https://doi.org/10.15218/ejnm.2019.18 Erbil j. nurs. midwifery, Vol. 2, No. (2), Nov, 2019 Original Article Knowledge of Pharmacy Staff Regarding Over the Counter Medications in Erbil City ABSTRACT Over the Counter (OTC) medications are defined as the medications available, and obtained without a physician prescription. Over the counter medications can be used with appropriate caution and proper dos- ages. However many do not know the dan- gers of misuse and continue to use OTC medications [1]. Before the Food and Drug Administration (FDA) existed in the united states, all medications were allowed to be self-medicated; alcohol, cocaine, marijua- na, and opium were included in some OTC products without notification to users. For example, in the United States of America, products containing over 80 active ingredi- ents of different therapeutic groups were switched from prescription-only to OTC Background and objectives: Use of over the counter (OTC) medications is an important area for research within different health care systems. It is also associated with increased risk of abuse and medication addiction. The need to avoid unnecessary exposure to medi- cation is a concern among the health-care community, in which pharmacy staff plays first line of response and their knowledge is critical. In Kurdistan region of Iraq, other medical and to some extend non-medical staff also works in pharmacies which may affect their sci- entific understanding of medication. The current study aims to determine the knowledge of pharmacies staff regarding OTC medication use in Erbil city. Methods: Across-sectional study was conducted from 15th- October 2018 to 15th - October 2019. A sample of 187 pharmacies in Erbil city Centre was recruited through a sys- tematic random sampling technique. Data were collected through direct interview with participants, A questionnaire was used for interviewing the pharmacy staff about socio- demographic characteristics and knowledge regarding OTC medications. The validity and reliability of the instrument was checked. Data were analyzed by using the software sys- tem of Statistical Package for Social Science (SPSS version 23). Results: The total number of the studied sample was 187 medical and para-medical staff working in Erbil pharmacies. Their mean age + SD were 28.56 + 5.33 years, ranging from 18 to 45 years. Generally only quarter (25%) of the whole sample had good level of knowledge. less than one third (29.4%) of the sample knew the correct definition of the OTC. Only 28.3% of the sample thinks that the OTC medications mostly cause side effects. Good level of knowledge was significantly associated with being female, and being a grad- uate and with being a specialized pharmacist. Conclusion: There is a limited knowledge about OTC medications among staff working in pharmacies. However among other specialties (nurses and paramedic) specialist pharma- cist had higher level of knowledge regarding OTC. Key words: Self-medication, OTC, Knowledge, Pharmacy Araz Abdulmajid Aziz; Department of Community Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. (Correspondence: araz.abdulmajed@gmail.com) Salih Ahmed Abdulla; Department of Community Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. 144 Erbil Journal of Nursing & Midwifery Received: 19/8/2019 Accepted: 13/10/2019 Published: 30/11/2019 INTRODUCTION https://ejnm.hmu.edu.krd/index.php/ejnm/article/view/105 mailto:araz.abdulmajed@gmail.com https://doi.org/10.15218/ejnm.2019.18 Erbil j. nurs. midwifery, Vol. 2, No. (2), Nov, 2019 Original Article status between 1976 and 2000. In 2007, a new law in United States of America be- came effective that required companies to report serious adverse events associated with OTC medications, from there the law and regulation of OTC medications was is- sued [2].In a study conducted by Knapp, (1998), found that, in the early 1970s anal- gesics, cold remedies, and laxatives were frequently and commonly found in Ameri- can homes, [7]. Referring to the study con- ducted in Malaysia in 2015, almost 60% respondents believed that OTC medica- tions are safe [6].People mostly reach for self-care products to help themselves their common health problems which include fever, body pains, diarrhea, vomiting, cough, indigestion and upper respiratory tract infections. This is because it is consid- ered easier, more cost-effective, time- saving, or the problem may seem too un- important to require making an appoint- ment with a healthcare profession, and in other cases, they may have few or no other options[8].Several studies on the subject indicate that there are risks such as misdi- agnosis, drug resistance, and use of medi- cations in excessive amounts, use of ex- pired medications, prolonged duration of use, and medication interactions[3].OTC medications are consumed by adults al- most in everyday life, referring to a study conducted in Maldives, in 2016; 76.6% of the 192respondents took OTC medications. In another study conducted in Jordan in 2011, the results revealed that 49.0% used left-over self-medication without physi- cian’s consultation, while 51.8% use self- medication based on a relative's advice [4].According to the FDA, as with pre- scribed medication there are many health risks related to the use of OTC medications such as: gastrointestinal problems, effect on kidney function, liver problem and risk of cardio vascular events[5].While people know the risks of OTC medications they use OTC medications for various reasons in- cluding because it is cheaper than the prescribed medication. Knowing the knowledge of people regarding OTC med- ications will help in exploring ways of awareness rising and conducting actions to reduce this phenomenon in our com- munity. The study aims to determine the knowledge of pharmacy staffregarding over the counter medication use in Erbil city. While the specific objectives were to find out the most common medications and indications used as OTC drugs among users and to find out the association be- tween socio-demographic characteristics of pharmacy staff and knowledge regard- ing OTC medications. A quantitative descriptive cross-sectional study was used to assess the knowledge of the pharmacy staff on over the counter medications in from October 2018 to Oc- tober 2019 in different locations in Erbil city. The study sample consisted of 187 pharmacy staff (pharmacist, nurse, para- medical staff) in Erbil city center, who were selected using systematic random sampling, according to the study’s inclu- sion and exclusion criteria. The study tar- geted pharmacy staff selling medication in pharmacies in Erbil city center and staff working during evening shifts upon providing their informed consent. The sample size was estimated based on the formula of. In which is standard normal variety at 5% type one error when pro- portion with a 95% level of confidence and a margin of error of 5%, = 1.96. P- value <0.05. The d is the absolute error and it’s equal to 0.05. And the p stands for the expected portion of population based Pharmacy syndicate, there is 373 pharmacies in Erbil city center, which is 86.4% of all pharmacies in Erbil (432), thus the p= 0.86%. And based 145 Erbil Journal of Nursing & Midwifery METHODS https://ejnm.hmu.edu.krd/index.php/ejnm/article/view/105 https://doi.org/10.15218/ejnm.2019.18 Erbil j. nurs. midwifery, Vol. 2, No. (2), Nov, 2019 Original Article agreed upon the items of the study instru- ment. The changing of the instrument was mostly in the Knowledge part where the experts added and modified some ques- tions which were general to be more knowledge directed. Prior of data collec- tion, ethical approval was obtained from ethical and scientific committee of College of Nursing / Hawler Medical University. Furthermore, the informed oral consent was taken from the candidates who par- ticipated in the study, after confirmation of confidentiality, anonymity and partici- pants self-determination by the research- er. Also formal approval was obtained from Kurdistan pharmacists syndicate (No:561, 20/12/2018) and Erbil pharma- cists syndicate (No: 1828, 26/12/2018). The statistical package for social science (SPSS, Version 23) was used for data pro- cessing and statistical analysis. The statis- tical analysis included descriptive statisti- cal analysis such as frequency and per- centage to describe the basic features of the data in a study and provide simple summaries about the sample and the measures, Inferential statistical analyses as Chi-square and fisher exact test were implemented to make judgment about inferences from our data to more general conditions. The confidence interval was 95%. The P-value of each test ≤ 0.05 con- sidered statistically significant. The sample consist of 187 medical and para-medical staff working in Erbil phar- macies (one staff was selected per each pharmacy according to the availability of the staff). Their mean age + SD was 28.56 + 5.33 years, ranging from 18 to 45 years. The highest proportion of the sample (33.7%) was aged 25 to 29 years, and only 11.2% were aged greater than or equal to ≥35years. The majority (73.3%) of the sample were males. Around two thirds on this formula the study sample will be 187 pharmacies in Erbil city center, which had been selected using systematic ran- dom sampling, 373/187=2 each second pharmacy will be recruited. A pilot study was conducted on 10 pharmacies. Internal consistency of the study was obtained through applying Pearson correlation (r) which was (0.74); it indicates that there was a medium positive correlation. Direct face to face interview through question- naire was conducted by researcher and separately with each of participated candi- date for at least 25 to 30minutes; the in- terview took place in a private pharmacy. The questionnaire consisted of two parts. The first part was on socio-demographic characteristics of Study Sample. This part composed of questions about the age of the participants, the occupation, and level of education, residential area, income, and years of working experience. The sec- ond part assessed the knowledge of the pharmacy staff regarding OTC medica- tions, which was consisted of 8items which are concerned with issue of the knowledge of the Pharmacy staff regard- ing OTC. The questions included; knowledge about the side effects, con- sumption, use, prescription, indications, and other information regarding OTCs. Multiple and best answer choice were de- signed to obtain the participants response to the specific questions. Each correct an- swer was equal to one score and total re- sult were from 23 scores with the segrega- tion of poor knowledge (≤7 scores), fair knowledge,(8-15 scores), and good knowledge (16-23 scores). The question- naire was validated through a panel of ten experts in different fields to investigate the content of questionnaire for its clarity, relevancy, and adequacy. The expert’s re- sponses were evaluated based on their agreements or disagreements. Results had indicated that the majority of the experts 146 Erbil Journal of Nursing & Midwifery RESULTS https://ejnm.hmu.edu.krd/index.php/ejnm/article/view/105 https://doi.org/10.15218/ejnm.2019.18 Erbil j. nurs. midwifery, Vol. 2, No. (2), Nov, 2019 Original Article (62%) of the sample were college gradu- ates, and only two personnel (1.1%) were graduates of primary school. Table (1) shows that 27.8% of the sample was phar- macists, and the rest were paramedical staff of different qualifications, except for 10.2% of the sample who were not related to the medical field. It is evident in the mentioned table that 62% of the sample were originally from urban settings, and 24.1% of the sample mentioned that their income was not sufficient for daily needs. Regarding the OTC medications and their side effects, Table 2 shows that; less than one third (29.4%) of the sample knew the correct definition of the OTC medications 147 Erbil Journal of Nursing & Midwifery which is ‘any medication that people can purchase without prescription’ as present- ed in, as for the probable side effects, only 28.3% of the sample think that the OTC medications may cause side effects while (71.1%) thought that these medications sometimes cause side effects. The follow- ing side effects of the OTC medications had been mentioned by the pharmacy staff: allergy (82.4%), tremor (12.8%), swelling of the face and limbs (15%), ab- dominal pain (58.3%), insomnia (15%), sweating (15%), liver damage (24.1%), nausea and vomiting (64.2%), and difficult breathing (18.7%). Table 1:Basic characteristics of the studied sample No. (%) Age <25 49 (26.2) 25-29 63 (33.7) 30-34 54 (28.9) ≥ 35 21 (11.2) Gender Male 137 (73.3) Female 50 (26.7) Educational level Primary school 2 (1.1) Intermediate school 6 (3.2) Secondary school 3 (1.6) Institute 60 (32.1) College 116 (62) Occupation (title) Pharmacist 52 (27.8) Assistant Pharmacist (institute) 36 (19.3) Nurse (college) 53 (28.3) Paramedical staff (institute) 27 (14.4) Others (not related to medical field) 19 (10.2) Residency Urban 116 (62) Rural 71 (38) Income Not sufficient 45 (24.1) Sufficient 111 (59.4) Exceeds needs 31 (16.6) https://ejnm.hmu.edu.krd/index.php/ejnm/article/view/105 https://doi.org/10.15218/ejnm.2019.18 Erbil j. nurs. midwifery, Vol. 2, No. (2), Nov, 2019 Original Article 148 Erbil Journal of Nursing & Midwifery Table 2: Definition of OTC medications and their side effects No. (%) OTC medications definition Any medication prescribed by medical professional 35 (18.7) Any medication sold by a pharmacist with or without prescription 97 (51.9) Any medication that people can buy without prescription 55 (29.4) Probable side effects Sometimes cause side effect 133 (71.1) Mostly cause side effect 53 (28.3) Never cause side effect 1 (0.5) Allergy Yes 154 (82.4) No 33 (17.6) Tremor Yes 24 (12.8) No 163 (87.2) Swelling of face and limbs Yes 28 (15) No 159 (85) Abdominal pain Yes 109 (58.3) No 78 (41.7) Insomnia Yes 28 (15) No 159 (85) Sweating Yes 28 (15) No 159 (85) Liver damage Yes 45 (24.1) No 142 (75.9) Nausea and vomiting Yes 120 (64.2) No 67 (35.8) Difficult breathing Yes 35 (18.7) No 152 (81.3) https://ejnm.hmu.edu.krd/index.php/ejnm/article/view/105 https://doi.org/10.15218/ejnm.2019.18 Erbil j. nurs. midwifery, Vol. 2, No. (2), Nov, 2019 Original Article Meanwhile; when the study sample were asked about OTC indicator, their answers as it demonstrated in Table 3 show that, the highest proportion (46.5%) of the staff thought that minor illnesses were the main indication for the OTC medications, and 27.3% of the staff thought that infections were the main indication for the OTC medi- cations. Meanwhile as showed in Table 4, the ma- jority (73.8%) of the staff believed that headache was the most common first indi- cation for the OTC medications, and 36.9% had chosen cold, cough, and sore throat as the second indication, while 23.1% and 22% of the staff had chosen body pain and fever, respectively, as the third indication of the OTC medications. 149 Erbil Journal of Nursing & Midwifery Table 3: General OTC medications indications No. (%) OTC indications Hereditary disease 11 (5.9) Minor Illness 87 (46.5) Heart diseases 3 (1.6) GI diseases 35 (18.7) Infections 51 (27.3) Table 4: Top three most common OTC medications indications No. (%) First most common indication Headache 138 (73.8) Fever 15 (8) Cold, cough 25 (13.4) Body pain 1 (0.5) Joint pain 3 (1.6) HTN 1 (0.5) GI problem 4 (2.1) Second most common indication Headache 23 (12.3) Fever 24 (12.8) Cold, cough, and sore throat 69 (36.9) Body pain 34 (18.2) Menses’ symptoms 6 (3.2) Joint pain 9 (4.8) GI problems 22 (11.8) Third most common indication Headache 6 (3.3) Fever 40 (22) Cold, cough, sore throat 25 (13.7) Body pain 42 (23.1) Menses’ symptoms 9 (4.9) Joint pain 28 (15.4) DM 2 (1.1) HTN 4 (2.2) GI problems 26 (14.3) https://ejnm.hmu.edu.krd/index.php/ejnm/article/view/105 https://doi.org/10.15218/ejnm.2019.18 Erbil j. nurs. midwifery, Vol. 2, No. (2), Nov, 2019 Original Article Regarding the knowledge of study sample about the proper person to decide on OTC medication consuming, Table 5 revealed that, 36.4% of the pharmacy staff think that the consumer is the person who de- cide to use the OTC medications (which is the correct response), while 42.8% thought that the pharmacist is the person who chose the medications. Knowledge about OTC medications that are considered as OTC was as follows: antacids (69%), cough syrups (58.3%), vitamins and food supple- ments (46%), decongestants (42.2%), and herbal products (26.2%). 150 Erbil Journal of Nursing & Midwifery The other groups of drugs are not consid- ered as OTC medications but in spite of that 70.6% and 66.3% of the staff consid- ered the analgesics and antibiotics, re- spectively, as OTC medications (Table 5). Considerable proportions of the pharmacy personnel considered the anti-diabetics and the antihypertensive medications as OTC medications (14.4% and 12.3% re- spectively). Figure 1 shows that 43.6% of the study sample had poor knowledge about the OTC medications, and only 25% of the whole sample had good level of knowledge. Table 5:The OTC list Group of medications considered as OTC by the pharmacy staff (n = 187) No (%) Analgesics 132 (70.6) Antacids* 129 (69) Antibiotics 124 (66.3) Cough syrups* 109 (58.3) Vitamins and food supplements* 86 (46) Decongestants* 79 (42.2) Laxatives 75 (40.1) Antidiarrheal 74 (39.6) Antihistamines 56 (29.9) Antiemetic medications 53 (28.3) Herbal products* 49 (26.2) Anti-diabetics 27 (14.4) Oral contraceptives 25 (13.4) Antihypertensive medications 23 (12.3) Figure 1: General knowledge of the study sample about the OTC *Included in the list of the OTC medications https://ejnm.hmu.edu.krd/index.php/ejnm/article/view/105 https://doi.org/10.15218/ejnm.2019.18 Erbil j. nurs. midwifery, Vol. 2, No. (2), Nov, 2019 Original Article It is worth to mention that 29.6% of those aged 30-34 years had good level of knowledge (Table 6) which is more than the other age categories. The same table shows that 32% of females had a good lev- el of knowledge compared with 13.1% of males (p = 0.003). It is clear that none of those with low levels of education had good level of knowledge, while 25% of the college graduates had good level of knowledge (p = 0.046). 151 Erbil Journal of Nursing & Midwifery The same can be applied for occupation, where 46.2% of the pharmacists who are college graduates had good level of knowledge (p < 0.001). A non-significant association was detected between age and the knowledge level (p = 0.063), also a non-significant association was detected between the level of knowledge with par- ticipation in medical courses (p = 0.096), residency (p = 0.110), and income (p = 0.347). Table6: The relationship between the demographic characteristic and the overall level of knowledge Poor and Fair knowledge Good knowledge Age No. (%) No. (%) P-volue < 25 44 (89.8) 5 (10.2) 25-29 53 (84.1) 10 (15.9) 30-34 38 (70.4) 16 (29.6) ≥ 35 18 (85.7) 3 (14.3) 0.063 Gender Male 119 (86.9) 18 (13.1) Female 34 (68) 16 (32) 0.003 Education Primary 2 (100) 0 (0) Intermediate 6 (100) 0 (0) Secondary 3 (100) 0 (0) Institute 55 (91.7) 5 (8.3) College and above 87 (75) 29 (25) 0.046 Occupation Pharmacist 28 (53.8) 24 (46.2) Assistant pharmacist 33 (91.7) 3 (8.3) Nurse 51 (96.2) 2 (3.8) Paramedic 24 (88.9) 3 (11.1) Other 17 (89.5) 2 (10.5) < 0.001 Medical course Yes 41 (74.5) 14 (25.5) No 112 (84.8) 20 (15.2) 0.096 Residential area Urban 99 (85.3) 17 (14.7) Rural 54 (76.1) 17 (23.9) 0.11 *fisher’s exact test https://ejnm.hmu.edu.krd/index.php/ejnm/article/view/105 https://doi.org/10.15218/ejnm.2019.18 Erbil j. nurs. midwifery, Vol. 2, No. (2), Nov, 2019 Original Article Self-medication is the practice where indi- viduals treat their illnesses with medica- tions which are approved and available without prescription, and which are safe and effective when used as per direction [9]. However they may result in unwanted effects if inappropriately used. Pharmacy staff comes across many consumers who request medication without prescription, some which are allowed and some which are forbidden; thus pharmacy staff knowledge plays the most important role in consumers' safety regarding medication consumption. The current study aimed at assessing the knowledge of pharmacy staff regarding the OTC. Result indicated that only one quarter of the sample had a good level of knowledge while the rest had poor to fair knowledge level, where in a study conducted in India by Ravichandran and Basavareddy, (2016)their result showed higher rate of knowledge regarding the OTC definition, where among the pharma- cists holding bachelor degree, 69% were able to define OTC correctly whereas only 31% of D. Pharmacy degree holders could define OTC [10]. However according to the researcher such differences is that the study conducted in India targeted only the pharmacist, while the current study also included other specialist as in Erbil not only pharmacist works in the pharmacies. No significant association was detected be- tween age and the knowledge level, but it is worth to mention that those in third de- cay of their age had more advanced level of knowledge that the other age groups. this result was similar to a study conducted in Iran about the pharmacy staff knowledge of sport supplement (a type of OTC) where their result also showed that lower age associated with lesser knowledge level [11]. Meanwhile the result of current study was different from a study conducted in India where knowledge of 152 Erbil Journal of Nursing & Midwifery pharmacist were assessed specifically re- garding OTC side effects, in which Bj et al., (2012) found that knowledge association is more in the age group 21 to 30 years (mean ± SD 5.16±2.89) and least was found in the age group of 51 to 60 years with mean score of (mean ± 3.33 ± 4.16 years) [12].While age has a direct relation- ship with years of experience, age was not associated with good knowledge level or practice skill of the pharmacy staff in this study. It was assumed that age association is different per studies as each study have selected different age group, and also number of study sample plays role in the differences. This study also revealed that regarding the sex of participants, females were more knowledgeable of the OTC, than the males, and the results were sta- tistically very significant. This result was similar to a study conducted by Ali et al (2012) in Malaysia. Which showed that males had lower level of knowledge than females [13]. However, the results con- tradict with findings observed by Boateng (2009), which indicated that females were more susceptible to self-medication due to strenuous job requirement[14].Females might be keener on continuous updating of the knowledge, and are more capable of memorizing and focusing on conten- tious education which resulted in having more knowledge than the males. As for the probable side effects, less than one- third of the sample knew that, the OTC medications mostly cause side effects. The majority of the sample study indicat- ed allergies as one of the most common side effects of the OTC medications, while half of them included abdominal pain as major side effect, and around two-thirds of the study sample indicated that nausea and vomiting are also one of the most common side effects of the OTC. This study's results were similar to those found in a cross sectional study conducted DISCUSSION https://ejnm.hmu.edu.krd/index.php/ejnm/article/view/105 https://doi.org/10.15218/ejnm.2019.18 Erbil j. nurs. midwifery, Vol. 2, No. (2), Nov, 2019 Original Article in India medications which revealed that the staff working in pharmacies are very aware (68.5%) about the adverse effect or side effect of medication [15]. No partici- pants with low levels of education had good level of knowledge, while only quar- ter of the college graduates had good level of knowledge. The same can be applied for occupation, where less than half of the pharmacists who are college graduates had good level of knowledge. According to the researcher it’s linked to the advanced and different education type which were re- ceived by different pharmacy workers. And also this difference among the pharmacy staff maybe it’s due to the fact that there were workers with no medical or health background. No significant association was detected between the level of knowledge with participation in medical courses, resi- dency, and income. However no similar studies were available to compare the cur- rent results with previous work; in the time that the researcher highlights this as a study limitation, yet it's necessary to men- tion that during literature review almost all previous studies conducted by other re- searchers were about knowledge of com- munity, or medical students about OTC, rather than the pharmacy staff, assuming that in most of the countries there is strong system for the pharmacy expending of OTC, thus the focus of researches is less on the performance of pharmacy staff but more on the students and the community group. Overall knowledge about OTC medications was low among the pharmacy staff, with slight differences in the knowledge level of the specialized pharmacists. Especially on OTC side effects, dosage, and reason for uses, which in term, increases the risk of OTC adverse effect on the consumers. The current study also concluded that, 153 Erbil Journal of Nursing & Midwifery the years of working in pharmacy did not contribute to increasing their knowledge level about OTC, which is probably due to using same system during all working years and no improvements were noted even with attending multiple courses on OTC. The researchers reported no conflict of interest. [1] Helal RM, Abou-ElWafa HS. Self-Medication in University Students from the City of Mansoura, Egypt. Journal of Environmental and Public Health. 2017;2017: 9145193. [Accessed 25.7.2019]Available from:https:// www.ncbi.nlm.nih.gov/pmc/articles/ PMC5396441/ [2] Le VT, Norris Turner A, McDaniel A, Hale KM, Athas C, Kwiek NC. Nonmedical use of over-the-counter medications is significant- ly associated with nonmedical use of pre- scription drugs among university students. Journal of Americans College Health. 2018;66(1):1–8.[ Accessed 7.5.2019] Availa- ble from: https://www.ncbi.nlm.nih.gov/ pubmed/28812451 [3] Khandeparkar A, Rataboli PV. A study of harmful drug-drug interactions due to polypharmacy in hospitalized patients in Goa Medical College. Perspectives in clinical research. 2017 Dec;8(4):180–6. [Accessed 5.6.2019] Available from: https:// www.ncbi.nlm.nih.gov/pmc/articles/ PMC5654218/ [4] Shehadeh M, Suaifan G, Darwish RM, Wazaify M, Zaru L, Alja’fari S. Knowledge, attitudes and behavior regarding antibiotics use and misuse among adults in the com- munity of Jordan. A pilot study. Saudi Phar- maceutical Journal. 2012 Apr;20(2):125–33. [Accessed27.6.2019] Available from:https:// www.ncbi.nlm.nih.gov/pubmed/23960783 [5] Imani F, Motavaf M, Safari S, Alavian SM. The Therapeutic Use of Analgesics in Pa- tients With Liver Cirrhosis: A Literature Re- view and Evidence-Based Recommenda- tions. 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