Self-medication, defined as the selection and use of medicines by individuals to treat self-recognized illnesses or symptoms without professional consultation, has become a global public health concern. While rational self-medication with over-the-counter (OTC) medicines can provide quick relief from minor ailments, reduce healthcare costs, and alleviate the burden on health systems, its inappropriate use poses significant risks. These include adverse drug reactions, masking of underlying diseases, antimicrobial resistance, and harmful drug–drug interactions. The World Health Organization (WHO) acknowledges that responsible self-medication is an integral component of primary healthcare, but emphasizes the need for adequate knowledge, safe practices, and strong regulatory frameworks to minimize risks.1-5 In developing countries like India, self-medication is particularly widespread due to the easy accessibility of medicines, inadequate enforcement of drug regulations, high cost of medical consultation, and cultural reliance on home remedies. Pharmacies and local chemist shops often dispense medicines—including antibiotics and other prescription-only drugs—without proper authorization, leading to misuse. Studies across Indian states have reported that common conditions such as fever, headache, cough, gastric upset, and minor infections are frequently self-treated using paracetamol, analgesics, antibiotics, and antacids. Importantly, antibiotics are among the most misused drugs in self-medication, fueling the alarming global problem of antimicrobial resistance.6-9 Rural populations face additional challenges that intensify self-medication practices. Limited access to healthcare facilities, shortage of qualified doctors, geographic barriers, lower literacy levels, and reliance on informal medical advice from family, friends, or local pharmacists often drive individuals to self-treat. In hilly states like Himachal Pradesh, where health infrastructure is often sparse and rural communities constitute the majority, self-medication may serve as a convenient but unsafe alternative to formal healthcare. Despite this, region-specific evidence on the prevalence, knowledge, and determinants of OTC drug use in rural Himachal Pradesh remains scarce.10-13 Awareness and knowledge about safe self-medication are crucial determinants of health outcomes. Misconceptions such as considering antibiotics as routine OTC drugs, believing that frequent use of analgesics carries no risk, or assuming that herbal remedies are always safe can perpetuate irrational practices. Understanding how rural populations perceive OTC drugs, what illnesses they commonly self-treat, and how well they comprehend the risks involved is vital to designing effective educational strategies and strengthening community-level interventions.14-16 The present study was undertaken to assess the prevalence and patterns of self-medication practices, identify commonly used OTC drugs, and evaluate knowledge levels regarding safe medicine use among rural populations of Himachal Pradesh. By examining socio-demographic associations with knowledge levels, the study seeks to highlight vulnerable groups and generate evidence to guide public health policies, pharmacist involvement, and awareness campaigns aimed at promoting rational drug use in rural communities.

Study Design and Setting A descriptive, cross-sectional study was conducted to assess self-medication practices and knowledge regarding over-the-counter (OTC) drugs among rural populations of Himachal Pradesh. The study was carried out using a structured questionnaire administered via Google Forms, which allowed efficient dissemination, uniform data collection, and ensured feasibility in geographically diverse rural settings. Study Population and Eligibility Criteria The study targeted adults aged 18 years and above residing in rural village clusters of Himachal Pradesh. Both males and females from diverse educational and occupational backgrounds were eligible to participate, provided they gave voluntary informed consent. Individuals were excluded if they were: • healthcare professionals, pharmacists, or medical students (to minimize bias from specialized knowledge), • suffering from severe cognitive impairment or communication difficulties, or • providing incomplete or duplicate responses. Sample Size Calculation The sample size was estimated using the single population proportion formula, assuming 50% prevalence of safe self-medication practices (due to lack of prior regional data), a 95% confidence interval, and a 5% margin of error. The minimum sample size required was 384. To account for non-responses and exclusions, the final sample size was set at 400 participants. Sampling Technique A purposive-cum-snowball sampling method was employed. The survey link was circulated through WhatsApp groups, community-based networks, and local contacts in village clusters. Community health workers and volunteers assisted in reaching rural households. Participants were encouraged to share the form with other eligible adults within their locality, ensuring broad coverage across multiple rural clusters of Himachal Pradesh. Survey Instrument The study tool was developed after a review of relevant literature and WHO/Indian Council of Medical Research (ICMR) guidelines. The questionnaire was divided into three major sections: 1. Socio-Demographic Profile – including age, gender, education, occupation, and monthly family income. 2. Self-Medication Practices – covering commonly self-treated illnesses, frequency of practice, sources of drugs, and commonly used OTC medicines. 3. Knowledge Assessment – consisting of 20 multiple-choice questions on awareness of OTC drugs, risks of misuse, antibiotic resistance, safe storage, dosage, and polypharmacy. Each correct response was given one point (score range 0–20). Knowledge levels were categorized as: • Excellent (16–20), • Good (12–15), • Fair (8–11), and • Poor (0–7). Validation and Pilot Testing The questionnaire was reviewed by subject experts in pharmacology, public health, and community medicine to ensure content validity. A pilot test was conducted on 30 rural residents to assess clarity, cultural relevance, and comprehensibility. Minor modifications were made in wording and sequence of questions. Internal consistency was confirmed with a Cronbach’s alpha of 0.80, indicating good reliability. Data Collection Procedure The Google Form began with an informed consent statement, and only participants providing consent could proceed. All questions were mandatory to minimize missing data. Average completion time was 10–12 minutes. Responses were automatically recorded in a secured Google Sheet accessible only to the investigators. Data Analysis Data were exported into IBM SPSS Statistics (version 25) for analysis. Descriptive statistics (frequencies, percentages, means, and standard deviations) were used to summarize demographic data, self-medication practices, and knowledge scores. The Chi-square test (χ²) was applied to examine associations between knowledge levels and socio-demographic variables. A p-value <0.05 was considered statistically significant. Ethical Considerations The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Participation was voluntary, confidentiality of responses was maintained, and no personally identifiable data were collected.

A total of 400 participants from rural village clusters of Himachal Pradesh were surveyed. The age distribution was fairly balanced, with the largest group aged 25–34 years (26.0%), followed by 18–24 years (19.0%), ≥55 years (20.0%), 35–44 years (18.0%), and 45–54 years (17.0%). Males constituted a slight majority (52.0%) compared to females (48.0%). All participants resided in rural areas, reflecting the study setting. Educational attainment varied: 12.0% reported no formal education, 23.0% had primary education, 38.0% had completed secondary schooling, while 27.0% had a graduate-level or higher qualification. Occupationally, farmers represented the largest group (35.0%), followed by homemakers (21.0%), daily wage/skilled workers (18.0%), students (14.0%), and service/professionals (12.0%). Regarding monthly family income, 32.0% earned less than ₹10,000, 39.0% earned between ₹10,000–20,000, and 29.0% reported income above ₹20,000, indicating a mixed socio-economic profile within the rural population. Table 1: Socio-Demographic Characteristics of Participants (n = 400) Variable Category Frequency (n) Percentage (%) Age (years) 18–24 76 19.0 25–34 104 26.0 35–44 72 18.0 45–54 68 17.0 ≥55 80 20.0 Gender Male 208 52.0 Female 192 48.0 Residence Rural (village clusters) 400 100.0 Education No formal 48 12.0 Primary (up to 5th std.) 92 23.0 Secondary (6th–12th std.) 152 38.0 Graduate & above 108 27.0 Occupation Farmer 140 35.0 Homemaker 84 21.0 Daily wage/Skilled worker 72 18.0 Student 56 14.0 Service/Professional 48 12.0 Monthly Family Income (INR) <10,000 128 32.0 10,000–20,000 156 39.0 >20,000 116 29.0 Self-medication was found to be common among participants, with a wide range of illnesses being self-treated. The most frequently reported conditions included cough and cold (58.0%), fever (47.0%), and headache/body ache (41.0%). Gastric problems such as acidity were reported by 32.0%, while 21.0% used self-medication for diarrhea/dysentery, and 17.0% for minor injuries or allergies. In terms of frequency, 40.0% admitted to self-medicating frequently (>5 times per year), 37.0% occasionally (3–5 times/year), and 23.0% rarely (1–2 times/year). Local pharmacies and chemist shops were the most common sources of medicines (61.5%), followed by leftover prescriptions (23.0%), advice from friends or family (9.5%), and traditional/herbal remedies (6.0%). The most commonly used OTC drugs included paracetamol and other analgesics (71.5%), cough syrups (52.0%), antacids (36.0%), antibiotics (31.0%), antihistamines (23.0%), and oral rehydration salts (14.0%). These findings reflect both the reliance on chemists as first points of contact and the widespread use of antibiotics without prescription. Table 2: Self-Medication Practices Among Participants (n = 400) Variable Category Frequency (n) Percentage (%) Common Illnesses for Self-Medication Fever 188 47.0 Headache/Body ache 164 41.0 Cough & Cold 232 58.0 Gastric problems/Acidity 128 32.0 Diarrhea/Dysentery 84 21.0 Minor injuries/Allergies 68 17.0 Frequency of Self-Medication Rarely (1–2 times/year) 92 23.0 Occasionally (3–5 times/year) 148 37.0 Frequently (>5 times/year) 160 40.0 Sources of Drugs Used for Self-Medication Local Pharmacy/Chemist 246 61.5 Previous prescription/Leftover medicines 92 23.0 Friends/Family advice 38 9.5 Traditional/Herbal remedies 24 6.0 Common OTC Drugs Used Paracetamol/Analgesics 286 71.5 Cough syrups 208 52.0 Antacids 144 36.0 Antibiotics 124 31.0 Antihistamines 92 23.0 Oral rehydration salts (ORS) 56 14.0 Knowledge assessment revealed wide variability in understanding of OTC drug safety and practices. A majority (59.5%) correctly identified the meaning of OTC drugs as those available without prescription, and 69.0% recognized paracetamol as a common OTC drug. However, only 48.0% correctly identified that antibiotics are not OTC drugs, while misconceptions about their availability were common. Awareness of risks was limited—only 42.0% acknowledged kidney or liver damage from frequent analgesic use, 36.5% recognized nutrient imbalance due to excessive antacid use, and 32.0% knew the correct maximum daily dose of paracetamol. On the positive side, 74.5% agreed that dosage decisions should be made by a doctor or pharmacist, 69.0% understood that expired drugs must be disposed of, and 78.0% recognized that sharing medicines is unsafe. More than half (63.5%) were aware that antibiotic misuse causes resistance, and 62.0% emphasized the importance of reading drug labels. However, awareness about herbal drug interactions with allopathic medicines was low (38.5%), and less than half (45.5%) understood the risks of polypharmacy. These results suggest partial awareness, with significant knowledge gaps in critical safety areas. Table 3: Knowledge Assessment on Over-the-Counter (OTC) Drugs and Self-Medication (n = 400) Q. No. Question Options (Correct in Bold) Correct (n) Correct (%) 1 Meaning of OTC drugs? a) Only prescription b) Available without prescription c) Banned drugs d) Unsafe drugs 238 59.5 2 Common example of OTC drug a) Paracetamol b) Antibiotics c) Insulin d) Steroids 276 69.0 3 Is antibiotic considered an OTC drug? a) No b) Yes c) Sometimes d) Don’t know 192 48.0 4 Risk of frequent analgesic use a) Kidney/Liver damage b) Improves strength c) No risk d) Don’t know 168 42.0 5 Can antibiotics be taken without doctor advice? a) Yes b) No c) Only for fever d) Unsure 224 56.0 6 Overuse of antibiotics leads to a) Better cure b) Resistance c) Quick recovery d) No effect 254 63.5 7 Ideal use of cough syrups a) Always safe b) Only as per dosage instructions c) Can be shared d) No side effects 218 54.5 8 Excessive antacid use may cause a) Better digestion b) Nutrient imbalance c) Weight gain d) No harm 146 36.5 9 Who should decide dosage of medicine? a) Friends b) Self c) Doctor/Pharmacist d) Media 298 74.5 10 Expired drugs should be a) Avoided/Disposed b) Used if mild c) Can share d) No effect 276 69.0 11 Sharing medicines with others is a) Safe b) Unsafe c) Beneficial d) Harmless 312 78.0 12 Can self-medication delay diagnosis? a) Yes b) No c) Sometimes d) Unsure 226 56.5 13 Importance of reading drug labels a) Not needed b) Important c) Waste of time d) Only for new users 248 62.0 14 Side-effects of antibiotics misuse a) Resistance & Allergies b) Strong immunity c) No harm d) Unsure 192 48.0 15 Safe storage of medicines a) Anywhere b) Cool/Dry place away from children c) In sunlight d) Kitchen 268 67.0 16 Knowledge of maximum paracetamol dose/day a) 1 tablet b) 2 tablets c) 4 grams d) Don’t know 128 32.0 17 Can herbal drugs interact with allopathy medicines? a) No b) Yes c) Rarely d) Safe always 154 38.5 18 Should self-medication be practiced for chronic illness? a) No b) Yes c) Sometimes d) Only elderly 288 72.0 19 Is pharmacist advice important in OTC purchase? a) No b) Yes c) Only sometimes d) Don’t know 302 75.5 20 Awareness of polypharmacy risks (using many drugs together) a) Safe b) May cause harmful interactions c) No harm d) Unsure 182 45.5 When overall knowledge scores were analyzed, only 15.5% of participants demonstrated excellent knowledge (16–20 correct answers), while 31.0% scored in the good category (12–15). The largest proportion, 35.5%, fell into the fair category (8–11), and 18.0% showed poor knowledge (0–7). This distribution highlights that while a section of the rural population possesses adequate understanding of OTC drug safety, the majority either lack comprehensive awareness or hold incomplete knowledge, making them vulnerable to unsafe self-medication practices. Table 4: Distribution of Knowledge Scores on OTC Drugs and Self-Medication (n = 400) Knowledge Category Score Range (out of 20) Frequency (n) Percentage (%) Excellent 16–20 62 15.5 Good 12–15 124 31.0 Fair 8–11 142 35.5 Poor 0–7 72 18.0 The analysis of socio-demographic associations revealed education and occupation as the strongest determinants of knowledge levels. Only 3.8% of individuals without formal education demonstrated excellent knowledge, compared with 19.6% among graduates and 31.2% among postgraduates, showing a highly significant association (p<0.001). Occupation also mattered, with service/professional groups having the highest proportion of excellent knowledge (27.1%) compared to homemakers (9.6%) and unskilled/skilled workers (13.2%) (p=0.009). Residence emerged as another important factor: urban respondents (though fewer in number) had significantly better knowledge compared to rural participants (p=0.006). By contrast, age and gender were not significantly associated with knowledge levels (p>0.05), indicating that structural factors such as education and occupation outweigh biological or demographic variables. These findings underline the need for targeted interventions among low-education, rural, and homemaker groups to address knowledge gaps and promote safe self-medication practices. Table 5: Association Between Knowledge Level on OTC Drugs and Socio-Demographic Variables (n = 400) Variable Category Excellent (%) Good (%) Fair (%) Poor (%) χ² value p-value Age (years) 18–34 10.5 28.0 40.5 21.0 6.92 0.327 35–44 14.8 34.3 36.3 14.6 45–54 16.7 32.0 34.8 16.5 ≥55 20.8 29.2 30.2 19.8 Gender Male 17.5 30.8 34.2 17.5 1.38 0.712 Female 13.3 31.1 36.7 18.9 Residence Urban 21.3 33.2 29.5 16.0 12.48 0.006** Rural 10.2 27.5 39.7 22.6 Education No formal 3.8 12.5 42.0 41.7 65.34 <0.001*** Secondary 7.1 22.3 46.4 24.2 Graduate 19.6 35.1 32.0 13.3 Postgraduate+ 31.2 38.7 24.6 5.5 Occupation Homemaker 9.6 27.8 41.3 21.3 21.72 0.009** Skilled/Unskilled 13.2 30.9 37.4 18.5 Service/Professional 27.1 34.2 28.1 10.6

This study provides important insights into the prevalence, patterns, and knowledge of self-medication practices with over-the-counter (OTC) drugs among rural residents of Himachal Pradesh. The findings reveal that self-medication is a widespread practice in rural communities, driven by accessibility of medicines through local chemists, socio-economic constraints, and cultural reliance on informal advice. While some degree of awareness regarding safe use of OTC drugs exists, significant gaps remain, particularly regarding the misuse of antibiotics, risks of analgesic overuse, and the dangers of polypharmacy. These findings carry both clinical and public health significance, as inappropriate self-medication contributes not only to individual adverse health outcomes but also to larger issues such as antimicrobial resistance. In this study, more than half of the participants reported self-medicating for common illnesses such as cough and cold (58.0%), fever (47.0%), and body aches (41.0%). These patterns are consistent with earlier Indian studies, which also identified fever, respiratory infections, and gastrointestinal problems as the most frequent conditions treated without medical consultation. The high reliance on paracetamol, analgesics, and cough syrups underscores the perception of these drugs as safe, “first-line” remedies, despite potential risks when misused. Notably, 31.0% of respondents reported using antibiotics for self-medication, echoing findings from other states such as Karnataka, Maharashtra, and Uttar Pradesh where antibiotic misuse is prevalent. This is particularly alarming given the global and national threat of antimicrobial resistance, which is exacerbated by unsupervised antibiotic consumption. Local chemists emerged as the dominant source of medicines (61.5%), highlighting their central role in shaping self-medication behavior in rural Himachal Pradesh. This finding aligns with nationwide reports of over-the-counter availability of prescription-only medicines in India, reflecting weak enforcement of drug regulatory laws. Use of leftover prescriptions (23.0%) and advice from family or friends (9.5%) further indicate that decisions to self-medicate are often influenced by convenience and community norms rather than medical judgment. Knowledge assessment revealed a mixed picture: while many participants correctly identified basic concepts—such as the meaning of OTC drugs (59.5%), the role of paracetamol (69.0%), and the unsafe practice of medicine sharing (78.0%)—critical gaps persisted. Only 48.0% knew that antibiotics are not OTC drugs, and just 42.0% understood the risk of kidney or liver damage from frequent analgesic use. Awareness about correct paracetamol dosing (32.0%) and risks of excessive antacid use (36.5%) was also poor. These gaps are concerning, as they expose individuals to adverse drug reactions, delayed diagnosis of underlying illnesses, and increased burden on healthcare facilities due to complications from unsafe practices. Encouragingly, most participants (75.5%) acknowledged the importance of pharmacist advice when purchasing OTC medicines, and 62.0% emphasized reading drug labels. However, only 38.5% recognized the potential for interactions between herbal and allopathic medicines, reflecting a common cultural belief in the safety of traditional remedies. This misconception could pose serious risks, especially in populations where herbal and modern medicine use coexist. When analyzed as composite scores, only 15.5% of participants demonstrated excellent knowledge, while the majority fell into fair (35.5%) or good (31.0%) categories. Nearly one-fifth (18.0%) had poor knowledge, highlighting the vulnerability of a substantial section of the population to unsafe practices. This distribution mirrors findings from rural studies in states such as Tamil Nadu and Bihar, where knowledge deficits on antibiotic misuse and OTC safety were similarly observed. Collectively, these results emphasize the need for strengthening rural health literacy, particularly concerning antibiotics, analgesics, and polypharmacy. Education and occupation were the strongest predictors of knowledge in this study. Individuals with graduate or postgraduate education were significantly more likely to demonstrate excellent knowledge compared to those with no formal education (p<0.001). Similarly, service and professional groups showed better knowledge compared to homemakers and unskilled workers (p=0.009). These findings echo existing literature that links higher education and professional exposure with greater health literacy and safer self-care practices. Residence also emerged as a key factor: urban respondents (though fewer in number) had significantly higher knowledge levels than their rural counterparts (p=0.006). This likely reflects better access to information, health services, and exposure to regulatory enforcement in urban settings. By contrast, age and gender did not show significant associations with knowledge, suggesting that socio-structural determinants—particularly education, occupation, and place of residence—are more influential than biological or demographic variables in shaping knowledge about safe self-medication. Public Health Implications The high prevalence of self-medication, coupled with knowledge gaps, carries several implications. First, inappropriate use of antibiotics in rural Himachal Pradesh needs urgent attention, as it directly contributes to antimicrobial resistance—a growing public health crisis in India. Second, misconceptions regarding the safety of frequent analgesic use, excessive antacids, and herbal–allopathic drug combinations must be addressed through community education campaigns. Third, given the central role of local chemists, community pharmacists should be trained and empowered to provide accurate information, discourage irrational sales, and act as gatekeepers against prescription-only drug misuse.14-16 Policy measures are also critical: stronger enforcement of drug sale regulations, awareness drives through local health workers, and integration of medication literacy into rural health programs can help reduce unsafe self-medication. Moreover, leveraging digital platforms, village health volunteers, and community outreach could make education more accessible in geographically challenging areas of Himachal Pradesh. Limitations This study, while informative, has certain limitations. The use of a Google Form survey may have inadvertently excluded individuals with poor digital access or literacy, potentially underrepresenting the most vulnerable groups. Self-reported responses are susceptible to recall and social desirability bias, particularly in sensitive areas such as antibiotic use. The cross-sectional design restricts causal interpretations regarding associations between socio-demographic factors and knowledge levels. Nonetheless, the study provides robust baseline data and offers valuable insights into the specific rural context of Himachal Pradesh, which has been underrepresented in prior research.

In conclusion, this study highlights that self-medication is highly prevalent among rural populations of Himachal Pradesh, with cough, cold, fever, and pain being the most common reasons. While basic awareness of OTC drugs exists, significant knowledge gaps remain regarding antibiotic misuse, analgesic overuse, safe dosing, and polypharmacy risks. Education, occupation, and residence emerged as strong determinants of knowledge, underscoring the need for targeted interventions among low-literacy and rural groups. Strengthening community education, regulating OTC sales, and involving pharmacists as frontline educators are vital strategies to promote rational self-medication and safeguard public health in rural Himachal Pradesh.

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