SELF MEDICATION

Mahasiswa : Amanda Arifianti Essen (8711221007)

Arniga Taufik Arwasputra (8711221011)
Ariaci Mandala Putri (8711221015)
Mata Kuliah : Farmasi Klinis I

Magister Farmasi
Universitas Jenderal Achmad Yani
2023
 BAB I
PENDAHULUAN

I.1 Latar Belakang

Self medication adalah suatu perawatan sendiri oleh masyarakat
terhadap penyakit yang umum diderita, dengan menggunakan obat-obatan
yang dijual bebas di pasaran atau obat keras yang bisa didapat tanpa resep
dokter dan diserahkan oleh apoteker di apotek (BPOM, 2004). The
International Pharmaceutical Federation (FIP) mendefinisikan
swamedikasi atau self-medication sebagai penggunaan obat-obatan tanpa
resep oleh seorang individu atas inisiatifnya sendiri (FIP, 1999).
Swamedikasi seringkali dilakukan dalam mengatasi keluhan-keluhan
dan penyakit ringan seperti demam, dismenorea, pusing, batuk, influenza,
sakit maag, diare, penyakit kulit dan lain-lain. Upaya pengobatan sendiri ini
dapat berupa pengobatan dengan obat modern atau obat tradisional. Bisa
disimpulkan dari beberapa pengertian diatas bahwasanya swamedikasi
merupakan praktik menyembuhkan diri sendiri dari penyakit-penyakit
ringan baik itu dengan penggunaan obat modern maupun obat tradisional
tanpa bantuan dari dokter tetapi dengan pengawasan apoteker.
Swamedikasi bertujuan untuk meningkatkan kesehatan diri,
mengobati penyakit ringan dan mengelola pengobatan rutin dari penyakit
kronis setelah melalui pemantauan dokter. Sedangkan fungsi dan peran
swamedikasi lebih terfokus pada penanganan terhadap gejala secara cepat
dan efektif tanpa intervensi sebelumnya oleh konsultan medis kecuali
apoteker, sehingga dapat mengurangi beban kerja pada kondisi terbatasnya
sumber daya dan tenaga (WHO, 1998).
Berdasarkan data Riset Kesehatan Dasar (RISKESDAS) tahun 2013
di Indonesia sebanyak 35,2% rumah tangga menyimpan obat untuk
swamedikasi yang mana terdiri dari jenis obat keras (35,7%), obat bebas
(82%), antibiotik (27,8%), obat tradisional (15,7%), dan obat tidak
teridentifikasi (6,4%). Berdasarkan indikator Kesehatan dari Badan Pusat
Statistik (BPS, 2019) pada tahun 2019, sebanyak 71,46% masyarakat
Indonesia melakukan swamedikasi. Angka ini terus naik selama 3 tahun
terakhir. Data BPS pada tahun 2020 menunjukkan presentase penduduk
yang melakukan swamedikasi di Indonesia adalah sebanyak 72,19%
sedangkan di Jawa Tengah penduduk yang melakukan swamedikasi
sebanyak 68,43% (BPS, 2021).
Self Medication harus dilakukan sesuai dengan penyakit yang dialami.
Pelaksanannya harus memenuhi kriteria penggunaan obat yang rasional,
antara lain ketepatan pemilihan obat, ketepatan dosis, ada tidaknya efek
samping, tidak adanya kontraindikasi, tidak adanya interaksi obat dan tidak
adanya polifarmasi (Depkes RI, 2008). Dalam praktiknya, kesalahan
penggunaan obat dalam swamedikasi ternyata masih terjadi, terutama
karena ketidaktepatan obat dan dosis obat. Apabila kesalahan terjadi terus-
menerus dalam waktu yang lama, dikhawatirkan dapat menimbulkan risiko
pada Kesehatan (Depkes RI, 2006). Keterbatasan pengetahuan masyarakat
adalah salah satu factor yang dapat mengakibatkan terjadinya kesalahan
pengobatan (medication error). Pengetahuan seseorang dipengaruhi oleh
banyak factor seperti pendidikan, informasi/media masa, social, budaya,
ekonomi, lingkungan , pengalaman dan usia.
Untuk meningkatkan Penggunaan Obat Rasional pada masyarakat,
secara nasional tahun 2015 telah dicanangkan Gerakan Masyarakat Cerdas
Menggunakan Obat (GeMa CerMat). Gerakan ini dimaksudkan untuk
meningkatkan pengetahuan, pemahaman, dan keterampilan masyarakat
dalam memilih, mendapatkan, menyimpan dan menggunakan obat dengan
benar. Pelaksanaan Gerakan ini melibatkan berbagai pertemuan dan melalui
media. Keterlibatan lintas sector diharapkan dapat menunjang keberhasilan
dan pencapaian tujuan Gema Cermat.
Berdasarkan latar belakang diatas, Makalah ini dibuat untuk melihat
studi kasus mengenai Self Medication khususnya di Indonesia
I.2 Rumusan Masalah
1. Bagaimana praktek Self Medication pada pengobatan penyakit atau
gejala penyakit yang umum diderita masyarakat?
2. Bagaimana tingkat pengetahuan dan rasionalitas Self Medication di
masyarakat?
3. Apakah edukasi gema cermat berpengaruh terhadap tingkat
pengetahuan masyarakat tentang Self Medication?

I.3 Tujuan Penelitian

1. Untuk mengetahui penanganan yang tepat pada Self Medication
terhadap penyakit atau gejala penyakit yang umum diderita
2. Mengetahui tingkat pengetahuan dan rasionalitas Self Medication di
masyarakat
3. Mengetahui pengaruh edukasi gema cermat terhadap tingkat
pengetahuan masyarakat tentang Self Medication

I.4 Metode Penulisan

Pada penulisan makalah ini, penulis menggunakan metode studi
pustaka untuk mencari data dan fakta dari jurnal yang berkaitan.
 BAB II
TINJAUAN PUSTAKA

II.1 Pengertian Swamedikasi

Swamedikasi, atau pengobatan sendiri adalah perilaku untuk
mengatasi sakit ringan sebelum mencari pertolongan ke petugas atau
fasilitas kesehatan. Lebih dari 60% dari anggota masyarakat melakukan
swamedikasi, dan 80% di antaranya mengandalkan obat modern.
Swamedikasi berarti mengobati segala keluhan pada diri sendiri
dengan obat-obat yang dibeli bebas di apotik atau toko obat atas inisiatif
sendiri tanpa nasehat dokter.
Dewasa ini masyarakat sudah menjadi lebih insyaf akan tanggung
jawabnya atas kesehatan diri dan keluarga. Dimana-mana dirasakan
kebutuhan akan penyuluhan yang jelas dan tepat mengenai penggunaan
secara aman dari obat obatan yang dapat dibeli bebas di apotik guna
swamedikasi.
Salah satu keuntungan swamedikasi yang dapat disebut adalah, bahwa
seringkali obat-obat untuk itu memang sudah tersedia di lemari obat dari
banyak rumah tangga. Lagipula bagi orang yang tinggal di desa terpencil,
dimana belum ada praktek dokter, swamedikasi akan menghemat banyak
waktu yang diperlukan untuk pergi ke kota mengunjungi seorang dokter1.
Sebetulnya, selain menggunakan obat-obat dari golongan “obat
bebas” dan gologan “obat bebas terbatas” yang dijual bebas, dalam rangka
meningkatkan kemampuan masyarakat melakukan pengobatan sendiri,
menteri kesehatan telah menetapkan beberapa obat dari golongan “obat
keras” yang dapat diperoleh tanpa resep dokter langsung dari apoteker di
apotik.
Kebijaksanaan menteri kesehatan tersebut tertuang dalam surat
Keputusan Menteri Kesehatan No.347/Menkes/Sk/VII/1990 tanggal 16 juli
 1990. Surat keputusan tersebut dilampiri dengan Daftar Obat Wajib Apotik
No.12.
Swamedikasi bertujuan untuk meningkatkan kesehatan diri,
mengobati penyakit ringan dan mengelola pengobatan rutin dari penyakit
kronis setelah melalui pemantauan dokter. Fungsi dan peran swamedikasi
lebih terfokus pada penangan terhadap gejala secara cepat dan efektif tanpa
intervensi sebelumnya oleh konsultan medis kecuali apoteker, sehingga
dapat mengurangi beban kerja pada kondisi terbatasnya sumber daya dan
tenaga (WHO, 1998).
Swamedikasi dilakukan masyarakat untuk mengatasi gejala penyakit
ringan yang dapat dikenali sendiri. Menurut Winfield dan Richards (1998)
kriteria penyakit ringan yang dimaksud adalah penyakit yang jangka
waktunya tidak lama dan dipercaya tidak mengancam jiwa pasien seperti
sakit kepala, demam, batuk, pilek, mual, sakit gigi dan sebagainya.

II.2 Kriteria Obat yang Digunakan Sendiri

Sesuai permenkes No.919/MENKES/PER/X/1993, kriteria obat yang
dapat dibeli tanpa resep dokter adalah :
• Tidak dikontraindikasikan untuk penggunaan pada wanita hamil, anak
di bawah usia 2 tahun dan orang tua di atas 65 tahun.
• Tidak memberikan risiko pada kelanjutan penyakit.
• Penggunaannya tidak memerlukan cara atau alat khusus yang harus
dilakukan oleh tenaga kesehatan.
• Penggunaannya diperlukan untuk penyakit yang prevalensinya tinggi di
Indonesia.
Memiliki rasio khasiat keamanan yang dapat dipertanggungjawabkan
untuk pengobatan sendiri.
II.3 Jenis Obat yang Digunakan Dalam Swamedikasi
Obat-obat yang dapat digunakan dalam swamedikasi meliputi obat-
obat yang dapat diserahkan tanpa resep, obat tersebut meliputi obat bebas
(OB), obat bebas terbatas (OBT) dan obat wajib apotek (OWA) (Depkes RI,
2008).
• Obat bebas adalah obat yang dijual bebas dipasaran dan dapat dibeli
tanpa resep dokter. Tanda khusus pada kemasan dan etiket obat bebas
adalah lingkaran hijau dengan garis tepi berwarna hitam (Menteri
Kesehatan RI, 2007).
• Obat bebas terbatas adalah obat yang sebenarnya termasuk obat keras
tetapi masih dapat dijual atau dibeli bebas tanpa resep dokter, dan disertai
dengan tanda peringatan. Tanda khusus pada kemasan dan etiket obat
bebas terbatas adalah lingkaran biru dengan garis tepi berwarna merah.
Tanda peringatan selalu tercantum pada kemasan obat bebas terbatas,
berupa empat persegi panjang berwarna hitam berukuran panjang 5 cm,
lebar 2 cm dan memuat pemberitahuan berwarna putih.
• Obat Wajib Apotek (OWA), yaitu obat keras (tanda lingkaran hitam,
dasar merah dengan huruf K besar) yang dapat dibeli di apotek tanpa
resep dari dokter, tetapi harus diserahkan langsung oleh seorang apoteker
kepada pasien disertai dengan informasi lengkap tentang penggunaan
obat.
• Suplemen makanan (vitamin, kalsium, dll).
4 Obat wajib apotek menjadi obat bebas terbatas yaitu :
• Aminofilin dalam bentuk supositoria.
• Bromheksin.
• Heksetidin sebagai obat luar untuk mulut dan tenggorokan dengan kadar
sama atau kurang dari 0,1%.
• Mebendazol.
1 Obat wajib apotek menjadi obat bebas yaitu :
• Tolnaftat sebagai obat luar untuk infeksi jamur local dengan kadar sama
atau kurang dari 1%.
II.4 Syarat Suatu Obat Swamedikasi
• Obat harus aman, kualitas dan efektif.
• Obat yang digunakan harus punya indikasi, dosis, bentuk sediaan yang
tepat.
• Obat yang diserahkan harus disertai informasi yang jelas dan lengkap.
II.5 Hal yang Harus Diperhatikan Saat Melakukan Swamedikasi
Ketika pasien atau konsumen memilih untuk melakukan swamedikasi,
ada beberapa hal yang harus diperhatikan supaya pengobatan tersebut
dilakukan dengan tepat dan bertanggung jawab :
• Pada swamedikasi, pasien memegang tanggung jawab utama terhadap
obat yang digunakan. Oleh karena itu sebaiknya baca label dan brosur
obat dengan seksama dan teliti. Kemudian perhatian khusus perlu
diberikan bagi penggunaan obat untuk kelompok tertentu, seperti pada
anak-anak, lanjut usia, pasien dengan gangguan fungsi hati atau ginjal,
maupun wanita hamil dan menyusui.
• Jika individu atau pasien memilih untuk melakukan pengobatan sendiri,
maka ia harus dapat mengenali gejala yang dirasakan, menentukan
kondisi mereka sesuai untuk pengobatan sendiri atau tidak, memilih
produk obat yang sesuai dengan kondisinya, mengetahui ada atau
tidaknya riwayat alergi terhadap obat yang digunakan, mengikuti intruksi
yang tertera pada label obat yang dikonsumsi.
Setiap orang yang melakukan swamedikasi juga harus menyadari
kelebihan ataupun kekurangan dari pengobatan yang dilakukan. Dengan
mengetahui manfaat dan resikonya, maka pasien dapat melakukan penilaian
apakah pengobatan tersebut perlu dilakukan atau tidak.
Bila gejala tidak membaik atau sembuh dalam waktu tiga hari, segera
kunjungi dokter untuk mendapat penanganan yang lebih baik.
Bila muncul gejala seperti sesak napas, kulit kemerahan, gatal,
bengkak di bagian tertentu, mual, dan muntah, maka kemunngkinan telah
terjadi gejala efek samping obat atau reaksi alergi terhadap obat yang
 diminum. Segera hentikan pengobatan dan kunjungi dokter untuk
mendapatkan penanganan medis3.
Adapun tips untuk melakukan swamedikasi terhadap diri sendiri
maupun orang-orang sakit diantara kita :
• Kita sebagai pasien harus dapat membaca dan mencermati secara teliti
informasi yang tertera pada kemasan atau brosur yang disiapkan di dalam
kemasan seperti komposisis zat aktif, indikasi (kegunaan), kontra
indikasi (larangan terhadap), efek samping, interaksi obat, dosis dan cara
penggunaan.
• Memilih obat dengan kandungan zat aktif sesuai keperluan, misalnya jika
gejala penyakitnya adalah demam, maka pilih obat yang bersifat
antipiretik (penurun panas) seperti parasetamol (panadol, dumin, tempra)
atau ibuprofen.
• Penggunaan obat swamedikasi hanya untuk penggunaan jangka pendek
saja (3 hari, atau boleh dilanjutkan sampai seminggu jika tidak
mengalami efek samping obat), karena jika gejala menetap atau bahkan
makin memburuk maka pasien harus segera ke dokter.
• Perhatikan aturan pemakaian obat, yang lain seperti frekuensi
pemakaian, obat digunakan sebelum atau sesudah makan dan
sebagainya.
Penting juga untuk memperhatikan masalah makanan, minuman atau
obat lain yang harus dihindari ketika mengkonsumsi obat tersebut, dan
perhatikan juga bagaimana penyimpanannya.

II.6 Kelebihan dan Kekurangan Swamedikasi

Menurut Anief (1997) kelebihan dari tindakan swamedikasi adalah
lebih mudah, cepat, tidak membebani pelayanan kesehatan dan dapat
dilakukan oleh diri sendiri. Selain itu dapat menghemat biaya ke dokter,
menghemat waktu dan segera dapat beraktivitas kembali. Kelebihan lainnya
menurut Supardi dkk (2005) meliputi aman apabila digunakan sesuai
dengan petunjuk (efek samping dapat diperkirakan), efektif untuk
menghilangkan keluhan karena 80% sakit yang bersifat selflimiting,
sembuh sendiri tanpa intervensi tenaga kesehatan, biaya pembelian obat
relatif lebih murah daripada biaya pelayanan kesehatan, hemat waktu karena
tidak perlu menggunakan fasilitas atau profesi kesehatan, kepuasan karena
ikut berperan serta dalam sistem pelayanan kesehatan, menghindari rasa
malu atau stres apabila harus menampakkan bagian tubuh tertentu di
hadapan tenaga kesehatan, dan membantu pemerintah untuk mengatasi
keterbatasan jumlah tenaga kesehatan pada masyarakat.
Kekurangan dalam swamedikasi antaralain, obat dapat
membahayakan kesehatan apabila tidak digunakan sesuai dengan aturan,
pemborosan biaya dan waktu apabila salah menggunakan obat,
kemungkinan kecil dapat timbul reaksi obat yang tidak diinginkan, misalnya
sensitifitas, efek samping atau resistensi, penggunaan obat yang salah
akibat salah diagnosis dan pemilihan obat dipengaruhi oleh pengalaman
menggunakan obat di masa lalu dan lingkungan sosialnya (Supardi dkk,
2005). Selain itu dampak negatif swamedikasi adalah masyarakat keyakinan
pengobatan swamedikasi dapat dilakukan untuk setiap penyakit. Menurut
Ruiz (2010) terdapat potensi resiko dalam swamedikasi antara lain
kesalahan dalam diagnosis diri (self-diagnosis), penundaan dalam mencari
nasihat medis ketika kondisi diri telah berada pada status parah dan
merugikan, interaksi obat yang berbahaya, salah cara penggunaan obat,
kesalahan dosis obat, pemilihan obat yang tidak tepat, adanya penyakit berat
yang tertutupi (masking of a severe disease), resiko ketergantungan dan
penyalahgunaan obat.
Tidak mengenali keseriusan gangguan. Akan tetapi swamedikasi juga
mengenal beberapa resiko. Pertama-tama keseriusannya keluhan-keluhan
dapat dinilai secara salah atau mungkin tidak dikenali, sehingga pengobatan
sendiri bisa dilakukan terlalu lama. Gangguan yang bersangkutan dapat
 memperhebat, sehingga kemudian dokter mungkin perlu menggunakan
obat-obat yg lebih keras atau bahkan datang terlambat.
Penggunaan kurang tepat. Resiko lain adalah bahwa obat-obat bisa
digunakan secara salah, terlalu lama atau dalam takaran yang terlalu besar.
Contoh terkenal adalah tetes hidung dan obat sembelit (laksansia), yang bila
digunakan terlampau lama, malah dapat memperburuk keluhan. Begitupula
apa yang dinamakan obat alamiah, yang mencakup ramuan jamu dan
tumbuhan yang dikeringkan, seringkali dianggap lebih baik dan lebih aman.
Ini adalah suatu kesalahpahaman, karena juga jamu adakalanya dapat
mengandung zat aktif dengan khasiat keras yang dapat menimbulkan efek
samping berbahaya.
Guna mengatasi resiko tersebut, maka perlu sekali untuk
dapat mengenali gangguan tersebut. Selain itu dengan sendirinya aturan
pakai atau peringatan yang selalu diikutsertakan, hendaknya dibaca secara
seksama dan ditaati dengan baik.

II.7 Penggolongan Obat

Maksud dan tujuan penggolongan obat ini adalah untuk meningkatkan
keamanan dan ketetapan penggunaan serta pengamanan distribusi obat,
seperti misalnya toko obat hanya boleh mendistribusikan obat bebas dan
bebas terbatas saja4. Beberapa penggolongan obat antara lain :
• Obat bebas
Obat ini dapat digunakan secara bebas tanpa perlu resep dokter.
Identitas obat yang termasuk dalam golongan obat bebas adalah ada
tanda “lingkaran berwarna hijau dengan garis tepi berwarna hitam.
Salah satu contoh obat ini adalah tablet parasetamol (sebagai
antipiretik atau penurun panas serta analgesik atau pereda nyeri).
• Obat bebas terbatas
Golongan obat ini adalah segolongan obat yang dalam jumlah
tertentu, penggunaanya aman, tetapi apabila terlalu banyak akan
menimbulkan efek berbahaya. Pemakaian tidak perlu dibawah
pengawasan dokter. Dikatakan terbatas karena pemberiannya dalam
jumlah atau dosis dibatasi.
Identitas obat yang termasuk dalam golongan obat bebas terbatas
adalah tanda “lingkaran berwarna biru dengan garis tepi berwarna
hitam”. Salah satu contoh obat yang termasuk golongan obat bebas
terbatas adalah dekstrometorfan (obat batu kering atau antitusif) dan
bromheksin (obat batuk berdahak atau ekspektoran).

• Obat keras dan psikotropika

Golongan obat ini adalah segolongan obat yang berbahaya, dimana
pemakainya harus dibawah pengawasan dokter. Hanya dapat
diperoleh di apotek, puskesmas, balai pengobatan/poliklinik.
Identitas obat keras maupun psikotropika atau yang dikenal sebagai
obat keras tertentu adalah tanda “lingkaran berwarna merah dengan
 huruf K yang berwarna hitam”. Contoh sediaan obat yang termasuk
sebagai obat keras adalah golongan antibiotik.

• Narkotika
Disebut sebagai obat daftar O atau opiat. Zat atau obat yang berasal
dari tanaman atau bukan tanaman baik sintesis maupun semi sintesis
yang dapat menyebabkan penurunan atau perubahan kesadaran,
hilangnya rasa, mengurangi sampai menghilangkan rasa nyeri dan
dapat menimbulkan ketergantungan. Contoh : morfin, petidin.

II.8 Manfaat Swamedikasi

Swamedikasi bermanfaat dalam pengobatan penyakit atau nyeri
ringan, hanya jika dilakukan dengan benar dan rasional, berdasarkan
pengetahuan yang cukup tentang obat yang digunakan dan kemampuan
mengenali penyakit atau gejala yang timbul. Swamedikasi secara
serampangan bukan hanya suatu pemborosan, namun juga berbahaya.
 BAB III
PEMBAHASAN

III.1 Kasus Penyakit yang Diobati dengan Swamedikasi

III.2 Jurnal 1
1. Judul
Self-medication and knowledge among pregnant women attending
primary healthcare service in Malang, Indonesia : a cross sectional
study / Swamedikasi dan pengetahuan ibu hamil yang datang ke
pelayanan kesehatan primer di Malang, Indonesia : studi cross sectional.

2. Abstrak
3. Reputasi scopus

4. Abstrak singkat
Latar belakang: Swamedikasi dengan obat bebas (OTC) merupakan
masalah kesehatan masyarakat yang penting, khususnya pada populasi
ibu hamil yang rentan karena potensi risiko bagi ibu dan janin. Beberapa
studi telah mempelajari bagaimana faktor-faktor, seperti pengetahuan,
mempengaruhi pengobatan sendiri. Penelitian ini menyelidiki
pengobatan sendiri dan faktor yang berhubungan dengan ibu hamil yang
datang ke pelayanan kesehatan di Malang, Indonesia. Metode:
menggunakan studi cross-sectional dilakukan dari Juli hingga
September 2018 di lima layanan kesehatan. Digunakan kuesioner yang
dikelola sendiri dan data dianalisis menggunakan model multiple
regression. Hasil: Dari 333 peserta wanita, sebanyak 39 orang
menggunakan obat OTC. Wanita dengan tingkat pengetahuan yang
lebih tinggi tentang pengobatan OTC cenderung lebih mengobati diri
sendiri. Dibandingkan dengan yang pengetahuannya kurang, ibu hamil
dengan pengetahuan yang tepat bahwa dapat terjadi kemungkinan risiko
apabila melakukan pengobatan sendiri. Pengaruh tingkat pengetahuan
yang lebih tinggi tentang pengobatan OTC signifikan diantara wanita
yang berpendidikan sekolah menengah atau lebih rendah. Pengaruh
pengetahuan yang tepat tentang kemungkinan risiko pengobatan sendiri
signifikan hanya di kalangan wanita dengan pendidikan SMA dan
pendidikan tinggi. Kesimpulan: Memberikan pengetahuan khusus
 tentang potensi risiko penggunaan obat yang tidak diresepkan selama
kehamilan dapat membantu wanita hamil mengendalikan dan mengelola
penggunaan OTC dengan lebih aman.
5. Metode
Menggunakan convenience sampling. Semua ibu hamil yang
datang ke puskesmas dan mengantri untuk bertemu baik bidan maupun
dokter yang memenuhi syarat untuk diikutsertakan dalam penelitian ini.
Wanita hamil yang tidak dapat membaca atau berbicara Bahasa
Indonesia tidak masuk dalam survey. Sekitar 80% ibu hamil setuju untuk
berpartisipasi dalam survei. Kuesioner dilakukan secara mandiri di ruang
tunggu di masing-masing layanan kesehatan. Setelah selesai,
pewawancara memeriksa kuesioner dan meminta responden untuk
meninjau kembali jawaban mereka.
Daftar pertanyaan terstruktur yang dikembangkan untuk menilai
ibu hamil :
1. Kondisi kesehatan dan kehamilan ibu hamil (status kehamilan,
kondisi kesehatan, dan perilaku kesehatan)
2. Pengetahuan tentang pengobatan OTC selama kehamilan
3. Keyakinan tentang penggunaan obat selama kehamilan
4. Karakteristik sosio-demografis
Kami juga menganalisis secara terpisah dua pertanyaan/pernyataan
penting di bagian pengetahuan tentang "Pengetahuan tentang perlunya
berkonsultasi dengan penyedia layanan kesehatan" dan "Pengetahuan
tentang kemungkinan risiko dari minum obat OTC selama kehamilan"
untuk menekankan pada pengobatan yang penting dan spesifik.
Pemahaman pentingnya konsultasi dengan penyedia layanan kesehatan
dan kemungkinan risiko selama kehamilan.
Data karakteristik sosio-demografis juga dikumpulkan.
1. Variabel dua level termasuk usia kehamilan, usia, paritas, tingkat
pendidikan, jumlah kunjungan perawatan antenatal (ANC),
pendapatan rumah tangga, dan tempat tinggal.
 2. Variabel tiga level termasuk pekerjaan dan perilaku brosur obat.
6. Hasil
A. Karakteristik sosial demografis

B. Swamedikasi selama kehamilan

Selama kehamilan, obat bebas yang digunakan antara lain obat
antiemetik (33%), obat pilek dan flu (29%), obat antidemam (15%),
pereda nyeri (13%), dan lain-lain (10%). Di antara mereka yang
melakukan pengobatan sendiri selama kehamilan, sekitar 10,3%
melakukannya pada trimester pertama. Tidak ada perbedaan
signifikan yang diamati dalam karakteristik sosio-demografi antara
mereka yang melakukan pengobatan sendiri dan mereka yang tidak
melakukan pengobatan sendiri (table 1).
C. Pengetahuan tentang pengobatan
Pada Tabel 2, dari 12 pertanyaan yang mengukur pengetahuan
tentang pengobatan OTC, 6 pertanyaan dijawab dengan benar oleh
>60% peserta. Pertanyaan yang memiliki proporsi jawaban benar
tertinggi (86,2%) adalah “Anda perlu berkonsultasi dengan penyedia
layanan kesehatan sebelum atau saat mengonsumsi obat OTC selama
kehamilan”, dan pertanyaan yang memiliki proporsi jawaban benar
terendah (28,8%) adalah “Antibiotik adalah salah satu obat bebas”.
Wanita yang mengonsumsi setidaknya satu obat OTC selama
kehamilan lebih cenderung menjawab dengan benar pernyataan
“Vitamin adalah salah satu obat OTC” (79,5%) dan “Obat OTC
dapat dalam bentuk sediaan obat oral” (92,3%). Sebaliknya, para
wanita ini lebih cenderung salah menjawab pernyataan “Saat
mengonsumsi obat OTC ada kemungkinan risiko obat OTC dapat
memengaruhi bayi” (59,0%).
D. Keyakinan tentang minum obat selama kehamilan
Keyakinan responden tentang minum obat selama kehamilan
disajikan pada Tabel 3. Mereka umumnya menyatakan keyakinan
negatif terhadap penggunaan obat selama kehamilan. Sebagian besar
responden setuju dengan pernyataan berikut. “Wanita hamil
memiliki ambang penggunaan obat yang lebih tinggi saat hamil
daripada saat tidak hamil.” (84,1%). “Sebaiknya bagi janin ibu hamil
menahan diri untuk tidak menggunakan obat-obatan selama masa
kehamilannya, bahkan ketika tidak hamil dan sedang sakit, tentu
sudah minum obat.” (61,3%). “Lebih baik untuk janin jika ibunya
minum obat dan sembuh daripada menderita penyakit yang tidak
diobati selama kehamilan. (63,1%). Sebaliknya, 56,5% wanita
sampel tidak setuju dengan pernyataan “Semua obat bisa berbahaya
bagi janin.”
E. Faktor yang terkait dengan Pengobatan Sendiri
Tabel 4 melaporkan hasil dari analisis regresi logistik
berganda. Secara khusus, Model 2 menunjukkan bahwa total skor
pengetahuan secara signifikan terkait dengan pengobatan sendiri—
rasio odds yang disesuaikan (aOR) = 1,16, 95% CI = 1,02–1,33.
Termasuk pengetahuan keseluruhan dengan hasil biner di Model 3,
diamati bahwa wanita dengan tingkat pengetahuan yang lebih tinggi
tentang pengobatan OTC lebih mungkin untuk mengobati diri
sendiri dibandingkan dengan wanita dengan pengetahuan yang lebih
rendah—aOR = 2,15, 95% CI = 1,03–4,46. Hasil dari Model 4
menunjukkan bahwa dibandingkan dengan mereka yang memiliki
tingkat pengetahuan yang lebih rendah tentang perlunya
berkonsultasi dengan penyedia layanan kesehatan sebelum minum
obat OTC selama kehamilan, ibu hamil yang memiliki tingkat
pengetahuan yang tinggi lebih mungkin untuk melakukan
pengobatan sendiri—aOR = 5,07, CI 95% = 1,11–23,2. Namun,
wanita hamil yang memiliki tingkat pengetahuan yang tinggi tentang
kemungkinan risiko pengobatan OTC pada janin secara signifikan
lebih kecil kemungkinannya untuk melakukan pengobatan sendiri—
aOR = 0,29, 95% CI = 0,14–0,60. Selain itu, usia tetap signifikan di
semua model yang disesuaikan Ini menunjukkan bahwa wanita
hamil yang lebih tua (28-45 tahun) secara signifikan lebih mungkin
untuk melakukan pengobatan sendiri—aOR = 2,14, 95% CI = 1,01-
4,50 (Model 4)
Akhirnya, karena pengetahuan dan keyakinan merupakan
faktor penting, kami selanjutnya memperkirakan efek pengetahuan
terhadap pengobatan sendiri, setelah mempertimbangkan efek
keyakinan. Hasilnya cukup konsisten. Secara khusus, pengetahuan
tentang pengobatan OTC tetap signifikan—aOR = 2,14, 95% CI =
1,03– 4,46 setelah mengontrol kepercayaan dan kovariat lainnya.
Sementara itu, tidak ada hubungan yang diamati antara keyakinan
dan pengobatan sendiri
Analisis subkelompok untuk efek pengetahuan tentang
pengobatan sendiri oleh sosio-demografi Istilah interaksi
pengetahuan biner dengan pendidikan dan pengetahuan biner
dengan pekerjaan memiliki efek signifikan pada pengobatan sendiri
(keduanya p<0,1) Analisis subkelompok kemudian dilakukan.
Secara khusus, efek dari tingkat pengetahuan yang lebih tinggi
tentang pengobatan sendiri adalah signifikan di antara wanita dengan
pendidikan sekolah menengah atau lebih rendah — aOR = 8,18, 95%
CI = 1,70–39,35 — tetapi tidak di antara wanita dengan pendidikan
sekolah menengah atau lebih tinggi ( Tabel 5). Selain itu, pengaruh
pengetahuan tentang kemungkinan risiko penggunaan obat OTC
selama kehamilan terhadap pengobatan sendiri hanya signifikan di
antara wanita dengan pendidikan SMA atau lebih tinggi —aOR =
0,17, 95% CI = 0,07–0,42 (Tabel 5). Efek moderasi pekerjaan pada
hubungan antara pengetahuan tentang kemungkinan risiko dan
pengobatan sendiri tidak signifikan.
7. Pembahasan
Penelitian ini difokuskan pada ibu hamil menghadiri layanan
kesehatan primer di Malang, Indonesia. Tingkat pengetahuan yang lebih
tinggi dikaitkan dengan kemungkinan pengobatan sendiri yang lebih
tinggi selama kehamilan. Namun, jika wanita memiliki pengetahuan
tentang risiko dari pengobatan OTC, mereka cenderung tidak
melakukan pengobatan sendiri. Efek dari tingkat pengetahuan yang
lebih tinggi pada pengobatan sendiri yang lebih tinggi signifikan di
antara wanita dengan pendidikan sekolah menengah atau lebih rendah,
sedangkan pengetahuan yang benar tentang efek risiko potensial
dikaitkan dengan kemungkinan pengobatan sendiri yang lebih rendah di
antara wanita dengan sekolah menengah atau lebih tinggi. pendidikan.
Proporsi pengobatan sendiri selama kehamilan dalam sampel kami
diamati rendah (11,7%). Temuan kami serupa dengan penelitian yang
dilakukan di Belanda (12,5%), Nigeria (22,3%), dan Arab Saudi
(13,2%). Proporsi dalam penelitian ini lebih rendah dari itu (40%) yang
diamati oleh penelitian yang dilakukan di Uni Emirat Arab. Sebuah
penelitian di AS melaporkan bahwa pengobatan sendiri adalah umum.
Kemungkinan besar ibu hamil di Malang memiliki pengetahuan yang
lebih tentang risiko minum obat bebas selama kehamilan.
 Konsisten dengan hasil dari penelitian yang dilakukan di Italia,
wanita hamil diamati lebih cenderung berkonsultasi dengan profesional
medis sebelum minum obat OTC. Perilaku seperti itu sehat dan
memungkinkan para profesional medis untuk memberikan informasi
yang baik tentang penggunaan obat-obatan selama kehamilan.
Pengamatan penting lainnya adalah wanita hamil cenderung tidak
mengobati sendiri jika mereka tahu ada kemungkinan risiko minum obat
selama kehamilan. Memberikan informasi yang spesifik dan penting
tentang pengobatan OTC mungkin lebih efektif untuk membantu wanita
hamil mengelola praktik mereka dengan aman terhadap pengobatan
OTC.
8. Kesimpulan
Penelitian ini mengamati 11,7% wanita dalam sampel melakukan
pengobatan sendiri selama kehamilan. Pengetahuan dan usia diamati
terkait dengan pengobatan sendiri selama kehamilan. Hasil kami
menunjukkan bahwa pengetahuan tentang obat OTC secara umum, dan
pengetahuan tentang kemungkinan risiko penggunaan obat OTC selama
kehamilan sangat kuat terkait dengan penggunaan swamedikasi pada ibu
hamil di Malang.

III.3 Jurnal 2
1. Judul
Self-medication and its risk factors among women before and during
pregnancy / Swamedikasi dan faktor resikonya pada wanita sebelum dan
selama”
2. Abstrak

3. Abstrak singkat
Pengantar: Pengobatan sendiri dapat menimbulkan tantangan yang
signifikan bagi individu dan masyarakat, terutama pada wanita selama
kehamilan. Ini Studi ini bertujuan untuk membandingkan prevalensi
pengobatan sendiri sebelum dan selama kehamilan di kalangan wanita
di Iran. Metode: dalam lintas ini studi sectional, total 384 wanita hamil
dievaluasi untuk prevalensi pengobatan sendiri dan faktor yang terkait
sebelum dan selama kehamilan. Stratified random sampling digunakan
sebagai metode pengambilan sampel. Statistik deskriptif dan uji chi-
square dan regresi logistik digunakan untuk analisis statistik data.
 Hasil:Hasil penelitian menunjukkan bahwa prevalensi pengobatan
sendiri, setidaknya pada wanita yang pernah sakit sekali, adalah 63,9%
sebelum kehamilan dan 43,5% dan selama kehamilan. Variabel seperti
tidak adanya asuransi, pendidikan SMA dan tidak memiliki anak
meningkatkan rasio odds pengobatan sendiri sebelum hamil, sedangkan
variabel tidak memiliki asuransi, tidak memiliki anak atau lebih sedikit
jumlah anak-anak dan tidak ada riwayat aborsi meningkatkan rasio
kemungkinan pengobatan sendiri selama kehamilan. Kesimpulan:
Meskipun prevalensi self-medication selama kehamilan lebih sedikit
daripada sebelum kehamilan, tetapi prevalensi selama kehamilan ini
masih signifikan. Oleh karena itu, tampaknya perlu untuk memberikan
pelatihan umum kepada semua wanita usia subur dan mendidik mereka
tentang bahaya dan efek samping pengobatan sendiri.
4. Metode
Dalam lintas ini studi sectional, total 384 wanita hamil dievaluasi untuk
prevalensi pengobatan sendiri dan faktor yang terkait sebelum dan
selama kehamilan. Stratified random sampling digunakan sebagai
metode pengambilan sampel. Statistik deskriptif dan uji chi-square dan
regresi logistic digunakan untuk analisis statistik data .
5. Hasil
Hasil penelitian menunjukkan bahwa prevalensi pengobatan sendiri,
setidaknya pada wanita yang pernah sakit sekali, adalah 63,9% sebelum
kehamilan dan 43,5% dan selama kehamilan. Variabel seperti tidak
adanya asuransi, pendidikan SMA dan tidak memiliki anak
meningkatkan rasio odds pengobatan sendiri sebelum hamil, sedangkan
variabel tidak memiliki asuransi, tidak memiliki anak atau lebih sedikit
jumlah anak-anak dan tidak ada riwayat aborsi meningkatkan rasio
kemungkinan pengobatan sendiri selama kehamilan
6. Kesimpulan
Meskipun prevalensi self-medication selama kehamilan lebih sedikit
daripada sebelum kehamilan, tetapi prevalensi selama kehamilan ini
 masih signifikan. Oleh karena itu, tampaknya perlu untuk memberikan
pelatihan umum kepada semua wanita usia subur dan mendidik mereka
tentang bahaya dan efek samping pengobatan sendiri.

III.3 Jurnal 3
1. Judul
The role of pharmacists in community education to promote responsible
self-medication in Indonesia: an application of the spiral educational
model / Peran Farmasis dalam Edukasi Komunitas untuk
Mempromosikan Swamedikasi yang Bertanggungjawab di Indonesia:
Sebuah Pengaplikasian dari Pendekatan Spiral.

2. Abstrak
3. Reputasi scopus

4. Abstrak singkat
Pengantar: Pemberdayaan masyarakat merupakan salah satu strategi
kunci untuk meningkatkan kesehatan masyarakat Indonesia. Pada tahun
2015, Pemerintah memprakarsai ‘Gerakan Masyarakat Cerdas
Menggunakan Obat’ (GeMa CerMat) untuk memberdayakan
masyarakat Indonesia dalam mempraktikkan pengobatan mandiri yang
bertanggung jawab. Analisis dari pilot program pelatihan pada tahun
2016 mengidentifikasi bahwa diperlukan perbaikan dalam konten dan
organisasi. Objek: Mengevaluasi modul yang telah direvisi
(menerapkan pendekatan model spiral) untuk memandu pelatihan
masyarakat sebagai bagian dari GeMa CerMat. Setting: Kabupaten
Ngawi, Indonesia. May 2018. Metode: Delapan apoteker (pelatih) dan
39 perwakilan masyarakat (peserta) terlibat dalam pelatihan berdasarkan
modul yang telah direvisi. Modul mengadopsi pendekatan spiral dan
terdiri dari tiga langkah progresif: (1) memahami konsep dasar
informasi pada label/kemasan salah satu produk obat; (2) menegakkan
kembali konsep tersebut untuk memahami klasifikasi obat (diterapkan
menggunakan tiga produk); dan (3) memperluas konsep untuk
memahami klasifikasi obat (diterapkan menggunakan kemasan dari 40
produk). Digunakan skor pre-/post-test, dan dilakukan Focus Group
 Discussion untuk mengeksplorasi perolehan pengetahuan. Pengukuran
hasil utama: pandangan peserta dan pelatih dalam proses spiral. Hasil:
Rata-rata perolehan pengetahuan peserta meningkat dari 12,53/15
menjadi 13,44/15 (p=0,001). Enam kelompok fokus peserta dan dua
focus kelompok pelatih menganggap bahwa baik pelatih maupun peserta
menemukan bahwa model spiral memfasilitasi pemahaman dengan
lebih baik, melibatkan pembelajaran langkah demi langkah. Mereka
juga menunjukkan pentingnya peran apoteker sebagai pelatih yang
memenuhi syarat serta pengembangan alat bantu pelatihan/media yang
tepat. Kesimpulan: Pelatihan berdasarkan spiral model ini berpotensi
diimplementasikan dalam pelatihan komunitas untuk meningkatkan
literasi swamedikasi di kalangan masyarakat Indonesia. Dukungan dari
apoteker serta badan nasional dan profesional terkait sangat penting
untuk keberhasilan pelaksanaan pelatihan.
5. Metode
Delapan apoteker (pelatih) dan 39 perwakilan masyarakat (peserta)
terlibat dalam pelatihan berdasarkan modul yang telah direvisi. Modul
mengadopsi pendekatan spiral dan terdiri dari tiga langkah progresif: (1)
memahami konsep dasar informasi pada label/kemasan salah satu
produk obat; (2) menegakkan kembali konsep tersebut untuk memahami
klasifikasi obat (diterapkan menggunakan tiga produk); dan (3)
memperluas konsep untuk memahami klasifikasi obat (diterapkan
menggunakan kemasan dari 40 produk). Digunakan skor pre-/post-test,
dan dilakukan Focus Group Discussion untuk mengeksplorasi perolehan
pengetahuan. Pengukuran hasil utama: pandangan peserta dan pelatih
dalam proses spiral
6. Hasil
Rata-rata perolehan pengetahuan peserta meningkat dari 12,53/15
menjadi 13,44/15 (p=0,001). Enam kelompok fokus peserta dan dua
focus kelompok pelatih menganggap bahwa baik pelatih maupun peserta
menemukan bahwa model spiral memfasilitasi pemahaman dengan
 lebih baik, melibatkan pembelajaran langkah demi langkah. Mereka
juga menunjukkan pentingnya peran apoteker sebagai pelatih yang
memenuhi syarat serta pengembangan alat bantu pelatihan/media yang
tepat.
7. Kesimpulan
Pelatihan berdasarkan spiral model ini berpotensi diimplementasikan
dalam pelatihan komunitas untuk meningkatkan literasi swamedikasi di
kalangan masyarakat Indonesia. Dukungan dari apoteker serta badan
nasional dan profesional terkait sangat penting untuk keberhasilan
pelaksanaan pelatihan.
 DAFTAR PUSTAKA

Atmadani, R.N., Nkoka O., Yunita L.S., dan Chen Y.H. 2020. “Self-medication and
knowledge among pregnant women attending primary healthcare service in
Malang, Indonesia : a cross sectional study”. BMC Pragnancy and
Childbirth. 20:42

BPS, 2021, Presentase Penduduk yang Mengobati Sendiri Selama Sebulan

Terakhir, Terdapat di:
https://www.bps.go.id/indicator/30/1974/1/persentase-penduduk-yang-
mengobati-sendiri-selama-sebulan-terakhir.html.

FIP, 1999. Joint Statement By The International harmaceutical Federation and The
World Self-Medication Industry: Responsible Self-Medication. FIP &
WSMI, p.1-2

WHO, 1998. The Role of The Pharmacist in Self-Care and Self-Medication. The
Hague, The Netherlands: WHO.

Widana Beni Agus Gede, 2014, Analisis Obat Kosmetik Dan Makanan, Graha
Ilmu, Yogyakarta.
Drs.H.T.Tan dan Drs.Rahardja Kirana, 1993, Swamedikasi, Jakarta.

Sartono, 2000, Obat Wajib Apotek, PT Graha Pustaka Utami, Jakarta.

https://swamedikasi.wordpress.com/category/pengertian-swamedikasi/

www.forumsains.com/artikel/logo.biru-hijau-dan-K-dalam-lingkaran-merah-pada-
obat
Adji Prayitno Setiadi, dkk. 2020. The role of pharmacists in community education
to promote responsible self-medication in Indonesia: an application
of the spiral educational model. International Journal of Clinical
Pharmacy.
SELF
MEDICATION
Farmasi Klinis I
Magister Farmasi APOTECHARY

Universitas Jenderal Achmad Yani

 Kelompok I

Amanda A. Essen Arniga T. Arwasputra Ariaci M. Putri

8711221007 8711221011 8711221015
 Self Medication
Suatu perawatan sendiri oleh masyarakat terhadap penyakit yang
umum diderita, dengan menggunakan obat-obatan yang dijual bebas
di pasaran atau obat keras yang bisa didapat tanpa resep dokter dan
diserahkan oleh apoteker di apotek (BPOM, 2004).

Swamedikasi adalah pemilihan dan penggunaan obat modern, herbal,

maupun obat tradisional oleh seorang individu untuk mengatasi
penyakit atau gejala penyakit (WHO, 2010)

Swamedikasi seringkali dilakukan dalam mengatasi keluhan-keluhan

dan penyakit ringan seperti demam, dismenorea, pusing, batuk,
influenza, sakit maag, diare, penyakit kulit dan lain-lain
 Riset Kesehatan Dasar 2013
90%
82%
80%

35,2% 70%

60%

50%

Rumah tangga menyimpan obat 40% 35,70%

untuk swamedikasi
30% 27,80%

20% 15,70%

10% 6,40%

0%
Category 1

Obat Bebas Obat Keras Obat Tradisional Antibiotik Tidak Teridentifikasi

Data Badan Pusat Statistik (BPS)

72%

72,2%
72%

72%

72%

72%
71%

71%

71%

71%

2019 2020
Self Medication harus dilakukan sesuai dengan penyakit yang dialami.
Pelaksanannya harus memenuhi kriteria penggunaan obat yang rasional,
antara lain ketepatan pemilihan obat, ketepatan dosis, ada tidaknya efek
samping, tidak adanya kontraindikasi, tidak adanya interaksi obat dan tidak
adanya polifarmasi (Depkes RI, 2008). Dalam praktiknya, kesalahan
penggunaan obat dalam swamedikasi ternyata masih terjadi, terutama karena
ketidaktepatan obat dan dosis obat. Apabila kesalahan terjadi terus-menerus
dalam waktu yang lama, dikhawatirkan dapat menimbulkan risiko pada
Kesehatan (Depkes RI, 2006). Keterbatasan pengetahuan masyarakat adalah
salah satu factor yang dapat mengakibatkan terjadinya kesalahan
pengobatan (medication error). Pengetahuan seseorang dipengaruhi oleh
banyak factor seperti pendidikan, informasi/media masa, social, budaya,
ekonomi, lingkungan , pengalaman dan usia
Untuk meningkatkan Penggunaan Obat Rasional pada masyarakat, secara
nasional tahun 2015 telah dicanangkan Gerakan Masyarakat Cerdas
Menggunakan Obat (GeMa CerMat). Gerakan ini dimaksudkan untuk
meningkatkan pengetahuan, pemahaman, dan keterampilan masyarakat
dalam memilih, mendapatkan, menyimpan dan menggunakan obat dengan
benar.
Syarat Pasien Bisa Self Medication

Tahu Jenis Obat Tahu Kegunaan Menggunakan Obat secara

Obat benar (cara, aturan, lama
pemakaian)

Tahu batas Tahu efek Tahu siapa yang tidak

penghentian obat samping boleh menggunakan obat
tersebut.
 Faktor Self Medication

Sosial Ekonomi Gaya Hidup Kemudahan memperoleh

produk obat

Faktor kesehatan Ketersediaan

lingkungan produk baru
Self Medication yang Rasional
• Tepat diagnosis
• Tepat pemilihan obat
• Tepat dosis
• Wasapada efek samping
• Efektif
• Tepat tindak lanjut
 Jenis Obat Self Medication

Obat Bebas
Obat Bebas Terbatas

K Obat Wajib
Apotek
Suplemen
 Kelebihan Self Medication
• Mudah dan cepat
• Tidak membebani pelayanan kesehatan dan dapat dilakukan oleh diri
sendiri.
• Menghemat biaya ke dokter
• Menghemat waktu dan segera dapat beraktivitas kembali.
• Aman apabila digunakan sesuai dengan petunjuk (efek samping dapat
diperkirakan)
• Efektif untuk menghilangkan keluhan karena 80% sakit yang bersifat
selflimiting, sembuh sendiri tanpa intervensi tenaga kesehatan
• Kepuasan karena ikut berperan serta dalam sistem pelayanan
kesehatan
• Menghindari rasa malu atau stres apabila harus menampakkan bagian
tubuh tertentu di hadapan tenaga kesehatan
• Membantu pemerintah untuk mengatasi keterbatasan jumlah tenaga
kesehatan pada masyarakat
 Kekurangan Self Medication
• Obat dapat membahayakan kesehatan apabila tidak digunakan sesuai
dengan aturan
• Pemborosan biaya dan waktu apabila salah menggunakan obat
• Ada kemungkinan kecil dapat timbul reaksi obat yang tidak diinginkan,
misalnya sensitifitas, efek samping atau resistensi
• Penggunaan obat yang salah akibat salah diagnosis
• Pemilihan obat dipengaruhi oleh pengalaman menggunakan obat di masa
lalu dan lingkungan sosialnya
• Masyarakat memiliki keyakinan pengobatan swamedikasi dapat
dilakukan untuk setiap penyakit.
• Self-diagnosis
• Penundaan dalam mencari nasihat medis ketika kondisi diri telah berada
pada status parah dan merugikan
• Resiko ketergantungan dan penyalahgunaan obat.
 Studi Kasus
Self-medication pada Ibu Hamil
 Jurnal 1
“Swamedikasi dan pengetahuan ibu
hamil yang datang ke pelayanan
kesehatan primer di Malang,
Indonesia : studi cross sectional”
 Abstrak
Latar belakang: Swamedikasi dengan obat bebas (OTC) merupakan masalah
kesehatan masyarakat yang penting, khususnya pada populasi ibu hamil yang rentan
karena potensi risiko bagi ibu dan janin. Beberapa studi telah mempelajari bagaimana
faktor-faktor, seperti pengetahuan, mempengaruhi swamedikasi. Penelitian ini untuk
mengetahui swamedikasi dan faktor yang berhubungan dengan ibu hamil yang datang
ke pelayanan kesehatan di Malang, Indonesia. Metode: menggunakan studi cross-
sectional dilakukan dari Juli hingga September 2018 di lima layanan kesehatan.
Digunakan kuesioner yang dikelola sendiri dan data dianalisis menggunakan model
multiple regression. Hasil: Dari 333 peserta wanita, sebanyak 39 orang menggunakan
obat OTC. Wanita dengan tingkat pengetahuan yang lebih tinggi tentang pengobatan
OTC cenderung lebih mengobati diri sendiri. Dibandingkan dengan yang
pengetahuannya kurang, ibu hamil dengan pengetahuan yang tepat bahwa dapat
terjadi kemungkinan risiko apabila melakukan pengobatan sendiri. Pengaruh tingkat
pengetahuan yang lebih tinggi tentang pengobatan OTC signifikan diantara wanita
yang berpendidikan sekolah menengah atau lebih rendah. Pengaruh pengetahuan yang
tepat tentang kemungkinan risiko pengobatan sendiri signifikan hanya di kalangan
wanita dengan pendidikan SMA dan pendidikan tinggi. Kesimpulan: Memberikan
pengetahuan khusus tentang potensi risiko penggunaan obat yang tidak diresepkan
selama kehamilan dapat membantu wanita hamil mengendalikan dan mengelola
penggunaan OTC dengan lebih aman.
 Jurnal 2
“Swamedikasi dan faktor resikonya
pada wanita sebelum dan selama”
 Abstrak
Pengantar: Pengobatan sendiri dapat menimbulkan tantangan yang signifikan bagi
individu dan masyarakat, terutama pada wanita selama kehamilan. Ini Studi ini bertujuan
untuk membandingkan prevalensi pengobatan sendiri sebelum dan selama kehamilan di
kalangan wanita di Iran. Metode: dalam lintas ini studi sectional, total 384 wanita hamil
dievaluasi untuk prevalensi pengobatan sendiri dan faktor yang terkait sebelum dan
selama kehamilan. Stratified random sampling digunakan sebagai metode pengambilan
sampel. Statistik deskriptif dan uji chi-square dan regresi logistik digunakan untuk analisis
statistik data. Hasil:Hasil penelitian menunjukkan bahwa prevalensi pengobatan sendiri,
setidaknya pada wanita yang pernah sakit sekali, adalah 63,9% sebelum kehamilan dan
43,5% dan selama kehamilan. Variabel seperti tidak adanya asuransi, pendidikan SMA dan
tidak memiliki anak meningkatkan rasio odds pengobatan sendiri sebelum hamil,
sedangkan variabel tidak memiliki asuransi, tidak memiliki anak atau lebih sedikit jumlah
anak-anak dan tidak ada riwayat aborsi meningkatkan rasio kemungkinan pengobatan
sendiri selama kehamilan. Kesimpulan: Meskipun prevalensi self-medication selama
kehamilan lebih sedikit daripada sebelum kehamilan, tetapi prevalensi selama kehamilan
ini masih signifikan. Oleh karena itu, tampaknya perlu untuk memberikan pelatihan umum
kepada semua wanita usia subur dan mendidik mereka tentang bahaya dan efek samping
pengobatan sendiri.
 Jurnal 3
“Peran Farmasis dalam Edukasi
Komunitas untuk Mempromosikan
Swamedikasi yang Bertanggungjawab
di Indonesia: Sebuah Pengaplikasian
dari Pendekatan Spiral”
 Abstrak
Pengantar: Pemberdayaan masyarakat merupakan salah satu strategi kunci untuk meningkatkan
kesehatan masyarakat Indonesia. Pada tahun 2015, Pemerintah memprakarsai ‘Gerakan Masyarakat
Cerdas Menggunakan Obat’ (GeMa CerMat) untuk memberdayakan masyarakat Indonesia dalam
mempraktikkan pengobatan mandiri yang bertanggung jawab. Analisis dari pilot program pelatihan
pada tahun 2016 mengidentifikasi bahwa diperlukan perbaikan dalam konten dan organisasi. Objek:
Mengevaluasi modul yang telah direvisi (menerapkan pendekatan model spiral) untuk memandu
pelatihan masyarakat sebagai bagian dari GeMa CerMat. Setting: Kabupaten Ngawi, Indonesia. May
2018. Metode: Delapan apoteker (pelatih) dan 39 perwakilan masyarakat (peserta) terlibat dalam
pelatihan berdasarkan modul yang telah direvisi. Modul mengadopsi pendekatan spiral dan terdiri dari
tiga langkah progresif: (1) memahami konsep dasar informasi pada label/kemasan salah satu produk
obat; (2) menegakkan kembali konsep tersebut untuk memahami klasifikasi obat (diterapkan
menggunakan tiga produk); dan (3) memperluas konsep untuk memahami klasifikasi obat (diterapkan
menggunakan kemasan dari 40 produk). Digunakan skor pre-/post-test, dan dilakukan Focus Group
Discussion untuk mengeksplorasi perolehan pengetahuan. Pengukuran hasil utama: pandangan peserta
dan pelatih dalam proses spiral. Hasil: Rata-rata perolehan pengetahuan peserta meningkat dari
12,53/15 menjadi 13,44/15 (p=0,001). Enam kelompok fokus peserta dan dua focus kelompok pelatih
menganggap bahwa baik pelatih maupun peserta menemukan bahwa model spiral memfasilitasi
pemahaman dengan lebih baik, melibatkan pembelajaran langkah demi langkah. Mereka juga
menunjukkan pentingnya peran apoteker sebagai pelatih yang memenuhi syarat serta pengembangan
alat bantu pelatihan/media yang tepat. Kesimpulan: Pelatihan berdasarkan spiral model ini berpotensi
diimplementasikan dalam pelatihan komunitas untuk meningkatkan literasi swamedikasi di kalangan
masyarakat Indonesia. Dukungan dari apoteker serta badan nasional dan profesional terkait sangat
penting untuk keberhasilan pelaksanaan pelatihan.
 ● Memberikan pengetahuan khusus tentang potensi risiko
penggunaan obat yang tidak diresepkan selama kehamilan
dapat membantu wanita hamil mengendalikan dan
mengelola penggunaan OTC dengan lebih aman.

● Meskipun prevalensi self-medication selama kehamilan lebih

sedikit daripada sebelum kehamilan, tetapi prevalensi
selama kehamilan ini masih signifikan. Oleh karena itu,
Kesimpulan tampaknya perlu untuk memberikan pelatihan umum
kepada semua wanita usia subur dan mendidik mereka
tentang bahaya dan efek samping pengobatan sendiri.

● Pelatihan GeMa CerMat berpotensi diimplementasikan

dalam pelatihan komunitas untuk meningkatkan literasi
swamedikasi di kalangan masyarakat Indonesia. Dukungan
dari apoteker serta badan nasional dan profesional terkait
sangat penting untuk keberhasilan pelaksanaan.
 Daftar Pustaka
Atmadani, R.N., Nkoka O., Yunita L.S., dan Chen Y.H. 2020. “Self-medication and knowledge among pregnant women
attending primary healthcare service in Malang, Indonesia : a cross sectional study”. BMC Pragnancy and
Childbirth. 20:42
BPS, 2021, Presentase Penduduk yang Mengobati Sendiri Selama Sebulan Terakhir, Terdapat di:
https://www.bps.go.id/indicator/30/1974/1/persentase-penduduk-yang-mengobati-sendiri-selama-sebulan-
terakhir.html.
FIP, 1999. Joint Statement By The International harmaceutical Federation and The World Self-Medication Industry:
Responsible Self-Medication. FIP & WSMI, p.1-2
WHO, 1998. The Role of The Pharmacist in Self-Care and Self-Medication. The Hague, The Netherlands: WHO.

Widana Beni Agus Gede, 2014, Analisis Obat Kosmetik Dan Makanan, Graha Ilmu, Yogyakarta.

Drs.H.T.Tan dan Drs.Rahardja Kirana, 1993, Swamedikasi, Jakarta.

Sartono, 2000, Obat Wajib Apotek, PT Graha Pustaka Utami, Jakarta.

https://swamedikasi.wordpress.com/category/pengertian-swamedikasi/

www.forumsains.com/artikel/logo.biru-hijau-dan-K-dalam-lingkaran-merah-pada-obat

Adji Prayitno Setiadi, dkk. 2020. The role of pharmacists in community education to promote responsible self-medication
in Indonesia: an application of the spiral educational model. International Journal of Clinical Pharmacy.
 Terima Kasih
PHARMACIST

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Atmadani et al. BMC Pregnancy and Childbirth (2020) 20:42
https://doi.org/10.1186/s12884-020-2736-2

RESEARCH ARTICLE Open Access

Self-medication and knowledge among

pregnant women attending primary
healthcare services in Malang, Indonesia: a
cross-sectional study
Rizka Novia Atmadani1,2, Owen Nkoka2, Sendi Lia Yunita1,2 and Yi-Hua Chen2*

Abstract
Background: Self-medication with over-the-counter (OTC) drugs is an important public health concern, especially
in the vulnerable population of pregnant women due to potential risks to both the mother and fetus. Few studies
have studied how factors, such as knowledge, affect self-medication. This study investigated self-medication and its
associated factors among pregnant women attending healthcare services in Malang, Indonesia.
Methods: A cross-sectional study was conducted from July to September 2018 in five healthcare services. A self-
administered questionnaire was used and the data were analyzed using multiple regression models.
Results: Of 333 female participants, 39 (11.7%) used OTC medication. Women with a higher level of knowledge of
OTC medication were more likely to self-medicate—adjusted odds ratio (aOR) = 2.15, 95% confidence interval (CI) =
1.03–4.46. Compared with those with less knowledge, pregnant women with more correct knowledge of the
possible risk of self-medication were less likely to self-medicate—aOR = 0.29; 95% CI = 0.14–0.60. The effect of a
higher level of knowledge of OTC medication was significant among women who had middle school and lower
education—aOR = 8.18; 95% CI = 1.70–39.35. The effect of correct knowledge on the possible risks of self-
medication was significant only among women with high school and higher education—aOR = 0.17; 95% CI = 0.07–
0.42.
Conclusion: Imparting specific knowledge of the potential risks of using non-prescribed medication during
pregnancy may help pregnant women navigate and more safely manage their OTC use. We also suggest further
collecting data from more healthcare services, such as hospitals, to obtain more findings generalizable to the
Indonesian community.
Keywords: Pregnancy, Over-the-counter medication, Knowledge, Healthcare service, Indonesia

Background the-counter (OTC) [2]; over 65% self-medicated with

The use of medication during pregnancy is a public
health concern. Globally, almost 50% of pregnant
women use medication in the early weeks of gestation
[1]. Using a web-based multinational study, Lupattelli
et al. discovered that 81.2% of pregnant women used at
least one type of medication, either prescribed or over-
* Correspondence: yichen@tmu.edu.tw
2
School of Public Health, College of Public Health, Taipei Medical University,
Taipei, Taiwan
Full list of author information is available at the end of the article
OTC medication.
Self-medication, particularly with OTC medication, is
considered a potential for harm for pregnant women [3–
5]. The United States Food and Drug Administration’s
(FDA’s) 1979 regulations categorized drugs by pregnancy
risk. There are five categories, each marked by a letter:
A, B, C, D, or X [6]. Only a few OTC medications or
prescription drugs are of category A or B (indicating no
evidence of risk to the fetus), whereas many drugs are of
category C (indicating evidence of potential benefits

© The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Atmadani et al. BMC Pregnancy and Childbirth (2020) 20:42
outweighing potential fetal risks), or of categories D or
X (indicating evidence of fetal risk) [7].
Indeed, medication use during pregnancy is a dilemma
because the vulnerable population (i.e., pregnant women
and children) is not included in clinical drug trials [8, 9].
Therefore, there is not enough data of the effects from
such medicine on the vulnerable groups. One such study
discovered an association between a pregnant woman’s
use of aspirin and intracranial hemorrhage in her new-
born baby [10]. Another study discovered an association
between a pregnant woman’s use of valproic acid and
the risk of neural tube defects in her fetus [11]. In gen-
eral, studies on the fetal effects of self-medication are
limited because of the complexity of the examination
[12].
Despite the dilemma, prenatal self-medication is re-
portedly frequent. Studies on self-medication have re-
ported its varying prevalence due to different study
populations, design, and socio-cultural contexts. For in-
stance, self-medication was reported among 12.5% of
pregnant women in a study conducted in Netherlands
[13], whereas a higher rate of 40% during pregnancy was
reported by another study conducted in the United Arab
Emirates [14]. In addition, there were inconsistent find-
ings of the effect of different factors on self-medication
during pregnancy from other studies [12, 15]. Studies
concluded that factors such as one’s knowledge, beliefs,
and socio-demographic background are associated with
self-medication during pregnancy [16–21]. For instance,
in studies conducted in Ethiopia and Italy, pregnant
women with more knowledge of the risks of self-
medication were less likely to self-medicate, compared
with those with less knowledge [19, 22]. However, stud-
ies investigating about the knowledge of potential risk
effects of those medications on the fetus are scarce.
In Indonesia, OTC medicines are readily available in
drug stores, retail stores, or kiosks [23]. Previous studies
have investigated self-medication in the Indonesian
population, but they did not focus on prenatal usage
[24]. Moreover, there is scant information in the litera-
ture on how a pregnant woman’s knowledge of OTC
medication and her beliefs on the use of medication af-
fects their practice of self-medication.
Due to self-medication’s potential for harm to both the
mother and fetus, it is therefore imperative to study the
prevalence of self-medication and factors associated with
self-medication during pregnancy. In addition, such a
study ought to focus on the factors of a pregnant woman’s
knowledge of OTC medication and beliefs on the use of
medication. Findings from such studies will help public
health practitioners appraise the importance of a woman’s
knowledge of the use of OTC medication. An appraisal
will help in the formulation of health education programs
to assist women in realizing how to safely manage their
Page 2 of 11
OTC use during pregnancy. For Indonesia in particular,
although self-medication use for the general population
has been investigated, the examination of the use during
critical periods of women’s pregnancy has been lacking.
Findings from those studies would be vital for tailor-made
interventions to promote the safe use of medication dur-
ing pregnancy for maternal and fetal health. Furthermore,
it is important to examine effect modifiers between the re-
lationship of knowledge of OTC medication with the
practice of self-medication. Some examinations are helpful
in the identification of high-risk groups with regard to
self-medication during pregnancy.
Therefore, this study aims to examine (1) the propor-
tion of pregnant women who self-medicated in this con-
venience sample in Malang, Indonesia; (2) the factors
associated with the practice of self-medication during
pregnancy; and (3) the moderating effects of socio-
demographic characteristics on the relationship between
knowledge of OTC medication and the practice of self-
medication during pregnancy.
Methods
Study area
This study was conducted in Malang City and Malang
Regency, Java, Indonesia. Malang Regency is the largest
regency in East Java province. In 2017, its population
was approximately 2,576,596 [25] and the population of
Malang City was approximately 861,414 [26].
Samples and data collection
This cross-sectional study was conducted from July to
September 2018 at five primary healthcare services (Pus-
kesmas, also called public health center) in Malang.
Three healthcare services are located in the southeast
area of Malang Regency, and two are located in the cen-
ter of Malang City. A convenience sampling method was
adopted. All pregnant women coming to the Puskesmas
and queuing to see a healthcare provider (either a mid-
wife or doctor) were eligible for inclusion in this study.
Pregnant women who were unable to read or speak the
language of Bahasa Indonesia were excluded from the
survey as the data collection instrument was adminis-
tered in this local language. Approximately 80 % of preg-
nant women agreed to participate in this survey among
those who accessed care at that time. The questionnaires
were self-administered in the waiting room at each of
the healthcare service. They were collected on-site im-
mediately after the questionnaires were completed.
Upon completion, the interviewer checked the question-
naire and asked the respondent to review their responses
if there were missing items.
The formula by Kish and Leslie (1965) was used for
sample size calculation. With the use of previous data
that 25% of pregnant women used OTC medication [27]
Atmadani et al. BMC Pregnancy and Childbirth (2020) 20:42
and a 5% margin of error was expected, the sample size
required for this study was 321 participants.
Questionnaire development
A structured self-reported questionnaire was developed to
assess pregnant women’s (1) health and pregnancy condi-
tion (pregnancy status, health condition, and health be-
havior), (2) knowledge of OTC medication during
pregnancy, (3) beliefs about medication use during preg-
nancy, and (4) socio-demographic characteristics. The
questionnaire was originally developed in English (Add-
itional file 1) and translated into Bahasa Indonesia. For the
evaluation of the content, semantics, and conceptual
equivalence of the instruments in both the source and tar-
get languages, translation, back-translation, expert review
and a pilot study was recommended by Guillemin et al.
(1993) as guidelines for cross-cultural adaptation of
health-related measures. The questionnaire utilized in this
study was developed based upon these guidelines [28].
To translate the English instrument into Bahasa
Indonesia version, we performed a forward and backward
translation. First, a bilingual expert who was fluent in both
English and Bahasa Indonesia translated the English ver-
sion to Bahasa Indonesia. Another expert from a language
center in Indonesia then back translated to English to en-
sure consistency of meaning. Then, two additional experts
independently compared the original English instrument
and the version translated back from Bahasa Indonesia to
certify the equivalence and cultural relevance. An overall
agreement was achieved. In addition, the instrument uti-
lized was edited and modified based upon expert review.
Four experts in pharmacy, public health, and epidemi-
ology fields comprehensively reviewed the scope of this
study and examined the content validity of the question-
naire in April, 2018. A pilot study was then conducted
among 20 pregnant women [29] in May 2018 to assess
practicability and face validity. This pilot study certified
women’s understanding and feasibility of implementation.
Minor modifications of the wording of the questions were
further performed to ensure easier comprehension based
upon experts’ evaluation.
Outcome variable
The outcome measure was “self-medication” (specific-
ally, of OTC medication) assessed by asking whether the
pregnant women had used at least one type of OTC
medication in their current pregnancy. They answered
either yes or no.
Independent variable
A pregnant woman’s knowledge of OTC medication, the
main independent factor of this study, was evaluated
relative to items generated from a literature review,
yielding a total of 12 knowledge statements that was
Page 3 of 11
validly used previously [22, 30]. In our study, content
validity index (CVI) calculated from expert review was
utilized to quantify content validity. Based upon expert
opinions along with CVI values over 0.8, all 12 questions
were retained. Questions were further edited based upon
the experts’ opinions. The Cronbach’s alphas for the
questions on knowledge of OTC medication during
pregnancy were 0.88 and 0.85 in the pilot study and in
the final enrolled sample, respectively, indicating appro-
priate internal consistency.
Assessments of pregnant women’s knowledge of OTC
medication involved statements such as “There are pos-
sible risks from the use of OTC medication during preg-
nancy” and “There is a need to consult a healthcare
provider before taking OTC medication.” Each statement
was accompanied by three possible responses: “yes,” “no,
” and “do not know.” Items answered correctly were
coded as “1” and items answered incorrectly (including
those having the response “do not know”) are coded as
“0.” These were summed into a knowledge score. As
there were 12 statements, the knowledge scores ranged
from 0 to 12. We used these total knowledge scores to
estimate the change in the likelihood of self-medication
per unit of change in knowledge.
In addition, we investigated whether women having
knowledge above a certain level behaved differently in
terms of OTC medication. We thus used the third quar-
tile as a cut-off point to categorize knowledge scores
into two (“high level of knowledge” and “low level of
knowledge”) subcategories [31]. We also separately ana-
lyzed the two important questions/statements in the
knowledge section of “Knowledge about the need to
consult any healthcare provider” and “Knowledge about
possible risk from taking OTC medication during preg-
nancy” to emphasize on the crucial and specific medica-
tion understanding of consultation with healthcare
provider and possible risks during pregnancy.
Other covariates
A pregnant woman’s beliefs regarding medication during
pregnancy was measured using nine questions (six for
medication and three for natural remedies usage)
adopted from previously validated surveys in Norway
[32], Saudi Arabia [33] and Belgium [34]. In our study,
all nine questions were retained based upon experts’
evaluation and CVI values larger than 0.8, with minor
editing performed corresponding with experts’ opinions.
The Cronbach’s alphas were 0.82 and 0.7 in the pilot
study and in the final enrolled sample, respectively, to
indicate acceptable internal consistency. For the assess-
ment of woman’s beliefs regarding medication during
pregnancy in the first six questions, each question had a
five-point Likert scale ranging from “strongly disagree”
to “strongly agree.” The sum of the scores ranged from 6
Atmadani et al. BMC Pregnancy and Childbirth (2020) 20:42
to 30. This sum measured the level of a pregnant
woman’s belief toward taking medication during preg-
nancy, with lower scores indicating a more positive be-
lief. The first quartile was used as a cut-off point to
categorize belief scores into two (“positive” and “nega-
tive”) subcategories.
Data on socio-demographic characteristics were also
gathered. Two- and three-level variables were used.
Two-level variables included gestational age (first vs. sec-
ond and third trimesters), age (16–27 vs. 28–45 years),
parity (0 vs. 1 or more children), education level (middle
school and lower vs. high school and higher), number of
antenatal care (ANC) visits (fewer than 4 vs. 4 or more),
household income (fewer than 1.5 million Rupiah vs. 1.5
million Rupiah or more), and residence (urban vs. rural).
Three-level variables included occupation (student,
homemaker, and employed) and health behavior with re-
gard to reading a drug’s accompanying leaflet (always,
sometimes, and never).
Statistical analysis
Data were entered and analyzed using SPSS version 18
(SPSS, Chicago, IL, USA). We used the chi-square tests
and Fisher’s exact tests to analyze differences in socio-
demographics (e.g., age, education), pregnancy related
variables (e.g., number of ANC visits), health related var-
iables (e.g., self-perceived heath status, checking drug
leaflet), and knowledge on OTC medication in relation
to self-medication. The variables that had been reported
previously to potentially confound the association exam-
ined or were possibly related to main independent and
outcome variables using simple logistic regression
models (p ≤ 0.25) were considered for multivariable re-
gression models selection [22, 35]. Logistic regression
using the “enter method” with all potential covariates
simultaneously included for consideration was per-
formed for final model selection. All factors were re-
ported with their crude and adjusted odds ratios (aORs)
and their 95% confidence intervals (CIs). A p value of <
0.05 was considered statistically significant.
We also examined the interaction between knowledge
and socio-demographic characteristics with the likeli-
hood of self-medication. An interaction p value of < 0.1
[36] was used to indicate potential moderation effects
and the warranting of further subgroup analyses.
Ethical considerations
The Commission of Research Ethics of the University of
Muhammadiyah Malang (E.5.a/226a/KEPK-UMM/VII/
2018) provided ethical approval. Informed consent was
sought from each respondent about the details of the
study’s background, objectives, and providing informa-
tion on the protection of the participant’s data. All re-
spondents signed a written informed consent.
Page 4 of 11
Results
Socio-demographic characteristics
In total, 340 respondents were enrolled for participation.
After excluding those with missing or incomplete infor-
mation on main variables, a valid sample of 333 women
was included for analyses. Most participants were aged
16–27 years (54.4%), had attended high school or insti-
tutes of higher education (70.3%), had adequate ANC
visits (68.5%), and were homemakers (72.1%) (Table 1).
Self-medication during pregnancy
In total, 39 (11.7%) women self-medicated at least once
during pregnancy. During pregnancy, the OTC medica-
tions used included antiemetic medicines (33%), cold
and flu remedies (29%), anti-fever medication (15%),
pain killers (13%), and others (10%). Among those who
self-medicated during pregnancy, approximately 10.3%
did so in their first trimester. No significant difference
was observed in socio-demographic characteristics be-
tween those who self-medicated and those who did not
(Table 1).
Knowledge of OTC medication
Of the 12 statements measuring knowledge of OTC
medication, 6 were answered correctly by over 60% of
participants. The statement having the highest propor-
tion (86.2%) of correct responses is “You need to consult
with healthcare provider before or when taking OTC
medication during pregnancy,” and the statement having
the lowest proportion (28.8%) of correct responses is
“Antibiotics is one of OTC medication” (Table 2). Table
2 lists the proportion of different knowledge responses
segmented by self-medication. Women who took at least
one OTC medication during pregnancy were more likely
to correctly answer the statements “Vitamin is one of
OTC medication” (79.5%) and “OTC medication can be
in the dosage form of oral medication” (92.3%). By con-
trast, these women were more likely to incorrectly an-
swer the statement “While taking OTC medication there
is possible risk that OTC drugs can affect the baby”
(59.0%).
Beliefs about taking medication during pregnancy
Respondents’ beliefs about taking medication during
pregnancy are presented in Table 3. They generally
expressed negative belief toward medication use during
pregnancy. A majority of respondents agreed with the
following statements. “Pregnant women have a higher
threshold for using medicine when pregnant than when
not pregnant.” (84.1%). “It is better for the fetus that
pregnant women refrain from using medicines during
pregnancy, even when they were not pregnant and have
an illness, they would have taken medicines.” (61.3%). “It
is better for the fetus if the mother takes medicines and
Atmadani et al. BMC Pregnancy and Childbirth (2020) 20:42 Page 5 of 11

Table 1 Distribution of participants by self-medication

Variables Total % Self-medication p valuea
(n =
Yes No
333)
n (%) n (%)
Self-medication in current pregnancy 39 (11.7) 294 (88.3)
Gestational age (trimester) 0.470
First trimester 37 11.1 4 (10.3) 33(11.2)
Second & Third trimester 296 88.9 35 (89.7) 261(88.8)
Age 0.075
16–27 181 54.4 16 (41.0) 165 (56.1)
28–45 152 45.6 23 (59.0) 129 (43.9)
Parity 0.137
0 148 44.4 13 (33.3) 135 (45.9)
1 or more children 185 55.6 26 (66.7) 159 (54.1)
Education level 0.880
Middle school or lower 99 29.7 12 (30.8) 87 (29.6)
High school or higher 234 70.3 27 (69.2) 207 (70.4)
Number of ANC Visits 0.174
<4 105 31.5 16 (41.0) 89 (30.3)
≥4 228 68.5 23 (59.0) 205 (69.7)
Occupation 0.901
Student 14 4.2 2 (5.1) 12 (4.1)
Homemaker 240 72.1 27 (69.2) 213 (72.4)
Employed 79 23.7 10 (25.6) 69 (23.5)
Household Income 0.897
< 1.5 Million Rupiah 159 47.7 19 (48.7) 140 (47.6)
1.5 Million Rupiah or more 174 52.3 20 (51.3) 154 (52.4)
Residence 0.174
Urban 243 73.0 32 (82.1) 211 (71.8)
Rural 90 27.0 7 (17.9) 83 (28.2)
Self-perceived Health Status 0.997
Good 239 71.8 28 (71.8) 211 (71.8)
Bad 94 28.2 11 (28.2) 83 (28.2)
Checking drug leaflet 0.510
Always 184 55.3 19 (48.7) 165 (56.1)
Sometimes 117 35.1 17 (43.6) 100 (34.0)
Never 32 9.6 3 (7.7) 29 (9.9)
a
p value from chi square tests and Fisher’s exact test

get well than having untreated illness during pregnancy.”
(63.1%). By contrast, 56.5% of the sampled women dis-
agreed with the statement “All medicines can be harmful
to the fetus.”
Factors associated with self-medication
Table 4 reports the results from the multiple logistic
regression analysis. Model 1 displays the crude odds
ratio. Models 2 to 4 display the effects of knowledge,
including the total knowledge score, binary knowledge
outcome, and binary outcome of the two aforemen-
tioned important pieces of knowledge on self-
medication during pregnancy, after adjusting for socio-
demographics. Specifically, Model 2 indicates that the
total knowledge score is significantly associated with
self-medication—adjusted odds ratio (aOR) = 1.16, 95%
CI = 1.02–1.33. Including overall knowledge with a
binary outcome in Model 3, we observe that women
Atmadani et al. BMC Pregnancy and Childbirth (2020) 20:42 Page 6 of 11

Table 2 Knowledge of OTC medication

Statements Total Self-medication
(n = 333)
Yes No p valuea
n (%)
n (%) n (%)
OTC medications are primarily used to treat condition that do not need direct supervision from doctors 0.471
Correct 187 (56.2) 24 (61.5) 163 (55.4)
Incorrect 146 (43.8) 15 (38.5) 131 (44.6)
OTC medication is used for treating minor illness/minor injuries 0.057
Correct 229 (68.8) 32 (82.1) 197 (67.0)
Incorrect 104 (31.2) 7 (17.9) 97 (33.0)
Antibiotic is one of OTC medication 0.509
Correct 96 (28.8) 13 (33.3) 83 (28.2)
Incorrect 237 (71.2) 26 (66.7) 211 (71.8)
Vitamin is one of OTC medication 0.003
Correct 191(57.4) 31 (79.5) 160 (54.4)
Incorrect 142 (42.6) 8 (20.5) 134 (45.6)
The decision for using OTC medication is primarily made by consumers 0.162
Correct 205 (61.6) 28 (71.8) 177 (60.2)
Incorrect 128 (38.4) 11 (28.2) 117 (39.8)
You can buy OTC medication without a prescription from a doctor 0.333
Correct 234 (70.3) 30 (76.9) 204 (69.4)
Incorrect 99 (29.7) 9 (23.1) 90 (30.6)
You can buy OTC medication only in a Pharmacy 0.900
Correct 114 (34.2) 13 (33.3) 101 (34.4)
Incorrect 219 (65.8) 26 (66.7) 193 (65.6)
You need to consult with healthcare provider before or when taking OTC medication during pregnancy 0.094
Correct 287 (86.2) 37 (94.9) 250 (85)
Incorrect 46 (13.8) 2 (5.1) 44 (15)
The most dangerous time during pregnancy for consuming OTC medication is the first trimester 0.408
Correct 193 (58.0) 25 (64.1) 168 (57.1)
Incorrect 140 (42.0) 14 (35.9) 126 (42.9)
While taking OTC medication there is possible risk that OTC drugs can affect the baby 0.002
Correct 211 (63.4) 16 (41.0) 195 (66.3)
Incorrect 122 (36.6) 23 (59.0) 99 (33.7)
OTC medication can be in the dosage form of oral medication < 0.001
Correct 215 (64.6) 36 (92.3) 179 (60.9)
Incorrect 118 (35.4) 3 (7.7) 115 (39.1)
OTC medication can be in the dosage form of topical medication 0.057
Correct 143 (42.9) 19 (48.7) 124 (42.2)
Incorrect 190 (57.1) 20 (51.3) 170 (57.8)
Knowledge total score (Mean;SD) 7.0 (3.1) 7.8 (2.6) 6.8 (3.2) 0.070b
Overall knowledge in binary outcome 0.087
Lower 212 (63.7) 20 (51.3) 192 (65.3)
Higher 121 (36.3) 19 (48.7) 102 (34.7)
a
p value from chi square tests
b
p value from student’s t-test
Bold p value means significant (i.e., p < 0.05)
Atmadani et al. BMC Pregnancy and Childbirth (2020) 20:42 Page 7 of 11

Table 3 Beliefs on taking medication during pregnancy

Beliefs on medication in pregnancy Total
(n = 333)
n (%)
All medicines can be harmful to the fetusa
Agree 84 (25.2)
Uncertain 61 (18.3)
Disagree 188 (56.5)
It is better for the fetus that pregnant women refrain from using medicines during pregnancy, even when they were not pregnant and have illness,
they would have taken medicinesa
Agree 204 (61.3)
Uncertain 24 (7.2)
Disagree 105 (31.5)
a
Pregnant women have a higher threshold for using medicine when pregnant than when not pregnant
Agree 280 (84.1)
Uncertain 27 (8.1)
Disagree 26 (7.8)
a
Many unborn children are saved because the mother take medicines during pregnancy when they have illness
Agree 178 (53.5)
Uncertain 87 (26.1)
Disagree 68 (20.4)
a
It is better for the fetus if the mother take medicines and get well than having untreated illness during pregnancy
Agree 210 (63.1)
Uncertain 61 (18.3)
Disagree 62 (18.6)
a
Doctors prescribe too many medicines to pregnant women
Agree 73 (21.9)
Uncertain 40 (12)
Disagree 220 (66.1)
Natural remedies can generally be used by pregnant women
Agree 205 (61.6)
Uncertain 67 (20.1)
Disagree 61 (18.3)
Pregnant women more likely to use natural remedies during pregnancy
Agree 185 (55.6)
Uncertain 67 (20.1)
Disagree 81 (24.3)
Pregnant women should not use natural remedies without advices from any health care providers
Agree 236 (70.9)
Uncertain 32 (9.6)
Disagree 65 (19.5)
Belief on taking medication during pregnancy (summary index from 6 items) Total Percentage
(n = 333) (%)
78.4
Negative 261
21.6
Positive 72
a
Statement selected into a 6-item summary index
Atmadani et al. BMC Pregnancy and Childbirth (2020) 20:42 Page 8 of 11

Table 4 Multiple logistic regression analysis of knowledge and other factors associated with self-medication during pregnancy
Variable Model 1a Model 2b Model 3c Model 4d
cOR (95% CI) aOR (95% CI) aOR (95% CI) aOR (95% CI)
Knowledge of OTC medication (all statements)
Knowledge total score 1.12 (0.99–1.26) 1.16 (1.02–1.33)* – –
Overall knowledge
Lower 1.00 – 1.00 –
Higher 1.79 (0.91–3.50) – 2.15 (1.03–4.46)* –
Knowledge regarding OTC medication with important statements
Knowledge about the need to consult any healthcare provider
Incorrect 1.00 – – 1.00
Correct 3.26 (0.76–14.00) – – 5.07 (1.11–23.2)*
Knowledge about possible risk from taking OTC medication during pregnancy
Incorrect 1.00 – – 1.00
Correct 0.35 (0.18–0.70)** – – 0.29 (0.14–0.60)**
Socio-demographic characteristic
Age
16–27 1.00 1.00 1.00 1.00
28–45 1.57 (0.80–3.07) 2.20 (1.05–4.57)* 2.18 (1.05–4.53)* 2.14 (1.01–4.50)*
OTC over-the-counter, cOR crude odds ratio, aOR adjusted odds ratio, CI confident interval
a
Crude Model
b
Model 2 included knowledge total scores and all adjusting variables of socio-demographic characteristics (age, gestational age, education, occupation, residence,
and household income), self-perceived health status, and check drug’s leaflet
c
Model 3 included overall knowledge (lower vs. higher) and all adjusting variables listed in Model 2
d
Model 4 included two knowledge statements of “the need to consult any healthcare provider” and “possible risk from taking OTC medication during pregnancy”
and all adjusting variables listed in Model 2
p value * < 0.05; ** < 0.01

with a higher level of knowledge of OTC medication
were more likely to self-medicate compared with
women with lower knowledge—aOR = 2.15, 95% CI =
1.03–4.46. Results from Model 4 indicate that com-
pared with those who had a lower level of knowledge
about the need to consult a healthcare provider before
taking OTC medication during pregnancy, pregnant
women who had high levels of such knowledge were
more likely to self-medicate—aOR = 5.07, 95% CI =
1.11–23.2. However, pregnant women who had high
levels of knowledge about the possible risks of OTC
medication in the fetus were significantly less likely to
self-medicate—aOR = 0.29, 95% CI = 0.14–0.60. Add-
itionally, age remains significant in all adjusted models.
This indicates that older pregnant women (28–45
years) were significantly more likely to self-medicate—
aOR = 2.14, 95% CI = 1.01–4.50 (Model 4).
Finally, as both knowledge and belief are important
factors, we further estimate the effects of knowledge on
self-medication, after considering the effects of belief.
The results were fairly consistent. Specifically, know-
ledge of OTC medication remains significant—aOR =
2.14, 95% CI = 1.03–4.46 after controlling for belief and
other covariates. Meanwhile, no association was ob-
served between belief and self-medication.
Subgroup analysis for the effects of knowledge on self-
medication by socio-demographics
The interaction terms of binary knowledge with educa-
tion and binary knowledge with occupation had signifi-
cant effects on self-medication (both p < 0.1). Subgroup
analyses were then performed. Specifically, the effect of
a higher level of knowledge on self-medication was sig-
nificant among women with middle school or lower edu-
cation—aOR = 8.18, 95% CI = 1.70–39.35—but not
among women with high school or higher education
(Table 5). Furthermore, the effect of knowledge of the
possible risks of taking OTC medication during preg-
nancy on self-medication was significant only among
women with high school or higher education—aOR =
0.17, 95% CI = 0.07–0.42 (Table 5). The moderation ef-
fects of occupation on the association between know-
ledge of possible risks and self-medication were not
significant.
Discussion
This study aimed to investigate first, the proportion of
pregnant women self-medicated in this collected sample
and factors associated with self-medication and second,
the potential moderation effects of socio-demographic
characteristics. This study focused on pregnant women
Atmadani et al. BMC Pregnancy and Childbirth (2020) 20:42
Table 5 Subgroup analysis for effects of knowledge on self-medication by socio-demographics
Outcomes
Higher level of knowledge a
Correct knowledge of risks of taking OTC medication during
pregnancyb
OTC over-the-counter, aOR adjusted odds ratio, CI confident interval
p value * < 0.05; ** < 0.01; *** < 0.001
a
Knowledge was categorized into two levels: higher and lower. Results were adjusted for socio-demographic variables (such as age, gestational age, self-rated
health status, education, occupation, household income, and residence) excluding variables treated as the effect modifier
b
Knowledge was categorized into two levels: correct and incorrect answer. Results were adjusted for socio-demographic variables (such as age, gestational age,
occupation, self-rated health status, household income, and residence)
attending primary healthcare services in Malang,
Indonesia. A higher level of knowledge was associated
with a higher likelihood of self-medication during preg-
nancy. However, if women had knowledge of the risks
from OTC medication, they were less likely to self-
medicate. The effects of a higher level of knowledge on
higher self-medication were significant among women
with middle school or lower education, whereas the cor-
rect knowledge of potential risk effects was associated
with a lower likelihood of self-medication among women
with high school or higher education.
The proportion of self-medication during pregnancy in
our sample was observed to be low (11.7%). Our findings
were similar to those of studies conducted in the
Netherlands (12.5%) [13], Nigeria (22.3%) [37], and Saudi
Arabia (13.2%) [33]. The proportion in this study is how-
ever lower than that (40%) observed by a study con-
ducted in the United Arab Emirates [14]. A US study
reported that self-medication is common [12]. It is likely
that pregnant women in Malang have more knowledge
of the risks of taking OTC medication during pregnancy.
This is evident in the high proportion of correct re-
sponse for the statement such as “While taking OTC
medication there is possible risk that OTC drugs can
affect the baby” (63.4%). These findings are consistent
with those of a study conducted in Saudi Arabia: 60% of
pregnant women were able to name some medications
to be avoided during pregnancy. This indicates relatively
high levels of knowledge of the risk of using medication
during pregnancy [33]. A lower proportion of self-
medication in this current study population may also be
partially explained by the relatively healthier group to in-
vestigate. Pregnant women in Malang who live in rural
areas could rely more on herbal or traditional remedies
than modern medicine.
Women with high levels of knowledge of OTC medi-
cation in our study were more likely to self-medicate
during pregnancy. Because they knew more about the
OTC medication, these women may be more likely to
Page 9 of 11
Education Occupation
Middle school and High school and Homemaker Employed
lower higher
aOR (95% CI) aOR (95% CI) aOR (95% aOR (95%
CI) CI)
8.18 1.23 3.02 0.67
(1.70–39.35)** (0.53–2.86) (1.18–7.70)* (0.15–3.04)
1.09 0.17 – –
(0.28–4.20) (0.07–0.42)***
manage self-medication responsibly. This result is con-
sistent with those of studies conducted in China [38],
Nigeria [18], and India [39]. To propose some possible
reasons explaining this phenomenon, first, a higher level
of knowledge from prior experiences of self-medication
to manage ill symptoms may increase the chance or
competence for later practice of self-medication during
pregnancy. Second, the faster alleviation of symptoms
may also be associated with the use of alternative medi-
cation [18]. However, our findings are inconsistent with
those of a study conducted in Delta State, Nigeria [37].
Examining the specific use of non-steroidal anti-
inflammatory drugs (NSAIDs) as their main dependent
factor might explain this inconsistency [40].
Two important knowledge statements were separately
examined. Consistent with results from a study con-
ducted in Italy [22], pregnant women were observed to
be more likely to consult a medical professional before
taking OTC medication. Such behavior is healthy and al-
lows medical professionals to impart sound information
on the use of medication during pregnancy. Another im-
portant observation was of pregnant women being less
likely to self-medicate if they knew there were possible
risks of taking medication during pregnancy. Imparting
specific and crucial information about OTC medication
may be more effective to help pregnant women safely
manage their practice towards OTC medication.
Previous studies have reported socio-demographic
characteristics, such as one’s education [18, 41–43], oc-
cupation [22, 41–43], health status [44], and household
income [41] to be important factors on the likelihood of
self-medication. Similarly, we observed that older preg-
nant women were significantly more likely to self-
medicate, after including other covariates in the logistic
regression. Nevertheless, this current study did not ob-
serve the significant effects of other socio-demographic
characteristics on self-medication. Instead, the moderat-
ing effects of socio-demographic characteristics on the
association between knowledge and self-medication were
Atmadani et al. BMC Pregnancy and Childbirth (2020) 20:42
observed. The effects of a higher level of knowledge on
taking at least one type of OTC medication were par-
ticularly significant among pregnant women with middle
school or lower education (p < 0.05). Highly educated
pregnant women with high levels of knowledge of the
risks of taking OTC medication during pregnancy were
less likely to self-medicate.
Our findings have important implications. Imparting
specific knowledge of the potential risks of using non-
prescribed medication during pregnancy may help preg-
nant women more safely manage their OTC use. The
significant effects of a higher level of knowledge on self-
medication among women with lower income and edu-
cation levels may indicate a level of their competence
that is a strength upon which a provider could build.
This study was conducted in primary healthcare services
(Puskesmas), a very basic type of healthcare service in
Indonesia. Here, knowledge and experiences using OTC
medication can be easily shared and spread. Most pa-
tients also come from low to middle-income families, es-
pecially in the rural area that is Malang Regency.
Expanding the role of healthcare providers together with
the provision of evidence-based information in prenatal
health education is crucial to promote pregnant women’s
safe management of OTC medication.
Our study is the first to examine self-medication dur-
ing pregnancy in Indonesia. We identified factors associ-
ated with self-medication in the Malang population. To
identify vulnerable segments of pregnant women for
possible unsafe use of self-medication, we further per-
formed subgroup analyses to examine moderation ef-
fects. These women should be targeted in the design and
implementation of future health programs.
There are some limitations to this study. First, this
study used a convenient sample drawn from the popula-
tion in Malang area. As the areas selected for investiga-
tion may not be representative, the study’s results may
not be generalized to all pregnant women in Indonesia.
Second, the proportion of self-medication in this sample
may have been underestimated. This study included
women in all trimesters when administering the ques-
tionnaire. Thus, the subsequent medication use among
women in their early trimester was not recorded in this
study. Third, the study’s cross-sectional design inhibited
causal inference.
Conclusion
This study observed 11.7% of women in this conveni-
ence sample self-medicated during pregnancy. Know-
ledge and age were observed to be associated with self-
medication during pregnancy. Our results demonstrated
that knowledge of OTC medication in general, and
knowledge of the possible risks of taking OTC medica-
tion during pregnancy in particular, were strongly
Page 10 of 11
associated with the use of self-medication among preg-
nant women in Malang.
This study can be improved by future studies using ei-
ther larger cohorts or a case-control method to examine
the effects of self-medication on the mother and child’s
health during pregnancy and postpartum. Based on our
findings, we also suggest collecting more data from more
healthcare services, such as hospitals, to obtain more
findings generalizable to the Indonesian community.
Supplementary information
Supplementary information accompanies this paper at https://doi.org/10.
1186/s12884-020-2736-2.
Additional file 1. Questionnaire – Self-medication Questionnaire.
Abbreviations
ANC: Antenatal care; aOR: adjusted odd ratio; CI: Confidence interval;
FDA: Food and Drug Administration; NTD: Neural tube defects; OTC: Over-
the-counter; Puskesmas: Pusat kesehatan masyarakat; SPSS: Statistical
Packages for Social Sciences
Acknowledgements
The authors would like to thank the pharmacists who helped with the data
collection process in Malang, Indonesia. We would also like to thank all the
pregnant women that participated in this study.
Authors’ contributions
RNA carried out data collection, data analysis, data interpretation, and
drafted the manuscript. ON provided suggestions for manuscript preparation
and critically revised the draft of the manuscript. SLY assisted in the data
collection process. YHC conceived and designed this study and supervised
all critical data analysis and manuscript preparation. All authors read and
approved the final manuscript.
Funding
None.
Availability of data and materials
The data used/or analyzed during the current study is available from the
corresponding author on a reasonable request.
Ethics approval and consent to participate
The Commission of Research Ethics of the University of Muhammadiyah
Malang (E.5.a/226a/KEPK-UMM/VII/2018) provided ethical approval. Informed
consent was sought from each respondent about the details of the study at
the beginning of the survey. All respondents signed a written informed
consent.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
1
Pharmacy Department, Faculty of Health Science, University of
Muhammadiyah Malang, Kampus II, Malang, Indonesia. 2School of Public
Health, College of Public Health, Taipei Medical University, Taipei, Taiwan.
Received: 4 July 2019 Accepted: 10 January 2020
References
1. Lagoy CT, Joshi N, Cragan JD, Rasmussen SA. Report from the CDC:
medication use during pregnancy and lactation: an urgent call for public
health action. J Women's Health. 2005;14(2):104–9.
Atmadani et al. BMC Pregnancy and Childbirth (2020) 20:42
2. Lupattelli A, Spigset O, Twigg MJ, Zagorodnikova K, Mårdby AC, Moretti ME,
Drozd M, Panchaud A, Hämeen-Anttila K, Rieutord A, et al. Medication use
in pregnancy: A cross-sectional, multinational web-based study. BMJ Open.
2014;4(2):e004365.
3. Bleek W, Asante-Darko NK. Illegal abortion in southern Ghana: methods,
Motives and Consequences. Human Organization. 1986;45(4):333–44.
4. Koren G, Florescu A, Costei AM, Boskovic R, Moretti ME. Nonsteroidal
antiinflammatory drugs during third trimester and the risk of premature
closure of the ductus arteriosus: a meta-analysis. Ann Pharmacother. 2006;
40(5):824–9.
5. Binyam Kebede TGAG. Assessment of drug use among pregnant women in
Addis Ababa; 2009. p. 462–8.
6. Kessler DA, Pines WL. The federal regulation of prescription drug advertising
and promotion. JAMA. 1990;264(18):2409–15.
7. Yang T, Walker MC, Krewski D, Yang Q, Nimrod C, Garner P, Fraser W,
Olatunbosun O, Wen SW. Maternal characteristics associated with
pregnancy exposure to FDA category C, D, and X drugs in a Canadian
population. Pharmacoepidemiol Drug Saf. 2008;17(3):270–7.
8. Svensson T. Drug use during pregnancy in Sweden – assessed by the
Prescribed Drug Register and the Medical Birth Register; 2011. p. 43–50.
9. Hardon A, Van der Geest S, Hardon A. Self-medication in developing
countries. J Soc Administr Pharmacy. 1990;7(4):199–204 2015(January 1990).
10. Briggs GG, Freeman RK, Yaffe SJ. Drugs in pregnancy and lactation. 5th ed.
Baltimore: Lippincott, Williams & Wilkins; 2003.
11. Robert E, Guibaud P. Maternal VALPROIC acid and congenital neural tube
defects. Lancet. 1982;320(8304):937.
12. Werler MM, Mitchell AA, Hernandez-Diaz S, Honein MA. Use of over-the-counter
medications during pregnancy. Am J Obstet Gynecol. 2005;193(3):771–7.
13. Verstappen GM, Smolders EJ, Munster JM, Aarnoudse JG, Hak E. Prevalence
and predictors of over-the-counter medication use among pregnant
women: A cross-sectional study in the Netherlands. BMC Public Health.
2013;13(1):185.
14. Abduelkarem AR, Mustafa H. Use of over-the-counter medication among
pregnant women in Sharjah, United Arab Emirates. J Pregnancy. 2017;2017:
4503793.
15. Cleary BJ, Butt H, Strawbridge JD, Gallagher PJ, Fahey T, Murphy DJ.
Medication use in early pregnancy-prevalence and determinants of use in a
prospective cohort of women. Pharmacoepidemiol Drug Saf. 2010;19(4):
408–17.
16. Abeje G, Admasie C, Wasie B. Factors associated with self medication
practice among pregnant mothers attending antenatal care at
governmental health centers in Bahir Dar city administration, Northwest
Ethiopia, a cross sectional study. Pan Afr Med J. 2015;20:276.
17. Bohio R, Brohi ZP, Bohio F. Utilization of over the counter medication
among pregnant women; a cross-sectional study conducted at Isra
University hospital, Hyderabad. J Pak Med Assoc. 2016;66(1):68–71.
18. Abasiubong F, Bassey EA, Udobang JA, Akinbami OS, Udoh SB, Idung AU.
Self-medication: potential risks and hazards among pregnant women in
Uyo, Nigeria. Pan Afr Med J. 2012;13:1–8.
19. Beyene KGM, Beza SW. Self-medication practice and associated factors
among pregnant women in Addis Ababa, Ethiopia. Trop Med Health. 2018;
46(1):1–14.
20. Odalovic M, Vezmar Kovacevic S, Nordeng H, Ilic K, Sabo A, Tasic L.
Predictors of the use of medications before and during pregnancy. Int J Clin
Pharm. 2013;35(3):408–16.
21. Ebrahimi H, Atashsokhan G, Amanpour F, Hamidzadeh A. Self-medication
and its risk factors among women before and during pregnancy. Pan Afr
Med J. 2017;27:1–8.
22. Navaro M, Vezzosi L, Santagati G, Angelillo IF. Knowledge, attitudes, and
practice regarding medication use in pregnant women in southern Italy.
PLoS One. 2018;13(6):1–14.
23. Indonesia Ministry of Health. Undang-undang obat keras:Staatsblad No.419;
22. Jakarta: Indonesia Ministry of Health; 1949.
24. Alfian SD, Sinuraya RK, Kautsar AP, Abdulah R. Consumer expectation on
service quality provide by pharmacist in self medication practices and its
associated factors in BANDUNG, Indonesia. Southeast Asian J Trop Med
Public Health. 2016;47(6):1379–84.
25. Badan Pusat S. Kabupaten Malang Dalam Angka 2017; 2017.
26. Badan Pusat S. Statistik Kesejahteraan Rakyat Kota Malang 2017; 2017.
27. Beyene A, Getachew E, Doboch A, Poulos E, Abdurahman K, Alebachew M.
Knowledge, attitude and practice of self medication among pharmacy
Page 11 of 11
students of rift Valley University, Abichu campus, Addis Ababa, Ethiopia. J
Health Med Informat. 2017;8(269):2.
28. Guillemin F, Bombardier C, Beaton D. Cross-cultural adaptation of health-
related quality of life measures: literature review and proposed guidelines. J
Clin Epidemiol. 1993;46(12):1417–32.
29. Isaac S, Michael WB. Handbook in research and evaluation. San Diego:
Educational and Industrial Testing Services; 1995.
30. Sharma D, Gurung D, Kafle R, Singh S. Knowledge and practice on over-the-
counter drugs among adults of age group 20 and above residing in
Chapapani-12, Pokhara, Kaski, Nepal. Int J Sci Rep. 2017;33(3):79–86.
31. Nkoka O, Chuang T-W, Chen Y-H. Multilevel analysis of factors associated
with treatment-seeking behaviors among caregivers with febrile children in
Malawi; 2019.
32. Nordeng H, Koren G, Einarson A. Pregnant women's beliefs about
medications - a study among 866 Norwegian women. Ann Pharmacother.
2010;44(9):1478–84.
33. Zaki NM, Albarraq AA. Use, attitudes and knowledge of medications among
pregnant women: a Saudi study. Saudi Pharm J. 2014;22(5):419–28.
34. Ceulemans M, Van Calsteren K, Allegaert K, Foulon V. Beliefs about
medicines and information needs among pregnant women visiting a
tertiary hospital in Belgium. Eur J Clin Pharmacol. 2019;75(7):995–1003.
35. Katz MH. Multivariable analysis: a practical guide for clinicians and public
health researchers: Cambridge university press; 2011.
36. Nkoka O, Chuang TW, Chen YH. Association between timing and number of
antenatal care visits on uptake of intermittent preventive treatment for
malaria during pregnancy among Malawian women. Malar J. 2018;17(1):1–
11.
37. Okandeji-Barry RO, Otovwe A, Uju OS. Pharmaceutical Knowledge , Attitude
and Use of Non-Prescription Drugs Among Pregnant Women in Okwe
General Hospital Asaba Delta State ,Nigeria. Eur J Pharm Med Res. 2016;
3(11):101–10.
38. Yuefeng L, Keqin R, Xiaowei R. Use of and factors associated with self-
treatment in China. BMC Public Health. 2012;12(1):995.
39. Selvaraj K, Kumar SG, Ramalingam A. Prevalence of self-medication practices
and its associated factors in urban Puducherry, India. Perspect Clin Res.
2014;5(1):32.
40. Kassaw C, Wabe NT. Pregnant women and non-steroidal anti-inflammatory
drugs: knowledge, perception and drug consumption pattern during
pregnancy in Ethiopia. N Am J Med Sci. 2012;4(2):72.
41. Awad AI, Eltayeb IB, Capps PA. Self-medication practices in Khartoum state,
Sudan. Eur J Clin Pharmacol. 2006;62(4):317–24.
42. Devkota R, Khan GM, Alam K, Sapkota B, Devkota D. Impacts of counseling
on knowledge, attitude and practice of medication use during pregnancy.
BMC Pregnancy Childbirth. 2017;17(1):1–7.
43. Marwa KJ, Njalika A, Ruganuza D, Katabalo D, Kamugisha E. Self-medication
among pregnant women attending antenatal clinic at Makongoro health
Centre in Mwanza, Tanzania: a challenge to health systems. BMC Pregnancy
Childbirth. 2018;18(1):1–9.
44. Lei X, Jiang H, Liu C, Ferrier A, Mugavin J. Self-medication practice and
associated factors among residents in Wuhan, China. Int J Environ Res
Public Health. 2018;15(1):68.
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 Open Access

Research
Self-medication and its risk factors among women before and during
pregnancy

Hossein Ebrahimi1, Giti Atashsokhan2, Farzaneh Amanpour3, Azam Hamidzadeh2,&

1
Center for Health Related Social and Behavioral Sciences Research, Shahroud University of Medical Sciences, Shahroud, Iran, 2Department of
Midwifery, School of Nursing & Midwifery, Shahroud University of Medical Sciences, Shahroud, Iran, 3Department of Epidemiology and Biostatistics,
School of Public Health, Shahroud University of Medical Sciences, Shahroud, Iran

&
Corresponding author: Azam Hamidzadeh, Department of Midwifery, School of Nursing & Midwifery, Shahroud University of Medical Sciences,
Shahroud, Iran

Key words: Self medication, risk factors, pregnancy

Received: 11/06/2016 - Accepted: 04/06/2017 - Published: 07/07/2017

Abstract
Introduction: Self-medication can cause significant challenges for the individuals and community, especially in women during pregnancy. This
study was aimed to compare the prevalence of self-medication before and during pregnancy among women in Iran. Methods: in this cross-
sectional study, a total of 384 pregnant women were evaluated for the prevalence of self-medication and its associated factors before and during
pregnancy. Stratified random sampling was used as the sampling method. Descriptive statistics and chi-square and logistic regression tests were
used for statistical analysis of data. Results: The results showed that the prevalence of self-medication, in women who had become ill at least
once, was 63.9% before pregnancy and 43.5% and during pregnancy. Variables such as lack of insurance, high school education and not having a
child increased odds ratio of self-medication before pregnancy, while the variables of lack of insurance, not having a child or fewer number of
children and no history of abortion increased the odds ratio of self-medication during pregnancy. Conclusion: Although the prevalence of self-
medication during pregnancy was less than that before pregnancy, but this prevalence during pregnancy was still significant. Therefore, it seems
necessary to provide public trainings for all women of reproductive age and train them about the dangers and side effects of self-medication.

Pan African Medical Journal. 2017; 27:183 doi:10.11604/pamj.2017.27.183.10030

This article is available online at: http://www.panafrican-med-journal.com/content/article/27/183/full/

© Hossein Ebrahimi et al. The Pan African Medical Journal - ISSN 1937-8688. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original
work is properly cited.

Pan African Medical Journal – ISSN: 1937- 8688 (www.panafrican-med-journal.com)

Published in partnership with the African Field Epidemiology Network (AFENET). (www.afenet.net)

Page number not for citation purposes 1

Introduction
Self-medication is an important part of daily self-care and one of the
vital issues of health care systems [1]. Self-medication is a serious
economic, social and health problem throughout the world,
including Iran [2]. Some of the reasons for the increased rate of
self-medication are the followings: the urge to self-care, feeling
sympathy for the family members during illness, lack of health care
services, poverty, ignorance, misconceptions, extensive
advertisements on drugs and the availability of drugs in places other
than pharmacies [3]. Given the current global economic downturn
and due to the difficulties to meet the health care needs of the
people, many countries are facing serious health challenges [4].
Such a condition in developing countries often motivates most of
the people to practice self-medication using different types of
materials and plants so that to meet their medical needs [5]. The
prevalence of self-medication widely varies in different countries
(6%-73%) [6-10]. The prevalence of self-medication in Iran is
reported from 76.6% to 83% [2, 11, 12]. The pattern of self-
treatment varies in different communities and is affected by several
factors such as age, sex, income, expenses, self-care orientation,
education level, medical knowledge, satisfaction and people's
perception of disease [1]. In most developing countries where the
health systems are not properly qualified, there is a high possibility
of self-medication in pregnant women [13]. The use of medication
during pregnancy still remains a medical challenge [14]. It is
estimated that 10% or more than 10% of birth defects are caused
due to the exposure of pregnant women to drugs [15]. Many
studies have shown that drug use and self-medication during
pregnancy may affect fetal health [16, 17]. The prevalence of self-
medication during pregnancy varies in Iran and other countries
(5%-92.6%) [13, 18-23]. Given the above mentioned facts and
since we did not find any study comparing the prevalence of self-
medication before and during pregnancy, this study was aimed to
determine the prevalence of self-medication and its determinants
among the pregnant women in Iran.
Methods
In this cross-sectional study, a total of 384 pregnant women were
evaluated for the prevalence of self-medication and its associated
factors before and during pregnancy. The samples were selected via
stratified random sampling method. The study was approved by the
ethics committee of Shahroud University of medical sciences
(project number: 87/930. Approval Date: 2015/4/8). Pregnancy was
the inclusion criterion; the exclusion criteria were long-term use of
drugs or history of any physical or mental illness. To obtain the
required data, we used a form for collecting demographic data and
a checklist for obtaining data on history of diseases and self-
medication before and during pregnancy. It is worth mentioning
that the question about the menstrual disorders was only used for
the period before pregnancy, while the question about the problems
during pregnancy was only used for the period during the
pregnancy. All individuals who used drugs before or during
pregnancy without a prescription by a physician were identified as
cases practicing self-medication. The data collection was carried out
from the beginning of October until the end of January 2014. After
obtaining informed consent, the women were enrolled in the study.
The selected women, in their last visit for prenatal care, completed
the checklist designed for the evaluation of self-medication before
and during pregnancy. Self-medication before pregnancy was
evaluated during the six months before gestation. To calculate the
sample size we considered α= 5%, self-medication ratio of 50% and
an accuracy of 95%; the final self sample size was 384. To analyze
the data we used descriptive statistics and chi-square and logistic
regression tests were used for statistical analysis.
Results
According to the results, the mean age of the women studied was
26.33±4.60 years, the mean number of children was 0.75, the
mean height of women was 160.48 ± 5.33, the mean body weight
was 60.31±0.14, the mean BMI was 23.42 ± 3.81, the mean
systolic blood pressure was 116.92 ± 8.75 and the mean diastolic
blood pressure was 74.64 ± 8.32, respectively. Table 1 shows
distribution absolute and relative frequency of study subjects in
terms of employment status, education level and insurance status.
53.4% of the participants had become ill at least once prior to the
pregnancy of whom 63.9% had a history of self-medication. Of all
the women surveyed, a total of 131 pregnant women (34.1%)
reported taking at least one type of drug for self-medication.
Moreover, 49.1% of the participants in the study had become ill at
least once during pregnancy, of whom 43.5% used at least one
drug for self-medication; of all the women studied, 78 patients
(20.3%) reported taking at least one drug for self-medication during
pregnancy. The results of Chi-square test indicated that self-
medication during pregnancy was significantly lower than that
before pregnancy (P < 0.001) (Table 2). Table 3 presents the
results of logistic regression analysis which was conducted to
estimate the odds ratio (OR) of self-medication before pregnancy
and its risk factors. It compared the women who practiced self-
medication compared with the women who did not practice self-
medication before getting pregnant.
The results showed that the variables of insurance, education level
and number of children had an impact on self-medication before
pregnancy, so that the odds ratio of self-medication among those
without any insurance was almost twice as much as that in women
with insurance. The odds ratio of self-medication in women with
secondary education (Group 2) was almost three times higher than
that in people with high education level (group 3). In addition, the
odds ratio of self-medication in women without a child was almost
three times higher than that in those with two children or more.
Table 4 presents the results of logistic regression analysis which was
conducted to estimate OR of self-medication during pregnancy and
its risk factors. It compared the women who practiced self-
medication compared with the women who did not practice self-
medication during pregnancy. The results showed that the factors of
insurance, number of children and history of abortion had an impact
on self-medication in women who become ill during pregnancy.
Thus, the odds ratio of self-medication was higher in people without
insurance than those with insurance. The odds ratio of self-
medication in women without a child and with only one child was
6.8 and 5.4 times higher than those with more than two children. In
addition, the odds ration of self-medication in women without a
history of abortion was 2.8 times higher than those with a history of
abortion.
Table 5 presents the results of logistic regression analysis which was
conducted to estimate OR of self-medication before and during
pregnancy and its risk factors. It compared the women who
practiced self-medication compared with the women who did not
practice self-medication before and during pregnancy. The results
showed that individuals who become ill both before and during
pregnancy, the variables of insurance, number of children, history of
abortion and drug use before pregnancy had an effect on drug use
during pregnancy. Accordingly, people without insurance had lower
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odds ratio of self-medication during pregnancy than those with In this study, the odds ratio of self-medication in terms of insurance
insurance. The odds ratio of self-medication in women without a coverage was significantly different among the participants before
child and with only one child was higher than those with more than pregnancy. Accordingly, odds ratio of self-medication among people
two children. Women with no history of abortion had higher odds without health insurance was about twice as much as that among
ratio of self-medication during pregnancy than those who had a women with insurance. This finding is in line with the results of a
history of abortion. In addition, people who took medications before study conducted in Ardebil [32]. The researchers of the mentioned
pregnancy had a higher chance of self-medication during pregnancy study reported that some factors such as lack of insurance and
compared with those who had not a history of self-medication financial difficulties were among the factors encouraging people to
before pregnancy. self-medicate. It seems that for people who do not have insurance,
the cost of treating common diseases such as headaches and colds
via self-medication is lower than the cost of visits to physicians,
Discussion because in the latter case, the patient not only must pay for the
medications but also for the visit as well. Hence, the patent would
prefer self-medication. Low drug cost and lack of insurance
The results of this study showed that 53.4% of the participants had
coverage could affect and lead to unreasonable drug consumption.
become ill at least once prior to the pregnancy of whom 63.9% had
Many families have a drug box at their home which they use for
a history of self-medication. Of all the women surveyed, a total of
treating different diseases.
131 pregnant women (34.1%) reported taking at least one type of
drug for self-medication. The results of previous studies also show
Based on the results of this study, before pregnancy, women with
that the rate of self-medication is high both in developed and
high school education self-medicated three times more than women
developing countries. For example, according to different reports
with high education. The results of studies conducted in China [33]
the prevalence of self-medication is more than 68% in European
and India [34-36] indicate that people with higher levels of
countries [24], 59% in Nepal (10), 76% in Pakistan [25] and from
education are more prone to self-medication than those with a
about 76.6% to 83% in Iran [2, 11, 12]. Easy purchase of drugs
lower education level; it is not in line with our results. It seems that
without prescription, easy access to drugs and prescribing excessive
higher rates of self-medication in people with higher education in
drugs for patients in previous visits are among the factors that could
the mentioned studies are due to their ability to learn from
lead to the storage of drugs at home and consequently lead to self-
brochures and repeat prescriptions when they are affected by the
medication. Self storage of drugs at home not only increases the
same disease. Another possible reason for this discrepancy can be
chance for self-medication, but also raises some other issues such
due to different levels of participants' access to health care
as the proper storage of drugs, expiration date, the possibility of
providers and their lower financial ability to pay for medical costs.
errors in the use of drugs, and other people's access to drugs [24].
Contrary to our findings, the results of a study by Afshary et al
In this study, the prevalence of self-medication during pregnancy
(2015) showed that the highest prevalence of self-medication in
was 20.3%. This rate of self-medication is consistent with the
pregnant women was observed among those with high school and
results of a study in Ethiopia which reported a rate of 20.1% (20),
academic education. According to the mentioned researchers, this is
but it is higher than the prevalence rates reported by other studies
due to the fact that these women can get enough information from
in Iran [26], Ethiopia [27] and Peru [28] where the prevalence rates
drug brochures. The results of the study indicated that the
are 12%, 12.4%, 10.5% and 8.8% respectively. Nevertheless, the
prevalence of self-medication in pregnant women was more
reported prevalence rate in our study was lower than that reported
common among those with an education level less than a high
in a study in Egypt which was 86% [29]. In line with the results of
school; it might be attributed to lack of financial capability to pay for
Kebede et al (2009), it seems that mild disease and fear of side
medical expenses [26]. According to the results of this research,
effects of medication on the fetus are the main reasons for the
there was a statistically significant relationship between the number
reduction of self-medication during pregnancy [27].
of children and self-medication before pregnancy, so that the odds
ratio of self-medication among people without children was three
According to the results of this study, the rate of self-medication
times more than those with more than two children. Results of a
during pregnancy, compared with the time before pregnancy,
study in Brazil showed that the rate of self-medication among
decreased and the difference was statistically significant. In line with
people with children was less than that among those without a
our findings, according to the result of a study in Ethiopia, the
child; in other words, having a child was a protective factor against
prevalence of self-medication before pregnancy was 63.7%, while it
self-medication [37]. It seems that previous history of childbirth and
was 20.1% during pregnancy [20]. Various studies have shown that
concerns about bearing children with congenital anomalies are
women are plainly interested in self-medication and they usually
among the factors which reduce the possibility of self-medication
practice self-medication to treat problems such as dysmenorrhea, to
among women with more children.
relieve symptoms of menopause, menstrual disorders and to
prevent osteoporosis, however, during pregnancy due to fear of side
Although having insurance increased the chance of self-medication
effects on fetus and embryonic malformations, pregnant women are
during pregnancy, Ghanei et al (2013) found no statistically
more cautious about medication [27]. Odalovic et al (2013) reported
significant relationship between insurance coverage and self-
that women who had a history of at least one delivery are less likely
medication among pregnant women [38]. However, Shamsi et al
to take medications during pregnancy because they are more alert
(2010) reported that the main causes of self-medication in pregnant
and aware of the potentially harmful effects on fetus [30]. But the
women were neglecting the impact of the diseases (58%) and lack
result of a study in Saudi Arabia is inconsistent with the results of
of insurance coverage (56%). They also reported that people
our study; according to results of the mentioned study, most
practiced self-medication because they did not pay for visits,
women believed that drug consumption during pregnancy was not
obtained necessary medicines by their own and used their
harmful however, they used drugs with caution [31]. It seems that
previously prescribed medications [39]. It seems that in this study,
social and individual factors such as occupation and level of
women with insurance practiced self-medication due to the
education have a significant impact on the attitudes and beliefs of
following factors: reuse of previously prescribed medications, storing
pregnant women about self-medication and they may be the
medication at home and the high cost of visits to physicians. In this
possible reason for the discrepancy in the results.
study, the OR of self-medication during pregnancy among women
with no children or with one child, respectively, was 6.86 and 5.42

Page number not for citation purposes 3

times more than that among women with two or more children in
this study. Afshary et al (2015) reported no statistically significant
relationship between the number of pregnancies and childbirth with
self-medication [26]. In Shamsi et al's study (2010), the highest
frequency of self-medication was observed among women with four
or more children; the higher rate of self-medication among the
mentioned group was attributed to their inability to pay for
treatment costs, more cases of childbirth and consequently more
experience and knowledge of pregnant women about prescribed
drugs [39]. It seems that the lower rate of self-medication reported
in this study can be attributed to their higher levels of experiences
and knowledge about low-risk pregnancy. Inconsistent with the
findings of our study, Guerra et al (2008) reported a positive
relationship between self-medication and having more children. The
researchers did not find any reason for this relationship in the
medical literature; however, they said that the higher rates of self-
medication among multiparous women might be due to their
previous experiences of self-treatment which might led them to
consider such a practice to be harmless. Because of such safe
experiences, the mentioned group of women continued self-
medication during pregnancy [28].
In this study, the odds ratio of self-medication during pregnancy
among women without a history of abortion was 2.85 times more
than that among women who had experienced at least one
abortion. Mohammad et al (2013) did not observe any statistically
significant relationship between self-medication and previous history
of abortion among pregnant women in Ethiopia [40]. In our review
of available medical literature, we did not find any data about the
relationship between abortion and self-medication. However, it
seems that, patients with a history of abortion are less prone to self-
medication because they may believe that self-medication may lead
to abortion; hence, this group of women are more sensitive toward
their pregnancy status and are less likely to self-medicate. Our
research showed that people who had used drugs before
pregnancy, compared with those who did not take medications
before pregnancy, had a higher odds ratio of self-medication during
pregnancy. According to the results of Mohammad et al's study
(2013) the continuation of self-medication during pregnancy is due
to the lack of proper consultation by health care providers; the
researchers concluded that in the absence of medical supervision
during pregnancy, the pregnant women continue taking drugs [40].
On the other hand, based on the results of a study on motivational
factors for self-medication during pregnancy, the most important
factors were: not paying enough attention to the disease and feeling
no need for medical care services [29].
Conclusion
Despite the decrease in the prevalence of self-medication during
pregnancy, compared with the time before pregnancy, the
prevalence of self-medication during pregnancy was still significant
in this study. Therefore, it seems necessary to provide public
trainings for all women of reproductive age and train them about
the risks and side effects of self-medication. In addition, to promote
the health status of people in the community and to increase their
knowledge, such training programs must be designed in health care
systems.
What is known about this topic
 Today, self-medication is now one of the greatest healths,
economic and social problems in different societies,
including Iran;
 Self-medication during pregnancy is associated with
adverse effects and lack of knowledge and little
information of mothers about use of drugs, could be
harmful for the family and society;
 Despite the increase knowledge about the use of drugs
during pregnancy in recent years there is increasing
evidence that self-medications among pregnant women
are common.
What this study adds
 Although the prevalence of self-medication during
pregnancy was less than before pregnancy, but this study
shows that self-medication is common among pregnant
women in our environment;
 The variables that increased the odds ratio of self-
medication, before and during pregnancy, were different;
 Adequate education of pregnant women during antenatal
clinics on the potential danger of self-medication is
necessary.
Competing interests
The authors declare no competing interest.
Authors’ contributions
All the authors have read and agreed to the final manuscript.
Acknowledgments
The authors express their appreciation to the vice chancellor for
research, Shahroud University of medical sciences for financial
support; also, the authors thank Rozgar Amini and Hamid
Hajiparvaneh for their assistance in collecting the data.
Tables
Table 1: Distribution absolute and relative frequency of study
subjects in terms of employment status, education level and
insurance status
Table 2: Distribution absolute and relative frequency of self-
medication before and during pregnancy
Table 3: The role of different independent variables on self-
medication before pregnancy
Table 4: The role of different independent variables on self-
medication during pregnancy
Table 5: The role of different independent variables on self-
medication before and during pregnancy
References
1. Almasdy D, Sharrif A. Self-medication practice with
nonprescription medication among university students: a
review of the literature. Archives of Pharmacy Practice. 2011;
2(3): 95. PubMed | Google Scholar
Page number not for citation purposes 4
2. Karimy M, Heidarnia A, Ghofrani F. Factors influencing self-
medication among elderly urban centers in Zarandieh based on
health belief model. Arak University of Medical Sciences
Journal. 2011; 14(5): 70-8.PubMed | Google Scholar
3. Ahmad A, Patel I, Mohanta GP, Balkrishnan R. Evaluation of
self medication practices in rural area of town Sahaswan at
Northern India. Annals of Medical and Health Sciences
Research. 2014; 4(Suppl 2): S73-S8.PubMed | Google
Scholar
4. Irvine L, Flynn RW, Libby G, Crombie IK, Evans JM. Drugs
dispensed in primary care during pregnancy: a record-linkage
analysis in Tayside, Scotland. Drug safety. 2010; 33(7): 593-
604. PubMed | Google Scholar
5. Rohra DK, Das N, Azam SI, Solangi NA, Memon Z, Shaikh AM
et al. Drug-prescribing patterns during pregnancy in the
tertiary care hospitals of Pakistan: a cross sectional study. BMC
pregnancy and childbirth. 2008; 8: 24. PubMed | Google
Scholar
6. Bamgboye EA, Amoran OE, Yusuf OB. Self medication practices
among workers in a tertiary hospital in Nigeria. African journal
of medicine and medical sciences. 2006; 35(4): 411-
5. PubMed | Google Scholar
7. Corrêa-Fissmer M, Mendonça MG, Martins AH, Galato D.
Prevalence of self-medication for skin diseases: a systematic
review. Anais Brasileiros de Dermatologia. 2014; 89(4): 626-
30. PubMed | Google Scholar
8. Loyola de Filho AI, Uchoa E, Guerra HL, Firmo JO, Lima-Costa
MF. Prevalência e fatores associados à automedicação:
resultados do projeto Bambuí. Rev Saúde Pública. 2002; 36(1):
55-62. PubMed |Google Scholar
9. Gutema GB, Gadisa DA, Kidanemariam ZA, Berhe DF, Berhe
AH, Hadera MG et al. Self-medication practices among health
sciences students: the case of Mekelle University. Journal of
Applied Pharmaceutical Science. 2011; 10(1): 183-
189. Google Scholar
10. Shankar P, Partha P, Shenoy N. Self-medication and non-
doctor prescription practices in Pokhara valley, Western Nepal:
a questionnaire-based study. BMC family practice. 2002; 3(1):
17. PubMed | Google Scholar
11. Jafari F, Khatony A, Rahmani E. Prevalence of self-medication
among the elderly in Kermanshah-Iran. Global Journal of
Health Science. 2015; 7(2): p360. PubMed | Google Scholar
12. Sarahroodi S, Maleki-Jamshid A, Sawalha AF, Mikaili P,
Safaeian L. Pattern of self-medication with analgesics among
Iranian University students in central Iran. Journal of Family &
Community Medicine. 2012; 19(2): 125-9. PubMed | Google
Scholar
13. Abasiubong F, Bassey EA, Udobang JA, Akinbami OS, Udoh SB,
Idung AU. Self-medication: potential risks and hazards among
pregnant women in Uyo, Nigeria. The Pan African medical
journal. 2012; 13: 15.PubMed | Google Scholar
14. Araújo DD, Leal MM, Santos EJV, Leal LB. Consumption of
medicines in high-risk pregnancy: evaluation of determinants
related to the use of prescription drugs and self-medication.
Brazilian Journal of Pharmaceutical Sciences. 2013; 49(3): 491-
9. PubMed | Google Scholar
15. Nakamura MU, Kulay Junior L, Pasquale M. Uso de fármacos na
gravidez: benefício e custo. Rev bras ginecol obstet. 2008;
30(1): 1-4. PubMed | Google Scholar
16. Chiriboga CA. Fetal alcohol and drug effects. The neurologist.
2003; 9(6): 267-79. PubMed | Google Scholar
17. Szymanowski K, Chmaj-Wierzchowska K, Florek E, Opala T.
Influence of tobacco smoking to development of the fetus,
newborn and child: a review. Przeglad lekarski. 2006; 63(10):
1135-7. PubMed | Google Scholar
18. Bagheri A, Abbaszadeh F. Self-medication and supplement use
by pregnant women in Kashan rural and urban areas. Journal
of Mazandaran University of Medical Sciences (JMUMS). 2014;
24(114): 151-157.PubMed | Google Scholar
19. Baghianimoghadam MH, Mojahed S, Baghianimoghadam M,
Yousefi N, Zolghadr R. Attitude and practice of pregnant
women regarding self-medication in Yazd, Iran. Archives of
Iranian medicine. 2013; 16(10): 580-3. PubMed | Google
Scholar
20. Befekadu A, Dhekama NH, Mohammed MA. Self-medication
and contributing factors among pregnant women attending
antenatal care in Ethiopia: The Case of Jimma University
Specialized Hospital. Medicine Science. 2014; 3(1): 969-
81. Google Scholar
21. Emmanuel AE, Achema G, Afoi BB, Maroof R. Self medication
practice among pregnant women attending antenatal clinic in
selected hospitals in Jos. International Journal of Nursing and
Health Science. 2014; 1(6): 55-59. PubMed | Google
Scholar
22. Glover DD, Amonkar M, Rybeck BF, Tracy TS. Prescription,
over-the-counter and herbal medicine use in a rural, obstetric
population. American Journal of Obstetrics and Gynecology.
2003; 188(4): 1039-45.PubMed | Google Scholar
23. Liao S, Luo B, Feng X, Yin Y, Yang Y, Jing W. Substance use
and self-medication during pregnancy and associations with
socio-demographic data: a cross-sectional survey. International
Journal of Nursing Sciences. 2015; 2(1): 28-
33. PubMed | Google Scholar
24. Bretagne JF, Richard-Molard B, Honnorat C, Caekaert A,
Barthelemy P. Gastroesophageal reflux in the French general
population: national survey of 8000 adults. Presse medicale,
Paris, France. 1983. 2006; 35(1 Pt 1): 23-
31. PubMed | Google Scholar
25. Zafar SN, Syed R, Waqar S, Zubairi AJ, Vaqar T, Shaikh M et al.
Self-medication amongst university students of Karachi:
prevalence, knowledge and attitudes. JPMA The Journal of the
Pakistan Medical Association. 2008; 58(4): 214-
7. PubMed | Google Scholar
Page number not for citation purposes 5
26. Afshary P, Mohammadi S, Najar S, Pajohideh Z, Tabesh H.
Prevalence and causes of self-medication in pregnant women
referring to health centers in Southern of Iran. International
Journal of Pharmaceutical Sciences and Research. 2015; 6(2):
612. PubMed | Google Scholar
27. Deshpande SG, Tiwari R. Self medication: a growing concern.
Indian journal of medical sciences. 1997; 51(3): 93-
6. PubMed | Google Scholar
28. Guerra GC, da Silva AQ, Franca LB, Assuncao PM, Cabral RX,
Ferreira AA. Drug use during pregnancy in Natal, Brazil. Rev
Bras Ginecol Obstet. 2008; 30(1): 12-8. PubMed | Google
Scholar
29. Garofalo L, Di Giuseppe G, Angelillo IF. Self-medication
practices among parents in Italy. Bio Med research
international. 2015; 2015: 580650. PubMed | Google
Scholar
30. Odalovic M, Vezmar Kovacevic S, Nordeng H, Ilic K, Sabo A,
Tasic L. Predictors of the use of medications before and during
pregnancy. International journal of clinical pharmacy. 2013;
35(3): 408-16. PubMed |Google Scholar
31. Zaki NM, Albarraq AA. Use, attitudes and knowledge of
medications among pregnant women: a Saudi study. Saudi
pharmaceutical journal: SPJ: the official publication of the
Saudi Pharmaceutical Society. 2014; 22(5): 419-
28. PubMed | Google Scholar
32. Amani F, Mohammadi S, Shaker A, Shahbazzadegan S. Study
of arbitrary drug use among students in Universities of Ardabil
City in 2010. Journal of Ardabil University of Medical Sciences.
2011; 11(3): 201-7.PubMed | Google Scholar
33. Yuefeng L, Keqin R, Xiaowei R. Use of and factors associated
with self-treatment in China. BMC public health. 2012; 12(1):
995. PubMed | Google Scholar
34. Kaushal J, Gupta MC, Jindal P, Verma S. Self-medication
patterns and drug use behavior in housewives belonging to the
middle income group in a city in northern India. Indian journal
of community medicine: official publication of Indian
association of preventive & social medicine. 2012; 37(1): 16-
9. PubMed |Google Scholar
35. Selvaraj K, Kumar SG, Ramalingam A. Prevalence of self-
medication practices and its associated factors in urban
Puducherry, India. Perspectives in clinical research. 2014; 5(1):
32-6. PubMed | Google Scholar
36. Shveta S, Jagmohan S. A study of self medication pattern in
Punjab. Indian Journal of Pharmacy Practice. 2011; 4(2): 43-
46. Google Scholar
37. Correa da Silva MG, Soares MC, Muccillo-Baisch AL. Self-
medication in university students from the city of Rio Grande,
Brazil. BMC Public Health. 2012; 12: 339. PubMed | Google
Scholar
38. Ganaeie R, Hemmati Maslakpak M, Baghi V. Self-medication in
pregnant women. Journal of research development in nursing
& midwifery. 2013; 10(1): 92-8. PubMed | Google Scholar
39. Shamsi M, Bayati A. A survey of the prevalence of self-
medication and the factors affecting it in pregnant mothers
referring to health centers in arak city, 2009. Pars journal of
medical sciences: jahrom medical journal. 2010; 7(3): 34-
42. PubMed | Google Scholar
40. Mohammed MA, Ahmed JH, Bushra AW, Aljadhey HS.
Medications use among pregnant women in Ethiopia: a cross
sectional study. Journal of Applied Pharmaceutical Science.
2013; 3(4): 116-23.PubMed | Google Scholar

Table 1: Distribution absolute and relative frequency of study subjects in terms of employment status, education level and insurance status
Variable Number %
Job Housewife 320 16.7
Employed 64 83.3
Education Illiterate 4 1.0
Elementary 22 5.7
Guidance 45 11.7
Diploma 165 43.0
Higher Education 148 38.5
Insurance Yes 178 46.4
No 206 53.6

Page number not for citation purposes 6

Table 2: Distribution absolute and relative frequency of self-medication before and during pregnancy
During pregnancy Total
Self-medication
No: N (%) Yes: N (%) N (%)
No: N (%) 226 (58.9) 27 (7) 253 (65.9)
Before Pregnancy
Yes: N (%) 80 (20.8) 51 (13.3) 131 (34.1)
Total: N (%) 306 (79.7) 78 (20.3) 384 (100)

Table 3: The role of different independent variables on self-medication before pregnancy

Adjusted Odds Ratio
Independent variable P value
(95% CI)
Age 1.03 (0.93-1.14) 0.562
Housewife Reference
Job
Employed 2.31 (0.87-5.96) 0.083
Yes Reference
Insurance
No 2.03 (1.00 -4.10) 0.049
College Reference
Education High School 2.96 (1.33- 6.61) 0.008
Primary 1.89 (0.66- 5.40) 0.233
>7000000 Reference
Income
≤7000000 0.65 (0.30- 1.39) 0.264
≥2 Reference
Child 1 1.33 (0.50- 3.53) 0.568
0 3.18 (1.04- 9.73) 0.042
Yes Reference
abortion
No 1.88 (0.75- 4.73) 0.178

Table 4: The role of different independent variables on self-medication during pregnancy

Adjusted Odds Ratio
Independent variable P value
(95% CI)
Age 1.03 (0.92- 1.14) 0.630
Housewife Reference
Job
Employed 1.17 (0.41- 3.25) 0.783
Yes Reference 0.014
Insurance
No 0.39 (0.18- 0.83)
College Reference
Education High School 1.21 (0.51- 2.87) 0.668
Primary 1.38 (0.42- 4.55) 0.594
>7000000 Reference
Income
≤7000000 0.84 (0.38- 1.88) 0.676
≥2 Reference
Child 1 5.42 (1.44- 20.40) 0.012
0 6.86 (1.53- 30.65) 0.012
Yes Reference
abortion
No 2.85 (1.02- 7.91) 0.045

Page number not for citation purposes 7

Table 5: The role of different independent variables on self-medication before and during pregnancy

Independent variable Adjusted Odds Ratio (95% CI) P value

Age 1.04 (0.89 - 1.21) 0.597

Job Housewife Reference
Employed 0.94 (0.24 - 3.63) 0.930
Insurance Yes Reference
No 0.17 (0.06 - 0.53) 0.002

Education College Reference

High School 1.15 (0.35 - 3.74) 0.819
Primary 1.79 (0.39 - 8.29) 0.455
Income >700 Reference
≤700 0.81 (0.27- 2.39) 0.702
Child ≥2 Reference
1 11.45 (2.29 - 57.17) 0.003
0 9.91 (1.55 - 63.42) 0.015
abortion Yes Reference
No 5.62 (1.27 - 24.88) 0.023
self-medication before
No Reference
pregnancy
Yes 5.11 (1.69- 15.39) 0.004

Page number not for citation purposes 8

International Journal of Clinical Pharmacy
https://doi.org/10.1007/s11096-020-01055-8

RESEARCH ARTICLE

The role of pharmacists in community education to promote

responsible self‑medication in Indonesia: an application of the spiral
educational model
Adji Prayitno Setiadi1 · Yosi Wibowo1   · Cecilia Brata1 · Steven Victoria Halim1 · Susilo Ari Wardhani2 ·
Bruce Sunderland3

Received: 24 October 2019 / Accepted: 9 May 2020

© Springer Nature Switzerland AG 2020

Abstract
Background Community empowerment is one key strategy to improve the health of Indonesians. In 2015, the Government
initiated the ‘Smart Use of Medications Campaign’ to empower Indonesians to practice responsible self-medication. Analysis
of a pilot training program established in 2016 identified that improvements were needed in the content and organisation of
the module. Objective To evaluate a revised module (applying a spiral model approach) to guide community training as part
of the ‘Smart Use of Medications Campaign’. Setting The Ngawi District, Indonesia in May 2018. Method Eight pharmacists
(trainers) and 39 community representatives (participants) were involved in the training based on the revised module. The
module adopted the spiral approach and consisted of three progressive steps: (1) understanding basic concepts of informa-
tion on the label/package of one medication product; (2) re-enforcing that concept to understand medication classification
(applied using three products); and (3) expanding the concept to understand medication classification (applied using a pack
of 40 products). Pre-/post-test scores were used, and Focus Group Discussions were conducted to explore the participants’
knowledge gain. Main outcome measure: participants’ and trainers’ views on the spiral process. Result Participants’ mean
overall knowledge gain increased from 12.53/15 to 13.44/15 (p = 0.001). Six focus groups of participants and two focus
groups of trainers perceived that both trainers and participants found the spiral model better facilitated understanding, as it
involved step-by-step learning. They also indicated the importance of the role of pharmacists as suitably qualified trainers
as well as the development of appropriate training aids/media and arrangements. Conclusion Training based on the spiral
model has the potential to be implemented in community training to improve self-medication literacy among the Indonesian
public. Support from pharmacists as well as the relevant national and professional bodies is essential for successful imple-
mentation of the training.

Keywords  Community-based education · Indonesia · Pharmacist · Self-medication · Spiral educational model

Impacts on practice

• The employment of a spiral educational model for com-

* Yosi Wibowo
yosi_wibowo@staff.ubaya.ac.id munity training in self-medication has the potential to
improve community self-medication knowledge.
1
Centre for Medicines Information and Pharmaceutical Care • The spiral model facilitates an improved learning pro-
(CMIPC), Faculty of Pharmacy, Universitas Surabaya, cess since it involves a step-by-step learning process,
5th Floor, Building FF, Jl. Raya Kalirungkut, Surabaya,
East Java 60293, Indonesia initially from one medication which is applied step-wise
2 to a range of medications.
Pharmaceutical and Medical Devices Section, East Java
Provincial Health Office, Ministry of Health Republic • Support from pharmacists as suitably qualified trainers
of Indonesia, Surabaya, East Java, Indonesia as well as the development of appropriate training aids/
3
School of Pharmacy, Faculty of Health Sciences, Curtin media and arrangements are essential to implement the
University, Perth, WA, Australia

13
Vol.:(0123456789)

model for training a community to promote responsible
self-medication in Indonesia.
Introduction
Indonesia is the largest archipelago and the fourth most
populous country in the world [1]. With approximately a
260 million population spread across almost 18,000 islands
[1], the range of health challenges in Indonesia is daunting.
In addition to the burden of both infectious and chronic non-
communicable diseases, Indonesia is wrestling with mald-
istribution and shortages of health workers and facilities
[1, 2]. Commencing in 2014, the Indonesian Government
inititated Jaminan Kesehatan Nasional (JKN), a national
health scheme, which aimed to provide basic healthcare to
all Indonesians [3]. Rapid expansion of health care demand
through JKN will require intensified and strategic invest-
ments. In light of the limited health resources available, it is
vital for JKN to invest in empowering individuals/families
and communities to maintain their own health, which is also
known as ‘self-care’ [4].
Self-medication has been an essential form of self-care
among Indonesians; based on a population survey in Indone-
sia, where 61% of the population practised self-medication
in 2014 [5]. Self-medication is "the selection and use of
medicines by individuals to treat self-recognised illnesses
or symptoms" [6]. Hence, self-medication has the potential
to move the population towards a greater independence to
treat minor ailments, thereby optimising the use of easily
accessible health resources for minor ailments and reduc-
ing health expenditure linked to the unnecessary medical
treatment of minor ailments [7]. However, major problems
related to self-medication have been reported, such as incor-
rect self-diagnosis, delays in seeking medical advice when
needed, and serious health hazards (e.g. adverse reactions
and prolonged suffering) [7, 8]. In this context, the gov-
ernment should take necessary steps to foster responsible
self-medication, which is defined as “the practice whereby
individuals treat their ailments and conditions with medi-
cines which are approved and available without prescription,
and which are safe and effective when used as directed” [6].
In addition to making available safer drugs which include
clear directions for use; it is important for the people who
are practising self-medication to have adequate knowledge
about these medications [9].
In 2015, the Indonesian Government launched the ‘Smart
Use of Medications Campaign’ (Gerakan Masyarakat Cerdas
Menggunakan Obat—GeMa CerMat) scheme which aimed
to empower Indonesians to practice responsible self-medi-
cation [10]. The GeMa CerMat initiative involved, but was
not limited to, community-based training to improve Indone-
sians’ self-medication literacy and quality use of medications.
13
International Journal of Clinical Pharmacy
Pharmacists, with their educational background on medica-
tions, were expected to be actively involved as trainers in the
program. One well established role of pharmacists is assisting
community members when purchasing non-prescription medi-
cations through pharmacies [11–14]; however, little evidence
is available for their role in community education. Previous
studies in Indonesia have reported positive outcomes of phar-
macist-led community training for patients with chronic condi-
tions, including diabetes and tuberculosis [15, 16].
Using the concept of the previous community training on
chronic conditions [15, 16], GeMa CerMat pilot training was
conceptualised and carried out across Indonesia in 2016 [17].
Follow-up discussions with the pharmacist trainers suggested
the need to improve the training module in terms of the con-
tent as well as the overall structure [17]. The initial module
organised the content into three serial activities: (1) medication
classification, (2) information on the medication label/package,
and (3) additional information; this serial approach requires
learners to understand one concept initially, before continuing
to another concept in the next stage, until all concepts were
learned. This approach might cause some difficulty for com-
munity member of limited literacy to understand [17]. As a
result, the spiral approach, based on Bruner’s theory (1960),
could have particular advantages; the spiral approach exposes
learners to the overall concepts (at the initial stage)—starting
from the simplest form and gradually building up in complex-
ity in the next stages [18, 19]. In addition, the spiral curricu-
lum has been widely applied and is particularly relevant to
integrated and problem-based learning [19–22], thus having
the potential to be applied to community based training on the
use of medications.
Aim of the study
This present study aims to evaluate the application of a spiral
model approach to community education to promote respon-
sible self-medication.
Ethics approval
The data collection instrument and methodology used in this
study were approved by the Ethics Committee of the Fac-
ulty of Medicine, Islamic University of Indonesia (No. 08/
Ka.Kom.Et/70/KE/IX/2016).
Method
Developing a module using the spiral model
approach
In 2016, the East Java Provincial Health Office conducted
GeMa CerMat community training across four cities/districts
International Journal of Clinical Pharmacy

of East Java (Blitar, Nganjuk, Sumenep, and Ngawi) to pro-
mote responsible self-medication. A module ‘Introduction
to the use of medications (1st edition)’ was used to guide the
training. The module was generated from The Indonesian
Ministry of Health module which was followed with imple-
mentation overseen by an expert panel; the final 1st edition
module consisted of three serial activities: (1) medication
classification, (2) information on the medication label/pack-
age (i.e. drug logo, name, active ingredients, indication,
administration and dosage, adverse effects, and storage),
and (3) additional information (i.e. special dosage forms and
safe disposal of medications) [17]. Following the training,
four Focus Group Discussions (FGDs)—each involving five
pharmacists/pharmacy staff trainers (detailed characteristics
were published elsewere [17])—were conducted to obtain
their views and feed-back regarding the training delivery.
Areas for module improvement were identified, including
content as well as the organisation of the content within the
overall structure of the module [17].
Based on these recommendations, a new module was
developed by the research pharmacists using a spiral
model approach ‘Introduction to the use of medications
(2nd edition)’. The approach was predicated on cognitive
theory advanced by Bruner (1960) [18], who stated, "We
begin with the hypothesis that any subject can be taught in
some intellectually honest form to any child at any stage
of development." Hence, even the most complex material,
if properly structured and presented, could be understood
even by very young children [18]. Key features of the spi-
ral curriculum model are: (1) topics are revisited; (2) there
is an increasing level of difficulty; and (3) new learning is
related to previous learning and is placed in context with
the old information [19]. Previous studies have reported
that features of a spiral curriculum have been linked to
improved learning outcomes; which were particularly rel-
evant when used in an integrated and problem-based learn-
ing curriculum [19–23].
Using similar goals and competencies as for the 1st edi-
tion module (i.e. to understand information on medica-
tion label/packages); the 2nd edition module was delivered
based on the spiral approach concept. The module con-
sisted of three progressive steps: (1) understanding basic
concepts regarding information on the label/package of
one medication product; (2) re-enforcing that concept to
understand medication classification (applied using three
medication products); and (3) expanding the concept to
broadly understand medication classification (applied
using a medication pack) (Table 1). A medication pack
included four sets of medications each containing 10
medications of the following minor ailment categories:
analgesics-antipyretics, cough and cold medications, vita-
mins and minerals, and gastrointestinal medications. These
therapeutic areas were chosen, because they were among
the most common minor illnesses treated in primary health
facilities in East Java, Indonesia [24].

Table 1  Summary of the steps involved in the revised spiral module

Step 1: to understand basic concept of information on one medication label/package

 Activities:
  -Provide one medication product to the participants
  -Discuss and illustrate basic information provided on the medication label/package (drug logo, name, active ingredient, indication, adminis-
tration, adverse effects, storage—fill in worksheet A
Step 2: to step-wise understand medication classifications (using three medication products)
 Activities:
  -Add two further medication products (one product that has the same active ingredient but a different indication to the first product, and one
product that has the same indication but different active ingredient to the first product)
  -Ask each participant to classify the medications based on the active ingredients—fill in worksheet B
  -Ask each participants to classify the medications based on the indications—fill in worksheet C
  -Ask each participants to classify the medications based on the logo: —general sale, —general sale with cautionary label, —pre-
scription only, —narcotics:—fill in worksheet D
  -Discuss the classifications
Step 3: to demonstrate understanding of medication classifications (using a medication pack of 40 items)
 Activities:
  -Provide a medication pack to a small group of participants
  -Ask participants to classify the medications based on the active ingredients
  -Ask participants to classify the medications based on the indications
  -Ask participants to classify the medications based on the logo
  -Discuss the classifications

13

Applying the spiral approach to community
education
A pilot study to implement the revised training model was
conducted in Ngawi. Ngawi is a district (kabupaten) located
in western part of East Java Province, Indonesia. Based on
the statistical data for Ngawi in 2012, Ngawi covers an area
of 1296 km2 with a population of 911,911 people; health
facilities in Ngawi included two hospitals, 24 Primary
Health Centres (PHC—Puskesmas), and 51 community
pharmacies [25].
The community training for this study planned to involve
eight pharmacists (trainers) and 40 community members
(participants) in Ngawi. The pharmacists were purposefully
selected by the Chief of Ngawi Health Office from pharma-
cists involved in the training completed in 2016; it included
those from community pharmacies, PHCs, and the Ngawi
Health Office. While participants were purposively selected
from community members actively involved in supporting
health activities in their local PHCs. The purposive sampling
was considered the most feasible, since not all community
members that visited the local PHCs in Ngawi have provided
their contact details. The best option was to ask the Ngawi
Health Office Chief to select community members actively
involved in the local PHCs as their contact details were read-
ily available.
Fourty community members and eight pharmacists were
verbally invited by Ngawi Health Office staff to attend the
community training session in the Ngawi Health Office in
May 2018. The day before the training session, the prin-
cipal researcher (an academic pharmacist) explained and
simulated the revised module to prepare the pharmacists as
trainers. At the beginning of the training, the nature of the
study was explained and informed consent were obtained.
Eight groups of approximately five participants were formed,
and each group was facilitated by one pharmacist trainer
using the spiral approach module (the research pharmacists
assisted to ensure consistency). The training session took
about three hours.
Participants’ knowledge before and after the spiral
approach learning was evaluated using the same 15-ques-
tion true/false test. The test was developed by an expert
panel (consisted of four pharmacists/academics expert in
the area of pharmacy practice) based on the basic concepts
of medication use covered in the module (Table 1). Each
question was scored “1” (for correct answer) and “0” (for
wrong answer), thus providing a total range of 0 to 15. A
short questionnaire was administered to obtain participant
characteristics data which was included with the test.
In addition to participants’ knowledge gain, trainers and
participants’ views on the spiral process were evaluated
using Focus Group Discussions (FGDs). Two FGDs of
trainers (each involving approximately four trainers) and
13
International Journal of Clinical Pharmacy
four FGDs of participants (each involving approximately
10 participants) were planned. Each FGD was facilitated
by one moderator (the research pharmacist) and the discus-
sion was assisted with a semi-structured guide. The guide
explored four aspects related to the training: (1) delivery
method (use of spiral approach), (2) material/content, (3)
trainer, and (4) training arrangements. All FGDs were
conducted in Bahasa Indonesia and lasted about 30 min;
a summary was provided to the participants at the end of
the discussion as a means of member-checking, ensuring
credibility of the data [26].
Data analysis
Community representative’s knowledge gain was determined
using the pre-and post-test scores; differences in the scores
were analysed using a paired t-test or Wilcoxon signed-rank
test if the data were not normally distributed. Statistical
analyses were performed using SPSS Statistics version 19.0.
Audio-recorded data from the focus group meetings were
transcribed, and transcripts were reviewed using inductive
thematic analysis [27]. All transcripts were coded manually
by cutting and pasting between documents, and the codes
were categorised at a broader conceptual level (i.e. themes).
The analysis was performed by one of the research phar-
macists, and extracted themes were validated by discussion
with the principal researcher to reach a consensus. Data
analysis was conducted in Bahasa Indonesia and the illus-
trative verbatim quotes and theme labels were translated into
English. While presenting the quotes, trainers/participants’
identity was coded to maintain confidentiality, e.g. Trainer
1.1 (trainer number 1 from FGD 1).
Results
A total of eight pharmacists and 39 community members
consented to the study. Characteristics of the community
members involved in the training in Ngawi are presented in
Table 2. A majority of the community members were female
and approximately 50% were housewives with a mean age
of 40 years. Almost 80% of the community members had
practised self-medication in the last month; their sources
of information for self-medication were mainly mass media
or friends/relatives, and almost all of them purchased their
medication from community pharmacies.
Of the eight pharmacists involved in the training, all were
female with a mean age of 37 years (Table 3). The pharma-
cists included those from community pharmacies, PHC and
the Ngawi Health Office; and all of them had past experience
with community training.
International Journal of Clinical Pharmacy

Table 2  Community members’ characteristics (n = 39) four basic concepts covered in the module; significant
Characteristics N (%) improvements were reported for participants’ knowledge
towards drug name and active ingredient as well as drug
Age (years) (mean ± SD) 40 ± 10 logo (all p < 0.05).
Gender
 Male 11 (28) Trainers and participants’ views related to spiral
 Female 28 (72) learning process
Education
 Primary school 2 (5) Six FGDs with participants and two FGDs with trainers
 Junior high school 4 (10) involved in the community training were conducted. Their
 Senior high school 20 (51) views related to the aspects of spiral model were explored,
 Diploma 3 (8) including: (1) delivery method, (2) material/content, (3)
 Bachelor 9 (23) trainer, and (4) training arrangements.
 Postgraduate 1 (3)
Occupation Aspect related to the delivery method
 Not working 1 (3)
 Housewife 20 (51) Both trainers and participants indicated positive responses
 Civil servants 7 (18) to the spiral model approach used to deliver the training.
 Private employee 1 (3) The spiral structure allowed participants to develop a logical
 Entrepreneur 10 (26) progression from simplistic ideas to more complex appli-
Monthly income (in Indonesian Rupiah)a cations, thus making the learning process easier; as illus-
 None 1 (3) trated by Trainer 1.1 “(the current organisation) is easier,
 ≤ 1 million 12 (33) starting to learn from one medication and adding more
 > 1–2.5 million 4 (11) medications step-by-step.”, and Participant 2.3 “(We learn
 > 2.5–5 million 16 (44) from) one medication first. One by one so that we did not
 > 5–10 million 3 (8) get confused.”
Self-medication practices N (%) While trainers and participants reported positive
responses, they identified some areas that should be fur-
Frequency of self-medication in the last month
ther discussed, including the use of worksheets, language of
 None 9 (23)
delivery, and visual aids. Some of the trainers indicated that
 1–2 times 28 (72)
 3–5 times 2 (5)
the worksheets were not suitable for older adults, as illus-
Source of i­nformationb
trated by Trainer 2.3: “for older adults, it would be difficult
 Mass media (television, radio, newspaper, magazine, 11 (28)
(to ask them to fill the worksheets) as (the worksheets) were
internet) quite a lot.”; while others believed that the worksheets would
 Friends or relatives 15 (36) help participants to be more engaged to the learning process
 GP or based on old prescription 3 (8) as illustrated by Trainer 1.4: “But it is good if they write
 Pharmacist or pharmacy staff 9 (21) (what they learn) as it forced them to read.” Thus, patients’
 Other health professionals 2 (5) characteristics should be considered while determining the
Source of m ­ edicationb appropriate training media, such as less written work and
 Street stall or drug shop 4 (10) more interactive activities for older participants. In addition,
 Community pharmacy 37 (95) trainers and participants indicated the need to simplify medi-
cal terms used in the worksheets, such as active ingredients
Abbreviation: GP general practitioner and indications.
a
 3 missing responses While trainers believed it is best to use Bahasa Indonesia
b
 Participant can provide more than 1 answer (the national language) for the module; trainers and partici-
pants pointed out the importance to recognise the language
background of the participants and use it when necessary
Participant’s knowledge gain while delivering the material. This was as illustrated by
Trainer 2.2, “What I did was using mixed (languages), I
The mean overall test scores for all participants signifi- sometimes used Javanese language (i.e. local language) as
cantly improved from mean of 12.53 (pre-test) to 13.44 well as Bahasa Indonesia depending on the participants’
(post-test) after the training (p = 0.001) (Table 4). There background.”; and Participant 3.5 “Better to use ‘our’ lan-
were non-significant increases in post-test scores for guage (i.e. local language or language they are using in daily

13
 International Journal of Clinical Pharmacy

Table 3  Pharmacist trainers’ characteristics (n = 8) of (brand) names”], indication [as Participant 7.3 stated:“(I
Characteristics N (%)
learn mostly on) what the drug use for”], and drug logo [as
Participant 4.2 mentioned: “We happened to know all kinds
Age (years) (mean ± SD) 37 ± 4 of drug logo, in the past we only saw blue or red circle (but
Gender did not know what it is)].”
 Female 8 (100)
Work experience Aspect related to trainer
 > 5–10 years 3 (38)
 > 10 years 5 (63) Trainers have a key role for a successful implementation of
Institution the spiral model approach as they should be able to facilitate
 Community pharmacies 4 (50) participant discussions in a controlled way while gradually
 PHC 3 (38) increasing the complexity of the material. Thus, in addi-
 Ngawi Health Office 1 (13) tion to competencies for the quality use of medications, par-
Experiences in community training ticipants indicated the importance of trainers to have good
 1–2 times 5 (62) communication skills; as illustrated by Participant 7.1: “She
 2–5 times 3 (38) (the trainer) has adequate communication skill so that (the
Abbreviation: PHC Primary Health Centre
discussion) was quite interactive”, and Participant 3.4 “The
language used was easy to follow.”

conversation), easy to understand.” Furthermore, trainers Aspects related to training arrangements

and participants indicated issues related to the medication
pack that accompanied the module, including: incomplete
information on the medication label/package (such as no
logo), very small text and difficult medical terms on the
medication label/package; all of those warrant further con-
sideration while delivering the training.
Aspects related to the material/content
Both trainers and participants believed that the training
module covered adequate information to improve literacy
on self-medication practice (i.e. drug logo, name, active
ingredients, indication, administration, adverse effects, and
storage). Participants also reported varied new skills and
knowledge gained after the training, particulary related
to the drug name or active ingredient [as Participant 2.5
stated: “I just knew that paracetamol has a different kinds
All participants indicated that the current training arrange-
ments using a roundtable small group discussion provided
an effective engagement and ensured individual attention; as
Participant 6.2 stated, “If using round table like this, we can
interact face to face, (so that) it is easier to discuss (about the
material).” In addition, time allocation (2–3 h) was consid-
ered sufficient for participants to learn the material. All par-
ticipants also suggested that the training could be conducted
on a regular basis to build community awareness towards
responsible self-medication; as illustrated by Participant 3.2,
“(the training) should be conducted every few months; so
that, (the community) could improve their knowledge.”

Table 4  Pre-/post-test scores Basic concepts of medication information Pre-test Post-test p ­valuea

of community members (mean ± SD) (mean ± SD)
participating in the training
Drug name and active ingredient (Q3, Q4, Q9, Q10; 3.17 ± 0.82 3.41 ± 0.72 0.039
range score 0–4)
Indication (Q5, Q7; Q11; range score 0–3) 2.53 ± 0.55 2.72 ± 0.51 0.052
Drug logo (Q1, Q2, Q 12; range score 0–3) 2.17 ± 0.51 2.49 ± 0.51 0.007
Administration (Q6, Q12; Q 13, range score 0–3) 2.74 ± 0.50 2.85 ± 0.43 0.331
Adverse effects (Q14; range score 0–1) 0.92 ± 0,27 0.97 ± 0.16 0.317
Storage (Q15; range score 0–1) 0.95 ± 0.22 1.00 ± 0.22 0.157
Totalb (range score 0–15) 12.43 ± 1.59 13.44 ± 1.37 0.001

Abbreviation: Q question number, SD standard deviation

a
 p value from Wilcoxon signed-rank test between pre-test versus post-test scores
b
 Total scores from 15 questions

13
International Journal of Clinical Pharmacy
Discussion
This study showed the potential of using the spiral model
approach for the provision of community training to improve
self-medication literacy and quality use of medicines among
Indonesians. This was evidenced with significant improve-
ments between pre- and post-test scores on module knowl-
edge among participants. Furthermore, the spiral model
approach was perceived to be easier to follow by both train-
ers and participants as it proposed step-by-step learning to
initially develop understanding of the relevant information
from one medication which was then applied step-wise to
a range of medications, thus preventing initial information
overload or confusion. In addition to well-designed mod-
ule content and structure, the implementation of the spiral
model approach would require support from pharmacists as
qualified trainers as well as appropriate training aids/media
and arrangements for a broader uptake.
There were some limitations to this study. This study used
a small sample size and purposive sampling of pharmacists
(trainers) and community members (participants); thus some
caution should be exercised in generalising the findings.
The study participants were selected from members of the
community actively involved in the local PHCs; hence they
might differ in the levels of education, health literacy, and/
or motivation compared to the general community members,
which might have accounted for them having reasonably
high initial test results. However, the positive results (sig-
nificant pre-/post-test differences) in this pilot study provide
insights to the potential use of a spiral model approach to
deliver training to improve self-medication literacy among
Indonesians. In addition, although pharmacists involved in
this study might not fully represent the general pharmacist
population, a prior briefing session was conducted to stand-
ardise their capability to conduct the training and to ensure
consistency. With regards to the FGDs of pharmacists (train-
ers) and community members (participants), it should be
noted the qualitative data are a product of views, experi-
ences and perceptions of respondents, thus it can be biased if
respondents are not sharing their true views [28]. To ensure
validity in the analysis, however, the results of this study
were provided to the trainers and participants (‘member-
checking’) [26].
A pre-/post-test methodology, a common methodology
in education research (28), was selected as a straight for-
ward approach to evaluate the impact of the spiral model
approach on community members’ knowledge acquisition
which was an important goal of the program. Although
the difference between pre-/post score in this study was
significant, the absolute gain was relatively small; this
might due the already high baseline (pre-test score) among
participants. It should be acknowledged that community
members involved in this study were selected from com-
munity members actively involved in supporting health
activities in local PHCs, thus they might have a higher
health literacy baseline; further, the majority of them were
high school graduates or higher. This figure might overes-
timate other Ngawi residents’ level of education; based on
the BPS Ngawi 2018 [25], the average of schooling years
among 15 years of age in Ngawi was 6.88 which is equiv-
alent to elementary school graduates. Hence, ordinary
Ngawi community members might have a lower knowl-
edge baseline, with possibly higher improvements could
be achieved with the implementation of spiral community
training. This needs further community based evaluation
before further modifications are contemplated.
In addition to the knowledge evaluation, a qualitative
approach—using Focus Group Discussion (FGD) [28]—
was applied in this study to provide broader feedback on
the spiral model process. In terms of the module content,
community members perceived the coverage was sufficient
to support them to understand basic information about medi-
cations; in particular, they were able to learn more in rela-
tion to ‘drug name and active ingredients’, ‘indication’ and
‘drug logo’. This was in line with significant improvements
of pre-/post test related to ‘drug name and active ingredi-
ents’ (p = 0.039) and ‘drug logo’ (p = 0.007). In terms of the
module stucture, trainers preferred the spiral structure over
the previous approach (serial activities) [17); participants
(community members) also provided positive responses sup-
porting the use of the spiral approach. The benefits of the
spiral model approach in teaching science at schools has
been demonstrated [19–22]. However, general community
members might have a wide range levels of health literacy;
thus, the step-by-step learning (from simple to complex idea)
provided by the spiral approach might provide some advan-
tages for community training.
To support the implementation of spiral approach, this
study indicated the importance of qualified trainers. Duze
(2012) suggested that the teacher’s knowledge about the
curriculum, and his/her teaching strategies are key fac-
tors in implementing a curriculum [29]. Pharmacists are
experts in medications where a high level of public trust
and confidence in pharmacists’ ability to advise on self-
medication have been reported [13, 30, 31]; thus, phar-
macists could be seen as the best candidates for train-
ers in self-medication community training. While this
study found that this group of community members often
obtained information regarding self-medication from mass
media and/or friends/relatives, the ‘GeMa CerMat’ initia-
tive and community training could be seen as an opportu-
nity for Indonesian pharmacists to have a proactive role in
promoting responsible self-medication. While pharmacists
in this study only needed a short briefing before the train-
ing (as they were also involved in the 2016 pilot training),
13

this might not be the case for the general pharmacist pop-
ulation; a standard system should be considered beyond
this study for pharmacists willing to take part as trainers
to ensure their capacity in conducting such training. In
addition to pharmacists as trainers, a previous study also
suggested the involvement of change agents from trusted
members of community, such as community health repre-
sentatives/leaders [32]. As part of the community, change
agents would have a close understanding of that commu-
nity [33–35], and thus are in an ideal positions to bridge
the knowledge and/or language gaps between pharmacists
and community members.
While the spiral process was well accepted, its applica-
tion to this study indicated some areas for consideration.
These include the development of different training media/
aids to suit different participant categories, such as more
interactive activities or visual aids for older participants. It
was suggested that the decision to use a particular medium
should first consider socio-economic and cultural back-
grounds of participants [36, 37]. Further, a careful selec-
tion of medication packs should be considered for training
purposes, including complete information and adequate
text size on the medication label/package (or otherwise
visual aids should be considered), which is also in line
with the finding from the previous community training
[17]. Further research would be required to develop appro-
priate training media/aids for different target groups for a
fully successful implementation of a spiral model based
curriculum in community training to promote responsible
self-medication in Indonesia.
Conclusion
The spiral model approach has the potential to improve
self-medication literacy among Indonesians. The imple-
mentation of the spiral approach requires support from
pharmacists as qualified trainers as well as appropriate
training aids/media and arrangements for a broader uptake.
Support is also essential from national and professional
bodies. Further research is required to confirm the find-
ings into a broader population of community members.
The development of a range of training media/aids to suit
different target groups is essential to further progress the
implementation of a spiral curriculum model in commu-
nity training to promote responsible self-medication in
Indonesia.
Acknowledgements  We would like to thank Ngawi and East Java Pro-
vincial Health Offices – Ministry of Health Republic of Indonesia, and
Centre of Medicines Information and Pharmaceutical Care (CMIPC)
– Faculty of Pharmacy, Universitas Surabaya, the staff and other com-
munity organisations that supported in our planning and hosted the
13
International Journal of Clinical Pharmacy
community training. Part of this research was presented at the 19th
Annual Scientific Meeting of Indonesian Pharmacist Association
(Pertemuan Ilmiah Tahunan Ikatan Apoteker Indonesia, PIT IAI) in
Bandung, 12–15 March 2019.
Funding  This study was funded by Ministry of Research, Technol-
ogy and Higher Education, Republic of Indonesia (No. 27/SP-Lit/
LPPM-01/Dikti/FF/V/2017).
Conflicts of interest  The authors declare that they have no conflict of
interest.
References
1. Statistics Indonesia (Badan Pusat Statistik - BPS). Statistical year
book of Indonesia 2018. Jakarta: BPS; 2018.
2. Misnaniarti M, Hidayat B, Pujiyanto P, Nadjib M, Thabrany
H, Junadi P, et al. Ketersediaan fasilitas dan tenaga kesehatan
dalam mendukung cakupan semesta jaminan kesehatan nasional
[The availability of health facilities and workforce to support the
national health coverage]. Jurnal Penelitian dan Pengembangan
Pelayanan Kesehatan. 2017;1:6–16.
3. Republic of Indonesia (Pemerintah Republik Indonesia – Pemer-
intah RI). Road map towards National Health Insurance (JKN)
2012–2019. Jakarta: Pemerintah RI; 2012.
4. Ministry of Health Republic of Indonesia (Kementerian Kesehatan
Republik Indonesia – Kemenkes RI). Rencana Strategis Kemen-
terian Kesehatan tahun 2015–2019 [The Ministry of Health stra-
tegic plan 2015–2019]. Jakarta: Kemenkes RI; 2015.
5. Statistics Indonesia (Badan Pusat Statistik - BPS). Persentase pen-
duduk yang mengobati sendiri selama sebulan terakhir menurut
provinsi dan jenis obat yang digunakan, 2000–2014 [The percent-
age of population practicing self-medication in the last month
according to the residing provinces and the medication use in
2000–2014]. Jakarta: BPS; 2014. https​://www.bps.go.id/linkT​
ableD​inami​s/view/id/926. Accessed 2 Aug 2019.
6. World Health Organisation (WHO). The role of the pharmacist in
self-care and self-medication. Geneva: WHO; 1998.
7. Hughes C, McElnay J, Fleming G. Benefits and risks of self-
medication. Drug Saf. 2001;24:1027–37.
8. Ruiz M. Risks of self-medication practices. Curr Drug Saf.
2010;5:315–23.
9. Bennadi D. Self-medication: a current challenge. J Basic Clin
Pharm. 2014;5:19–23.
10. Ministry of Health Republic of Indonesia (Kementerian Keseha-
tan Republik Indonesia – Kemenkes RI). SK Menteri Keseha-
tan RI Nomor HK.02.02/MENKES/427/2015 tentang Gerakan
Masyarakat Cerdas Menggunakan Obat (GeMa CerMat) [Ministry
of Health Republic of Indonesia Decree Number HK.02.02/MEN-
KES/427/2015 on ‘Smart Use of Medication Campaign’ (GeMa
CerMat)]. Jakarta: Kemenkes RI; 2015.
11. Brata C, Gudka S, Schneider C, Clifford R. A review of the provi-
sion of appropriate advice by pharmacy staff for self-medication
in developing countries. Res Soc Adm Pharm. 2014;11:136–53.
12. Piecuch A, Kozlowska-Wojciechowska M. Self-medication in
Poland: the pharmacists’ advisory role in Warsaw. Int J Clin
Pharm. 2013;35:225–9.
13. Rutter P. Role of community pharmacistsin patients’ self-care and
self-medication. Integr Pharm Res Pract. 2015;4:57–655.
14. Suleiman A. Self-medication and the advisory role of pharmacists
in Riyadh, Saudi Arabia. Arch Pharm Pract. 2013;4:180–5.
15. Hartayu T, Izham M, Suryawati S. Improving of type 2 diabetic
patients’ knowledge, attitude and practice towards diabetes
International Journal of Clinical Pharmacy
self-care by implementing community-based interactive approach-
diabetes mellitus strategy. BMC Res Notes. 2012;5:315.
16. Susantini E. Implementing CBIA strategy to improve tuberculosis
patients’ adherence to treatment program. Yogyakarta: Universitas
Gajah Mada; 2006.
17. Setiadi A, Wibowo Y, Setiawan E, Presley B, Mulyono I, Ward-
hani SA, et al. Evaluation of a community-based training to pro-
mote responsible self-medication in East Java, Indonesia. Int J
Pharm Pract. 2019;27:63–70.
18. Bruner J. The process of education. Cambridge, MA: The Presi-
dent and Harvard College; 1960.
19. Harden R, Stamper N. What is a spiral curriculum? Med Teach.
1999;21:141–3.
20. Merza L, Orge N, Agatep J, Edano D. Factors affecting the imple-
mentation of spiral progression approach in relation to students’
academic performance in mathematics. Int J Soc Sci Humanit Res.
2007;6:490–5.
21. Resurreccion G, Taala W, Adanza J. Spiral progression approach
in teaching science in selected private and public schools in Cav-
ite. In: International conference on research in social sciences,
humanities and education. 2016, May 20–21.
22. Lima V. Constructivist spiral: an active learning methodology.
Interface (Botucatu). 2017;21:421–37.
23. Johnston H. The spiral curriculum: research into practice. Edu-
cation Partnership, Inc; 2012. https​://files​.eric.ed.gov/fullt​ext/
ED538​282.pdf. Accessed 28 Jul 2019.
24. Surabaya City Health Office (Dinas Kesehatan Kota Surabaya).
10 Penyakit terbanyak Kota Surabaya bulan Januari-Mei Tahun
2017 [The top ten diseases in Surabaya in January–May 2017].
Surabaya: Surabaya City Health Office; 2018. https:​ //dinkes​ .surab​
aya.go.id/porta​l/profi​l/dkk-dalam​-angka​/stati​stik-10-penya​kit-
terba​nyak/. Accessed 8 Aug 2019.
25. Statistics Indonesia (Badan Pusat Statistik - BPS). Ngawi District.
Ngawi in figures 2018. Ngawi: BPS Ngawi District; 2018.
26. Shenton A. Strategies for ensuring trustworthiness in qualitative
research projects. Educ Inf. 2004;22:63–75.
27. Braun V, Clarke V. Using thematic analysis in psychology. Qual
Res Psychol. 2006;3:77–101.
28. Smith F. Research methods in pharmacy practice. London: Phar-
maceutical Press; 2002.
29. Duze CO. The changing role of school leadership and teacher
capacity building in teaching and learning. J Emerg Trends Educ
Res Policy Stud. 2012;3:111–7.
30. Lynas K. Professionals you can trust: pharmacists top the list again
in Ipsos Reid survey. Can Pharm J. 2012;145:55.
31. Saxena H. How Australians rank pharmacists for ethics. Pharmacy
News. 2018. https​://www.pharm​acyne​ws.com.au/news/how-austr​
alian​s-rank-pharm​acist​s-ethic​s. Accessed 2 Aug 2019.
32. Setiadi A, Wibowo Y, Setiawan E, Mulyono I, Wardhani SA, Sun-
derland B. Strategies to implement community training to promote
responsible self-medication in Indonesia: a qualitative study of
trainers. Int Health. 2019. https​://doi.org/10.1093/inthe​alth/ihz11​5.
33. Simovska V, Carlson M. Health-promoting changes with children
as agents: findings from a multiple case study research. Health
Educ. 2012;112:292–304.
34. Lehman U, Sanders D. Community health workers: what do we
know about them. The state of the evidence on programmes, activ-
ities, costs and impact on health outcome of using community
health workers. Geneva: WHO; 2007.
35. Clausen L, Schmidt C, Aagaard-Hansen J, Reinbach H, Toft
U, Bloch P. Children as visionary change agents in Danish
school health promotion. Health Promot Int. 2018. https​://doi.
org/10.1093/heapr​o/day04​9.
36. Wakefield M, Loken B, Hornik R. Use of mass media campaigns
to change health behaviour. Lancet. 2010;376:1261–71.
37. O’Mara B. Social media, digital video and health promotion in a
culturally and linguistically diverse Australia. Health Promot Int.
2013;28:466–76.
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