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. 2022 Dec 30;17(12):e0278843. doi: 10.1371/journal.pone.0278843

Prevalence and determinants of self-medication consumption of antibiotics in children in Iran: A population-based cross-sectional study, 2018–19

Javad Nazari 1, Nahid Chezani-Sharahi 2, Babak Eshrati 3, Ali Yadegari 4, Mobin Naghshbandi 5, Hamidreza Movahedi 5, Rahmatollah Moradzadeh 6,*
Editor: Ugurcan Sayili7
PMCID: PMC9803171  PMID: 36584040

Abstract

Introduction

The prevalence of self-medication of antibiotics has been revealed in various studies. The main aim of this work is to investigate the frequency of self-medication in children under 6 years and the factors affecting it.

Methods

This is a population-based cross-sectional study conducted in the Arak metropolitan in the center of Iran from January 2019 to January 2020. We used stratified random sampling to determine recruitment criteria. As 1754 households were invited to the study that 1483 were approved to participate. Children’s data were obtained by the interview with their mothers. In order to define self-medication consumption of antibiotics, it was adapted between annually maternal self-reported consumption of antibiotics among their children and history of received antibiotics registered in insurance services during the same time period. Logistic regression models were exploited to obtain odds ratios and 95% confidence intervals.

Results

Mean age of mothers was 31.8 years (SD = 5.4), 52.1% of the children were boys. Annually self-medication of antibiotic consumption was estimated 61.6% (n = 914). Based on the logistic regression analysis, in the adjusted analysis, girls were associated with self-medication consumption of antibiotics lower than boys’ children (p = 0.016). Older mothers were lower self-medication consumption of antibiotics than youngers (p = 0.001). Moreover, the permanent job of fathers was associated with lower self-medication consumption of antibiotics than temporarily and unemployment (p = .001). The odds of self-medication consumption of antibiotics were increasing with the increase in age of children (OR: 1.21, CI95%: 1.12, 1.31 and p = 0.001). The increase in parity has been a significant association with the self-medication consumption of antibiotics (OR: 1.64, CI95%: 1.38, 1.95and p = 0.001).

Conclusion

Results of this study show that some factors such as children’s age, gender, mother’s age, father’s occupational status, and parity are the determinants that significantly impact the self-medication prevalence.

Introduction

Self-medication is defined as the utilization of drugs to treat self-diagnosed disorders or symptoms, and also irregular or continuous use of a prescribed drug for chronic or repeated symptoms of diseases [1]. According to the World Health Organization(WHO), in order to achieve rational drug use, it is necessary to use appropriate drugs that can eliminate the clinical needs of patients in a specific geographical area with the least complications and costs [2, 3].

On average, antibiotics make up from 30 to 50% of prescription drugs. Although antibiotics are necessary in most bacterial infections and non-prescription can be life-threatening in some cases, most studies have shown that prescribing antibiotics in 30% of prescriptions is incorrect and in 60% are inappropriate, and these errors are usually done by either the physicians or patient’s self-medication [4, 5]. There is always the concern that new strains of microbes won’t be treated with existing antibiotics, causing mortality in patients infected with these new strains. The highest incidence of resistance to antibiotics has been observed in the countries with the highest consumption of antibiotics, thus, new and more effective policies need to be implemented to control the overuse of antibiotics [68].

In 1990, antibiotics accounted for 12% of all drugs sales worldwide; 19% percent in developing countries, which reached 34% in 2000. Economically, the cost of antibiotic treatment in 2000 was estimated to be 40 billion dollars, one-third of which was in developing countries. Thus, despite efforts taking place, the growth in the antibiotic’s price, especially in developing countries, has continued [9]. A study by Eili Y. Klein et al. which looked at the global increase and geographic convergence of antibiotics usage between 2000 and 2015 in 76 countries, found that antibiotics usage increased by about 39 percent between mentioned years. This increase was more prominent among middle to lower-income countries [10].

The prevalence of self-medication of antibiotics has been distinct in different countries, these figures are as follows: Sudan (48.1%), Spain (41%), Greece (74.6%), Malta (30%) and Iran (83%), As can be seen, this statistic is higher in Iran than in many other developing countries. This is a matter of concern and it seems that more studies are needed on this issue and the factors affecting it at the community level [8, 1115].

Despite various studies on the usage of antibiotics in different countries at various levels of society, only sporadic studies in this regard have been conducted in Iran, most of them investigated antibiotic resistance and the types of microbial resistant strains, and there are very few population-based studies, that investigate how to use antibiotics. Therefore, the prevalence of self-medication of antibiotics in Iran and the affecting factors was surveyed using the abovementioned method. In accordance with this report and the registered insurance sources, it was determined whether the consumption was self-medication or was done according to the physician’s prescription.

Lack of coordination in prescribing drugs by physicians in our country is a serious issue and implementing careful policies in the field of prescribing antibiotics seems necessary, but before that, full knowledge of the details of the pattern of prescription and consumption of antibiotics is important [16].

Due to the underdevelopment of their immune system, children are susceptible to many diseases and infections, especially viral and bacterial types. More than 80% of these infections are viral and have many similarities to bacterial infections in clinical signs and symptoms. Self-medication is a critical health concern that might cause several problems for children such as antibiotic-induced drug resistance, raised drug use per capita, non-desired treatment, and drug toxicity. Studies have shown that self-medication of antibiotics is accounted for 3% of congenital anomalies. In many patients, it has been observed that the use of antibiotics is decided by the family or given to them by the pharmacy. We must train people of the community not to take antibiotics without a physician’s prescription and inform them about the side effects of overuse of antibiotics.

Regarding the prevalence of self-medication of antibiotics in Iran, it seems that such studies like this are necessary and it is important to determine what steps can be taken to improve the rational use of antibiotics. Therefore, the purpose of this study is to investigate the frequency of self-medication in children under 6 years and factors affecting it, as to be the basis of controlling to use of antibiotics and subsequent complications in the city of Arak.

Methods

This is a population-based cross-sectional study conducted in the Arak metropolitan in the center of Iran from January 2019 to January 2020. We used stratified random sampling to determine the recruitment criteria. There are 50 centers to provide health care in the whole of Arak that cover the whole population of the city. These centers were organized study strata. Among strata, the study samples were selected proportion to size by simple random sampling from the covered population. Finally, 1754 households were invited to the study that 1483 were approved to participate. The response rate obtained was 85%.

Inclusion criteria were having Iranian citizenship, having lived in Arak for at least 3 years, having at least one child aged between0-5 years old. The provided questionnaires were completed by interviews. Children’s data were obtained by the interview with their mothers.

In this study, we asked families whether or not they had used antibiotics for their children in the past year, either with physicians prescription or self-medicated. In order to define self-medication consumption of antibiotic, it was adapted between annually maternal self-reported consumption of antibiotic among their children and history of received antibiotics registered in insurance services in same time duration, so any maternal self-reported consumption of antibiotic that was not reported in insurance services was considered as self-medication of antibiotics.

Other variables that included in this study were the age of children and mother (years) and gender (male/female) of children, mother educational level (illiterate and preliminary, guidance school, high school, diploma, higher than a diploma, undergraduate and postgraduate), father educational level (illiterate and preliminary, guidance school, high school, diploma, higher than a diploma, undergraduate and postgraduate), mother occupational status (unemployment, housekeeper, temporary job, permanent job), father occupational status (unemployment, temporary job, permanent job), parity (count), insurance coverage (yes/no) and socio-economic status (SES) (1st to 5th quintiles based on assets). SES was obtained based on the assets including owning a usual refrigerator, side by side refrigerator, color TV, LCD TV, LED TV, cell phone, washing machine, dishwasher, microwave, vacuum cleaner, motorcycle, laptop, access to the internet at home, car, home, number of rooms for sleeping, sanitation facility, bathroom, cooling equipment, heating devices, cooking equipment and place of cooking at home [17]. Health literacy was assessed by Health Literacy for Iranian Adults (HELIA) questionnaire [18] on a 5-point Likert scale. To calculate the total score for HELIA, a scoring manual based on a study by Tavousi et al. was used [18].

Ethics

Ethic approval was achieved from the Ethics Committee of Arak University of Medical Sciences with the code of ethics as following: IR.ARAKMU.REC.98.217. A written informed consent was obtained from all participants. Participants were informed that they are free to participate and can withdraw from the study at any time.

Statistical analysis

Frequency, mean and standard deviation (SD) were calculated for the categorical and continuous variables. SES based on asset indices was obtained by principal component analysis [17]. Chi-square and Mann-Whitney U test were used to compare mean or median values by self-medication of antibiotic consumption. Univariate and multiple logistic regression models were applied to obtain odds ratio (OR) and 95% confidence intervals. In the final model of the multiple logistic regression model, the variables with p-value > 0.2 were excluded. All analysis was applied in SPSS version 16.0 and STATA version 12.0 software. P-values < 0.05 were considered to indicate statistical significance.

Results

Descriptive characteristics of the participants were shown in Table 1. The mean age of mothers was 31.8 years (SD = 5.4). 52.1% of the children were boys. Most of the mothers’ and fathers’ educational levels were diplomas (38% and 37.8%, respectively). Occupation of the majority of the mothers and fathers were in order of housekeeper (88.2%) and permanent works (61.0%). Most mothers had a maximum of two children (89.2%). The mean of birth weight of children was 3174 grams (SD = 466.7). Insurance coverage was also found among 93.1% of the participants.

Table 1. Demographic characteristics of the maternal self-medication consumption of antibiotic among children under 6 years, 2018–2019.

Variables N (%) Self-medication consumption of antibiotic
No (%) Yes (%) P-value
Mother age Mean (SD) 31.8 (5.4) 32.1(5.3) 31.6(5.5) 0.094b
Children sex boy 772 (52.1) 276 (48.5) 496 (54.3) 0.031a
girl 711 (47.9) 293 (51.5) 418 (45.7)
Mother education Illiterate and preliminary 99(6.7) 39(6.9) 60(6.6) 0.042a
Guidance school 183(12.3) 59(10.4) 124(13.6)
High school 60(4.0) 15(2.6) 45(4.9)
Diploma 564(38.0) 209(36.7) 355(38.8)
Higher diploma 115(7.8) 50(8.8) 65(7.1)
undergraduate 396(26.7) 171(30.1) 225(24.6)
postgraduate 66(4.5) 26(4.6) 40(4.4)
Father education Illiterate and preliminary 102(6.9) 33(5.8) 69(7.5) 0.141a
Guidance school 188(12.7) 60(10.5) 128(14.0)
High school 66(4.5) 30(5.3) 36(3.9)
Diploma 560(37.8) 210(36.9) 350(38.3)
Higher diploma 149(10.0) 58(10.2) 91(10.0)
undergraduate 302(20.4) 128(22.5) 174(19.0)
postgraduate 116(7.8) 50(8.8) 66(7.2)
Mother job unemployment 6(0.4) 3(0.5) 3(0.3) 0.598a
housekeeper 1308(88.2) 498(87.5) 810(88.6)
Temporary job 45(3.0) 15(2.6) 30(3.3)
Permanent job 124(8.4) 53(9.3) 71(7.8)
Father job unemployment 15(1.0) 3(0.5) 12(1.3) 0.013a
Temporary job 563(38.0) 194(34.1) 369(40.4)
Permanent job 905(61.0) 372(65.4) 533(58.3)
Parity 1 692(46.7) 1.5(0.7) 1.7(0.7) 0.001b
2 631(42.5)
3 138(9.3)
4 19(1.3)
5 3(0.2)
Birth weight Mean (SD) 3174(466.7) 3183(455.1) 3168(473) 0.755b
Insurance coverage Yes 1381(93.1) 526(92.4) 855(93.5) 0.415a
No 102 (6.9) 43(7.6) 59(6.5)
Socio-economic status 1st quintile 297(20) 118(20.7) 179(19.6) 0.077a
2nd quintile 297(20) 113(19.9) 184(20.1)
3rd quintile 296(20) 102(17.9) 194(21.2)
4th quintile 297(20) 104(18.3) 193(21.1)
5th quintile 296(20) 132(23.2) 164(17.9)
Health literacy Mean (SD) 70.16(17.55) 70.15(17.66) 70.17(17.38) 0.775

Annually self-medication of antibiotic consumption was estimated 61.6% (n = 914). Furthermore, in chi-square and Mann-Whitney analysis, there were statistically significant differences in self-medication of antibiotic consumption by children sex (p = 0.013), mother education (p = 0.042), father job (p = 0.013) and parity (p = 0.001).

Based on the logistic regression analysis, univariate and adjusted findings were shown in Table 2. Finally, in the adjusted analysis, girls were associated with lower self-medication consumption of antibiotics than boys (p = 0.016). Older mothers were lower self-medication consumption of antibiotics than youngers (p = 0.001). Moreover, the permanent job of fathers was associated with lower self-medication consumption of antibiotics than temporarily and unemployment (p = .001). The odds of self-medication consumption of antibiotics were increasing with an increase in the age of children (OR: 1.21, CI95%: 1.12, 1.31 and p = 0.001). The increase in parity has been a significant association with the self-medication consumption of antibiotics (OR: 1.64, CI95%: 1.38, 1.95and p = 0.001).

Table 2. Association between maternal self-medication of antibiotics for children and independent variables in univariate and adjusted logistic regression analysis among children 0–5 years old, 2018–2019.

Variable Univariate analysis Adjusted analysis*
OR (95%CI)** P-value OR (95%CI)** P-value
Children sex (girl) 0.79(0.64, 0.98) 0.031 0.77 (0.62, 0.95) 0.016
Age of children 1.18(1.09, 1.27) 0.001 1.21(1.12, 1.31) 0.001
Age of mother 0.99(0.97, 1.01) 0.207 0.96(0.94, 0.98) 0.001
Mother education 0.92(0.86, 0.98) 0.015 - -
Father education 0.92(0.86, 0.98) 0.010 - -
Mother job 0.94(0.78, 1.12) 0.465 - -
Father job 0.74(0.60, 0.91) 0.004 0.80(0.65, 0.99) 0.046
Parity 1.48(1.26, 1.72) 0.001 1.64(1.38, 1.95) 0.001
Birth weight 1.00(0.99, 1.01) 0.545 - -
Insurance coverage 1.18(0.79, 1.78) 0.415 -
Socio-economic status 0.97(0.90, 1.05) 0.455 - -
Health literacy 1.00(0.99, 1.01) 0.985 - -

Discussion

Nowadays, the overuse of antibiotics is one of the most important health issues in various countries from developed to developing countries. Their side effects, like any other drug, can affect people’s health in several ways. In addition, their excessive consumption can lead to microbial resistance in community members. Moreover, interactions of antibiotics with other drugs can cause irreversible side effects for antibiotic consumers without real necessity. Self-medication of antibiotics, especially if accompanied by the incorrect dosage, can thwart treatment of curable infections in the future.

Today, the role of the individual as a central factor in health management is emphasized. Terms such as patient centralization, lifestyle, patient actions, and empowerment all emphasize that the individuals have a vital role more than the health care provider in controlling their health and they can participate in its healthcare decisions [19]. Some factors such as the production of new drugs, the growth of various diseases, access to health information through the Internet, are important factors that in recent decades have increased the possibility for people to participate in health decisions and management themselves. this issue has led to an increase in the importance of health literacy in an individual’s life [20]. Health literacy should be considered as a set of cognitive and social skills that can determine the motivation and ability of individuals to access, insight, and use the information that a person achieves and uses in a way that one can maintain and promote one’s health [21]. Although it is not yet clear exactly how much health literacy affects human health outcomes, there are many reasons why many of the unfortunate health outcomes are the result of inadequate health literacy in different societies.

It is observed in different countries, both developed and underdeveloped, the level of health literacy can affect the level of public health, for example in a country like the United States, a meta-analysis study which summarized the results of 85 different studies, showed that the percentage of inadequate and borderline health literacy in the United States was estimated between 20 and 25 percent [22]. The study by Wizadi et al. in 1394, showed that people with better health literacy, could assess their general health status more suitably, they also took more prevention behaviors than others [23].

In a study conducted in Tehran in 1998 on prescriptions and their amount of antibiotics, it was found that in 43% of prescriptions, antibiotics were prescribed [24]. Also, in another study of the pattern of antibiotic use in Taleghani Hospital in Tehran, it was observed that about 57% of the patients had received antibiotics [25]. The first few years of life, despite the small share it has in the whole human life, will have a large contribution to health in adulthood. Antibiotic treatment can cause many problems in children, for instance, physicians should consider the types of common infectious diseases at different ages, their specific antibiotics, and the specific dosage therapy of each agent, and the toxicity of the drugs. This indicates that the use of antibiotics needs more serious attention in future studies.

A cross-sectional study that was conducted in 2013 by Francesco et al. showed that only 10% of people had a correct definition of antimicrobial resistance, 20% of them were familiar with the proper use of antibiotics, and one-third of them had self-medicated antibiotics last year. Finally, the researchers of this study suggested holding training courses to increase the level of awareness and improve community performance concerning antibiotic use [19]. Another study by Belongia et al. in 1999, also suggests providing information and educational messages about antibiotics for people, resulting in an enhancement in the knowledge of people and reduction in patients’ demand for antibiotics [26]. In a study conducted by Greek researchers, a very low percentage of patients(0.4%) had taken antibiotics as self-medication(22), Although this study about the use of antibiotics in the community during the last year was done through a questionnaire, but the target population was selected from the parents of children hospitalized, which can be biased in the selection of the study population and does not reflect the situation of the whole community, Perhaps the difference in the results regarding the prevalence of antibiotic use in this study with our survey is due to these differences that existed in the selection of demographic samples in the two studies.

In accordance to our findings, which resulted in that the rate of antibiotic self-medication was increased by the mothers age, the study by Sayer I. Al-Azzam et al. on the overuse of antibiotics and self-medication in Jordan showed that the rate of self-medication was significantly affected by age (P < 0.001), income (P = 0.037), and educational level (P < 0.001), but not by gender (P = 0.528) [27]. In this survey, which has been planned at the community level, the self-medication and the factors affecting have been studied, and among the effective factors, the level of education, age, and income have been associated significantly. However, in a study by Vaananen & colleagues on Finnish immigrants in southern Spain in 2002, The results indicated that there are no statistical differences between gender, age, marital status, working situation, self-reported health, or smoking of antibiotic consumers, which was inconsistent with our obtained results [8]. In this study, different statistics have been obtained from our research on self-medication, which in itself can confirm that the issue of self-medication of antibiotics in different communities and countries gives distinct results. Whilst in this study, unlike other studies, no significant relationship was observed between various individual and social factors and the rate of self-medication antibiotics. We believe that the difference seen among results various studies may be occurred due to the effect of different geographical, cultural and historical factors affecting each region.

In a cross-sectional study by Zolali et al., Antibiotic prescription was correlated to the current diagnosis, mother education, and parents perception score for the proper antibiotic. There were certain factors defined as protective and risky affecting antibiotic prescription. Protective factors included physician specialty mother education and work status. Risk factors included parents’ perception of antibiotics and the presence or absence of fever [28]. In this survey as in our study, sampling was performed based on the community level using valid questionnaires on the population of children, with the difference that the samples selected for the survey were among outpatients of the hospital clinic, which may cause bias in this survey, while in our study, the samples were randomly selected from the community and the questionnaires were completed by trained individuals referring to their home.

Conclusion

In conclusion, our findings indicate a remarkable prevalence of antibiotic self-medication among children aged between 0–6 in Iran. Elements recognized as determinants that could potentially impact the self-medication prevalence consisted of children’s age, gender, mother’s age, father’s occupational status, and parity. Further studies are suggested to designate other effective agents on self-medication prevalence and methods to reduce it.

Suggestions

These results clearly show that to correct the irregular use of antibiotics, basic measures should be taken at all levels, from society level to pharmacy staff and physicians and pharmacist. Also, measures should be planned in order to raise the level of health literacy of the people in this regard. In addition, it seems that the establishment of serious deterrent laws and efforts to implement them accurately and completely can pave the way for the improvement of the existing process, which has led to the irrational and over use of medications, especially antibiotics in our community. The health system should be organized to improve the universal access, offering the essential care and the essential medicines required according to the population needs. It is needed to rethink how the health interventions should be planned and performed, especially at the primary care setting.

Supporting information

S1 Data. Minimal child antibiotic.

(SAV)

Data Availability

All relevant data are within the paper and its Supporting Information files.

Funding Statement

The author(s) received no specific funding for this work.

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Decision Letter 0

Hans-Uwe Dahms

26 Jan 2022

PONE-D-21-31099Prevalence and determinants of self-medication consumption of antibiotics in children in Iran: a population-based cross-sectional study, 2018-19PLOS ONE

Dear Dr. Moradzadeh,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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We look forward to receiving your revised manuscript.

Kind regards,

Hans-Uwe Dahms, Ph.D.

Academic Editor

PLOS ONE

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Additional Editor Comments:

This contribution needs major changes as indicated by the 2 reviewers.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Paper Review

Prevalence and determinants of self-medication consumption of antibiotics in children in Iran: a population-based cross-sectional study, 2018-19

The main objective of this study is to investigate the frequency of self medication in children under 6 years and the factors affecting it. Self-medication is utilization of drugs to treat self-diagnosed disorders or symptoms, and also irregular or continuous use of a prescribed drug for chronic or repeated symptoms of diseases. This study uses Chi- 5 square and Mann-Whitney U test were used to compare mean or median values by self-medication of antibiotic consumption. Univariate and multiple logistic regression models were used and p < 0.05 were considered. This study was in Arak metropolitan in the center of Iran from January 2019 to January 2020 and 1754 households were invited to the study that 1483 were approved to participate.

This paper analyses factors such as children’s age, gender, mother’s age, father’s occupational status, and parity .

Key Results Obtained:-

Annually self-medication of antibiotic consumption = 61.6% (n = 914).

Mean age of mothers = 31.8 years (SD = 5.4)

Older mothers were lower self-medication consumption of antibiotics than youngers (p = 0.001)

Association of girls with self-medication consumption of antibiotics was lower than boys (p = 0.016)

Chi-square and Mann-Whitney analysis, gave the results significant differences in selfmedication of antibiotic consumption by children sex (p = 0.013), mother education (p = 0.042), father job (p = 0.013) and parity (p = 0.001).

Permanent job of fathers was associated with lower self-medication consumption of antibiotics than temporarily and unemployment (p = .001)

Odds of self-medication consumption of antibiotics were increasing with an increase in the age of children (OR: 1.21, CI95%: 1.12, 1.31 and p = 0.001)

Increase in parity shown a significant association with the self-medication consumption of antibiotics (OR: 1.64, CI95%: 1.38, 1.95and p = 0.001).

Positive feedback

The factors considered for the study are effective , valid and as the samples were selected randomly , study was unbiased.

The models and softwares which used were updated and the study considered most of the points which are important in investigating the factors affecting self – medication consumption of antibiotics.

Critical Comments

Others factors such as production of new drugs, the growth of various diseases, access to health information through the Internet could have been considered diring study cause they play important role in health literacy.

Measures to increase the level of awareness and improve community performance about antibiotic use could be suggested

Reviewer #2: The article needs fundamental changes. please pay attention:

This study is about self-medication in children, but in the introduction, not enough explanation is given about the target group, for example, explain what are the side effects of self-medication in children? Explain the negative consequences of self-medication in children.

Was the questionnaire valid and reliable? Give a full explanation.

The final conclusion is a very general written and repetitive text of the results.

Add restrictions and suggestions to the article.

At the end of the article, suggest solutions to reduce self-medication in children.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

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PLoS One. 2022 Dec 30;17(12):e0278843. doi: 10.1371/journal.pone.0278843.r002

Author response to Decision Letter 0


25 Mar 2022

Thank you for the comments on our manuscript entitled " Prevalence and determinants of self-medication consumption of antibiotics in children in Iran: a population-based cross-sectional study, 2018-19". We appreciate the suggested modifications and have revised the manuscript accordingly. The revised sections are shown in boldface type and written with different color. The detailed responses to the reviewers’ comments are presented as follows:

Journal Academic Editor

Comment 1: Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming

Response: Thanks for your concern upon style requirements, the mentioned naming style requirements of the files will be fulfilled upon re-submission process.

Comment 2: Please amend your current ethics statement to address the following concerns:

a) Did participants provide their written or verbal informed consent to participate in this study?

b) If consent was verbal, please explain i) why written consent was not obtained, ii) how you documented participant consent, and iii) whether the ethics committees/IRB approved this consent procedure.

Response: A written informed consent was obtained from the participants of the study. The full ethics statement including the ethic codes and criteria of the informed consent will be available in the renewed manuscript in the paragraph entitled “Ethnicity criteria”, located in the first paragraph of the page No 5.

Comment 3: In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available.

Response: In our re-submission, this issued will be addressed via providing a supporting additional file consisting of the minimal data set of the results of our study. Thanks for your concern.

Comment 4: PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager.

Response: The ORCID iD of the corresponding author will be available in the re-submission process and also on the renewed title page.

Comment 5: Please ensure that you include a title page within your main document. You should list all authors and all affiliations as per our author instructions and clearly indicate the corresponding author.

Response: Thanks, a renewed title paged including the authors names and affiliations will be uploaded upon the re-submission.

Comment 6: Please include your full ethics statement in the ‘Methods’ section of your manuscript file. In your statement, please include the full name of the IRB or ethics committee who approved or waived your study, as well as whether or not you obtained informed written or verbal consent. If consent was waived for your study, please include this information in your statement as well.

Response: The full ethics statement including the ethic codes and criteria of the informed consent will be available in the renewed manuscript in the paragraph entitled “Ethnicity criteria”, located in the first paragraph of the page No 5.

Reviewer 1:

Comments: Positive feedback

The factors considered for the study are effective , valid and as the samples were selected randomly , study was unbiased.

The models and softwares which used were updated and the study considered most of the points which are important in investigating the factors affecting self – medication consumption of antibiotics.

Critical Comments

Others factors such as production of new drugs, the growth of various diseases, access to health information through the Internet could have been considered diring study cause they play important role in health literacy.

Measures to increase the level of awareness and improve community performance about antibiotic use could be suggested.

Response: Thanks for your elegit and precise comments, the necessary changes are applied to the reviewed manuscript. Proposed corrective measures are mentioned in the “Suggestions” section located as the last paragraph of the page No 10.

Reviewer 2:

Comments: This study is about self-medication in children, but in the introduction, not enough explanation is given about the target group, for example, explain what are the side effects of self-medication in children? Explain the negative consequences of self-medication in children.

Was the questionnaire valid and reliable? Give a full explanation.

The final conclusion is a very general written and repetitive text of the results.

Add restrictions and suggestions to the article.

At the end of the article, suggest solutions to reduce self-medication in children.

Response: Thanks for your concern,

A more detailed explanation of the side effects of self-medication of antibiotics in children is added to the Introduction section.

By referring to the questionnaire, we believe that you are referring to HELIA (Health Literacy for Iranian Adults) questionnaire. Numerous previously published studies suggest that the Health Literacy for Iranian Adults (HELIA) is a reliable and valid instrument for measuring health literacy in Iran.(1-4)

The conclusion section has been changed, thanks for your apprehension.

Suggestions for solutions to reduce self-medication has been added to the renewed manuscript in the paragraph entitled “Suggestions” located

References

1. Chahardah-Cherik S, Gheibizadeh M, Jahani S, Cheraghian B. The relationship between health literacy and health promoting behaviors in patients with type 2 diabetes. International journal of community based nursing and midwifery. 2018;6(1):65.

2. Khoshnudi M, Safari A, Vahedian-Shahroodi M, Sadeghnejhad H, Nejati Parvaz N. The Relationship between Health Literacy and Quality of Life in Nurses of hospitals of Kashmar in 2018. Journal of Health Literacy. 2019;4(1):9-17.

3. Montazeri A, Tavousi M, Rakhshani F, Azin SA, Jahangiri K, Ebadi M, et al. Health Literacy for Iranian Adults (HELIA): development and psychometric properties. 2014.

4. Tavousi M, Haeri-Mehrizi A, Rakhshani F, Rafiefar S, Soleymanian A, Sarbandi F, et al. Development and validation of a short and easy-to-use instrument for measuring health literacy: the Health Literacy Instrument for Adults (HELIA). BMC public health. 2020;20(1):1-11.

Attachment

Submitted filename: Response to reviewers.docx

Decision Letter 1

Ugurcan Sayili

25 Oct 2022

PONE-D-21-31099R1Prevalence and determinants of self-medication consumption of antibiotics in children in Iran: a population-based cross-sectional study, 2018-19PLOS ONE

Dear Dr. Moradzadeh,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Dec 09 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Ugurcan Sayili, M.D.

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: All comments have been addressed

********** 

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #3: Yes

********** 

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: Yes

********** 

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #3: Yes

********** 

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #3: Yes

********** 

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #3: Overall, I believe this is an interesting study that can contribute to the literature, but needs further clarification and improvement.

1. In the introduction,

Sentence starting with “Therefore, by implementing this study..” This sentence must be come before the aim sentence.

2.Sentence starting with “In this study, we asked families …” This information can be transferred to the method section and synthesized with appropriate sentences.

3.In the method, the title of the information about ethics can be corrected as “Ethics” not “Ethnicity Criteria:"

4.When I read this article, I would like to have information about Arak, in a few short sentences.

For example, the socioeconomic status of Arak city, education, industrial city? Are the people ethnically similar? Migration level?

5.It is not clear which tests were applied in the table. a, b Which tests should be shown.

6.The limitations of the study should be given more space. As a cross-sectional study it can be difficult to establish cause-effect connections. This is an example.

7. The findings of the study after the regression analysis are actually very important findings. More insight discussion is needed on these.

Interesting findings, for example, in girls and elderly mothers have lower self-medication. Authors should provide explanations to it in their discussion.

********** 

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #3: Yes: Ugurcan Sayili

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2022 Dec 30;17(12):e0278843. doi: 10.1371/journal.pone.0278843.r004

Author response to Decision Letter 1


22 Nov 2022

Reviewer #3: Overall, I believe this is an interesting study that can contribute to the literature, but needs further clarification and improvement.

In the introduction,

Sentence starting with “Therefore, by implementing this study..” This sentence must be come before the aim sentence.

Thanks for your concern, the necessary changes were implied.

Sentence starting with “In this study, we asked families …” This information can be transferred to the method section and synthesized with appropriate sentences.

Thanks for your concern, the necessary changes were implied.

In the method, the title of the information about ethics can be corrected as “Ethics” not “Ethnicity Criteria:"

Thanks for your concern, the necessary changes were implied.

When I read this article, I would like to have information about Arak, in a few short sentences.

For example, the socioeconomic status of Arak city, education, industrial city? Are the people ethnically similar? Migration level?

Arak is the capital of Markazi Province, Iran. At the 2011 census, its population was 526,182, in 160,761 families.[3][4] The city is nicknamed the "Industrial Capital of Iran". As a major industrial city, Arak hosts several industrial factories inside and within a few kilometers outside the city, including the factory of Machine Sazi Arak and the Iranian Aluminum Company. These factories produce nearly half of the needs of the country in steel, petrochemical, and locomotive industries. As an industrial city in a developing country, Arak suffers from air pollution.

Moreover, websites containing additional information useful about Arak are enlisted as follows in the references:

(1-4)

It is not clear which tests were applied in the table. a, b Which tests should be shown.

In Table 1, the results of Chi-square and Mann-Whitney U test which were used to compare mean or median values by self-medication of antibiotic consumption are depicted. In Table 2, the results of Univariate and multiple logistic regression models in order to obtain odds ratio (OR) and 95% confidence intervals is shown.

The findings of the study after the regression analysis are actually very important findings. More insight discussion is needed on these.

Interesting findings, for example, in girls and elderly mothers have lower self-medication. Authors should provide explanations to it in their discussion.

Additional explanations are added in the discussion section, thanks.

References

1. https://en.wikipedia.org/wiki/Arak,_Iran.

2. https://www.wikidata.org/wiki/Q212628.

3. https://www.macrotrends.net/cities/21484/arak/population.

4. https://www.iranicaonline.org/articles/arak.

Attachment

Submitted filename: Response to Reviewers.docx

Decision Letter 2

Ugurcan Sayili

25 Nov 2022

Prevalence and determinants of self-medication consumption of antibiotics in children in Iran: a population-based cross-sectional study, 2018-19

PONE-D-21-31099R2

Dear Dr. Moradzadeh,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Ugurcan Sayili, M.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

The authors have made the necessary corrections.

Reviewers' comments:

Acceptance letter

Ugurcan Sayili

19 Dec 2022

PONE-D-21-31099R2

Prevalence and determinants of self-medication consumption of antibiotics in children in Iran: a population-based cross-sectional study, 2018-19

Dear Dr. Moradzadeh:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Ugurcan Sayili

Academic Editor

PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 Data. Minimal child antibiotic.

    (SAV)

    Attachment

    Submitted filename: Response to reviewers.docx

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    Submitted filename: Response to Reviewers.docx

    Data Availability Statement

    All relevant data are within the paper and its Supporting Information files.


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