INTRODUCTION
Skin diseases are responsible for huge disease burden all over the world, and delayed or inappropriate management has been associated with serious detrimental effect on quality of life.[ 1 ] Self-medication for majority of skin ailments is common in Indian scenario. Self-medication according to the World Health Organization has been defined as selection and consumption of one or more drugs without physician’s advice.[ 2 ] It is usually a habit of the patients to use drugs prescribed to other family members or friends for the same type of illness to avoid doctors’ consultation. Consultation with the local pharmacist is also common in India. On the other hand, quackery in India is a constant source of misdiagnosis and mismanagement, significantly affecting the course of illness and thus causing adverse outcome as well as financial burden on the patient.[ 3 ]
Nearly, every medicine in India is available as over the counter drug in India, though these drugs have proven safety and efficacy but patients lack the knowledge regarding their correct dose, duration, side effects, and drug interactions.[ 4 , 5 ] Self-medication may have several benefits, i.e., patients may get immediate symptomatic relief, especially in cases with minor ailments and may be cost effective in some cases. However, self-medication, particularly in dermatological practice, may have certain potential risks such as incorrect self-diagnosis, progression of disease, delay in seeking health care, dangerous drug interactions, incorrect dose and manner of administration, masking severe disease, and risk of abuse.[ 6 ]
Verma et al . documented that topical corticosteroids are one of the most commonly used drugs in dermatology which is often misused by both medical and nonmedical personnel as they are easily available, low cost over-the-counter medication.[ 7 ] The topical steroid abuse is commonly observed even for wrong indications such as fungal infections and acne. Even, it is prescribed by a MBBS for wrong indication and wrong duration due to a lack of awareness and practice during their training.[ 8 ] The present study was therefore conducted at a tertiary care center with the broad aim to assess the impact of quackery, self-medication, and alternate medicine on skin diseases in the current scenario.
Objective
We conducted this study with the following objectives:
To determine the preferred source of treatment among patients with various skin disease
To determine influencing factors among these patients in choosing the source of treatment
To determine the outcome of medicine on skin diseases based on source of medication.
MATERIALS AND METHODS
This study was conducted as a cross-sectional study among patients seeking care for various ailments at outpatient department, department of dermatology during the study period of 3 months, i.e., from November 1, 2019 to January 31, 2020, after approval from the Institutional Ethical Committee (IEC-2019/59). A self-predesigned questionnaire in English and Hindi language was prepared, and a pilot study for 1 week was done, during which a total of twenty adult patients could be observed, and necessary changes were made in final questionnaire following pilot project. The patients enrolled in the pilot study were not included in final calculation of results.
As during the pilot study of 1 week, twenty eligible patients could be enrolled, and the final study was planned for 3 months. Estimating the patient’s size of 20/week, a total of 300 patients during the study period of 3 months was calculated. All the 300 patients of all age groups who have been suffering from present illness for a minimum duration of 2 weeks were selected using convenient sampling. Two resident doctors were appointed to monitor and assist participants to fill the form whenever required.
Two separate sets of questionnaires were prepared, one for patients who received modern medicine and another for complementary and alternative medicine. Questionnaire for modern medicine included following variables other than demographic profile and general information.
Source of medication was divided into four classes based on whose recommendation patient took medicine and was divided into four groups
Qualified dermatologist
Qualified doctors – which included MBBS and specialist from other branches (MD/MS/DNB)
Unqualified doctors – doctors without any degree, doctors trained in alternate medicine such as Homeopathy/Ayurvedic/Unani/naturopathy practicing modern medicine
Medical store personal.
Outcome of previous treatment on current disease – it was divided into four subgroups based on the changes observed by the patient after minimum 2-week interval
Source of information for previous treatment – patients were enquired about the source under whose influence patients take treatment from various sources.
Statistical analysis used
On completion of data collection, data were compiled using Microsoft Excel version 2013, and analysis was done using IBM SPSS Statistics for Windows, version 20 (IBM Corp., Armonk, N.Y., USA). Numerical data were expressed as mean and standard deviation, whereas categorical variables were expressed as frequency and proportions. Independent sample t -test was applied to assess the difference in mean between two groups, whereas Chi-square test was applied to assess the difference between proportions. P < 0.05 was considered statistically significant.
RESULTS
The present study was conducted on a total of 300 patients with skin diseases, out of them, 264 (88%) patients opted for modern treatment, whereas 36 (12%) patients received alternate medicine such as Ayurvedic, homeopathic, or Unani. The patients were aged between 6 years and 70 years with a mean age of 27.97 ± 10.44 years. About 54.9% of patients were male and 45.1% were females. Sociodemographic variables of our study are presented in Table 1 . The mean age of patients receiving modern medicine was 28.1 ± 10.5 years, whereas the mean age of patients receiving alternate medicine was 27.3 ± 10.4 years. Test of significance (independent t -test) showed no significant difference in mean age between patients receiving modern and alternate medicine (P > 0.05). Chi-square test was applied to assess the difference in proportions between two groups of patients and showed no significant difference in sociodemographic variables (P > 0.05).
Table 1: Distribution of patients according to sociodemographic variables
Out of 300 patients, 169 (56.3%) suffered from tinea out of which 151 (89.3) preferred modern medication and 18 (6%) preferred alternate medication. We observed no significant difference in clinical profile of patients seeking modern and alternative medicine (P > 0.05) [Table 2 ].
Table 2: Distribution according to clinical profile
Out of 264 patients who took modern medicine, most of the patients (126%–47.7%) preferred buying medicines directly from medical store after consulting the pharmacist [Figure 1 ]. Most of the patients who were advised treatment by medical store worsened, followed by unregistered doctors, qualified doctors, and least by dermatologist [Figure 2 ].
Figure 1: Impact of previous treatment on current disease
Figure 2: Source of modern medicine
Our study documented significantly better awareness about qualified dermatologist among patients with upper class, followed by middle and lower class (P < 0.05) [Table 3 ].
Table 3: Source of medicine preferred by patients according to socioeconomic status
Self-medication was seen in 47% of patients which were under influence from the information by self (based on advertisement or past treatment), friends, or pharmacist [Table 4 ].
Table 4: Influence to choose the previous treatment
About 36 patients (12%) took alternate medicine, of them, 58.4% got them from qualified alternate medicine doctors, whereas 16.7% bought them after advice from medical store pharmacist and 25% took home remedy which included application of garlic, turmeric, and paste of multiple herbs usually used for cooking. None of the patient reported improvement from alternate medicine that was probable reason to shift to modern medicine and visit tertiary care hospital [Table 5 ].
Table 5: Impact of complementary and alternative medicine on present disease
DISCUSSION
Dermatology has seen its own trend toward complementary and alternative therapies.[ 9 ] Although modern medicine and alternative medicine both have a role in the management of dermatological diseases, the roles of the different professions are poorly coordinated.[ 10 ] Due to shortage of MBBS doctors in India, Ayurvedic, Homeopathic, and Unani (AYUSH) doctors openly practice modern medicine and are only doctors at rural areas, even Government appoint AYUSH doctors at public health center as a medical officer who take cares of patients and even performs postmortems which is illegal as AYUSH doctors have no training to perform any procedure or prescribe modern medicine.[ 11 ]
Our study aimed at assessing the care-seeking behavior of patients with skin ailments. The study also stressed on assessing the factors responsible for opting treatment at sources other than medical professional and outcome following seeking care at various sources. To the best of our knowledge, none of the previous studies emphasized on assessing such associations. We observed that maximum patients opted for modern treatment (88%), whereas only 12% opted for alternate medicine such as Ayurvedic, Homeopathic, or Unani for the management of skin conditions. No significant difference in sociodemographic profile and clinical profile could be observed between patients seeking modern medicine and alternative medicine. Although modern medicine has gained importance all over the world, complementary and alternative practices have their roots since ancient times and are adjuncts to modern medicine. Pandey et al . documented that various factors determine the health-seeking behavior of patients, which include social, cultural, economic, and literacy. Economic factor is one of the major determinants of choosing source of medication as alternative medicine is usually cheaper than modern medicine.[ 12 ] Apart from this, Debas et al . highlighted patient’s faith, belief, confidence in the treatment, ease of access, and convenience as other important factors which are important determinant of health-seeking behavior.[ 13 ]
Patients opting for modern medicine and alternative medicine were further categorized based on the source of medication in our study. Among patients opting for modern medicine, about 47.7% of patients preferred buying medicines directly from medical store after consulting the pharmacist. However, 32.2% of patients sought care with unqualified doctors and 15.2% of cases visited qualified doctor. Only 4.9% of cases received care from dermatologists. The findings of the present study were supported by findings of Kumar, in which the authors documented that, in India, the role of specialist is negligible in health care as most of patients self-medicate under influence of a friend, family member, or a medical store personal or visit an unqualified doctor.[ 14 ] Significantly better outcome was observed in patients who took treatment from professional doctor, whereas outcome was significantly poor among patients seeking care from medical store and unregistered doctor (P < 0.05). Quackery is often the primary source of medical facility, especially in rural areas.[ 14 ] Kamat and Nichter documented that medical store plays a pivotal role in self-medication, patients consider medical store personals a learned person with information of drugs and diseases, but 60% of the pharmacies are run by unqualified personals with no training or degree in pharmacy for the sole purpose of cost-cutting qualified pharmacist are not employed and only exist on paper, even big pharmacies employee 8-10 personals, and none are qualified pharmacist.[ 15 ] According to Verma et al ., topical corticosteroids are commonly prescribed for majority of skin ailments, and this drug is often misused by both medical and nonmedical personnel as they are easily available, low cost over-the-counter medication.[ 7 ] Meena et al . concluded that even MBBS doctor prescribe these medicines for wrong indication and wrong duration affecting the outcome.[ 8 ]
Self-medication was common among patients with skin disease under the influence of advertisement or past treatment, friends, or pharmacist. Furthermore, socioeconomic status was observed to be an important determinant of seeking care from the professionals. Our study findings were supported by findings of Pandey et al .[ 12 ] and Debas et al .,[ 13 ] i.e. economic factor is one of the major factors which helps in determining the source of medication as dermatologist consultation charges are higher as compared to MBBS doctor. Seeking care from unregistered practitioner and pharmacist may appear cheaper in terms of money but may increase the suffering of patients and thus contribute to higher cost in long run.
Not only for modern medicine, quackery, and self-medication is also observed in alternative medicine. Out of 36 patients who took alternate medicine, majority, i.e., 58.4% sought treatment from qualified alternate medicine doctors, whereas 16.7% bought them after advice from medical store pharmacist and 25% took home remedy. Number of patients getting medicine from qualified alternate medicine doctors is high as most alternate medicine doctors self-dispense medicines after formulation.
CONCLUSION
Modern medicine as well as alternative medicine both is opted by patients depending on availability, sociocultural factors, and beliefs of patients. Although modern medicine has gained considerable importance for the management of dermatological conditions, still the majority of patients seek care from medical store, unregistered doctors, and MBBS doctors. Care seeking from dermatologist is <5%. Socioeconomic factors and influence from friends, advertisement, and pharmacist are significantly associated with source of medication. Self-medication and quackery significantly affect the outcome as symptoms worsened in majority of patients. General public is not yet aware of importance of specialty clinics which is resulting into steroid-induced adverse effects, drug resistance, and prolong illness. There is a need to control unqualified doctors and medical stores for drug dispensing.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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