in knowledge between clinical and pre-clinical years [50], a pattern also observed in the current study where first-year students demonstrated statistically lower knowledge and attitude scores. Previous research from Jordan [41], Lebanon [44], and Sudan [51] also found better knowledge and attitudes among medical students compared to their non-medical peers.

The study comprehensively included all the colleges in the country, providing a comprehensive and representative sample. It thoroughly assessed the effect of demographics, knowledge, and attitude on SMA, offering valuable insights into the factors influencing these behaviors across a diverse student population. The study was limited to students in the degree program, potentially excluding the experiences of those in diploma or certificate programs. Additionally, there may be recall bias regarding antibiotic SMA, as participants need to remember or report their past behaviors.

Conclusion

In conclusion, this study revealed substantial knowledge regarding antibiotic drugs among participants, with the majority correctly identifying the target pathogens of antibiotics. However, significant gaps existed in knowledge concerning appropriate antibiotic use, particularly about treating viral infections and the consequences of self-medication. Self-medication practices with antibiotics were prevalent among university students, with a considerable proportion reporting ever using antibiotics without professional guidance. Factors contributing to self-medication included ease of access to antibiotics without prescription, perceptions of illness severity, and previous successful experiences with self-medication. Notably, drug stores or pharmacies were the primary sources of antibiotics for self-medication, highlighting the need for stricter regulation and enforcement of prescription requirements. Factors such as college of study, residence, knowledge of antibiotic resistance, and attitude toward self-medication influenced self-medication practices.

Acknowledgements

The authors express their gratitude to all individuals across all the colleges who assisted in facilitating the data collection process. Additionally, sincere thanks are extended to the participating students for generously contributing their valuable time to this study.

Author contributions

The conceptualization and design of the study were done by BT, HH, NM, TBN, and NKG. Data collection, data entry, and initial draft writing were undertaken by BT, HH, and NM. TBN and NKG provided contextualization and supervision and conducted the data analysis. All authors contributed equally to this study and reviewed and approved the final manuscript.

Funding

No fund was received for this survey.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

The study received ethical clearance from the Research Ethics and Protocol Review Committee, Research and Human Resource Development Unit of the Ministry of Health, Eritrea, and permissions were obtained from relevant authorities at each college. Written informed consent was obtained from participants after providing a detailed explanation of the study’s purpose, and confidentiality was maintained by anonymizing participants’ identities. Participants were assured the right to withdraw from the study at any point. The research adhered to ethical principles outlined in the Declaration of Helsinki, ensuring the protection of human subjects in medical research. Participants retained the autonomy to withdraw their participation during the interview process.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Abbreviations

WHO World Health Organization

SMA Self-medication with antibiotics

OTC Over-the-counter

OCMHS Orotta College of Medicine and Health Sciences

COE Mai-Nefhi College of Engineering

COS Mai-Nefhi College of Science

ACBSS Adi-Keih College of Business and Social Science

and HAC Hamelmalo College of Agriculture

IQR Interquartile Range

AOR Adjusted odds ratio

COR Crude odds ratio

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
==== Refs
References

1. Aslam B Wang W Arshad MI Khurshid M Muzammil S Rasool MH Antibiotic resistance: a rundown of a global crisis Infect Drug Resist 2018 11 1645 58 10.2147/IDR.S173867 30349322
Aslam B, Wang W, Arshad MI, Khurshid M, Muzammil S, Rasool MH, et al. Antibiotic resistance: a rundown of a global crisis. Infect Drug Resist. 2018;11:1645–58.30349322
2. Ayukekbong JA Ntemgwa M Atabe AN The threat of antimicrobial resistance in developing countries: causes and control strategies Antimicrob Resist Infect Control 2017 6 1 47 10.1186/s13756-017-0208-x 28515903
Ayukekbong JA, Ntemgwa M, Atabe AN. The threat of antimicrobial resistance in developing countries: causes and control strategies. Antimicrob Resist Infect Control. 2017;6(1):47.28515903
3. Roberts SC Zembower TR Global increases in antibiotic consumption: a concerning trend for WHO targets Lancet Infect Dis 2021 21 1 10 1 10.1016/S1473-3099(20)30456-4 32717207
Roberts SC, Zembower TR. Global increases in antibiotic consumption: a concerning trend for WHO targets. Lancet Infect Dis. 2021;21(1):10–1.32717207
4. Bennadi D Self-medication: a current challenge J Basic Clin Pharm 2013 5 1 19 23 10.4103/0976-0105.128253 24808684
Bennadi D. Self-medication: a current challenge. J Basic Clin Pharm. 2013;5(1):19–23.24808684
5. Government of the United Kingdom. Tackling drug-resistant infections globally: final report and recommendations. [cited 2024 Mar 27]. https://apo.org.au/node/63983
6. McGowan JE Economic impact of antimicrobial resistance Emerg Infect Dis 2001 7 2 286 92 10.3201/eid0702.010228 11294725
McGowan JE. Economic impact of antimicrobial resistance. Emerg Infect Dis. 2001;7(2):286–92.11294725
7. Ahmad M Khan AU The global economic impact of antibiotic resistance: a review J Glob Antimicrob Resist 2019 19 313 6 10.1016/j.jgar.2019.05.024 31176071
Ahmad M, Khan AU. The global economic impact of antibiotic resistance: a review. J Glob Antimicrob Resist. 2019;19:313–6.31176071
8. Founou RC Founou LL Essack SY Clinical and economic impact of antibiotic resistance in developing countries: a systematic review and meta-analysis PLoS ONE 2017 12 12 e0189621 10.1371/journal.pone.0189621 29267306
Founou RC, Founou LL, Essack SY. Clinical and economic impact of antibiotic resistance in developing countries: a systematic review and meta-analysis. PLoS ONE. 2017;12(12):e0189621.29267306
9. Global action plan on antimicrobial resistance. [cited 2024 Mar 27]. https://www.who.int/publications-detail-redirect/9789241509763
10. Chokshi A Sifri Z Cennimo D Horng H Global contributors to Antibiotic Resistance J Glob Infect Dis 2019 11 1 36 42 10.4103/jgid.jgid_110_18 30814834
Chokshi A, Sifri Z, Cennimo D, Horng H. Global contributors to Antibiotic Resistance. J Glob Infect Dis. 2019;11(1):36–42.30814834
11. Malik B Bhattacharyya S Antibiotic drug-resistance as a complex system driven by socio-economic growth and antibiotic misuse Sci Rep 2019 9 1 9788 10.1038/s41598-019-46078-y 31278344
Malik B, Bhattacharyya S. Antibiotic drug-resistance as a complex system driven by socio-economic growth and antibiotic misuse. Sci Rep. 2019;9(1):9788.31278344
12. Prestinaci F Pezzotti P Pantosti A Antimicrobial resistance: a global, multifaceted phenomenon Pathog Glob Health 2015 109 7 309 18 10.1179/2047773215Y.0000000030 26343252
Prestinaci F, Pezzotti P, Pantosti A. Antimicrobial resistance: a global, multifaceted phenomenon. Pathog Glob Health. 2015;109(7):309–18.26343252
13. Publications. Health Policy Plan. 2000 Sep [cited 2024 Mar 27];15(3). https://pubmed.ncbi.nlm.nih.gov/11012412/
14. Atif M, Asghar S, Mushtaq I, et al. What drives inappropriate use of antibiotics? A mixed methods study from Bahawalpur, Pakistan. Infect Drug Resist. 2019;12:687–99. 10.2147/IDR.S189114.
15. Ocan M Obuku EA Bwanga F Akena D Richard S Ogwal-Okeng J Household antimicrobial self-medication: a systematic review and meta-analysis of the burden, risk factors and outcomes in developing countries BMC Public Health 2015 15 1 742 10.1186/s12889-015-2109-3 26231758
Ocan M, Obuku EA, Bwanga F, Akena D, Richard S, Ogwal-Okeng J, et al. Household antimicrobial self-medication: a systematic review and meta-analysis of the burden, risk factors and outcomes in developing countries. BMC Public Health. 2015;15(1):742.26231758
16. Aslam A, Gajdács M, Zin CS, Rahman NSA, Ahmed SI, Zafar MZ et al. Evidence of the Practice of Self-Medication with Antibiotics among the Lay Public in Low- and Middle-Income Countries: A Scoping Review. Antibiotics. 2020 Sep [cited 2024 Mar 27];9(9). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7558641/
17. Cars O, Nordberg P. Antibiotic resistance – the faceless threat. Int J Risk Saf Med. 2005;17(3):103–10.
18. Otaigbe II Elikwu CJ Drivers of inappropriate antibiotic use in low- and middle-income countries JAC-Antimicrob Resist 2023 5 3 dlad062 10.1093/jacamr/dlad062 37265987
Otaigbe II, Elikwu CJ. Drivers of inappropriate antibiotic use in low- and middle-income countries. JAC-Antimicrob Resist. 2023;5(3):dlad062.37265987
19. Sunny TP Jacob R Varghese KK Self-medication: is a serious challenge to control antibiotic resistance? Natl J Physiol Pharm Pharmacol 2019 9 9 821 821
Sunny TP, Jacob R, Varghese KK. Self-medication: is a serious challenge to control antibiotic resistance? Natl J Physiol Pharm Pharmacol. 2019;9(9):821–821.
20. Belachew SA, Hall L, Selvey LA. Non-prescription dispensing of antibiotic agents among community drug retail outlets in Sub-Saharan African countries: a systematic review and meta-analysis. Antimicrob Resist Infect Control. 2021 [cited 2024 Mar 27];10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7807893/
21. Chalker J. Improving antibiotic prescribing in Hai Phong Province, Viet Nam: the “antibiotic-dose” indicator. Bull World Health Organ. 2001;79(4):313–20.
22. Antimicrobial resistance. [cited 2024 Mar 27]. https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance
23. Behzadifar M, Behzadifar M, Aryankhesal A, Ravaghi H, Baradaran HR, Sajadi HS, et al. Prevalence of self-medication in university students: systematic review and meta-analysis. East Mediterr Health J. 2020;26(7):846–57. 10.26719/emhj.20.052.
24. Xu R Mu T Wang G Shi J Wang X Ni X Self-medication with antibiotics among University students in LMIC: a systematic review and meta-analysis J Infect Dev Ctries 2019 13 08 678 89 10.3855/jidc.11359 32069251
Xu R, Mu T, Wang G, Shi J, Wang X, Ni X. Self-medication with antibiotics among University students in LMIC: a systematic review and meta-analysis. J Infect Dev Ctries. 2019;13(08):678–89.32069251
25. Osemene K Lamikanra A A study of the prevalence of self-medication practice among University students in Southwestern Nigeria Trop J Pharm Res 2012 11 4 683 9 10.4314/tjpr.v11i4.21
Osemene K, Lamikanra A. A study of the prevalence of self-medication practice among University students in Southwestern Nigeria. Trop J Pharm Res. 2012;11(4):683–9.
26. Eticha T. Prevalence and predictors of self- medication with antibiotics among Adi-Haqi campus students of Mekelle University. Ethiopia. 2014;5(10).
27. Zhu X Pan H Yang Z Cui B Zhang D Ba-Thein W Self-medication practices with antibiotics among Chinese university students Public Health 2016 130 78 83 10.1016/j.puhe.2015.04.005 26008209
Zhu X, Pan H, Yang Z, Cui B, Zhang D, Ba-Thein W. Self-medication practices with antibiotics among Chinese university students. Public Health. 2016;130:78–83.26008209
28. Jairoun A Hassan N Ali A Jairoun O Shahwan M Hassali M University students’ knowledge, attitudes, and practice regarding antibiotic use and associated factors: a cross-sectional study in the United Arab Emirates Int J Gen Med 2019 12 235 46 10.2147/IJGM.S200641 31388309
Jairoun A, Hassan N, Ali A, Jairoun O, Shahwan M, Hassali M. University students’ knowledge, attitudes, and practice regarding antibiotic use and associated factors: a cross-sectional study in the United Arab Emirates. Int J Gen Med. 2019;12:235–46.31388309
29. Araia ZZ Gebregziabher NK Mesfun AB Self medication practice and associated factors among students of Asmara College of Health Sciences, Eritrea: a cross sectional study J Pharm Policy Pract 2019 12 1 3 10.1186/s40545-019-0165-2 30828458
Araia ZZ, Gebregziabher NK, Mesfun AB. Self medication practice and associated factors among students of Asmara College of Health Sciences, Eritrea: a cross sectional study. J Pharm Policy Pract. 2019;12(1):3.30828458
30. Tesfamariam S Anand IS Kaleab G Berhane S Woldai B Habte E Self-medication with over the counter drugs, prevalence of risky practice and its associated factors in pharmacy outlets of Asmara, Eritrea BMC Public Health 2019 19 1 159 10.1186/s12889-019-6470-5 30727984
Tesfamariam S, Anand IS, Kaleab G, Berhane S, Woldai B, Habte E, 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 Health. 2019;19(1):159.30727984
31. Bahta M Tesfamariam S Weldemariam DG Yemane H Tesfamariam EH Alem T Dispensing of antibiotics without prescription and associated factors in drug retail outlets of Eritrea: a simulated client method PLoS ONE 2020 15 1 e0228013 10.1371/journal.pone.0228013 31978180
Bahta M, Tesfamariam S, Weldemariam DG, Yemane H, Tesfamariam EH, Alem T, et al. Dispensing of antibiotics without prescription and associated factors in drug retail outlets of Eritrea: a simulated client method. PLoS ONE. 2020;15(1):e0228013.31978180
32. Ateshim Y Bereket B Major F Emun Y Woldai B Pasha I Prevalence of self-medication with antibiotics and associated factors in the community of Asmara, Eritrea: a descriptive cross sectional survey BMC Public Health 2019 19 1 726 10.1186/s12889-019-7020-x 31182071
Ateshim Y, Bereket B, Major F, Emun Y, Woldai B, Pasha I, et al. Prevalence of self-medication with antibiotics and associated factors in the community of Asmara, Eritrea: a descriptive cross sectional survey. BMC Public Health. 2019;19(1):726.31182071
33. Igbeneghu OA. Knowledge and practices in the use of antibiotics among a group of Nigerian university students. Int J Infect Control. 2013 Feb 7 [cited 2024 Mar 27];9(1). https://ijic.info/article/view/10539
34. Zulu A Matafwali SK Banda M Mudenda S Assessment of knowledge, attitude and practices on antibiotic resistance among undergraduate medical students in the school of medicine at the University of Zambia Int J Basic Clin Pharmacol 2020 9 2 263 70 10.18203/2319-2003.ijbcp20200174
Zulu A, Matafwali SK, Banda M, Mudenda S. Assessment of knowledge, attitude and practices on antibiotic resistance among undergraduate medical students in the school of medicine at the University of Zambia. Int J Basic Clin Pharmacol. 2020;9(2):263–70.
35. Sobierajski T Wanke-Rytt M Mazińska B Karpierz K Hryniewicz W The knowledge on antibiotics and antimicrobial resistance among Polish medical students Eur J Public Health 2019 29 Supplement4 ckz186517 10.1093/eurpub/ckz186.517
Sobierajski T, Wanke-Rytt M, Mazińska B, Karpierz K, Hryniewicz W. The knowledge on antibiotics and antimicrobial resistance among Polish medical students. Eur J Public Health. 2019;29(Supplement_4):ckz186517.
36. Lin L Fearon E Harbarth S Wang X Lu C Zhou X Decisions to use antibiotics for upper respiratory tract infections across China: a large-scale cross-sectional survey among university students BMJ Open 2020 10 8 e039332 10.1136/bmjopen-2020-039332 32843519
Lin L, Fearon E, Harbarth S, Wang X, Lu C, Zhou X, et al. Decisions to use antibiotics for upper respiratory tract infections across China: a large-scale cross-sectional survey among university students. BMJ Open. 2020;10(8):e039332.32843519
37. Wong LP Alias H Husin SA Ali ZB Sim B Ponnampalavanar SSLS Factors influencing inappropriate use of antibiotics: findings from a nationwide survey of the general public in Malaysia PLoS ONE 2021 16 10 e0258698 10.1371/journal.pone.0258698 34669733
Wong LP, Alias H, Husin SA, Ali ZB, Sim B, Ponnampalavanar SSLS. Factors influencing inappropriate use of antibiotics: findings from a nationwide survey of the general public in Malaysia. PLoS ONE. 2021;16(10):e0258698.34669733
38. Widayati A Suryawati S de Crespigny C Hiller JE Knowledge and beliefs about antibiotics among people in Yogyakarta City Indonesia: a cross sectional population-based survey Antimicrob Resist Infect Control 2012 1 1 38 10.1186/2047-2994-1-38 23176763
Widayati A, Suryawati S, de Crespigny C, Hiller JE. Knowledge and beliefs about antibiotics among people in Yogyakarta City Indonesia: a cross sectional population-based survey. Antimicrob Resist Infect Control. 2012;1(1):38.23176763
39. Sulayman AA. Factors associated with self-medication of antibiotics among university students in Kampala. Qual Prim Care. [cited 2024 Mar 27]; https://www.primescholars.com/
40. Aljayyousi GF Abdel-Rahman ME Heneidy AE Kurdi R Faisal E Public practices on antibiotic use: a cross-sectional study among Qatar University students and their family members PLoS ONE 2019 14 11 e0225499 10.1371/journal.pone.0225499 31770408
Aljayyousi GF, Abdel-Rahman ME, Heneidy AE, Kurdi R, Faisal E. Public practices on antibiotic use: a cross-sectional study among Qatar University students and their family members. PLoS ONE. 2019;14(11):e0225499.31770408
41. Ghadeer ARY, Suaifan. A cross-sectional study on knowledge, attitude and behavior related to \ antibiotic use and resistance among medical and non-medical university students in Jordan. Afr J Pharm Pharmacol. 2012 Mar 15 [cited 2024 Mar 27];6(10). http://www.academicjournals.org/ajpp/abstracts/abstracts/abstract%202012/15%20Mar/Suaifan%20et%20al.htm
42. Wall S Prevention of antibiotic resistance – an epidemiological scoping review to identify research categories and knowledge gaps Glob Health Action 2019 12 sup1 1756191 10.1080/16549716.2020.1756191 32475304
Wall S. Prevention of antibiotic resistance – an epidemiological scoping review to identify research categories and knowledge gaps. Glob Health Action. 2019;12(sup1):1756191.32475304
43. Lv B Zhou Z Xu G Yang D Wu L Shen Q Knowledge, attitudes and practices concerning self-medication with antibiotics among university students in western China Trop Med Int Health 2014 19 7 769 79 10.1111/tmi.12322 24941883
Lv B, Zhou Z, Xu G, Yang D, Wu L, Shen Q, et al. Knowledge, attitudes and practices concerning self-medication with antibiotics among university students in western China. Trop Med Int Health. 2014;19(7):769–79.24941883
44. Sakr S, Ghaddar A, Hamam B, Sheet I. Antibiotic use and resistance: an unprecedented assessment of university students’ knowledge, attitude and practices (KAP) in Lebanon.BMC Public Health. 2020;20(1):535.
45. Khalid GM, Jatau AI, Ibrahim UI, Dungus FM, Shitu Z, Sha’aban A, et al. Antibiotics self-medication among undergraduate pharmacy students in Northern Nigeria. Med Access Point Care. 2019;3:2399202619846847.
46. Helal RM, Abou-ElWafa HS. Self-Medication in University Students from the City of Mansoura, Egypt. J Environ Public Health. 2017;2017:9145193.
47. Ullah S, Ali Q, Mohammad D, Anisa, Ahmed T, Arif M, et al. Self-medication with antibiotics and its associated factors among university students: a cross-sectional study. Asia-Pac J Pharmacother Toxicol. 2024 Mar 24 [cited 2024 Apr 1]; Available from: http://ajpt.asmepress.com/articles/new-26-294.html
48. Shitindi L, Issa O, Poyongo BP, Horumpende PG, Kagashe GA, Sangeda RZ. Comparison of knowledge, attitude, practice and predictors of self-medication with antibiotics among medical and non-medical students in Tanzania. Front Pharmacol. 2024 Jan 11 [cited 2024 Mar 28];14. Available from: https://www.frontiersin.org/journals/pharmacology/articles/10.3389/fphar.2023.1301561/full
49. Amponsah SK, Odamtten G, Adams I, Kretchy IA. A comparative analysis of pattern and attitude towards self-medication among pharmacy and non-pharmacy students in University of Ghana. Pan Afr Med J. 2022;41:254.
50. Kanneppady SS, Oo AM, Lwin OM, Ahmed Al-Abed AAA, Kanneppady SK. Knowledge, Attitude,and Awareness of Antibiotic Resistance among Medical Students. Arch Med Health Sci. 2019;7(1):57.
51. Shah P, Shrestha R, Mao Z, Chen Y, Chen Y, Koju P, et al. Knowledge, Attitude,and Practice Associated with Antibiotic Use among University Students: A Survey in Nepal. Int J Environ Res Public Health. 2019;16(20):3996.
