The Relationship between Fear of COVID-19 and Self-Medication and the Rate of Antibiotic Use in Patients Referred to COVID-19

Introduction The coronavirus pandemic can cause anxiety and stress among people, which can make them practice self-medication. This study aimed to investigate the relationship between fear of corona and self-medication and antibiotics use. Methods In a convenience sampling method, 250 people referring to COVID-19 centers including 16-hour comprehensive health services in Kermanshah, Iran, who tested positive and were not hospitalized were extracted from the SIB system. Data collection tools include three questionnaires including corona fear questionnaire, self-medication questionnaire, and self-medication by antibiotic questionnaire and an information form including demographic characteristics. Data were analyzed by SPSS version 25. Results The prevalence of self-medication was 59.6%. There was a significant correlation between self-medication and gender (P value <0.05) and education level (P value <0.05); the most common reason for self-medication was easy access to medicines through pharmacy drug stores. The mean score of fear of corona was higher in women and those who were not in a good financial position due to a lack of suitable economic status to see a doctor. Conclusion There was a direct and significant relationship between self-medication and self-medication by antibiotics. 59.6% of the participants used medicines themselves, buying over-the-counter in pharmacies. Also, there was a statistically significant difference between the mean score of corona fear in terms of not having a suitable economic status to see a doctor. This indicates that the lack of proper economic status among people with the coronavirus positive test to see a doctor increases the fear of the disease.


Introduction
Coronaviruses (CoVs) are a large family of viruses, ranging from the common cold virus to the cause of more serious illnesses such as severe acute respiratory syndrome (SARS), Middle East respiratory syndrome coronavirus (MERS-CoV), and COVID-19. Te COVID-19 pandemic is an ongoing global health crisis that currently causes severe and acute respiratory distress syndrome in some patients and may lead to the death of some patients [1]. Te recent COVID-19 pandemic is in fact a major social event that has been raised not only in one region but also in the country and even the whole world, and it is necessary to consider its social efects [2]. Fear and anxiety caused by a possible illness are destructive and can lead to mental disorders and stress in people [3]. One of the types of people's fears is the fear of getting sick [4]. Because there is still no defnitive cure for coronavirus, many people around the world are afraid of getting it. People who are afraid of getting sick constantly think that anything can cause them to get sick, and as a result, they constantly see a doctor or seek self-medication [5].
Self-medication is a process that involves preparation and use of medications without a doctor's recommendation for diagnosis or treatment [6]. Te results of published articles show that the prevalence of "self-medication" in Iran is 4 times more than the global average [7]. Antibiotics have the highest rate of arbitrary use. A study on the arbitrary use of herbal and chemical drugs in Isfahan showed that 86% of women had used drugs arbitrarily for at least one disease in the past 6 months [8]. Self-medication in Iran has been increasing in recent years, and about 83% of Iranians living in Tehran practiced self-medication [9].
Self-medication with antibiotics (SMI) and other medications is a problem that increases each year [10]. With the approach of the cold seasons of the year, the risk of catching the fu increases, an issue that is always emphasized by experts because self-administration of antibiotics can increase microbial resistance. With the outbreak of the corona epidemic, due to the similarity of the symptoms of the virus with the fu, colds, and respiratory infections, some people may think that antibiotics are the cure. A study of antibiotic use in developing countries found that people identifed antibiotics as an "extraordinary drug" or "a powerful drug" that could prevent and treat any disease [11].
Misconceptions and lack of awareness about antibiotic use have been reported by various studies in developed and developing countries [12]. Te World Health Organization (WHO) is concerned that the misuse of antibiotics during the coronavirus crisis will exacerbate this trend.
Limited research has been conducted on anxiety experiences in patients with severe respiratory symptoms. Anxiety can cause people to be unable to distinguish between right and wrong information, so they may be exposed to false news [13]. Due to the rapid spread of the disease and the increasing number of patients and deaths, the fear of getting the disease in the community is increasing, which may lead to selfmedication and irrational use of medicines without consulting a doctor. Tis study also aimed to investigate the relation between fear of getting infected with coronavirus and selfmedication among people living in Kermanshah, Iran.

Methods
Tis study was conducted using a cross-sectional research plan. Te data collected from the dataset and fles of patients between 10 July and 20 December 2021 were extracted. 250 people referred to corona centers in Kermanshah, Iran, whose polymerase chain reaction (PCR) test was positive and were not hospitalized were studied. Te data were extracted from the SIB system (the latest electronic health record system in Iran). Te inclusion criteria was having positive PCR test for corona during the last two weeks with no need for hospitalization. Te participants were selected from the 16-hour comprehensive health services in the SIB system. All information about patients would be recorded in the SIB system. Te sample size was calculated based on the study of Nasir et al. [14] using the sample size equation with a confdence level of 0.95% and an estimation error of 5%. Incomplete questionnaires were excluded from the study.
Data collection tools included three questionnaires and a demographic form: fear of corona, self-medications, and self-medication with antibiotics. Te demographic form included 8 questions about demographic characteristics (age, sex, marital status, economic status, level of education, employment status, and underlying disease).
Te corona fear questionnaire was a 5-item test that measured the degree of corona fear on a 5-point Likert scale (1 representing very low to 5 representing very high). Tis questionnaire was designed in the spring of 1399 by Veisi et al. to evaluate the psychometric properties of the short-term fear of coronavirus disease and its validity and reliability [15].
Te self-medication questionnaire was a 13-item test that includes information on over-the-counter medication, causes of self-medication, medications, forms, and frequency of use. Tis questionnaire was used by Tabiei et al. In a study entitled "Self-medication with drugs in students of Birjand universities," the validity of its content was confrmed by 5 faculty members of Birjand University of Medical Sciences [16].
Te questionnaire of the self-medication with antibiotics included questions about the use of antibiotics in the last three months, how to prepare antibiotics, the symptom that started the use of antibiotics, keeping antibiotics at home, using antibiotics without a doctor's prescription, willingness to keep antibiotics at home or use them without a doctor's prescription, and the reason for the arbitrary use of antibiotics. Tis questionnaire was used by Alipour et al. and colleagues in a study entitled "Te relationship between personality traits and the arbitrary use of antibiotics in students" [17].
After getting the permission of the Vice Chancellor for Research at Kermanshah University of Medical Sciences, data collections were done from May to July 2021. Te purpose of the study was explained to the subjects and they were assured about the confdentiality of their personal information and responses to questions. Written informed consent was obtained from all subjects after receiving an explanation of the study. Tis study has been registered with the Ethics Committee of Kermanshah University of Medical Sciences with the ethics code IR.KUMS.REC.1400.030.
Data analysis was performed using SPSS software version 25. Descriptive statistical methods were used to summarize and describe the variables. Te Kolmogorov-Smirnov test was used to evaluate the normality of the distribution of scores of the studied indices. Te obtained data were analyzed at a level of signifcance less than 0.05. Te Pearson correlation test (Spearman correlation) was used to examine the correlation between fear score, self-medication, and antibiotic use.

Results
A total of 250 people participated in this study. Te mean age of patients was 31.7 years with a standard deviation of 11.01 years; 47.2% were female, 54% were single, 68% had a university degree, and 91.2% had no underlying disease (Table 1).
Te results showed that 63.2% were familiar with the concept of drug resistance. 59.6% of the participants practiced self-medication. 43.6% used the medicine themselves due to the lack of need to see a doctor (Table 2). 40.4% of people considered the insignifcance of the disease and 40.4% of the inability to diagnose the symptoms of the disease as the cause of using antibiotics (Table 3).
According to the fndings of Table 4, the fndings of the Mann-Whitney test showed that there was a statistically signifcant diference between the mean score of corona fear in terms of not having a suitable economic status to see a doctor (P < 0.05).
According to Table 5, the fndings of the Spearman correlation test showed that there was a statistically direct and signifcant relationship between self-medication and self-medications with antibiotics (P < 0.05).
Te result showed that there are a signifcant relationship between self-medication and gender (Table 6).
Te correlation between the three variables of corona fear, self-medication, and self-medication with antibiotics with demographic variables (age, sex, marital status, economic status, education, employment status, and underlying disease) is given in Table 6.

Discussion
Te results showed that 59.6% of the participants who had a corona positive test practiced self-medication. A previous study that examined the frequency of self-medication in medical students studying at Rafsanjan University of Medical Sciences concluded that approximately 70% of students did self-medication [18]. Another study conducted by Korani et al. 2016 [19] in Kermanshah on assessment of self-medication and associated factors among elderly living in Kermanshah city in 2014 showed that about 90% of the subjects had used self-medicines.
Other studies have reported a prevalence of more than 60% of self-medication: about 71.7% in Kasulkar and Gupta' studies [20], 92% in Badiger et al.' studies [21], and 74% in Zafar' studies [22]. Te results of the present study on the frequency of self-medication with antibiotics are consistent with other studies conducted in Iran and the Middle East.
Te results of this study and its comparison with other results showed that self-medication is a major problem among people. Te issue of medicine use is something that is related to all cultural, social, and economic aspects of people. Self-medication is not a personal issue, and most sections of society are involved in it. People who have tried self-medication and faced side efects and been referred to medical centers do not acknowledge this issue, so health centers cannot provide accurate statistics of people who have tried to practice self-medication, and therefore, the relevant agencies cannot make the necessary plans in this regard. Culture and education have an important role in self-medication. We expect that self-medication rate will decrease by the awareness of the people and the elimination of misconceptions.
Te results showed that there was a direct and signifcant statistical relationship between self-medication and SMI (P < 0.05), which shows the tendency of individuals to use antibiotics. People who self-medicated said that the reason for this was the existence of free medicine market in the country (about 43.2%) and the conclusion from previous consumption. A similar study conducted by Zeinali et al. in Tehran showed that about half of participants in the study did self-medication [23]. Furthermore, 52.8% continue to refll their last prescription rather to visit a doctor. Another study conducted among college students in Tehran showed that 53% of students practiced self-medication with antibiotics [24]. Tis is an alarm for the healthcare system because it shows access to any medicine in the country can be easily done in pharmacies.
Te results showed that self-medication with antibiotics was associated with gender and education. Antibiotic selfmedication was higher in women than men and was more in people with at least a diploma and university education. Similar results were obtained in previous studies, for example, a study conducted by Jafari et al. on the self-medication in Kermanshah. Self-medication was signifcantly higher in women and people with university education [25]. In other studies, self-medication was also higher among educated people [26,27]. Educated people seem to believe that they can get all the information they need from their medicine brochures or previous prescriptions; therefore, they diagnose their disease and start self-medication according to their previous treatment.
Te main source that people declare for supplying the medicines for self-medication was pharmacy drug stores [28], which are consistent with the results of this study. Tis shows that selling over-the-counter drugs has a signifcant impact on the high prevalence of self-medication.
Also, a study conducted by Tabiei et al. [16] showed that antibiotics (53.1%) are the most commonly used drugs arbitrarily after analgesics. Tis amount needs more refection and more careful study because the irrational use of these drugs will increase bacterial resistance, exposure to side efects, and increase treatment costs.
In other studies, the reasons that were declared for selfmedication were factors such as keeping drugs at home, believing that the self-medication is safe, not having enough time to see a doctor to solve the problem, delivery of the    medicines by pharmacies without a doctor's prescription [29,30], the cost of doctors' visits, the lack of access to doctors due to fnancial poverty and high cost of doctors' visits, not covered by health insurance [31,32], the lack of accurate information about the efects of the medicines, also lack of trust in doctors' medicine [33], lack of need to refer to the physician, and the fear and embarrassment of medical examinations, the crowds of doctors' ofces or medical centers have been mentioned as factors related to selfmedication [34]. It seems that the cheap price of the medicines also afects its excessive use [35]. Te results showed that there was a statistically signifcant diference between the mean score of corona fear in terms of inexperience and insufcient knowledge of physicians in treatment according to the patient (P < 0.05). Tere was no signifcant relationship between other components of arbitrary drug use (self-medication) and fear of corona disease.
Findings showed that the level of fear of corona was signifcantly related to gender; the average score of fear of corona in women was much higher than in men. In a study done by Wang et al. [36], female gender was an important factor in the negative psychological impact of the prevalence of COVID-19. Te study included 1,210 respondents from 194 cities in China. According to the authors, women sufered more from the psychological impact of corona disease and also face higher levels of stress, anxiety, and depression. In Italy, results have also been reported to show greater psychological vulnerability associated with COVID-19 in women. Te results of this study showed that women are signifcantly more likely to have higher levels of stress, anxiety, insomnia, and depression [37]. Te fact that women are more afraid than men during COVID-19 may be related to several factors. Some factors may be immediate and others may have long-term consequences. Fear may be caused by predicting Table 6: Measuring the relationship between the three variables of corona fear, self-medication, and self-medication with antibiotics with demographic variables (age, sex, marital status, economic status, education, employment status, and underlying disease).

Variables
Self-mediation with antibiotics Fear of corona Self-medication Mean ± SD Mean ± SD Mean ± SD  the negative impact of the disease on the health of the individual and the health of family and close friends. On the other hand, the closure of schools and kindergartens has greatly increased the need for child care, which has a signifcant impact on working mothers. Tis result addresses the need to design interventions that reduce the negative impact of the current prevalence on women's mental health. Tis may also be explained by the fact that women have shown exaggerated emotional reactions and negative emotions in response to stressful situations and are usually more burdened than men during the epidemic, including housework, caring role, or they have domestic violence. In addition, women are more likely than men to sufer from stressful life events. Te mean score of corona fear was higher among employed people and students. Tese results were generally in line with the results of other studies. In a study conducted in Bangladesh, the results showed that more than two-thirds of students experienced mild-to-severe depression (82.4%) and anxiety (87.7%) [38]. Terefore, more psychological evaluation and even, in some cases, intervention are needed.
Another study conducted in China examined the psychological efects of the epidemic on students. Te results showed the corona's economic efects and its efect on daily life, such as delays in academic activities, increased anxiety, and fear symptoms among students [39]. Other studies have concluded that the prevalence of corona disease has a signifcant efect on work stress and that employed people are more afected by the consequences of the epidemic. In other words, physical, psychological, fnancial, and social concerns about infectious diseases cause work stress, which negatively afects the overall performance of employees [40].

Conclusions
Te results of this study showed that the arbitrary use of the drug for self-medication rate is signifcantly high and the sale of overthe-counter antibiotics by pharmacies and the lack of sufcient information provided to patients about the correct use of the drug is a medical problem. Te mean score of corona fear and the rate of self-medication with antibiotics were higher in women than men, and the rate of self-medication was higher in people with higher education. Also, there was a statistically signifcant diference between the mean score of corona fear in terms of not having a suitable economic status to see a doctor. Tis indicates that the lack of proper economic status of people with a positive corona test to see a doctor increases the fear of corona disease.

Data Availability
Te data used to support the fndings of this study are available from the corresponding author upon request (ks_jalali@yahoo.com).

Ethical Approval
Tis study was approved by the Ethics Committee of Kermanshah University of Medical Sciences with the code of IR.KUMS.REC.1400.030.

Consent
Not applicable.

Conflicts of Interest
Te authors declare that they have no conficts of interest.

Authors' Contributions
FF and RJ contributed to the design and prepared the manuscript. NS contributed to statistical analysis. RJ participated in most of the study steps. All authors have read and approved the content of the manuscript.