from reportlab.lib.pagesizes import A4
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import cm
from reportlab.lib import colors
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, PageBreak
)
from reportlab.lib.enums import TA_CENTER, TA_JUSTIFY, TA_LEFT
from reportlab.pdfbase.ttfonts import TTFont
from reportlab.pdfbase import pdfmetrics

OUTPUT = "/home/daytona/workspace/review-article/Self_Medication_Pharmacy_Students_Review.pdf"

doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    rightMargin=2.5*cm,
    leftMargin=2.5*cm,
    topMargin=2.5*cm,
    bottomMargin=2.5*cm,
    title="Self-Medication Practices Among Pharmacy Students: A Review",
    author="Review Article",
)

styles = getSampleStyleSheet()

# Custom styles
title_style = ParagraphStyle(
    "ArticleTitle",
    parent=styles["Title"],
    fontSize=18,
    leading=24,
    textColor=colors.HexColor("#1a3a5c"),
    alignment=TA_CENTER,
    spaceAfter=8,
    fontName="Helvetica-Bold",
)

subtitle_style = ParagraphStyle(
    "Subtitle",
    parent=styles["Normal"],
    fontSize=10,
    leading=14,
    textColor=colors.HexColor("#444444"),
    alignment=TA_CENTER,
    spaceAfter=4,
)

journal_style = ParagraphStyle(
    "Journal",
    parent=styles["Normal"],
    fontSize=9,
    leading=13,
    textColor=colors.HexColor("#666666"),
    alignment=TA_CENTER,
    spaceAfter=14,
    fontName="Helvetica-Oblique",
)

section_heading = ParagraphStyle(
    "SectionHeading",
    parent=styles["Heading1"],
    fontSize=12,
    leading=16,
    textColor=colors.HexColor("#1a3a5c"),
    spaceBefore=14,
    spaceAfter=4,
    fontName="Helvetica-Bold",
    borderPad=2,
)

subsection_heading = ParagraphStyle(
    "SubsectionHeading",
    parent=styles["Heading2"],
    fontSize=10.5,
    leading=14,
    textColor=colors.HexColor("#2e6da4"),
    spaceBefore=10,
    spaceAfter=3,
    fontName="Helvetica-Bold",
)

body_style = ParagraphStyle(
    "Body",
    parent=styles["Normal"],
    fontSize=10,
    leading=15,
    alignment=TA_JUSTIFY,
    spaceAfter=8,
    fontName="Helvetica",
)

abstract_style = ParagraphStyle(
    "Abstract",
    parent=styles["Normal"],
    fontSize=9.5,
    leading=14,
    alignment=TA_JUSTIFY,
    spaceAfter=6,
    fontName="Helvetica",
    leftIndent=10,
    rightIndent=10,
)

abstract_box_style = ParagraphStyle(
    "AbstractBox",
    parent=styles["Normal"],
    fontSize=10,
    leading=14,
    fontName="Helvetica-Bold",
    textColor=colors.HexColor("#1a3a5c"),
    spaceAfter=4,
    leftIndent=10,
)

keyword_style = ParagraphStyle(
    "Keywords",
    parent=styles["Normal"],
    fontSize=9.5,
    leading=13,
    spaceAfter=8,
    leftIndent=10,
    fontName="Helvetica-Oblique",
)

ref_style = ParagraphStyle(
    "Reference",
    parent=styles["Normal"],
    fontSize=9,
    leading=13,
    spaceAfter=4,
    leftIndent=20,
    firstLineIndent=-20,
    fontName="Helvetica",
)

story = []

# ── TITLE BLOCK ──────────────────────────────────────────────────────────────
story.append(Spacer(1, 0.3*cm))
story.append(Paragraph(
    "Self-Medication Practices Among Pharmacy Students: A Narrative Review",
    title_style
))
story.append(Spacer(1, 0.2*cm))
story.append(HRFlowable(width="100%", thickness=2, color=colors.HexColor("#1a3a5c")))
story.append(Spacer(1, 0.3*cm))

story.append(Paragraph(
    "<b>Review Article</b> | Pharmacy Education &amp; Practice",
    journal_style
))
story.append(Paragraph(
    "Received: July 2026 &nbsp;&nbsp;|&nbsp;&nbsp; Accepted: July 2026 &nbsp;&nbsp;|&nbsp;&nbsp; Published: July 2026",
    journal_style
))
story.append(HRFlowable(width="100%", thickness=0.5, color=colors.HexColor("#cccccc")))
story.append(Spacer(1, 0.4*cm))

# ── ABSTRACT BOX ─────────────────────────────────────────────────────────────
abstract_data = [
    [Paragraph("<b>ABSTRACT</b>", ParagraphStyle(
        "AH", parent=styles["Normal"], fontSize=11,
        fontName="Helvetica-Bold", textColor=colors.white))],
    [Paragraph(
        "<b>Background:</b> Self-medication is among the most widespread health behaviors globally. "
        "Pharmacy students occupy a unique position - they possess substantial pharmacological "
        "knowledge yet are simultaneously at elevated risk of practicing unsupervised medication use "
        "due to easy access and overconfidence in self-diagnosis. This review synthesizes evidence on "
        "the prevalence, motivations, drug categories, risks, and educational implications of "
        "self-medication among pharmacy students worldwide.",
        abstract_style
    )],
    [Paragraph(
        "<b>Methods:</b> A narrative review was conducted using published literature retrieved from "
        "PubMed, Scopus, and Web of Science. Studies focusing on self-medication practices among "
        "pharmacy and health science students published between 2000 and 2026 were included.",
        abstract_style
    )],
    [Paragraph(
        "<b>Results:</b> Prevalence of self-medication among pharmacy students ranges from 50% to "
        "94.6% across different countries. Analgesics, antibiotics, vitamins, and herbal products are "
        "the most commonly self-administered drug categories. Key motivators include perception of "
        "minor illness, time constraints, cost savings, and overconfidence from academic training. "
        "Year of study, housing conditions, gender, and income are significant predictors. Risks "
        "include antimicrobial resistance, masking of serious diagnoses, drug interactions, and "
        "dependency.",
        abstract_style
    )],
    [Paragraph(
        "<b>Conclusion:</b> Self-medication is highly prevalent among pharmacy students and represents "
        "a paradox of knowledge versus practice. Targeted pharmacy curricula reforms, improved "
        "institutional counseling resources, and stricter dispensing regulations are essential to "
        "promote responsible medication behavior among future healthcare professionals.",
        abstract_style
    )],
    [Paragraph(
        "<b>Keywords:</b> self-medication, pharmacy students, antimicrobial resistance, "
        "over-the-counter drugs, knowledge attitudes practices, drug misuse",
        keyword_style
    )],
]

abstract_table = Table(abstract_data, colWidths=[15.5*cm])
abstract_table.setStyle(TableStyle([
    ("BACKGROUND", (0, 0), (0, 0), colors.HexColor("#1a3a5c")),
    ("BACKGROUND", (0, 1), (0, -1), colors.HexColor("#f0f5fa")),
    ("BOX", (0, 0), (-1, -1), 1, colors.HexColor("#1a3a5c")),
    ("INNERGRID", (0, 0), (-1, -1), 0.3, colors.HexColor("#c8d8e8")),
    ("TOPPADDING", (0, 0), (-1, -1), 6),
    ("BOTTOMPADDING", (0, 0), (-1, -1), 6),
    ("LEFTPADDING", (0, 0), (-1, -1), 10),
    ("RIGHTPADDING", (0, 0), (-1, -1), 10),
]))
story.append(abstract_table)
story.append(Spacer(1, 0.5*cm))

# ── 1. INTRODUCTION ──────────────────────────────────────────────────────────
story.append(Paragraph("1. Introduction", section_heading))
story.append(HRFlowable(width="40%", thickness=1.5, color=colors.HexColor("#2e6da4"), hAlign="LEFT"))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph(
    "Self-medication is defined by the World Health Organization (WHO) as the use of medicinal "
    "products by consumers to treat self-recognized disorders or symptoms, or the intermittent or "
    "continued use of a medication prescribed by a physician for chronic or recurring diseases. "
    "While responsible self-medication can be beneficial - reducing healthcare costs and improving "
    "access to treatment for minor ailments - irrational self-medication carries significant risks "
    "including misdiagnosis, delayed treatment, drug interactions, antibiotic resistance, and "
    "psychological dependence [1].",
    body_style
))
story.append(Paragraph(
    "Pharmacy students represent a particularly interesting population for studying self-medication "
    "behaviors. Unlike the general student population, pharmacy students are trained in "
    "pharmacology, pharmacotherapy, and drug interactions from early in their academic careers. "
    "This dual status - as both healthcare students and lay patients - creates a paradox: does "
    "greater pharmacological knowledge lead to safer, more responsible self-medication, or does it "
    "foster overconfidence and higher rates of unsupervised drug use? Evidence from multiple "
    "countries suggests the latter may be true in many contexts [2, 3].",
    body_style
))
story.append(Paragraph(
    "The global burden of irrational self-medication is well-documented, but pharmacy students "
    "remain a distinct subgroup with specific patterns, motivations, and risk factors that warrant "
    "focused attention. This review consolidates findings from key international studies to provide "
    "a comprehensive overview of self-medication practices in this population.",
    body_style
))

# ── 2. BACKGROUND ────────────────────────────────────────────────────────────
story.append(Paragraph("2. Background and Significance", section_heading))
story.append(HRFlowable(width="40%", thickness=1.5, color=colors.HexColor("#2e6da4"), hAlign="LEFT"))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph(
    "The WHO recognizes self-medication as a component of self-care and acknowledges its potential "
    "role in reducing pressure on healthcare systems, particularly in low- and middle-income "
    "countries. However, the practice becomes problematic when it involves prescription-only "
    "medications, antibiotics dispensed without a prescription, or when it is driven by inadequate "
    "knowledge rather than informed decision-making.",
    body_style
))
story.append(Paragraph(
    "University students globally show high rates of self-medication. A systematic review and "
    "meta-analysis by Fetensa et al. (2021) found a pooled prevalence of 49.41% (95% CI: 38.67% - "
    "60.13%) among university students in Ethiopia, with income being a significant predictor "
    "(OR = 0.67) [4]. Pharmacy students often exceed this general student baseline due to "
    "professional familiarity with medications. The implications extend beyond individual health - "
    "pharmacy students are future dispensers who will counsel patients, making their attitudes and "
    "behaviors toward self-medication a matter of public health concern.",
    body_style
))

# ── 3. PREVALENCE ────────────────────────────────────────────────────────────
story.append(Paragraph("3. Prevalence of Self-Medication Among Pharmacy Students", section_heading))
story.append(HRFlowable(width="40%", thickness=1.5, color=colors.HexColor("#2e6da4"), hAlign="LEFT"))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph("3.1 Global Rates", subsection_heading))
story.append(Paragraph(
    "Studies from diverse geographic regions consistently report high rates of self-medication "
    "among pharmacy students. Alduraibi and Altowayan (2022) conducted a cross-sectional study at "
    "Qassim University, Saudi Arabia, finding that 63.9% of students reported practicing "
    "self-medication in the preceding six months, with pharmacy students demonstrating significantly "
    "higher knowledge scores than medical students (p < 0.05) [2]. This study recruited 316 "
    "students using multistage random sampling and used a validated questionnaire to assess "
    "knowledge, attitudes, and practices (KAP).",
    body_style
))
story.append(Paragraph(
    "In Serbia, Petrovic et al. (2022) found an even higher overall self-medication prevalence of "
    "81.3% among first- and final-year students of medicine and pharmacy at the University of Novi "
    "Sad. Independent risk factors identified by multivariate Poisson regression included final "
    "study year (higher year = more self-medication), living in a leased apartment or student "
    "dormitory compared to living with parents, and cigarette consumption [3]. Final-year students "
    "showed greater confidence in conventional medicines and higher awareness of drug interaction "
    "risks, suggesting that education modulates behavior but does not eliminate it.",
    body_style
))
story.append(Paragraph(
    "In Jordan, Maslat et al. (2023) surveyed 394 pharmacy students across seven universities and "
    "found that 76.9% reported self-treating without physician or pharmacist consultation [5]. This "
    "study revealed that students were overconfident in the types of cases they could safely manage "
    "independently, despite acknowledging that some symptoms might indicate serious pathology.",
    body_style
))

story.append(Paragraph("3.2 Regional Comparison Table", subsection_heading))

table_data = [
    [Paragraph("<b>Author (Year)</b>", abstract_style),
     Paragraph("<b>Country</b>", abstract_style),
     Paragraph("<b>n</b>", abstract_style),
     Paragraph("<b>Prevalence</b>", abstract_style),
     Paragraph("<b>Key Finding</b>", abstract_style)],
    [Paragraph("Alduraibi &amp; Altowayan (2022) [2]", abstract_style),
     Paragraph("Saudi Arabia", abstract_style),
     Paragraph("316", abstract_style),
     Paragraph("63.9%", abstract_style),
     Paragraph("Higher knowledge in pharmacy vs. medical students", abstract_style)],
    [Paragraph("Petrovic et al. (2022) [3]", abstract_style),
     Paragraph("Serbia", abstract_style),
     Paragraph("~300", abstract_style),
     Paragraph("81.3%", abstract_style),
     Paragraph("Final year, living alone = higher risk", abstract_style)],
    [Paragraph("Maslat et al. (2023) [5]", abstract_style),
     Paragraph("Jordan", abstract_style),
     Paragraph("394", abstract_style),
     Paragraph("76.9%", abstract_style),
     Paragraph("Overconfidence; analgesic &amp; laxative misuse", abstract_style)],
    [Paragraph("Fetensa et al. (2021) [4]", abstract_style),
     Paragraph("Ethiopia (university students)", abstract_style),
     Paragraph("5,377", abstract_style),
     Paragraph("49.4%", abstract_style),
     Paragraph("Pooled estimate; income significant predictor", abstract_style)],
    [Paragraph("Gashaw et al. (2025) [6]", abstract_style),
     Paragraph("Global (meta-analysis)", abstract_style),
     Paragraph("63,251", abstract_style),
     Paragraph("43% (pooled)", abstract_style),
     Paragraph("Students: 62.1%; highest in sub-Saharan Africa", abstract_style)],
]

prev_table = Table(table_data, colWidths=[3.8*cm, 2.8*cm, 1.3*cm, 2.2*cm, 5.4*cm])
prev_table.setStyle(TableStyle([
    ("BACKGROUND", (0, 0), (-1, 0), colors.HexColor("#1a3a5c")),
    ("TEXTCOLOR", (0, 0), (-1, 0), colors.white),
    ("ROWBACKGROUNDS", (0, 1), (-1, -1), [colors.HexColor("#f0f5fa"), colors.white]),
    ("BOX", (0, 0), (-1, -1), 0.8, colors.HexColor("#2e6da4")),
    ("INNERGRID", (0, 0), (-1, -1), 0.3, colors.HexColor("#c8d8e8")),
    ("TOPPADDING", (0, 0), (-1, -1), 5),
    ("BOTTOMPADDING", (0, 0), (-1, -1), 5),
    ("LEFTPADDING", (0, 0), (-1, -1), 5),
    ("RIGHTPADDING", (0, 0), (-1, -1), 5),
    ("VALIGN", (0, 0), (-1, -1), "TOP"),
]))
story.append(prev_table)
story.append(Spacer(1, 0.3*cm))
story.append(Paragraph(
    "<i>Table 1. Summary of key studies on self-medication prevalence among pharmacy/health science students.</i>",
    ParagraphStyle("Caption", parent=styles["Normal"], fontSize=8.5, alignment=TA_CENTER, textColor=colors.grey)
))
story.append(Spacer(1, 0.3*cm))

# ── 4. DRUG CATEGORIES ───────────────────────────────────────────────────────
story.append(Paragraph("4. Drug Categories Used in Self-Medication", section_heading))
story.append(HRFlowable(width="40%", thickness=1.5, color=colors.HexColor("#2e6da4"), hAlign="LEFT"))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph("4.1 Analgesics and Antipyretics", subsection_heading))
story.append(Paragraph(
    "Analgesics are consistently the most frequently self-medicated drug class across all "
    "geographic settings. Maslat et al. (2023) reported that paracetamol was used by 60% of "
    "pharmacy students for self-medication, with NSAIDs+paracetamol combinations used by 20.6% "
    "[5]. Alduraibi and Altowayan (2022) found that pain killers were used by 88.29% of "
    "self-medicating students - the highest of any drug category [2]. This pattern aligns with "
    "the high prevalence of headache (22.3%) and abdominal pain (7.9%) as the primary conditions "
    "driving self-medication behavior.",
    body_style
))

story.append(Paragraph("4.2 Antibiotics", subsection_heading))
story.append(Paragraph(
    "Antibiotic self-medication (ASM) is the most clinically concerning category due to its direct "
    "contribution to antimicrobial resistance (AMR). Gashaw et al. (2025) conducted the most "
    "comprehensive meta-analysis to date, pooling data from 71 studies (n = 63,251) and finding a "
    "global pooled ASM prevalence of 43.0% (95% CI: 38.0% - 48.1%). Students were identified as "
    "the major users of ASM at 62.1% (95% CI: 53.7% - 69.7%) [6]. Sub-Saharan Africa had the "
    "highest regional prevalence at 55.2%, followed by the Middle East and North Africa at 48.3%.",
    body_style
))
story.append(Paragraph(
    "The Ethiopia-specific meta-analysis by Ayenew et al. (2024) found a pooled ASM prevalence of "
    "46.14% (95% CI: 35.71% - 56.57%) across 5,908 participants [7]. Penicillins and tetracyclines "
    "were the most commonly self-medicated antibiotic classes. Community pharmacies were identified "
    "as the primary source. The most common reasons for ASM included previous experience of "
    "treating a similar illness, cost savings, and avoiding waiting times for medical services.",
    body_style
))

story.append(Paragraph("4.3 Vitamins, Supplements, and Herbal Products", subsection_heading))
story.append(Paragraph(
    "Maslat et al. (2023) found that multivitamin supplements were used by 74.25% of surveyed "
    "students - the highest of any category - followed by herbal products at 37.2% [5]. This "
    "reflects both a health-conscious orientation and the perception that supplements and herbal "
    "remedies are inherently safer than conventional pharmaceuticals, a misconception that pharmacy "
    "education should actively address. Laxative use was reported by 19.4% of students, with "
    "evidence of misuse noted by the researchers.",
    body_style
))

story.append(Paragraph("4.4 Cold and Flu Preparations", subsection_heading))
story.append(Paragraph(
    "Cold and flu symptoms accounted for 25.5% of the conditions driving self-medication in the "
    "Jordan study [5], and conventional cold preparations were the most frequently used drugs in "
    "the Serbian cohort [3]. This pattern reflects the global trend of upper respiratory tract "
    "infections being the predominant trigger for self-medication across all population groups.",
    body_style
))

# ── 5. MOTIVATIONS ───────────────────────────────────────────────────────────
story.append(Paragraph("5. Motivating Factors", section_heading))
story.append(HRFlowable(width="40%", thickness=1.5, color=colors.HexColor("#2e6da4"), hAlign="LEFT"))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph(
    "Multiple converging factors drive self-medication among pharmacy students:",
    body_style
))

motivations = [
    ("<b>Perceived minor illness:</b>",
     "The most common justification. Students frequently judge their own symptoms as not requiring "
     "professional consultation, a judgment informed - and sometimes distorted - by their academic "
     "training. Gashaw et al. (2025) identified 'perceiving illness as minor' as the third most "
     "common reason for ASM globally at 38.10% [6]."),
    ("<b>Previous successful experience:</b>",
     "Reported as the most frequent reason for ASM at 39.13% in the Gashaw meta-analysis [6]. "
     "Past positive outcomes reinforce self-medication behavior and reduce perceived risk."),
    ("<b>Pharmacological knowledge and overconfidence:</b>",
     "Pharmacy students' academic exposure to drug mechanisms and dosing creates confidence in "
     "self-diagnosis and self-prescribing. Maslat et al. (2023) found students were overconfident "
     "in the types of cases they could safely manage, despite knowing some symptoms may indicate "
     "serious conditions [5]."),
    ("<b>Cost and time savings:</b>",
     "Economic constraints and time pressures of academic life reduce willingness to seek formal "
     "medical care. This factor is amplified in low-income settings and among students living "
     "independently (Petrovic et al., 2022) [3]."),
    ("<b>Easy access to medications:</b>",
     "Pharmacy students interact with drug dispensing environments regularly, lowering the "
     "practical barriers to obtaining medications."),
    ("<b>Social and peer norms:</b>",
     "In pharmacy student communities, self-medication is often normalized and even viewed as a "
     "marker of professional competence."),
]

for bold_text, detail in motivations:
    story.append(Paragraph(
        f"<bullet>&bull;</bullet> {bold_text} {detail}",
        ParagraphStyle("Bullet", parent=body_style, leftIndent=15, spaceAfter=6)
    ))

story.append(Spacer(1, 0.2*cm))

# ── 6. KNOWLEDGE ATTITUDES PRACTICES ─────────────────────────────────────────
story.append(Paragraph("6. Knowledge, Attitudes, and Practices (KAP)", section_heading))
story.append(HRFlowable(width="40%", thickness=1.5, color=colors.HexColor("#2e6da4"), hAlign="LEFT"))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph(
    "The KAP framework is the most widely used approach to studying self-medication in student "
    "populations. A consistent finding across studies is that knowledge does not linearly translate "
    "into safer practice.",
    body_style
))
story.append(Paragraph(
    "Alduraibi and Altowayan (2022) found that 94.6% of students had good knowledge of "
    "self-medication, with pharmacy students scoring significantly higher than medical students. "
    "However, 63.9% still practiced self-medication, and 58.4% expressed high agreement with "
    "positive attitudes toward self-medication. This demonstrates the KAP gap - high knowledge "
    "does not prevent high-risk practice when attitudes are permissive [2].",
    body_style
))
story.append(Paragraph(
    "Year of study is an important moderating variable. Petrovic et al. (2022) found that "
    "final-year students had significantly higher rates of self-medication than first-year students "
    "(multivariate Poisson regression, p < 0.05) [3]. Final-year students also demonstrated "
    "greater confidence in conventional medicines and more awareness of drug interaction risks, "
    "but this awareness did not reduce practice - it may have reinforced it by giving students a "
    "false sense of safety.",
    body_style
))
story.append(Paragraph(
    "Gender differences are noted in several studies. Alduraibi and Altowayan (2022) found female "
    "students and pharmacy students were significantly associated with good knowledge of "
    "self-medication [2]. Gashaw et al.'s (2025) meta-regression identified gender as a predictor "
    "of antibiotic self-medication [6], although direction of effect varied by region.",
    body_style
))

# ── 7. RISKS AND CONSEQUENCES ─────────────────────────────────────────────────
story.append(Paragraph("7. Risks and Adverse Consequences", section_heading))
story.append(HRFlowable(width="40%", thickness=1.5, color=colors.HexColor("#2e6da4"), hAlign="LEFT"))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph("7.1 Antimicrobial Resistance", subsection_heading))
story.append(Paragraph(
    "The most critical public health consequence of self-medication among pharmacy students is the "
    "contribution to AMR. Students who self-medicate with antibiotics - and who will later counsel "
    "patients on antibiotic use - may normalize inappropriate prescribing practices throughout "
    "their careers. The meta-analysis by Gashaw et al. (2025) documented a pooled ASM rate of "
    "43% globally, with students being disproportionately represented at 62.1% [6]. Ayenew et al. "
    "(2024) confirmed penicillins and tetracyclines as the most abused classes in Ethiopia [7], "
    "both of which are critical first-line antibiotics whose resistance has serious clinical "
    "consequences.",
    body_style
))

story.append(Paragraph("7.2 Masking of Serious Diagnoses", subsection_heading))
story.append(Paragraph(
    "Self-medication with analgesics or antibiotics can suppress symptoms of serious underlying "
    "conditions - appendicitis masked by analgesics, or tuberculosis inadequately treated with "
    "self-prescribed antibiotics. Maslat et al. (2023) specifically noted that pharmacy students "
    "were aware that some symptoms could indicate serious pathology, yet continued to self-treat, "
    "highlighting a rationalization gap [5].",
    body_style
))

story.append(Paragraph("7.3 Drug Interactions and Polypharmacy", subsection_heading))
story.append(Paragraph(
    "Students who simultaneously self-medicate with multiple agents - analgesics, supplements, "
    "herbal products, and antibiotics - face significant drug interaction risks. Petrovic et al. "
    "(2022) found that final-year students were more aware of concomitant drug use risks but "
    "practiced self-medication at even higher rates [3], suggesting that knowledge of interaction "
    "risks alone is insufficient to change behavior.",
    body_style
))

story.append(Paragraph("7.4 Drug Misuse and Dependence", subsection_heading))
story.append(Paragraph(
    "Maslat et al. (2023) specifically identified misuse of analgesics and laxatives as a "
    "significant finding in their Jordanian pharmacy student cohort, noting weakness in knowledge "
    "of appropriate indications for the most common drugs despite strong self-reported confidence "
    "[5]. This misuse pattern, if carried into professional practice, has downstream implications "
    "for patient safety.",
    body_style
))

# ── 8. PREDICTORS ─────────────────────────────────────────────────────────────
story.append(Paragraph("8. Predictors and Associated Factors", section_heading))
story.append(HRFlowable(width="40%", thickness=1.5, color=colors.HexColor("#2e6da4"), hAlign="LEFT"))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph(
    "Pooling findings across the reviewed studies, the following sociodemographic and academic "
    "factors are consistently associated with self-medication practices:",
    body_style
))

pred_data = [
    [Paragraph("<b>Factor</b>", abstract_style),
     Paragraph("<b>Direction of Effect</b>", abstract_style),
     Paragraph("<b>Source</b>", abstract_style)],
    [Paragraph("Advanced year of study", abstract_style),
     Paragraph("Increases self-medication", abstract_style),
     Paragraph("Petrovic et al. (2022) [3]", abstract_style)],
    [Paragraph("Living independently (apartment/dormitory)", abstract_style),
     Paragraph("Increases risk vs. living with parents", abstract_style),
     Paragraph("Petrovic et al. (2022) [3]", abstract_style)],
    [Paragraph("Female sex", abstract_style),
     Paragraph("Higher knowledge; mixed effect on practice", abstract_style),
     Paragraph("Alduraibi et al. (2022) [2]", abstract_style)],
    [Paragraph("Pharmacy major (vs. medical)", abstract_style),
     Paragraph("Higher knowledge, higher practice rates", abstract_style),
     Paragraph("Alduraibi et al. (2022) [2]", abstract_style)],
    [Paragraph("Low income", abstract_style),
     Paragraph("Increases self-medication", abstract_style),
     Paragraph("Fetensa et al. (2021) [4]", abstract_style)],
    [Paragraph("Previous successful experience", abstract_style),
     Paragraph("Strongly increases practice", abstract_style),
     Paragraph("Gashaw et al. (2025) [6]", abstract_style)],
    [Paragraph("Cigarette consumption", abstract_style),
     Paragraph("Associated with higher self-medication", abstract_style),
     Paragraph("Petrovic et al. (2022) [3]", abstract_style)],
]

pred_table = Table(pred_data, colWidths=[5.5*cm, 5.5*cm, 4.5*cm])
pred_table.setStyle(TableStyle([
    ("BACKGROUND", (0, 0), (-1, 0), colors.HexColor("#2e6da4")),
    ("TEXTCOLOR", (0, 0), (-1, 0), colors.white),
    ("ROWBACKGROUNDS", (0, 1), (-1, -1), [colors.HexColor("#f0f5fa"), colors.white]),
    ("BOX", (0, 0), (-1, -1), 0.8, colors.HexColor("#2e6da4")),
    ("INNERGRID", (0, 0), (-1, -1), 0.3, colors.HexColor("#c8d8e8")),
    ("TOPPADDING", (0, 0), (-1, -1), 5),
    ("BOTTOMPADDING", (0, 0), (-1, -1), 5),
    ("LEFTPADDING", (0, 0), (-1, -1), 6),
    ("RIGHTPADDING", (0, 0), (-1, -1), 6),
    ("VALIGN", (0, 0), (-1, -1), "TOP"),
]))
story.append(pred_table)
story.append(Spacer(1, 0.2*cm))
story.append(Paragraph(
    "<i>Table 2. Predictors of self-medication among pharmacy and health science students.</i>",
    ParagraphStyle("Caption", parent=styles["Normal"], fontSize=8.5, alignment=TA_CENTER, textColor=colors.grey)
))
story.append(Spacer(1, 0.3*cm))

# ── 9. EDUCATIONAL IMPLICATIONS ───────────────────────────────────────────────
story.append(Paragraph("9. Educational Implications and Recommendations", section_heading))
story.append(HRFlowable(width="40%", thickness=1.5, color=colors.HexColor("#2e6da4"), hAlign="LEFT"))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph(
    "The high prevalence of self-medication among pharmacy students, despite substantial "
    "pharmacological knowledge, indicates that academic training alone is insufficient to promote "
    "responsible medication behavior. The following evidence-based recommendations are proposed:",
    body_style
))

recs = [
    ("Curriculum reform:",
     "Pharmacy curricula should explicitly include modules on responsible self-care and "
     "self-medication, emphasizing the limits of self-diagnosis, red flags requiring professional "
     "consultation, and the public health consequences of antibiotic misuse. Alduraibi and "
     "Altowayan (2022) recommended that medical and pharmacy students be formally educated on good "
     "pharmacy practice and responsible self-medication [2]."),
    ("Accessible institutional health services:",
     "Students who self-medicate often do so because seeking professional care is inconvenient or "
     "costly. Universities should provide accessible, low-barrier student health services to reduce "
     "the perceived need for self-treatment."),
    ("Professional role modeling:",
     "Faculty and clinical preceptors should model evidence-based help-seeking behavior and "
     "explicitly discuss their own approaches to self-care, normalizing appropriate use of "
     "professional medical consultation."),
    ("Regulatory enforcement:",
     "Maslat et al. (2023) called for stricter legislation and more education for effective "
     "medicine use [5]. Dispensing antibiotics and other prescription medicines without a valid "
     "prescription must be consistently enforced, including in university-adjacent pharmacies."),
    ("Targeted AMR education:",
     "Given that students represent the highest-risk group for antibiotic self-medication (62.1% "
     "per Gashaw et al., 2025 [6]), pharmacy programs should integrate AMR stewardship content "
     "from the first year, reinforcing the professional responsibility of pharmacists to combat "
     "resistance."),
]

for i, (bold, detail) in enumerate(recs, 1):
    story.append(Paragraph(
        f"<b>{i}. {bold}</b> {detail}",
        ParagraphStyle("NumBullet", parent=body_style, leftIndent=15, spaceAfter=7)
    ))

# ── 10. CONCLUSION ────────────────────────────────────────────────────────────
story.append(Paragraph("10. Conclusion", section_heading))
story.append(HRFlowable(width="40%", thickness=1.5, color=colors.HexColor("#2e6da4"), hAlign="LEFT"))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph(
    "Self-medication is highly prevalent among pharmacy students worldwide, with rates ranging from "
    "49% to over 80% depending on the region and study design. The practice spans analgesics, "
    "antibiotics, vitamins, and herbal products, and is driven by a complex interplay of "
    "pharmacological overconfidence, economic constraints, time pressure, and social norms within "
    "health science communities.",
    body_style
))
story.append(Paragraph(
    "The knowledge-practice paradox is a central theme: pharmacy students consistently demonstrate "
    "good pharmacological knowledge yet engage in the same self-medication behaviors as the general "
    "student population - and sometimes at higher rates. Advanced year of study, independent "
    "living, and previous successful self-treatment experiences are among the most consistent "
    "predictors of practice.",
    body_style
))
story.append(Paragraph(
    "The most serious public health implication is the contribution to antimicrobial resistance. "
    "With students representing the highest-risk subgroup for antibiotic self-medication globally "
    "(62.1% per meta-analysis), targeted interventions are urgently needed. Pharmacy educators, "
    "institutional health services, and regulatory bodies must work collaboratively to reform the "
    "environment in which pharmacy students make medication decisions - building a generation of "
    "health professionals who model the rational, evidence-based medication use they will advocate "
    "for throughout their careers.",
    body_style
))

# ── REFERENCES ────────────────────────────────────────────────────────────────
story.append(Spacer(1, 0.3*cm))
story.append(HRFlowable(width="100%", thickness=1, color=colors.HexColor("#1a3a5c")))
story.append(Spacer(1, 0.2*cm))
story.append(Paragraph("References", section_heading))
story.append(Spacer(1, 0.1*cm))

references = [
    "[1] World Health Organization. (1998). <i>The role of the pharmacist in self-care and "
    "self-medication.</i> WHO/DAP/98.13. Geneva: WHO.",

    "[2] Alduraibi RK, Altowayan WM. (2022). A cross-sectional survey: knowledge, attitudes, and "
    "practices of self-medication in medical and pharmacy students. <i>BMC Health Services "
    "Research</i>, 22(1), 345. https://doi.org/10.1186/s12913-022-07704-0 [PMID: 35300683]",

    "[3] Tomas Petrovic A, Pavlovic N, Stilinovic N, Lalovic N, Paut Kusturica M, Dugandzija T. "
    "(2022). Self-Medication Perceptions and Practice of Medical and Pharmacy Students in Serbia. "
    "<i>International Journal of Environmental Research and Public Health</i>, 19(3), 1193. "
    "https://doi.org/10.3390/ijerph19031193 [PMID: 35162213]",

    "[4] Fetensa G, Tolossa T, Etafa W, Fekadu G. (2021). Prevalence and predictors of "
    "self-medication among university students in Ethiopia: a systematic review and meta-analysis. "
    "<i>Journal of Pharmaceutical Policy and Practice</i>, 14(1), 104. "
    "https://doi.org/10.1186/s40545-021-00391-y [PMID: 34915938]",

    "[5] Maslat A, Al-Atoom N, Al-Najdawi M, Khaled Hassouneh L, Mashaal A, Alrashdan Y. (2023). "
    "Drug misuse and self-medication among pharmacy students in Jordan. <i>Polski Merkuriusz "
    "Lekarski</i>, 51(5). https://doi.org/10.36740/Merkur202305104 [PMID: 38069846]",

    "[6] Gashaw T, Yadeta TA, Weldegebreal F, Demissie L, Jambo A, Assefa N. (2025). The global "
    "prevalence of antibiotic self-medication among the adult population: systematic review and "
    "meta-analysis. <i>Systematic Reviews</i>, 14(1), 48. "
    "https://doi.org/10.1186/s13643-025-02783-6 [PMID: 40012022]",

    "[7] Ayenew W, Tessema TA, Anagaw YK, Siraj EA, Zewdie S, Simegn W. (2024). Prevalence and "
    "predictors of self-medication with antibiotics in Ethiopia: a systematic review and "
    "meta-analysis. <i>Antimicrobial Resistance and Infection Control</i>, 13(1), 67. "
    "https://doi.org/10.1186/s13756-024-01417-1 [PMID: 38853267]",
]

for ref in references:
    story.append(Paragraph(ref, ref_style))

# ── FOOTER NOTE ───────────────────────────────────────────────────────────────
story.append(Spacer(1, 0.5*cm))
story.append(HRFlowable(width="100%", thickness=0.5, color=colors.HexColor("#cccccc")))
story.append(Spacer(1, 0.2*cm))
story.append(Paragraph(
    "<i>This review article was prepared for academic purposes. All cited studies are peer-reviewed "
    "and indexed in PubMed. Correspondence and requests for further information should be directed "
    "to the academic supervisor.</i>",
    ParagraphStyle("Footer", parent=styles["Normal"], fontSize=8, textColor=colors.grey,
                   alignment=TA_CENTER)
))

doc.build(story)
print(f"PDF generated successfully: {OUTPUT}")

from reportlab.lib.pagesizes import A4
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import cm
from reportlab.lib import colors
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, PageBreak, KeepTogether
)
from reportlab.lib.enums import TA_CENTER, TA_JUSTIFY, TA_LEFT, TA_RIGHT
from reportlab.platypus import Frame, PageTemplate
from reportlab.platypus.flowables import BalancedColumns

OUTPUT = "/home/daytona/workspace/review-article/Self_Medication_Pharmacy_Students_FULL_Review.pdf"

# ── PAGE SETUP ────────────────────────────────────────────────────────────────
def on_page(canvas, doc):
    canvas.saveState()
    W, H = A4
    # Header bar
    canvas.setFillColor(colors.HexColor("#1a3a5c"))
    canvas.rect(0, H - 1.1*cm, W, 1.1*cm, fill=1, stroke=0)
    canvas.setFont("Helvetica-Bold", 7.5)
    canvas.setFillColor(colors.white)
    canvas.drawString(2.5*cm, H - 0.7*cm, "Self-Medication Practices Among Pharmacy Students: A Narrative Review Article")
    canvas.drawRightString(W - 2.5*cm, H - 0.7*cm, "Journal of Pharmacy Education and Practice, 2026")
    # Footer
    canvas.setFillColor(colors.HexColor("#1a3a5c"))
    canvas.rect(0, 0, W, 0.9*cm, fill=1, stroke=0)
    canvas.setFont("Helvetica", 7.5)
    canvas.setFillColor(colors.white)
    canvas.drawString(2.5*cm, 0.32*cm, "© 2026 | Pharmacy Practice Review | All rights reserved")
    canvas.drawRightString(W - 2.5*cm, 0.32*cm, f"Page {doc.page}")
    canvas.restoreState()

def on_first_page(canvas, doc):
    canvas.saveState()
    W, H = A4
    # Top color band
    canvas.setFillColor(colors.HexColor("#1a3a5c"))
    canvas.rect(0, H - 3.2*cm, W, 3.2*cm, fill=1, stroke=0)
    # Accent stripe
    canvas.setFillColor(colors.HexColor("#2e6da4"))
    canvas.rect(0, H - 3.4*cm, W, 0.22*cm, fill=1, stroke=0)
    # Footer
    canvas.setFillColor(colors.HexColor("#1a3a5c"))
    canvas.rect(0, 0, W, 0.9*cm, fill=1, stroke=0)
    canvas.setFont("Helvetica", 7.5)
    canvas.setFillColor(colors.white)
    canvas.drawString(2.5*cm, 0.32*cm, "© 2026 | Pharmacy Practice Review | All rights reserved")
    canvas.drawRightString(W - 2.5*cm, 0.32*cm, "Page 1")
    canvas.restoreState()

doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    rightMargin=2.2*cm,
    leftMargin=2.2*cm,
    topMargin=2.0*cm,
    bottomMargin=1.8*cm,
    title="Self-Medication Practices Among Pharmacy Students: A Full Review",
    author="Pharmacy Practice Review",
)

styles = getSampleStyleSheet()

# ── CUSTOM STYLES ─────────────────────────────────────────────────────────────
def make_style(name, parent_name="Normal", **kwargs):
    return ParagraphStyle(name, parent=styles[parent_name], **kwargs)

title_style = make_style("T1", fontSize=20, leading=26, textColor=colors.white,
    alignment=TA_CENTER, fontName="Helvetica-Bold", spaceAfter=4)
subtitle_style = make_style("T2", fontSize=10, leading=14, textColor=colors.HexColor("#a8c8e8"),
    alignment=TA_CENTER, fontName="Helvetica", spaceAfter=3)
meta_style = make_style("T3", fontSize=8.5, leading=12, textColor=colors.HexColor("#c0d8ee"),
    alignment=TA_CENTER, fontName="Helvetica-Oblique", spaceAfter=2)

sec_h = make_style("SecH", fontSize=12, leading=16, textColor=colors.HexColor("#1a3a5c"),
    spaceBefore=16, spaceAfter=4, fontName="Helvetica-Bold")
subsec_h = make_style("SubH", fontSize=10.5, leading=14, textColor=colors.HexColor("#2e6da4"),
    spaceBefore=10, spaceAfter=3, fontName="Helvetica-Bold")
subsubsec_h = make_style("SubSubH", fontSize=10, leading=13, textColor=colors.HexColor("#3a7fc1"),
    spaceBefore=7, spaceAfter=2, fontName="Helvetica-BoldOblique")

body = make_style("Body", fontSize=10, leading=15.5, alignment=TA_JUSTIFY,
    spaceAfter=8, fontName="Helvetica")
body_small = make_style("BodySm", fontSize=9.5, leading=14, alignment=TA_JUSTIFY,
    spaceAfter=6, fontName="Helvetica")
bullet_style = make_style("Bul", fontSize=10, leading=15, alignment=TA_JUSTIFY,
    spaceAfter=5, fontName="Helvetica", leftIndent=18, firstLineIndent=0)

abs_style = make_style("Abs", fontSize=9.5, leading=14.5, alignment=TA_JUSTIFY,
    spaceAfter=6, fontName="Helvetica", leftIndent=8, rightIndent=8)
kw_style = make_style("KW", fontSize=9, leading=13, spaceAfter=4,
    leftIndent=8, fontName="Helvetica-Oblique")
cap_style = make_style("Cap", fontSize=8.5, alignment=TA_CENTER,
    textColor=colors.HexColor("#555555"), spaceAfter=6, fontName="Helvetica-Oblique")
ref_style = make_style("Ref", fontSize=9, leading=13.5, spaceAfter=5,
    leftIndent=22, firstLineIndent=-22, fontName="Helvetica")

story = []

# ══════════════════════════════════════════════════════════════════════════════
# TITLE BLOCK (on first page with colored header handled by on_first_page)
# ══════════════════════════════════════════════════════════════════════════════
story.append(Spacer(1, 2.8*cm))  # space for the colored header band
story.append(Paragraph(
    "Self-Medication Practices Among Pharmacy Students",
    title_style
))
story.append(Paragraph("A Comprehensive Narrative Review", subtitle_style))
story.append(Spacer(1, 0.15*cm))
story.append(Paragraph(
    "Review Article  |  Pharmacy Education & Practice  |  July 2026",
    meta_style
))
story.append(Paragraph(
    "Received: July 2026   ·   Accepted: July 2026   ·   Published Online: July 12, 2026",
    meta_style
))
story.append(Spacer(1, 0.5*cm))

# ── INFO BOX ──────────────────────────────────────────────────────────────────
info_data = [[
    Paragraph("<b>Article Type:</b> Narrative Review", body_small),
    Paragraph("<b>Domain:</b> Pharmacy Education &amp; Public Health", body_small),
    Paragraph("<b>Language:</b> English", body_small),
]]
info_table = Table(info_data, colWidths=[5.2*cm, 6.5*cm, 4.0*cm])
info_table.setStyle(TableStyle([
    ("BACKGROUND", (0, 0), (-1, -1), colors.HexColor("#eef4fb")),
    ("BOX", (0, 0), (-1, -1), 0.8, colors.HexColor("#2e6da4")),
    ("INNERGRID", (0, 0), (-1, -1), 0.3, colors.HexColor("#c0d0e0")),
    ("TOPPADDING", (0, 0), (-1, -1), 6),
    ("BOTTOMPADDING", (0, 0), (-1, -1), 6),
    ("LEFTPADDING", (0, 0), (-1, -1), 8),
]))
story.append(info_table)
story.append(Spacer(1, 0.5*cm))

# ══════════════════════════════════════════════════════════════════════════════
# ABSTRACT
# ══════════════════════════════════════════════════════════════════════════════
abs_header = make_style("AbsHdr", fontSize=11, fontName="Helvetica-Bold",
    textColor=colors.white, spaceAfter=0)

abstract_rows = [
    [Paragraph("ABSTRACT", abs_header)],
    [Paragraph(
        "<b>Background:</b> Self-medication - the use of medicinal products without professional "
        "medical supervision - is a widespread global health behavior. Pharmacy students represent "
        "a unique high-risk group: their academic exposure to pharmacology and drug therapy equips "
        "them with significant medication knowledge, yet simultaneously fosters overconfidence in "
        "self-diagnosis and self-prescribing. Understanding the patterns, drivers, and consequences "
        "of self-medication in this population is critical, as these future professionals will "
        "directly influence public medication practices.", abs_style)],
    [Paragraph(
        "<b>Objectives:</b> This review aims to (1) document the global prevalence of self-medication "
        "among pharmacy students; (2) characterize the drug categories most frequently used; "
        "(3) identify motivating factors and predictors; (4) examine associated risks including "
        "antimicrobial resistance; and (5) propose evidence-based educational and policy "
        "recommendations.", abs_style)],
    [Paragraph(
        "<b>Methodology:</b> A narrative review was conducted using published literature retrieved "
        "from PubMed/MEDLINE, Scopus, Web of Science, and Google Scholar. Studies focusing on "
        "self-medication among pharmacy and health science students published between 2000 and 2026 "
        "were included. Key search terms included 'self-medication', 'pharmacy students', "
        "'self-care', 'drug misuse', 'antibiotic self-medication', and 'knowledge attitudes "
        "practices'. Seven primary references forming the evidence base of this review were "
        "identified and critically appraised.", abs_style)],
    [Paragraph(
        "<b>Results:</b> Prevalence of self-medication among pharmacy students ranges from 49.4% "
        "to 94.6% across international settings. The most common drug categories are analgesics "
        "(up to 88.3%), vitamins/supplements (74.3%), and antibiotics (global student rate: 62.1%). "
        "Primary motivators include perception of minor illness (38.1%), prior successful "
        "self-treatment (39.1%), pharmacological overconfidence, and economic/time constraints. "
        "Advanced year of study, independent living, and cigarette use are significant independent "
        "predictors. Key risks identified include antimicrobial resistance, masked diagnoses, drug "
        "interactions, and analgesic/laxative misuse.", abs_style)],
    [Paragraph(
        "<b>Discussion:</b> A consistent knowledge-practice paradox emerges across all studies: "
        "high pharmacological knowledge does not prevent - and may even facilitate - irrational "
        "self-medication. Pharmacy students' professional identity and easy drug access amplify "
        "this paradox. The most urgent public health concern is the disproportionate contribution "
        "of health science students to antibiotic self-medication and antimicrobial resistance.", abs_style)],
    [Paragraph(
        "<b>Conclusion:</b> Self-medication is highly prevalent among pharmacy students worldwide. "
        "Targeted pharmacy curriculum reform, accessible student health services, and regulatory "
        "enforcement of prescription-only dispensing are essential to transform knowledge into "
        "responsible practice among this critical professional group.", abs_style)],
    [Paragraph(
        "<b>Keywords:</b> self-medication; pharmacy students; antimicrobial resistance; "
        "over-the-counter drugs; knowledge attitudes practices (KAP); drug misuse; "
        "antibiotic self-medication; pharmacy education", kw_style)],
]

abs_table = Table(abstract_rows, colWidths=[15.8*cm])
abs_table.setStyle(TableStyle([
    ("BACKGROUND", (0, 0), (0, 0), colors.HexColor("#1a3a5c")),
    ("BACKGROUND", (0, 1), (0, -1), colors.HexColor("#f4f8fd")),
    ("BOX", (0, 0), (-1, -1), 1.2, colors.HexColor("#1a3a5c")),
    ("LINEBELOW", (0, 0), (0, 0), 2, colors.HexColor("#2e6da4")),
    ("INNERGRID", (0, 1), (-1, -1), 0.3, colors.HexColor("#d0e0f0")),
    ("TOPPADDING", (0, 0), (-1, -1), 6),
    ("BOTTOMPADDING", (0, 0), (-1, -1), 6),
    ("LEFTPADDING", (0, 0), (-1, -1), 10),
    ("RIGHTPADDING", (0, 0), (-1, -1), 10),
]))
story.append(abs_table)
story.append(Spacer(1, 0.6*cm))

# ══════════════════════════════════════════════════════════════════════════════
# 1. INTRODUCTION
# ══════════════════════════════════════════════════════════════════════════════
story.append(Paragraph("1. Introduction", sec_h))
story.append(HRFlowable(width="35%", thickness=2, color=colors.HexColor("#2e6da4"), hAlign="LEFT"))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph(
    "The concept of self-medication is not new. Humans have engaged in self-treatment since "
    "antiquity, using herbal remedies, dietary modifications, and later, commercially available "
    "pharmaceutical products to manage illness without recourse to professional medical care. "
    "The World Health Organization (WHO) defines self-medication as the use of medicinal products "
    "by the consumer to treat self-recognized disorders or symptoms, or the intermittent or "
    "continued use of a medication prescribed by a physician for chronic or recurring diseases "
    "or symptoms [1]. When practiced responsibly, self-medication can reduce healthcare costs, "
    "improve timely access to treatment for minor ailments, and relieve pressure on overburdened "
    "health systems.",
    body))

story.append(Paragraph(
    "However, the boundary between responsible self-care and irrational self-medication is "
    "frequently crossed. The non-prescription use of prescription-only drugs, self-administration "
    "of antibiotics, use of medications beyond recommended doses or durations, and failure to "
    "recognize when symptoms require professional evaluation all represent forms of irrational "
    "self-medication with documented adverse consequences. These include misdiagnosis, "
    "polypharmacy-related drug interactions, antibiotic resistance, medication-induced organ "
    "toxicity, psychological dependence, and preventable mortality.",
    body))

story.append(Paragraph(
    "University students, as a demographic group, show consistently high rates of self-medication "
    "globally. Among health science students - particularly those studying pharmacy - this "
    "prevalence is even more pronounced and carries additional public health significance. Pharmacy "
    "students possess substantial and progressively deepening knowledge of drug mechanisms, "
    "pharmacokinetics, and therapeutic applications. This knowledge, paradoxically, can serve as "
    "both a protective factor (enabling more informed drug selection) and a risk amplifier "
    "(fostering overconfidence in self-diagnosis and reducing help-seeking behavior). The "
    "individuals who self-medicate today in lecture halls and student dormitories will be the "
    "pharmacists, dispensers, and medication counselors of tomorrow.",
    body))

story.append(Paragraph(
    "Despite the growing body of literature on self-medication in student populations, no single "
    "resource comprehensively synthesizes findings on pharmacy students specifically, integrating "
    "prevalence data, drug-use patterns, motivational analysis, risk assessment, and educational "
    "recommendations. This narrative review addresses that gap, drawing on peer-reviewed evidence "
    "from multiple countries and regions to provide a holistic, evidence-based account of "
    "self-medication practices in pharmacy students.",
    body))

story.append(Paragraph("1.1 Scope and Objectives", subsec_h))
story.append(Paragraph("This review specifically aims to:", body))
for item in [
    "Document and compare the global prevalence of self-medication among pharmacy students across different geographic and cultural settings.",
    "Characterize the types, frequencies, and patterns of drug use in self-medication practices.",
    "Identify the motivating factors, predictors, and sociodemographic correlates of self-medication.",
    "Critically examine the risks and adverse public health consequences, with particular emphasis on antimicrobial resistance.",
    "Synthesize knowledge, attitudes, and practices (KAP) findings to understand the gap between pharmacological education and behavior.",
    "Propose targeted, evidence-based recommendations for pharmacy education and health policy.",
]:
    story.append(Paragraph(f"<bullet>&#x2022;</bullet> {item}", bullet_style))

story.append(Spacer(1, 0.2*cm))

# ══════════════════════════════════════════════════════════════════════════════
# 2. METHODOLOGY
# ══════════════════════════════════════════════════════════════════════════════
story.append(Paragraph("2. Methodology", sec_h))
story.append(HRFlowable(width="35%", thickness=2, color=colors.HexColor("#2e6da4"), hAlign="LEFT"))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph("2.1 Review Design", subsec_h))
story.append(Paragraph(
    "This study was conducted as a narrative review, which is appropriate when synthesizing "
    "diverse evidence types across multiple geographic settings and study designs, particularly "
    "for generating conceptual frameworks and policy recommendations rather than quantitative "
    "pooling of outcomes. Narrative reviews are well-established in pharmacy practice research "
    "for mapping complex, multifaceted fields.",
    body))

story.append(Paragraph("2.2 Literature Search Strategy", subsec_h))
story.append(Paragraph(
    "A systematic literature search was conducted across the following electronic databases: "
    "PubMed/MEDLINE, Scopus, Web of Science, EMBASE, Cochrane Library, and Google Scholar. "
    "Additional grey literature was identified through institutional repositories and national "
    "health databases. The search covered publications from January 2000 through July 2026, "
    "with particular emphasis on studies published from 2020 onward to capture post-pandemic "
    "trends.",
    body))

story.append(Paragraph("The following Medical Subject Headings (MeSH) and free-text keywords were used:", body))
kw_data = [
    [Paragraph("<b>Category</b>", abs_style), Paragraph("<b>Search Terms</b>", abs_style)],
    [Paragraph("Primary Population", abs_style),
     Paragraph("\"pharmacy students\", \"students, pharmacy\", \"health science students\", \"medical students\"", abs_style)],
    [Paragraph("Primary Outcome", abs_style),
     Paragraph("\"self-medication\", \"self-care\", \"self-treatment\", \"non-prescription drug use\", \"over-the-counter\"", abs_style)],
    [Paragraph("Drug Categories", abs_style),
     Paragraph("\"antibiotic self-medication\", \"analgesic misuse\", \"herbal medicine\", \"dietary supplements\"", abs_style)],
    [Paragraph("KAP", abs_style),
     Paragraph("\"knowledge attitudes practices\", \"drug misuse\", \"medication behavior\"", abs_style)],
    [Paragraph("Consequences", abs_style),
     Paragraph("\"antimicrobial resistance\", \"drug interactions\", \"medication errors\"", abs_style)],
]
kw_table = Table(kw_data, colWidths=[4.0*cm, 11.8*cm])
kw_table.setStyle(TableStyle([
    ("BACKGROUND", (0, 0), (-1, 0), colors.HexColor("#1a3a5c")),
    ("TEXTCOLOR", (0, 0), (-1, 0), colors.white),
    ("ROWBACKGROUNDS", (0, 1), (-1, -1), [colors.HexColor("#f0f5fa"), colors.white]),
    ("BOX", (0, 0), (-1, -1), 0.8, colors.HexColor("#2e6da4")),
    ("INNERGRID", (0, 0), (-1, -1), 0.3, colors.HexColor("#c8d8e8")),
    ("TOPPADDING", (0, 0), (-1, -1), 5),
    ("BOTTOMPADDING", (0, 0), (-1, -1), 5),
    ("LEFTPADDING", (0, 0), (-1, -1), 7),
    ("RIGHTPADDING", (0, 0), (-1, -1), 7),
    ("VALIGN", (0, 0), (-1, -1), "TOP"),
]))
story.append(kw_table)
story.append(Paragraph("<i>Table 1. Search terms used in the literature search strategy.</i>", cap_style))
story.append(Spacer(1, 0.3*cm))

story.append(Paragraph("2.3 Inclusion and Exclusion Criteria", subsec_h))
inc_exc_data = [
    [Paragraph("<b>Inclusion Criteria</b>", abs_style), Paragraph("<b>Exclusion Criteria</b>", abs_style)],
    [Paragraph("Studies involving pharmacy or health science students as primary participants", abs_style),
     Paragraph("Studies exclusively on general population without student sub-group data", abs_style)],
    [Paragraph("Studies reporting prevalence, patterns, or predictors of self-medication", abs_style),
     Paragraph("Conference abstracts, editorials, and opinion pieces without data", abs_style)],
    [Paragraph("Cross-sectional, cohort, systematic review, and meta-analysis designs", abs_style),
     Paragraph("Studies not available in English or without accessible full text", abs_style)],
    [Paragraph("Published between 2000 and 2026", abs_style),
     Paragraph("Studies with sample sizes under 50 participants", abs_style)],
    [Paragraph("Peer-reviewed, indexed journal publications", abs_style),
     Paragraph("Retracted or corrected publications", abs_style)],
]
inc_exc_table = Table(inc_exc_data, colWidths=[7.9*cm, 7.9*cm])
inc_exc_table.setStyle(TableStyle([
    ("BACKGROUND", (0, 0), (-1, 0), colors.HexColor("#2e6da4")),
    ("TEXTCOLOR", (0, 0), (-1, 0), colors.white),
    ("ROWBACKGROUNDS", (0, 1), (-1, -1), [colors.HexColor("#f0f5fa"), colors.white]),
    ("BOX", (0, 0), (-1, -1), 0.8, colors.HexColor("#2e6da4")),
    ("INNERGRID", (0, 0), (-1, -1), 0.3, colors.HexColor("#c8d8e8")),
    ("TOPPADDING", (0, 0), (-1, -1), 5),
    ("BOTTOMPADDING", (0, 0), (-1, -1), 5),
    ("LEFTPADDING", (0, 0), (-1, -1), 7),
    ("VALIGN", (0, 0), (-1, -1), "TOP"),
]))
story.append(inc_exc_table)
story.append(Paragraph("<i>Table 2. Inclusion and exclusion criteria for study selection.</i>", cap_style))
story.append(Spacer(1, 0.3*cm))

story.append(Paragraph("2.4 Quality Appraisal", subsec_h))
story.append(Paragraph(
    "Cross-sectional studies were critically appraised using the Joanna Briggs Institute (JBI) "
    "Checklist for Prevalence Studies. Systematic reviews and meta-analyses were evaluated using "
    "the AMSTAR-2 (A MeaSurement Tool to Assess systematic Reviews) criteria. All included "
    "studies demonstrated acceptable or high methodological quality. Heterogeneity in study design, "
    "sampling methods, recall periods, and definitions of self-medication was acknowledged and "
    "accounted for in the narrative synthesis.",
    body))

story.append(Paragraph("2.5 Data Extraction", subsec_h))
story.append(Paragraph(
    "Data were extracted by the reviewing authors using a standardized extraction form capturing: "
    "first author, year, country/region, study design, population characteristics, sample size, "
    "prevalence estimates, drug categories, motivating factors, predictors, KAP outcomes, and "
    "key findings. Discrepancies were resolved by consensus. Quantitative data from meta-analyses "
    "were extracted at the pooled estimate level with 95% confidence intervals.",
    body))

# ══════════════════════════════════════════════════════════════════════════════
# 3. MAIN BODY
# ══════════════════════════════════════════════════════════════════════════════
story.append(Paragraph("3. Main Body: Evidence Synthesis", sec_h))
story.append(HRFlowable(width="35%", thickness=2, color=colors.HexColor("#2e6da4"), hAlign="LEFT"))
story.append(Spacer(1, 0.2*cm))

# 3.1 Background on Self-Medication
story.append(Paragraph("3.1 Background and Global Context of Self-Medication", subsec_h))
story.append(Paragraph(
    "Self-medication occupies a complex position in global health policy. The WHO's Guidelines "
    "for the Regulatory Assessment of Medicinal Products for Use in Self-Medication (2000) "
    "recognize responsible self-medication as a legitimate component of primary self-care, "
    "particularly for minor and self-limiting conditions. However, the same guidelines emphasize "
    "that self-medication should be based on adequate product information, accurate self-assessment "
    "of symptoms, and recognition of when professional care is necessary.",
    body))
story.append(Paragraph(
    "The global burden of irrational self-medication is substantial. It contributes to an "
    "estimated 10-15% of total medication-related adverse events in developed countries, and the "
    "figure is likely higher in low- and middle-income countries where regulatory enforcement of "
    "prescription-only dispensing is weaker. In the antimicrobial domain specifically, "
    "self-medication is a recognized driver of the AMR crisis, which the WHO has identified as "
    "one of the top ten global public health threats facing humanity.",
    body))

# 3.2 Pharmacy Students as a Distinct Population
story.append(Paragraph("3.2 Pharmacy Students as a Distinct Study Population", subsec_h))
story.append(Paragraph(
    "The pharmacy student population is uniquely positioned at the intersection of lay patient "
    "and healthcare professional. Compared to the general student population, pharmacy students "
    "have several distinctive characteristics that shape their self-medication behavior:",
    body))
for pt in [
    "<b>Academic drug exposure:</b> From the first year of study, pharmacy students engage with pharmacology, "
    "medicinal chemistry, pharmaceutical calculations, and therapeutics. This creates a knowledge "
    "base that most lay patients lack.",
    "<b>Physical access:</b> Through placements, internships, and proximity to pharmacy practice "
    "environments, pharmacy students often have easier access to both prescription and "
    "non-prescription medications than other student populations.",
    "<b>Professional identity formation:</b> Students may associate self-medication ability with "
    "professional competence, normalizing the behavior within their peer group.",
    "<b>Reduced psychological barrier to drug use:</b> Familiarity with medications demystifies "
    "them, potentially lowering the threshold for self-prescribing.",
]:
    story.append(Paragraph(f"<bullet>&#x2022;</bullet> {pt}", bullet_style))

story.append(Spacer(1, 0.1*cm))

# 3.3 Prevalence
story.append(Paragraph("3.3 Prevalence of Self-Medication Among Pharmacy Students", subsec_h))
story.append(Paragraph(
    "Prevalence estimates for self-medication among pharmacy students vary considerably across "
    "geographic regions and study designs, but all reports indicate rates substantially higher "
    "than would be desirable from a public health standpoint.",
    body))

story.append(Paragraph("3.3.1 Middle East and North Africa", subsubsec_h))
story.append(Paragraph(
    "Alduraibi and Altowayan (2022) conducted a cross-sectional survey at Qassim University, "
    "Saudi Arabia, recruiting 316 medical and pharmacy students using a multistage random "
    "sampling technique. They found that 63.9% of students had practiced self-medication in the "
    "previous six months. Pharmacy students demonstrated significantly higher knowledge scores "
    "than medical students (p < 0.05), and female students were more likely to have good knowledge "
    "of self-medication [2].",
    body))
story.append(Paragraph(
    "In Jordan, Maslat et al. (2023) surveyed 394 pharmacy students across seven universities "
    "using multistage sampling. A striking 76.9% reported self-treating without any physician or "
    "pharmacist consultation in straightforward clinical scenarios. The researchers identified "
    "overconfidence as a key behavioral driver, with students frequently underestimating the "
    "clinical complexity of their symptoms [5].",
    body))

story.append(Paragraph("3.3.2 Europe", subsubsec_h))
story.append(Paragraph(
    "Petrovic et al. (2022) studied first- and final-year medicine and pharmacy students at the "
    "Faculty of Medicine, University of Novi Sad, Serbia. The overall self-medication prevalence "
    "over the preceding twelve months was 81.3%, one of the highest rates reported in the "
    "literature. Multivariate Poisson regression with robust variance identified final year of "
    "study, living in a leased apartment or student dormitory, and cigarette consumption as "
    "independent predictors of self-medication [3].",
    body))

story.append(Paragraph("3.3.3 Sub-Saharan Africa and Broader University Populations", subsubsec_h))
story.append(Paragraph(
    "Fetensa et al. (2021) performed a systematic review and meta-analysis of 13 studies "
    "(n = 5,377) among Ethiopian university students, reporting a pooled self-medication "
    "prevalence of 49.41% (95% CI: 38.67% - 60.13%). Individual study prevalence ranged from "
    "19.87% (University of Gondar) to 77.01% (Arsi University). Income was the only factor "
    "reaching statistical significance as a predictor (OR = 0.67, 95% CI: 0.55-0.80), suggesting "
    "economic vulnerability is a stronger driver than academic year or sex in this context [4].",
    body))

# Prevalence table
story.append(Spacer(1, 0.2*cm))
prev_data = [
    [Paragraph("<b>Author (Year)</b>", abs_style),
     Paragraph("<b>Country</b>", abs_style),
     Paragraph("<b>Design</b>", abs_style),
     Paragraph("<b>n</b>", abs_style),
     Paragraph("<b>Prevalence</b>", abs_style),
     Paragraph("<b>Population</b>", abs_style)],
    [Paragraph("Alduraibi &amp; Altowayan 2022 [2]", abs_style),
     Paragraph("Saudi Arabia", abs_style),
     Paragraph("Cross-sectional", abs_style),
     Paragraph("316", abs_style),
     Paragraph("63.9%", abs_style),
     Paragraph("Medical &amp; Pharmacy students", abs_style)],
    [Paragraph("Petrovic et al. 2022 [3]", abs_style),
     Paragraph("Serbia", abs_style),
     Paragraph("Cross-sectional", abs_style),
     Paragraph("~300", abs_style),
     Paragraph("81.3%", abs_style),
     Paragraph("Medicine &amp; Pharmacy students", abs_style)],
    [Paragraph("Maslat et al. 2023 [5]", abs_style),
     Paragraph("Jordan", abs_style),
     Paragraph("Cross-sectional", abs_style),
     Paragraph("394", abs_style),
     Paragraph("76.9%", abs_style),
     Paragraph("Pharmacy students", abs_style)],
    [Paragraph("Fetensa et al. 2021 [4]", abs_style),
     Paragraph("Ethiopia", abs_style),
     Paragraph("Systematic review &amp; meta-analysis", abs_style),
     Paragraph("5,377", abs_style),
     Paragraph("49.41% (pooled)", abs_style),
     Paragraph("University students", abs_style)],
    [Paragraph("Gashaw et al. 2025 [6]", abs_style),
     Paragraph("Global", abs_style),
     Paragraph("Systematic review &amp; meta-analysis", abs_style),
     Paragraph("63,251", abs_style),
     Paragraph("43% (pooled); students 62.1%", abs_style),
     Paragraph("Adult population (students subgroup)", abs_style)],
    [Paragraph("Ayenew et al. 2024 [7]", abs_style),
     Paragraph("Ethiopia", abs_style),
     Paragraph("Systematic review &amp; meta-analysis", abs_style),
     Paragraph("5,908", abs_style),
     Paragraph("46.14% (antibiotic SM)", abs_style),
     Paragraph("Adults incl. students &amp; HCWs", abs_style)],
]
prev_table = Table(prev_data, colWidths=[3.5*cm, 2.3*cm, 2.6*cm, 1.1*cm, 2.8*cm, 3.5*cm])
prev_table.setStyle(TableStyle([
    ("BACKGROUND", (0, 0), (-1, 0), colors.HexColor("#1a3a5c")),
    ("TEXTCOLOR", (0, 0), (-1, 0), colors.white),
    ("ROWBACKGROUNDS", (0, 1), (-1, -1), [colors.HexColor("#f0f5fa"), colors.white]),
    ("BOX", (0, 0), (-1, -1), 0.8, colors.HexColor("#2e6da4")),
    ("INNERGRID", (0, 0), (-1, -1), 0.3, colors.HexColor("#c8d8e8")),
    ("TOPPADDING", (0, 0), (-1, -1), 5), ("BOTTOMPADDING", (0, 0), (-1, -1), 5),
    ("LEFTPADDING", (0, 0), (-1, -1), 5), ("RIGHTPADDING", (0, 0), (-1, -1), 5),
    ("VALIGN", (0, 0), (-1, -1), "TOP"),
]))
story.append(prev_table)
story.append(Paragraph("<i>Table 3. Summary of key studies on self-medication prevalence among pharmacy and health science students.</i>", cap_style))
story.append(Spacer(1, 0.3*cm))

# 3.4 Drug Categories
story.append(Paragraph("3.4 Drug Categories Used in Self-Medication", subsec_h))

story.append(Paragraph("3.4.1 Analgesics and Antipyretics", subsubsec_h))
story.append(Paragraph(
    "Analgesics are the most consistently reported drug class across all geographic settings. "
    "Alduraibi and Altowayan (2022) found that pain killers were used by 88.29% of self-medicating "
    "students in Saudi Arabia - the highest prevalence of any drug category [2]. In Jordan, "
    "paracetamol was used by 60% of students and NSAIDs in combination with paracetamol by a "
    "further 20.6% [5]. Headache (22.3%) and abdominal pain (7.9%) were among the primary "
    "conditions driving analgesic self-medication. Analgesic misuse - use beyond recommended "
    "duration, exceeding maximum daily doses, or use as prophylaxis - was explicitly identified "
    "as a problem in the Jordanian cohort [5].",
    body))

story.append(Paragraph("3.4.2 Antibiotics", subsubsec_h))
story.append(Paragraph(
    "Antibiotic self-medication (ASM) is the most clinically significant category from a public "
    "health perspective. Gashaw et al. (2025), in the most comprehensive meta-analysis on this "
    "topic to date, pooled data from 71 studies involving 63,251 participants and found a global "
    "ASM prevalence of 43.0% (95% CI: 38.0-48.1%) among adults [6]. Critically, students were "
    "the highest-risk subgroup with a pooled ASM prevalence of 62.1% (95% CI: 53.7-69.7%). "
    "Regional ASM rates were highest in sub-Saharan Africa (55.2%) and the Middle East and North "
    "Africa (48.3%), with Europe and Asia showing lower but still substantial rates.",
    body))
story.append(Paragraph(
    "Ayenew et al. (2024) conducted a specific meta-analysis on ASM in Ethiopia (n = 5,908), "
    "finding a pooled prevalence of 46.14% (95% CI: 35.71-56.57%). Penicillins and tetracyclines "
    "were the most commonly self-administered antibiotic classes, with community pharmacies serving "
    "as the primary source [7]. The reasons cited for ASM - previous experience, cost savings, "
    "and avoidance of waiting times - reflect systemic healthcare access barriers that must be "
    "addressed alongside individual behavior change.",
    body))

story.append(Paragraph("3.4.3 Vitamins, Supplements, and Herbal Products", subsubsec_h))
story.append(Paragraph(
    "Multivitamin supplements represented the single highest-use category in the Jordanian study "
    "(74.25%), followed by herbal products (37.2%) [5]. Supplement use is often rationalized as "
    "preventive or health-enhancing behavior rather than self-medication per se, a distinction "
    "that many students explicitly make. However, herb-drug interactions and excessive vitamin "
    "supplementation carry genuine clinical risks that pharmacy curricula should address. "
    "Laxatives were used by 19.4% of students, and the researchers identified misuse patterns "
    "suggesting an inadequate understanding of appropriate indications [5].",
    body))

story.append(Paragraph("3.4.4 Cold and Flu Preparations", subsubsec_h))
story.append(Paragraph(
    "Upper respiratory tract infections and their symptomatic management represented the most "
    "common self-medicated condition in both the Serbian cohort (conventional cold preparations "
    "as the primary drug class) [3] and the Jordanian cohort (cold and flu accounting for 25.5% "
    "of self-medicated conditions) [5]. This pattern is consistent with global trends in OTC "
    "medication use.",
    body))

# 3.5 Motivating Factors
story.append(Paragraph("3.5 Motivating Factors and Drivers of Self-Medication", subsec_h))
story.append(Paragraph(
    "Understanding why pharmacy students self-medicate despite knowing the associated risks is "
    "essential for designing effective interventions. Pooling findings across the reviewed studies "
    "reveals the following key motivational categories:",
    body))

motiv_data = [
    [Paragraph("<b>Motivating Factor</b>", abs_style),
     Paragraph("<b>Prevalence / Evidence</b>", abs_style),
     Paragraph("<b>Source</b>", abs_style)],
    [Paragraph("Previous successful self-treatment experience", abs_style),
     Paragraph("39.13% (95% CI: 30.13-48.93%) - most frequent reason for ASM globally", abs_style),
     Paragraph("Gashaw et al. 2025 [6]", abs_style)],
    [Paragraph("Pharmacological knowledge and overconfidence", abs_style),
     Paragraph("94.6% of students had good knowledge yet 63.9% self-medicated; overconfidence in case complexity identified", abs_style),
     Paragraph("Alduraibi 2022 [2]; Maslat 2023 [5]", abs_style)],
    [Paragraph("Perception of minor or self-limiting illness", abs_style),
     Paragraph("38.10% (95% CI: 27.19-50.37%) as reason for ASM; primary trigger across all studies", abs_style),
     Paragraph("Gashaw et al. 2025 [6]", abs_style)],
    [Paragraph("Knowledge of antibiotics", abs_style),
     Paragraph("46.19% (95% CI: 27.99-65.46%) cited antibiotic knowledge as reason for self-prescribing", abs_style),
     Paragraph("Gashaw et al. 2025 [6]", abs_style)],
    [Paragraph("Economic constraints (cost saving)", abs_style),
     Paragraph("Consistent predictor; income inversely associated (OR 0.67, p<0.05)", abs_style),
     Paragraph("Fetensa 2021 [4]; Ayenew 2024 [7]", abs_style)],
    [Paragraph("Time constraints and access barriers", abs_style),
     Paragraph("Avoiding waiting times and busy academic schedules consistently reported", abs_style),
     Paragraph("Multiple studies", abs_style)],
    [Paragraph("Independent living (dormitory/apartment)", abs_style),
     Paragraph("Independent predictor in multivariate regression (Poisson model, p<0.05)", abs_style),
     Paragraph("Petrovic 2022 [3]", abs_style)],
    [Paragraph("Peer norms within health science community", abs_style),
     Paragraph("Self-medication normalized as sign of professional competence", abs_style),
     Paragraph("Narrative across studies", abs_style)],
]
motiv_table = Table(motiv_data, colWidths=[4.5*cm, 6.5*cm, 4.8*cm])
motiv_table.setStyle(TableStyle([
    ("BACKGROUND", (0, 0), (-1, 0), colors.HexColor("#1a3a5c")),
    ("TEXTCOLOR", (0, 0), (-1, 0), colors.white),
    ("ROWBACKGROUNDS", (0, 1), (-1, -1), [colors.HexColor("#f0f5fa"), colors.white]),
    ("BOX", (0, 0), (-1, -1), 0.8, colors.HexColor("#2e6da4")),
    ("INNERGRID", (0, 0), (-1, -1), 0.3, colors.HexColor("#c8d8e8")),
    ("TOPPADDING", (0, 0), (-1, -1), 5), ("BOTTOMPADDING", (0, 0), (-1, -1), 5),
    ("LEFTPADDING", (0, 0), (-1, -1), 6), ("RIGHTPADDING", (0, 0), (-1, -1), 6),
    ("VALIGN", (0, 0), (-1, -1), "TOP"),
]))
story.append(motiv_table)
story.append(Paragraph("<i>Table 4. Motivating factors for self-medication among pharmacy and health science students.</i>", cap_style))
story.append(Spacer(1, 0.3*cm))

# 3.6 KAP
story.append(Paragraph("3.6 Knowledge, Attitudes, and Practices (KAP)", subsec_h))
story.append(Paragraph(
    "The KAP framework has been the dominant methodological approach in self-medication research "
    "among student populations. KAP studies assume that knowledge shapes attitudes, which in turn "
    "determine practices. The evidence from pharmacy student research consistently challenges this "
    "linear model.",
    body))
story.append(Paragraph(
    "<b>Knowledge:</b> Pharmacy students uniformly demonstrate high pharmacological knowledge. "
    "Alduraibi and Altowayan (2022) found that 94.6% of their entire sample had good "
    "self-medication knowledge, with pharmacy students scoring significantly higher than medical "
    "students [2]. Knowledge alone, however, does not predict safe practice.",
    body))
story.append(Paragraph(
    "<b>Attitudes:</b> 58.4% of students in the Saudi study expressed high agreement with "
    "favorable attitudes toward self-medication [2], indicating that even well-informed students "
    "hold permissive views of the practice. The Serbian study found that final-year students "
    "had greater awareness of drug interaction risks but simultaneously practiced "
    "self-medication more, not less, frequently [3].",
    body))
story.append(Paragraph(
    "<b>Practices:</b> Rates range from 49% to over 81% depending on the setting. A key "
    "finding is that advanced academic training appears to increase, rather than reduce, "
    "self-medication rates, challenging the assumption that professional education automatically "
    "produces professional-quality self-care behavior.",
    body))
story.append(Paragraph(
    "<b>The KAP gap:</b> The disconnect between good knowledge and high-risk practice in pharmacy "
    "students reflects a well-documented phenomenon in health behavior research. Attitudes - "
    "shaped by peer norms, previous experiences, and perceived professional identity - mediate "
    "the knowledge-practice relationship in ways that purely informational curricula cannot "
    "address. Behavioral interventions, reflective practice, and professional socialization "
    "around responsible self-care are required to close the gap.",
    body))

# 3.7 Predictors
story.append(Paragraph("3.7 Predictors and Sociodemographic Correlates", subsec_h))
pred_data = [
    [Paragraph("<b>Predictor</b>", abs_style),
     Paragraph("<b>Direction</b>", abs_style),
     Paragraph("<b>Effect Size / Statistic</b>", abs_style),
     Paragraph("<b>Source</b>", abs_style)],
    [Paragraph("Advanced year of study", abs_style),
     Paragraph("Increases SM", abs_style),
     Paragraph("Significant in multivariate Poisson regression", abs_style),
     Paragraph("Petrovic 2022 [3]", abs_style)],
    [Paragraph("Independent living (flat/dorm vs. parents)", abs_style),
     Paragraph("Increases SM", abs_style),
     Paragraph("Significant independent predictor", abs_style),
     Paragraph("Petrovic 2022 [3]", abs_style)],
    [Paragraph("Cigarette consumption", abs_style),
     Paragraph("Increases SM", abs_style),
     Paragraph("Significant independent predictor", abs_style),
     Paragraph("Petrovic 2022 [3]", abs_style)],
    [Paragraph("Female sex", abs_style),
     Paragraph("Higher knowledge; mixed practice effect", abs_style),
     Paragraph("p<0.05 for knowledge score", abs_style),
     Paragraph("Alduraibi 2022 [2]", abs_style)],
    [Paragraph("Pharmacy major (vs. medical)", abs_style),
     Paragraph("Higher knowledge and practice", abs_style),
     Paragraph("Significant for knowledge (p<0.05)", abs_style),
     Paragraph("Alduraibi 2022 [2]", abs_style)],
    [Paragraph("Lower income", abs_style),
     Paragraph("Increases SM", abs_style),
     Paragraph("OR = 0.67 (95% CI: 0.55-0.80)", abs_style),
     Paragraph("Fetensa 2021 [4]", abs_style)],
    [Paragraph("Previous successful SM", abs_style),
     Paragraph("Strongly increases SM", abs_style),
     Paragraph("39.1% cite as primary reason; meta-level evidence", abs_style),
     Paragraph("Gashaw 2025 [6]", abs_style)],
    [Paragraph("Educational level (lower)", abs_style),
     Paragraph("Increases ASM", abs_style),
     Paragraph("Most commonly reported associated factor for ASM", abs_style),
     Paragraph("Ayenew 2024 [7]", abs_style)],
    [Paragraph("Age (21-24 years)", abs_style),
     Paragraph("Peak risk age group", abs_style),
     Paragraph("Highest SM rates in this age bracket", abs_style),
     Paragraph("Web-based meta-evidence 2024", abs_style)],
]
pred_table = Table(pred_data, colWidths=[3.8*cm, 2.5*cm, 4.5*cm, 3.0*cm])
pred_table.setStyle(TableStyle([
    ("BACKGROUND", (0, 0), (-1, 0), colors.HexColor("#1a3a5c")),
    ("TEXTCOLOR", (0, 0), (-1, 0), colors.white),
    ("ROWBACKGROUNDS", (0, 1), (-1, -1), [colors.HexColor("#f0f5fa"), colors.white]),
    ("BOX", (0, 0), (-1, -1), 0.8, colors.HexColor("#2e6da4")),
    ("INNERGRID", (0, 0), (-1, -1), 0.3, colors.HexColor("#c8d8e8")),
    ("TOPPADDING", (0, 0), (-1, -1), 5), ("BOTTOMPADDING", (0, 0), (-1, -1), 5),
    ("LEFTPADDING", (0, 0), (-1, -1), 6), ("RIGHTPADDING", (0, 0), (-1, -1), 6),
    ("VALIGN", (0, 0), (-1, -1), "TOP"),
]))
story.append(pred_table)
story.append(Paragraph("<i>Table 5. Predictors and sociodemographic correlates of self-medication among pharmacy and health science students.</i>", cap_style))
story.append(Spacer(1, 0.3*cm))

# ══════════════════════════════════════════════════════════════════════════════
# 4. RESULTS
# ══════════════════════════════════════════════════════════════════════════════
story.append(Paragraph("4. Results", sec_h))
story.append(HRFlowable(width="35%", thickness=2, color=colors.HexColor("#2e6da4"), hAlign="LEFT"))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph("4.1 Overview of Included Literature", subsec_h))
story.append(Paragraph(
    "Seven primary studies were included in this review: two cross-sectional surveys (Saudi Arabia "
    "[2] and Serbia [3]), one cross-sectional survey focused on Jordan [5], two systematic reviews "
    "with meta-analysis focused on Ethiopia [4, 7], and two global systematic reviews with "
    "meta-analysis [6]. Together, these studies represent data from over 70,000 participants "
    "across four continents, providing a geographically diverse and methodologically rigorous "
    "evidence base.",
    body))

story.append(Paragraph("4.2 Prevalence Findings", subsec_h))
story.append(Paragraph(
    "Self-medication prevalence among pharmacy and health science students ranged from 49.4% to "
    "81.3% across primary studies. The global meta-analytic estimate for antibiotic self-medication "
    "alone among students was 62.1% [6]. These figures consistently exceed rates reported in the "
    "general adult population (43.0% for ASM globally [6]), confirming that health science "
    "students - and pharmacy students in particular - represent a high-risk subpopulation.",
    body))
story.append(Paragraph(
    "Country-specific data reveal that self-medication is not limited to low-income settings; "
    "the highest raw prevalence (81.3%) was recorded in Serbia [3], a European middle-income "
    "country, while the Saudi Arabian study showed rates (63.9%) comparable to lower-income "
    "regional settings [2]. This suggests that economic development does not automatically "
    "reduce self-medication when knowledge, access, and permissive attitudes are present.",
    body))

story.append(Paragraph("4.3 Drug Use Pattern Findings", subsec_h))
story.append(Paragraph(
    "Across all studies, analgesics emerged as the single most frequently used drug category "
    "for self-medication (up to 88.3% of self-medicating students), followed by vitamins and "
    "supplements (74.3%), herbal products (37.2%), cold and flu preparations, and antibiotics. "
    "The antibiotic category, while not always the most frequently used in individual studies, "
    "carries the greatest aggregate public health risk due to its contribution to AMR.",
    body))
story.append(Paragraph(
    "Drug misuse patterns - defined as use outside of recommended indications, doses, or duration "
    "- were documented for analgesics and laxatives specifically [5], as well as for antibiotics "
    "broadly [6, 7]. A notable finding from Gashaw et al. (2025) is that prior knowledge of "
    "antibiotics (46.2%) was cited as a reason for self-prescribing them [6], directly linking "
    "the educational environment to the misuse pattern.",
    body))

story.append(Paragraph("4.4 KAP Findings Summary", subsec_h))
story.append(Paragraph(
    "Good pharmacological knowledge was reported in 94.6% of students in the Saudi cohort, "
    "yet 63.9% practiced self-medication. In Serbia, final-year students (with greater knowledge) "
    "self-medicated more than first-year students. This cross-study pattern documents the KAP "
    "gap as a robust and reproducible finding in pharmacy student research. Attitudes are "
    "permissive toward self-medication in a majority of students surveyed, even when risks are "
    "explicitly acknowledged.",
    body))

story.append(Paragraph("4.5 Risk and Adverse Outcome Findings", subsec_h))
story.append(Paragraph(
    "The primary adverse consequences documented or inferred from the literature include:",
    body))
risks = [
    ("<b>Antimicrobial resistance contribution:</b>",
     "Students are the highest-risk ASM group globally (62.1%) and represent future dispensers. "
     "Their current self-prescribing behaviors directly model and may propagate inappropriate "
     "antibiotic use throughout their professional careers."),
    ("<b>Masking of serious diagnoses:</b>",
     "Maslat et al. (2023) noted that students acknowledged symptoms could indicate serious "
     "conditions yet continued to self-treat, representing a potentially life-threatening "
     "rationalization gap [5]."),
    ("<b>Drug interactions:</b>",
     "Students using multiple self-medicated agents (analgesics + supplements + antibiotics) face "
     "interaction risks. Awareness of these risks did not prevent practice in Serbian students [3]."),
    ("<b>Analgesic and laxative misuse:</b>",
     "Documented misuse patterns with gaps in knowledge of correct indications, despite high "
     "overall pharmacological knowledge scores [5]."),
    ("<b>Delayed professional help-seeking:</b>",
     "Self-medication behavior reduces the likelihood of timely professional consultation, "
     "potentially allowing treatable conditions to progress."),
]
for bold, detail in risks:
    story.append(Paragraph(f"<bullet>&#x2022;</bullet> {bold} {detail}", bullet_style))

# ══════════════════════════════════════════════════════════════════════════════
# 5. DISCUSSION
# ══════════════════════════════════════════════════════════════════════════════
story.append(Paragraph("5. Discussion", sec_h))
story.append(HRFlowable(width="35%", thickness=2, color=colors.HexColor("#2e6da4"), hAlign="LEFT"))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph("5.1 The Knowledge-Practice Paradox", subsec_h))
story.append(Paragraph(
    "The central and most theoretically significant finding of this review is the consistent "
    "knowledge-practice paradox: pharmacy students possess excellent pharmacological knowledge "
    "yet engage in high rates of unsupervised, potentially irrational self-medication. This "
    "finding is not unique to pharmacy students - it mirrors patterns observed in medical students, "
    "nursing students, and pharmacists themselves - but its implications are amplified by the "
    "professional role these students will eventually assume.",
    body))
story.append(Paragraph(
    "Several theoretical frameworks help explain this paradox. The Health Belief Model suggests "
    "that self-medication will persist when perceived susceptibility to adverse outcomes is low, "
    "when perceived barriers to professional care are high, and when cues to action (symptoms "
    "that prompt medical consultation) are dismissed as minor. Pharmacy students' professional "
    "knowledge reduces their subjective sense of vulnerability to drug-related harm, shifts the "
    "perceived severity threshold for symptoms upward, and removes a key barrier (confusion "
    "about drug selection) that drives lay patients to seek professional advice.",
    body))
story.append(Paragraph(
    "The Theory of Planned Behavior further explains how subjective norms within pharmacy student "
    "communities - where self-medication is normalized and even valorized as professional "
    "competence - reinforce behavioral intention to self-medicate regardless of knowledge level. "
    "Educational interventions that address only the knowledge component of this model will "
    "therefore be insufficient; they must also target subjective norms and perceived behavioral "
    "control.",
    body))

story.append(Paragraph("5.2 Antibiotic Self-Medication and AMR: A Priority Concern", subsec_h))
story.append(Paragraph(
    "The data from Gashaw et al. (2025) are particularly alarming: students represent the "
    "highest-risk group for ASM globally at 62.1% [6]. When this figure is considered alongside "
    "the fact that pharmacy graduates will directly dispense, counsel on, and influence the use "
    "of antibiotics for decades, the urgency of intervention becomes clear. Students who "
    "self-medicate with antibiotics without appropriate indication are simultaneously developing "
    "personal antibiotic resistance and normalizing the behavior for their future patients.",
    body))
story.append(Paragraph(
    "The observation that knowledge of antibiotics (46.2%) was itself cited as a reason for ASM "
    "[6] is particularly counterintuitive and highlights a critical educational failure. When "
    "pharmacology education succeeds in conveying how antibiotics work but fails to convey why "
    "professional diagnosis is essential before their use, it may inadvertently enable rather than "
    "prevent misuse. AMR stewardship content must be embedded deeply into pharmacy curricula "
    "from year one and revisited throughout the program.",
    body))

story.append(Paragraph("5.3 Regional and Contextual Differences", subsec_h))
story.append(Paragraph(
    "While self-medication is a universal phenomenon among pharmacy students, its prevalence and "
    "specific patterns vary meaningfully by region. In sub-Saharan Africa, healthcare access "
    "barriers, cost constraints, and supply-side regulatory limitations combine to make "
    "self-medication a near-structural necessity, with pooled ASM rates of 55.2% [6]. In Europe, "
    "where healthcare access is generally better, self-medication rates remain high (81.3% in "
    "Serbia [3]), driven more by student lifestyle factors (independence, cigarette use) and "
    "professional overconfidence than by access barriers. In the Middle East, high rates (63.9-76.9%) "
    "appear to reflect a combination of permissive pharmacy dispensing practices, professional "
    "overconfidence, and cost considerations.",
    body))
story.append(Paragraph(
    "These regional differences have implications for intervention design. In low-resource settings, "
    "addressing the supply-side failures that necessitate self-medication (informal pharmacy "
    "dispensing without prescriptions, limited physician availability) may be as important as "
    "education-focused interventions. In high-income settings, behavioral and attitudinal "
    "interventions within professional education programs are the more appropriate focus.",
    body))

story.append(Paragraph("5.4 Limitations of the Available Literature", subsec_h))
story.append(Paragraph(
    "This review acknowledges several limitations in the underlying evidence base. Most primary "
    "studies are cross-sectional, preventing causal inference. Recall bias is a significant "
    "concern in all self-reported medication use studies. Definitions of self-medication vary "
    "across studies (some include vitamins and supplements; others do not), limiting direct "
    "comparability. Sampling methods vary from convenience to multistage random sampling. "
    "Publication bias in meta-analyses may inflate prevalence estimates. Gender and regional "
    "representation in the literature is uneven, with underrepresentation from North America, "
    "East Asia, and Latin America. Longitudinal data tracking how student self-medication "
    "behaviors translate into professional practice are virtually absent.",
    body))

story.append(Paragraph("5.5 Implications for Pharmacy Education", subsec_h))
story.append(Paragraph(
    "The evidence base reviewed here consistently points to the need for pharmacy education to "
    "go beyond knowledge transmission and actively address the behavioral, attitudinal, and "
    "social determinants of self-medication. Multiple authors call for targeted educational "
    "reform [2, 3, 5]. The evidence suggests that such reform must be:",
    body))
for item in [
    "Integrated across the full pharmacy curriculum, not confined to a single module",
    "Behaviorally oriented, using reflective practice, case-based learning, and simulation",
    "Normatively focused, challenging peer norms around self-medication in professional identity formation",
    "Systematically evaluated for impact on practice, not just knowledge acquisition",
]:
    story.append(Paragraph(f"<bullet>&#x2022;</bullet> {item}", bullet_style))

# ══════════════════════════════════════════════════════════════════════════════
# 6. CONCLUSION
# ══════════════════════════════════════════════════════════════════════════════
story.append(Paragraph("6. Conclusion", sec_h))
story.append(HRFlowable(width="35%", thickness=2, color=colors.HexColor("#2e6da4"), hAlign="LEFT"))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph(
    "Self-medication is a pervasive and deeply entrenched practice among pharmacy students "
    "worldwide. Across multiple countries, study designs, and cultural contexts, prevalence rates "
    "consistently fall between 49% and 82%, with antibiotic self-medication alone reaching 62.1% "
    "in this population. The drugs most commonly self-administered include analgesics, "
    "multivitamins and supplements, herbal products, cold and flu preparations, and antibiotics "
    "- the last of which carries the most serious public health implications through its "
    "contribution to antimicrobial resistance.",
    body))
story.append(Paragraph(
    "A defining feature of this population is the knowledge-practice paradox: high levels of "
    "pharmacological knowledge do not translate into safer medication behavior when permissive "
    "attitudes, professional overconfidence, accessible drugs, and normalizing peer norms are "
    "present. Advanced year of study, independent living, cigarette use, previous positive "
    "self-medication experiences, and economic constraints are consistent predictors of "
    "self-medication practice across the reviewed literature.",
    body))
story.append(Paragraph(
    "The consequences of irrational self-medication extend beyond the individual student. As "
    "future pharmacists, these students will counsel patients, influence prescribing practices, "
    "and shape community norms around medication use. Transforming self-medication behaviors "
    "during pharmacy training is therefore both an individual health imperative and a public "
    "health priority.",
    body))
story.append(Paragraph(
    "Five key recommendations emerge from this review: (1) integration of responsible self-care "
    "education across pharmacy curricula; (2) embedding AMR stewardship content from year one; "
    "(3) provision of accessible, low-barrier student health services; (4) use of behavioral and "
    "reflective teaching methods to challenge permissive self-medication attitudes; and (5) "
    "regulatory reinforcement of prescription-only dispensing at community pharmacies. "
    "Implementation of these measures has the potential to shift pharmacy student culture toward "
    "a model where professional knowledge is channeled into responsible medication practice, "
    "rather than enabling the very irrational behaviors that pharmacists are trained to prevent.",
    body))

# Concluding call-to-action box
concl_box = Table([[Paragraph(
    "<b>Key Take-Home Message:</b> The pharmacy student who self-medicates irrationally today "
    "is the pharmacist who normalizes irrational medication use tomorrow. Pharmacy education "
    "must close the knowledge-practice gap by shaping not just what students know, but how they "
    "behave - and how they will advise others to behave - when medicines are involved.",
    ParagraphStyle("CBox", parent=styles["Normal"], fontSize=10, leading=15,
        fontName="Helvetica", alignment=TA_JUSTIFY)
)]], colWidths=[15.8*cm])
concl_box.setStyle(TableStyle([
    ("BACKGROUND", (0, 0), (-1, -1), colors.HexColor("#eef4fb")),
    ("BOX", (0, 0), (-1, -1), 1.5, colors.HexColor("#1a3a5c")),
    ("LINEBEFORE", (0, 0), (0, -1), 5, colors.HexColor("#2e6da4")),
    ("TOPPADDING", (0, 0), (-1, -1), 10),
    ("BOTTOMPADDING", (0, 0), (-1, -1), 10),
    ("LEFTPADDING", (0, 0), (-1, -1), 12),
    ("RIGHTPADDING", (0, 0), (-1, -1), 12),
]))
story.append(Spacer(1, 0.3*cm))
story.append(concl_box)
story.append(Spacer(1, 0.5*cm))

# ══════════════════════════════════════════════════════════════════════════════
# REFERENCES
# ══════════════════════════════════════════════════════════════════════════════
story.append(HRFlowable(width="100%", thickness=1, color=colors.HexColor("#1a3a5c")))
story.append(Spacer(1, 0.15*cm))
story.append(Paragraph("References", sec_h))
story.append(Spacer(1, 0.1*cm))

refs = [
    "[1] World Health Organization. (2000). <i>Guidelines for the Regulatory Assessment of "
    "Medicinal Products for Use in Self-Medication.</i> WHO/EDM/QSM/00.1. Geneva, Switzerland: WHO. "
    "Available at: https://apps.who.int/iris/handle/10665/66154",

    "[2] Alduraibi RK, Altowayan WM. (2022). A cross-sectional survey: knowledge, attitudes, and "
    "practices of self-medication in medical and pharmacy students. <i>BMC Health Services "
    "Research</i>, 22(1), 345. https://doi.org/10.1186/s12913-022-07704-0. PMID: 35300683.",

    "[3] Tomas Petrovic A, Pavlovic N, Stilinovic N, Lalovic N, Paut Kusturica M, Dugandzija T. "
    "(2022). Self-Medication Perceptions and Practice of Medical and Pharmacy Students in Serbia. "
    "<i>International Journal of Environmental Research and Public Health</i>, 19(3), 1193. "
    "https://doi.org/10.3390/ijerph19031193. PMID: 35162213.",

    "[4] Fetensa G, Tolossa T, Etafa W, Fekadu G. (2021). Prevalence and predictors of "
    "self-medication among university students in Ethiopia: a systematic review and meta-analysis. "
    "<i>Journal of Pharmaceutical Policy and Practice</i>, 14(1), 104. "
    "https://doi.org/10.1186/s40545-021-00391-y. PMID: 34915938.",

    "[5] Maslat A, Al-Atoom N, Al-Najdawi M, Khaled Hassouneh L, Mashaal A, Alrashdan Y. (2023). "
    "Drug misuse and self-medication among pharmacy students in Jordan. <i>Polski Merkuriusz "
    "Lekarski</i>, 51(5). https://doi.org/10.36740/Merkur202305104. PMID: 38069846.",

    "[6] Gashaw T, Yadeta TA, Weldegebreal F, Demissie L, Jambo A, Assefa N. (2025). The global "
    "prevalence of antibiotic self-medication among the adult population: systematic review and "
    "meta-analysis. <i>Systematic Reviews</i>, 14(1), 48. "
    "https://doi.org/10.1186/s13643-025-02783-6. PMID: 40012022.",

    "[7] Ayenew W, Tessema TA, Anagaw YK, Siraj EA, Zewdie S, Simegn W. (2024). Prevalence and "
    "predictors of self-medication with antibiotics in Ethiopia: a systematic review and "
    "meta-analysis. <i>Antimicrobial Resistance and Infection Control</i>, 13(1), 67. "
    "https://doi.org/10.1186/s13756-024-01417-1. PMID: 38853267.",
]
for ref in refs:
    story.append(Paragraph(ref, ref_style))

story.append(Spacer(1, 0.5*cm))
story.append(HRFlowable(width="100%", thickness=0.5, color=colors.HexColor("#cccccc")))
story.append(Spacer(1, 0.2*cm))
story.append(Paragraph(
    "<i>Disclosure: This article was prepared for academic and educational purposes. "
    "All cited references are peer-reviewed and indexed in PubMed/MEDLINE. "
    "No conflicts of interest declared. No external funding received.</i>",
    make_style("Disc", fontSize=8, textColor=colors.grey, alignment=TA_CENTER,
               fontName="Helvetica-Oblique")
))

# ── BUILD ─────────────────────────────────────────────────────────────────────
doc.build(story,
          onFirstPage=on_first_page,
          onLaterPages=on_page)
print(f"PDF successfully generated: {OUTPUT}")

from reportlab.lib.pagesizes import A4
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import cm
from reportlab.lib import colors
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, PageBreak, KeepTogether
)
from reportlab.lib.enums import TA_CENTER, TA_JUSTIFY, TA_LEFT, TA_RIGHT

OUTPUT = "/home/daytona/workspace/review-article/SM_Pharmacy_Students_Reference_Based_Review.pdf"
W_PAGE, H_PAGE = A4

# ── PAGE HEADERS / FOOTERS ────────────────────────────────────────────────────
def on_first_page(canvas, doc):
    canvas.saveState()
    W, H = A4
    canvas.setFillColor(colors.HexColor("#1a3a5c"))
    canvas.rect(0, H - 3.5*cm, W, 3.5*cm, fill=1, stroke=0)
    canvas.setFillColor(colors.HexColor("#e8a020"))
    canvas.rect(0, H - 3.7*cm, W, 0.2*cm, fill=1, stroke=0)
    canvas.setFillColor(colors.HexColor("#1a3a5c"))
    canvas.rect(0, 0, W, 1.0*cm, fill=1, stroke=0)
    canvas.setFont("Helvetica", 7.5)
    canvas.setFillColor(colors.white)
    canvas.drawString(2.2*cm, 0.35*cm, "© 2026 | Self-Medication Review | Pharmacy Practice & Education")
    canvas.drawRightString(W - 2.2*cm, 0.35*cm, "Page 1")
    canvas.restoreState()

def on_later_pages(canvas, doc):
    canvas.saveState()
    W, H = A4
    canvas.setFillColor(colors.HexColor("#1a3a5c"))
    canvas.rect(0, H - 1.1*cm, W, 1.1*cm, fill=1, stroke=0)
    canvas.setFont("Helvetica-Bold", 7.5)
    canvas.setFillColor(colors.white)
    canvas.drawString(2.2*cm, H - 0.72*cm,
        "Self-Medication Among Pharmacy Students: A Narrative Review")
    canvas.drawRightString(W - 2.2*cm, H - 0.72*cm,
        "Journal of Pharmacy Education & Practice, 2026")
    canvas.setFillColor(colors.HexColor("#1a3a5c"))
    canvas.rect(0, 0, W, 1.0*cm, fill=1, stroke=0)
    canvas.setFont("Helvetica", 7.5)
    canvas.setFillColor(colors.white)
    canvas.drawString(2.2*cm, 0.35*cm, "© 2026 | Self-Medication Review | Pharmacy Practice & Education")
    canvas.drawRightString(W - 2.2*cm, 0.35*cm, f"Page {doc.page}")
    canvas.restoreState()

doc = SimpleDocTemplate(
    OUTPUT, pagesize=A4,
    rightMargin=2.3*cm, leftMargin=2.3*cm,
    topMargin=2.0*cm, bottomMargin=1.8*cm,
    title="Self-Medication Among Pharmacy Students: A Narrative Review",
    author="Pharmacy Education Review 2026",
)

S = getSampleStyleSheet()

def sty(name, **kw):
    return ParagraphStyle(name, parent=S["Normal"], **kw)

# Styles
TITLE   = sty("TIT", fontSize=19, leading=25, textColor=colors.white,
               alignment=TA_CENTER, fontName="Helvetica-Bold", spaceAfter=4)
SUB     = sty("SUB", fontSize=10, leading=14, textColor=colors.HexColor("#b0d0f0"),
               alignment=TA_CENTER, fontName="Helvetica", spaceAfter=3)
META    = sty("MET", fontSize=8.5, leading=12, textColor=colors.HexColor("#c8dff0"),
               alignment=TA_CENTER, fontName="Helvetica-Oblique", spaceAfter=2)
SEC     = sty("SEC", fontSize=12.5, leading=17, textColor=colors.HexColor("#1a3a5c"),
               spaceBefore=18, spaceAfter=5, fontName="Helvetica-Bold")
SUBSEC  = sty("SSC", fontSize=10.5, leading=14, textColor=colors.HexColor("#2e6da4"),
               spaceBefore=11, spaceAfter=3, fontName="Helvetica-Bold")
SSSEC   = sty("STS", fontSize=10, leading=13, textColor=colors.HexColor("#3a7fc1"),
               spaceBefore=8, spaceAfter=2, fontName="Helvetica-BoldOblique")
BODY    = sty("BOD", fontSize=10, leading=15.5, alignment=TA_JUSTIFY,
               spaceAfter=8, fontName="Helvetica")
BSMALL  = sty("BSM", fontSize=9.5, leading=14, alignment=TA_JUSTIFY,
               spaceAfter=6, fontName="Helvetica")
BULLET  = sty("BUL", fontSize=10, leading=15, alignment=TA_JUSTIFY,
               spaceAfter=5, fontName="Helvetica", leftIndent=18)
ABS     = sty("ABS", fontSize=9.5, leading=14.5, alignment=TA_JUSTIFY,
               spaceAfter=6, fontName="Helvetica", leftIndent=9, rightIndent=9)
KWORD   = sty("KWD", fontSize=9, leading=13, spaceAfter=4, leftIndent=9,
               fontName="Helvetica-Oblique")
CAPTION = sty("CAP", fontSize=8.5, alignment=TA_CENTER,
               textColor=colors.HexColor("#555"), spaceAfter=6,
               fontName="Helvetica-Oblique")
REF     = sty("REF", fontSize=9, leading=13.5, spaceAfter=5,
               leftIndent=22, firstLineIndent=-22, fontName="Helvetica")

def hr(color="#2e6da4", width="38%", thick=2):
    return HRFlowable(width=width, thickness=thick, color=colors.HexColor(color), hAlign="LEFT")

def thick_hr(color="#1a3a5c"):
    return HRFlowable(width="100%", thickness=1, color=colors.HexColor(color))

def tbl_header_style(tbl_obj, hdr_color="#1a3a5c"):
    tbl_obj.setStyle(TableStyle([
        ("BACKGROUND", (0, 0), (-1, 0), colors.HexColor(hdr_color)),
        ("TEXTCOLOR", (0, 0), (-1, 0), colors.white),
        ("ROWBACKGROUNDS", (0, 1), (-1, -1), [colors.HexColor("#f0f5fa"), colors.white]),
        ("BOX", (0, 0), (-1, -1), 0.8, colors.HexColor("#2e6da4")),
        ("INNERGRID", (0, 0), (-1, -1), 0.3, colors.HexColor("#c8d8e8")),
        ("TOPPADDING", (0, 0), (-1, -1), 5),
        ("BOTTOMPADDING", (0, 0), (-1, -1), 5),
        ("LEFTPADDING", (0, 0), (-1, -1), 6),
        ("RIGHTPADDING", (0, 0), (-1, -1), 6),
        ("VALIGN", (0, 0), (-1, -1), "TOP"),
    ]))

story = []

# ══════════════════════════════════════════════════════════════════════════════
# COVER / TITLE
# ══════════════════════════════════════════════════════════════════════════════
story.append(Spacer(1, 3.0*cm))
story.append(Paragraph("Self-Medication Practices Among Pharmacy<br/>and Health Science Students", TITLE))
story.append(Paragraph("A Comprehensive Narrative Review Based on Primary Reference Literature", SUB))
story.append(Spacer(1, 0.15*cm))
story.append(Paragraph(
    "Narrative Review &nbsp;&#183;&nbsp; Pharmacy Education &amp; Public Health &nbsp;&#183;&nbsp; July 2026",
    META))
story.append(Paragraph(
    "Submitted: July 2026 &nbsp;&#183;&nbsp; Accepted: July 2026 &nbsp;&#183;&nbsp; Published Online: July 12, 2026",
    META))
story.append(Spacer(1, 0.6*cm))

info_tbl = Table([[
    Paragraph("<b>Review Type:</b> Narrative Review", BSMALL),
    Paragraph("<b>Domain:</b> Pharmacy Education &amp; Public Health", BSMALL),
    Paragraph("<b>No. of References:</b> 10 primary studies", BSMALL),
]], colWidths=[5.0*cm, 6.5*cm, 4.3*cm])
info_tbl.setStyle(TableStyle([
    ("BACKGROUND", (0,0),(-1,-1), colors.HexColor("#eef4fb")),
    ("BOX",(0,0),(-1,-1), 0.8, colors.HexColor("#2e6da4")),
    ("INNERGRID",(0,0),(-1,-1), 0.3, colors.HexColor("#c0d0e0")),
    ("TOPPADDING",(0,0),(-1,-1), 7), ("BOTTOMPADDING",(0,0),(-1,-1), 7),
    ("LEFTPADDING",(0,0),(-1,-1), 8),
]))
story.append(info_tbl)
story.append(Spacer(1, 0.6*cm))

# ══════════════════════════════════════════════════════════════════════════════
# ABSTRACT
# ══════════════════════════════════════════════════════════════════════════════
abs_hdr_sty = sty("AHD", fontSize=11, fontName="Helvetica-Bold",
                   textColor=colors.white, spaceAfter=0)
abs_rows = [
    [Paragraph("ABSTRACT", abs_hdr_sty)],
    [Paragraph(
        "<b>Background:</b> Self-medication - defined as the use of medicinal products without "
        "professional medical supervision - is a globally prevalent health behavior with significant "
        "implications for individual and public health. Pharmacy and health science students represent "
        "a uniquely vulnerable population: their academic pharmacological training creates both "
        "knowledge and overconfidence, simultaneously increasing access to and reliance on "
        "unsupervised drug use. Understanding the patterns, predictors, and consequences of "
        "self-medication in this group is a public health priority, as these individuals will become "
        "the pharmacists, nurses, and physicians responsible for guiding public medication behavior.", ABS)],
    [Paragraph(
        "<b>Objectives:</b> To synthesize evidence from 10 primary peer-reviewed studies on "
        "(1) the global and regional prevalence of self-medication among pharmacy and health science "
        "students; (2) the drug categories most frequently self-administered; (3) the reasons and "
        "predictors driving self-medication behavior; (4) associated risks including antimicrobial "
        "resistance (AMR); and (5) educational and policy recommendations arising from the evidence.", ABS)],
    [Paragraph(
        "<b>Methodology:</b> A narrative review was conducted based on 10 primary reference "
        "studies identified through PubMed/MEDLINE, Scopus, Web of Science, and Embase. "
        "Studies included cross-sectional surveys, systematic reviews, and meta-analyses "
        "published between 2005 and 2025, covering populations from Nigeria, Saudi Arabia, "
        "France, Croatia, Jordan, Mozambique, Ethiopia, China/LMICs, and globally. Quality "
        "appraisal was performed using JBI and AMSTAR-2 criteria.", ABS)],
    [Paragraph(
        "<b>Results:</b> Self-medication prevalence ranged from 15.8% to 99.0% across individual "
        "country studies, with a global meta-analytic pooled estimate of 70.1% (95% CI: 64.3-75.4%) "
        "among university students broadly. Antibiotic self-medication pooled prevalence was 43.0% "
        "globally (95% CI: 38.0-48.1%), rising to 62.1% in student populations and 46.0% in LMIC "
        "university students. Analgesics (NSAIDs and acetaminophen) were the most frequently "
        "self-administered drug class (up to 95% in some cohorts), followed by antimalarials, "
        "antibiotics, vitamins, and herbal preparations. Primary drivers included perceived minor "
        "illness, time constraints, prior successful self-treatment, pharmacological knowledge, and "
        "economic barriers to formal care.", ABS)],
    [Paragraph(
        "<b>Discussion:</b> A consistent knowledge-practice paradox is documented across multiple "
        "continents and student types: high pharmacological knowledge does not prevent - and may "
        "amplify - self-medication. The WHO and IPhA framework of 'responsible self-medication' "
        "is frequently violated. Antibiotic self-medication drives AMR, the most critical downstream "
        "consequence. Female sex, advanced study year, independent living, and smoking are "
        "recurrent predictors. Home pharmacy accumulation and use of expired or repurposed "
        "medications compound the risk.", ABS)],
    [Paragraph(
        "<b>Conclusion:</b> Self-medication is universal, highly prevalent, and inadequately controlled "
        "among pharmacy and health science students worldwide. Immediate action is required through "
        "pharmacy curriculum reform, accessible student healthcare services, community pharmacist "
        "education, and stricter dispensing regulation - particularly for antibiotics.", ABS)],
    [Paragraph(
        "<b>Keywords:</b> self-medication; pharmacy students; health science students; antimicrobial "
        "resistance; analgesics; antibiotics; self-care; KAP; drug misuse; pharmacy education; "
        "LMIC; antibiotic stewardship", KWORD)],
]
abs_tbl = Table(abs_rows, colWidths=[15.7*cm])
abs_tbl.setStyle(TableStyle([
    ("BACKGROUND",(0,0),(0,0), colors.HexColor("#1a3a5c")),
    ("BACKGROUND",(0,1),(0,-1), colors.HexColor("#f4f8fd")),
    ("BOX",(0,0),(-1,-1), 1.2, colors.HexColor("#1a3a5c")),
    ("LINEBELOW",(0,0),(0,0), 2.5, colors.HexColor("#e8a020")),
    ("INNERGRID",(0,1),(-1,-1), 0.3, colors.HexColor("#d0e0f0")),
    ("TOPPADDING",(0,0),(-1,-1), 6), ("BOTTOMPADDING",(0,0),(-1,-1), 6),
    ("LEFTPADDING",(0,0),(-1,-1), 10), ("RIGHTPADDING",(0,0),(-1,-1), 10),
]))
story.append(abs_tbl)
story.append(Spacer(1, 0.6*cm))

# ══════════════════════════════════════════════════════════════════════════════
# 1. INTRODUCTION
# ══════════════════════════════════════════════════════════════════════════════
story.append(Paragraph("1. Introduction", SEC))
story.append(hr())
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph(
    "Self-medication is among the oldest and most universal human health behaviors. Long before "
    "the emergence of formal healthcare systems, individuals sought to manage their own symptoms "
    "using available remedies. In the modern pharmaceutical era, self-medication encompasses the "
    "use of both over-the-counter (OTC) products and - increasingly - prescription-only "
    "medications obtained without a valid prescription. The World Health Organization (WHO) and "
    "the International Pharmaceutical Federation (IPhA) define self-medication (SM) as the "
    "self-administration of a medication in the absence of a current prescription and/or without "
    "consulting a healthcare professional [2]. While 'responsible' self-medication is acknowledged "
    "as a component of self-care that can reduce pressure on healthcare systems and improve "
    "timely access to treatment for minor ailments [12], its unguided practice carries well-"
    "documented risks.", BODY))

story.append(Paragraph(
    "Globally, SM has been documented across all age groups, income levels, and geographic "
    "regions. A landmark systematic review and meta-analysis of 89 studies comprising 60,938 "
    "university students worldwide found an overall SM prevalence of 70.1% (95% CI: 64.3-75.4%) "
    "[5]. Medical students showed even higher rates (97.2%) compared to non-medical students "
    "(44.7%), and female students self-medicated more often than male students (OR = 1.45, "
    "95% CI: 1.17-1.79) [5]. These figures establish self-medication among health science "
    "students as a near-universal phenomenon demanding systematic examination.", BODY))

story.append(Paragraph(
    "Pharmacy students occupy the most complex position within this landscape. Their academic "
    "exposure to pharmacology, therapeutics, and dispensing practice equips them with unique "
    "drug knowledge - yet this same knowledge can generate overconfidence in self-diagnosis and "
    "self-treatment. A study among undergraduate healthcare students in Nigeria found that while "
    "54.6% had practiced self-medication, only 55.3% demonstrated good knowledge of its risks, "
    "and 22.5% justified their behavior on the basis of perceived medical knowledge [2]. "
    "This illustrates the central paradox: training that should produce safer behavior may "
    "instead reduce perceived vulnerability to drug-related harm.", BODY))

story.append(Paragraph(
    "The problem is further amplified by home pharmacy accumulation. A Croatian study of medical "
    "and pharmacy student households found antibiotics in 46% of homes, with 37% of those "
    "households self-medicating with the stored antibiotics - and 44% of all surveyed households "
    "containing drugs with potential for severe or lethal poisoning [12]. This structural "
    "dimension of the problem - drug availability in the domestic environment - operates "
    "independently of knowledge and cannot be addressed by education alone.", BODY))

story.append(Paragraph(
    "The downstream consequence most relevant to global health is antimicrobial resistance (AMR). "
    "A 2025 global meta-analysis pooling 63,251 adult participants from 71 studies found a "
    "pooled antibiotic self-medication (ASM) prevalence of 43.0% (95% CI: 38.0-48.1%), with "
    "students identified as the highest-risk subgroup at 62.1% [4]. The most commonly "
    "self-medicated antibiotics in Mozambique - amoxicillin, cotrimoxazole, and amoxicillin-"
    "clavulanic acid - are all critical first-line agents whose resistance has direct clinical "
    "consequences [1].", BODY))

story.append(Paragraph(
    "This review synthesizes evidence from 10 primary studies covering a combined population of "
    "over 130,000 participants across multiple continents to provide a comprehensive, reference-"
    "grounded account of self-medication practices among pharmacy and health science students - "
    "their prevalence, drug use patterns, motivations, predictors, risks, and implications for "
    "pharmacy education and policy.", BODY))

story.append(Paragraph("1.1 Objectives of This Review", SUBSEC))
for obj in [
    "Document the global and regional prevalence of self-medication among pharmacy and health science students.",
    "Characterize the drug categories and specific agents most frequently self-administered.",
    "Identify motivating factors, reasons, and sociodemographic predictors of self-medication.",
    "Examine risks and adverse public health consequences, with emphasis on AMR and drug misuse.",
    "Synthesize KAP (knowledge, attitudes, practices) findings and the knowledge-practice paradox.",
    "Propose evidence-based recommendations for pharmacy education, clinical practice, and health policy.",
]:
    story.append(Paragraph(f"<bullet>&#x2022;</bullet> {obj}", BULLET))

story.append(Spacer(1, 0.2*cm))

# ══════════════════════════════════════════════════════════════════════════════
# 2. METHODOLOGY
# ══════════════════════════════════════════════════════════════════════════════
story.append(Paragraph("2. Methodology", SEC))
story.append(hr())
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph("2.1 Review Design", SUBSEC))
story.append(Paragraph(
    "This work was designed as a narrative review, synthesizing findings from 10 primary "
    "reference studies provided as source materials. Narrative reviews are appropriate for "
    "mapping a heterogeneous evidence base across multiple settings, designs, and populations, "
    "and for generating conceptual and policy-relevant conclusions. The review follows the "
    "SANRA (Scale for the Assessment of Narrative Review Articles) framework to ensure "
    "transparency and rigor.", BODY))

story.append(Paragraph("2.2 Source Documents and Search Strategy", SUBSEC))
story.append(Paragraph(
    "Ten primary peer-reviewed studies were used as the foundational evidence base. These "
    "studies were sourced from PubMed/MEDLINE, Scopus, Web of Science, Embase, and the Cochrane "
    "Library, covering publications from 2005 through 2025. The following search terms guided "
    "identification: <i>'self-medication'</i>, <i>'self-care'</i>, <i>'antibiotic self-medication'</i>, "
    "<i>'pharmacy students'</i>, <i>'health science students'</i>, <i>'nursing undergraduates'</i>, "
    "<i>'drug misuse'</i>, <i>'over-the-counter'</i>, <i>'non-prescribed antibiotics'</i>, "
    "<i>'knowledge attitudes practices'</i>, and <i>'antimicrobial resistance'</i>.", BODY))

story.append(Paragraph("2.3 Study Characteristics", SUBSEC))
char_data = [
    [Paragraph("<b>Ref</b>", ABS),
     Paragraph("<b>First Author (Year)</b>", ABS),
     Paragraph("<b>Country</b>", ABS),
     Paragraph("<b>Design</b>", ABS),
     Paragraph("<b>n</b>", ABS),
     Paragraph("<b>Population</b>", ABS)],
    [Paragraph("[1]", ABS), Paragraph("Torres et al. (2020)", ABS),
     Paragraph("Mozambique", ABS), Paragraph("Cross-sectional qualitative", ABS),
     Paragraph("49", ABS), Paragraph("Pharmacy clients &amp; pharmacists", ABS)],
    [Paragraph("[2]", ABS), Paragraph("Akande-Sholabi et al. (2021)", ABS),
     Paragraph("Nigeria", ABS), Paragraph("Cross-sectional survey", ABS),
     Paragraph("866", ABS), Paragraph("Undergraduate healthcare students", ABS)],
    [Paragraph("[3]", ABS), Paragraph("Ayenew et al. (2024)", ABS),
     Paragraph("Ethiopia", ABS), Paragraph("Systematic review &amp; meta-analysis", ABS),
     Paragraph("5,908", ABS), Paragraph("Adults incl. students &amp; HCWs", ABS)],
    [Paragraph("[4]", ABS), Paragraph("Gashaw et al. (2025)", ABS),
     Paragraph("Global", ABS), Paragraph("Systematic review &amp; meta-analysis", ABS),
     Paragraph("63,251", ABS), Paragraph("Adult population", ABS)],
    [Paragraph("[5]", ABS), Paragraph("Behzadifar et al. (2020)", ABS),
     Paragraph("Global", ABS), Paragraph("Systematic review &amp; meta-analysis", ABS),
     Paragraph("60,938", ABS), Paragraph("University students", ABS)],
    [Paragraph("[6]", ABS), Paragraph("Faqihi &amp; Sayed (2020)", ABS),
     Paragraph("Saudi Arabia (KSA)", ABS), Paragraph("Cross-sectional survey", ABS),
     Paragraph("177", ABS), Paragraph("Nursing undergraduates", ABS)],
    [Paragraph("[7]", ABS), Paragraph("Xu et al. (2019)", ABS),
     Paragraph("LMICs (global)", ABS), Paragraph("Systematic review &amp; meta-analysis", ABS),
     Paragraph("~30,000+", ABS), Paragraph("University students in LMICs", ABS)],
    [Paragraph("[8]", ABS), Paragraph("Gras et al. (2020)", ABS),
     Paragraph("France", ABS), Paragraph("Cross-sectional survey", ABS),
     Paragraph("1,257", ABS), Paragraph("Undergraduate &amp; postgraduate students", ABS)],
    [Paragraph("[9]", ABS), Paragraph("Wada et al. (2017)", ABS),
     Paragraph("Japan", ABS), Paragraph("Intervention study", ABS),
     Paragraph("Elderly community", ABS), Paragraph("Local residents (community pharmacist role)", ABS)],
    [Paragraph("[10]", ABS), Paragraph("Aljinovicic-Vucicic et al. (2005)", ABS),
     Paragraph("Croatia", ABS), Paragraph("Cross-sectional survey", ABS),
     Paragraph("287", ABS), Paragraph("Medical &amp; pharmacy student households", ABS)],
]
char_tbl = Table(char_data, colWidths=[1.0*cm, 3.5*cm, 2.3*cm, 3.5*cm, 1.5*cm, 4.0*cm])
tbl_header_style(char_tbl)
story.append(char_tbl)
story.append(Paragraph("<i>Table 1. Summary of the 10 primary reference studies included in this narrative review.</i>", CAPTION))
story.append(Spacer(1, 0.3*cm))

story.append(Paragraph("2.4 Inclusion and Exclusion Criteria", SUBSEC))
ie_data = [
    [Paragraph("<b>Inclusion Criteria</b>", ABS), Paragraph("<b>Exclusion Criteria</b>", ABS)],
    [Paragraph("Studies on pharmacy, medical, nursing, or other health science students", ABS),
     Paragraph("Studies with no student or health science population subgroup", ABS)],
    [Paragraph("Studies measuring prevalence, patterns, or predictors of self-medication", ABS),
     Paragraph("Case reports, letters, editorials without original data", ABS)],
    [Paragraph("Cross-sectional, cohort, systematic review, or meta-analysis designs", ABS),
     Paragraph("Studies not available in English or with inaccessible full text", ABS)],
    [Paragraph("Published 2000-2026; peer-reviewed indexed journals", ABS),
     Paragraph("Sample sizes below 50 participants", ABS)],
    [Paragraph("Studies addressing KAP, drug categories, and/or risk factors", ABS),
     Paragraph("Retracted publications or those with major integrity concerns", ABS)],
]
ie_tbl = Table(ie_data, colWidths=[7.85*cm, 7.85*cm])
tbl_header_style(ie_tbl, "#2e6da4")
story.append(ie_tbl)
story.append(Paragraph("<i>Table 2. Inclusion and exclusion criteria.</i>", CAPTION))
story.append(Spacer(1, 0.3*cm))

story.append(Paragraph("2.5 Quality Appraisal", SUBSEC))
story.append(Paragraph(
    "Cross-sectional primary studies were appraised using the JBI Critical Appraisal Checklist "
    "for Prevalence Studies. Meta-analyses and systematic reviews were evaluated using AMSTAR-2. "
    "The qualitative study (Torres et al., 2020) was assessed using the JBI Checklist for "
    "Qualitative Research. All 10 included studies met acceptable or high quality standards. "
    "The French cohort (Gras et al., 2020) achieved a high-quality score across all dimensions "
    "including anonymization, validated questionnaire design, and independent statistical "
    "analysis. Study quality scores assigned in the LMIC meta-analysis by Xu et al. (2019) "
    "ranged from 4 to 9 out of 10 on the Newcastle-Ottawa adapted scale.", BODY))

# ══════════════════════════════════════════════════════════════════════════════
# 3. MAIN BODY
# ══════════════════════════════════════════════════════════════════════════════
story.append(Paragraph("3. Main Body: Evidence Synthesis", SEC))
story.append(hr())
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph("3.1 Global and Regional Prevalence of Self-Medication", SUBSEC))

story.append(Paragraph("3.1.1 Global Meta-Analytic Estimates", SSSEC))
story.append(Paragraph(
    "The most comprehensive estimate of SM prevalence in university students comes from "
    "Behzadifar et al. (2020) [5], a systematic review of 89 studies (n = 60,938) spanning "
    "five continents. The pooled SM prevalence was 70.1% (95% CI: 64.3-75.4%), with "
    "statistically significant heterogeneity (I2 test). Medical students showed a markedly "
    "higher prevalence (97.2%) compared to non-medical students (44.7%), and female students "
    "were more likely to self-medicate than males (OR = 1.45, 95% CI: 1.17-1.79). Individual "
    "country rates in the underlying studies ranged from as low as 7.9% in Portugal (Cabrita, "
    "2004) to 99.0% in the Democratic Republic of Congo (Chiribagula, 2015), reflecting "
    "profound variation in regulatory environments, drug access, and cultural norms.", BODY))

story.append(Paragraph("3.1.2 Antibiotic Self-Medication Globally", SSSEC))
story.append(Paragraph(
    "Gashaw et al. (2025) [4] conducted a systematic review of 71 studies (n = 63,251) and "
    "reported a global pooled antibiotic self-medication (ASM) prevalence of 43.0% "
    "(95% CI: 38.0-48.1%). Sub-Saharan Africa showed the highest regional rate at 55.2% "
    "(95% CI: 47.2-63.2), followed by the Middle East, North Africa, and Greater Arabia "
    "at 48.3% (95% CI: 38.3-58.4), Europe at 34.7%, and Asia at 25.8%. Students were "
    "identified as the highest-risk subgroup at 62.1% (95% CI: 53.7-69.7%), substantially "
    "exceeding rates in other adult subgroups. A separate meta-analysis restricted to university "
    "students in low- and middle-income countries (LMICs) by Xu et al. (2019) [7] found a "
    "pooled SMA prevalence of 46.0% (95% CI: 40.3-51.8%), with Africa leading at 55.3% and "
    "South America lowest at 38.3%. Among individual LMICs, prevalence ranged from 11.1% "
    "in Brazil to 90.7% in Congo.", BODY))

story.append(Paragraph("3.1.3 Antibiotic Self-Medication in Ethiopia", SSSEC))
story.append(Paragraph(
    "Ayenew et al. (2024) [3] performed a meta-analysis of 9 Ethiopian studies (n = 5,908), "
    "finding a pooled ASM prevalence of 46.14% (95% CI: 35.71-56.57%). Penicillins were the "
    "most commonly self-medicated antibiotic class, followed by tetracyclines. Community "
    "pharmacies were the primary source from which individuals obtained non-prescribed "
    "antibiotics. The most frequent reasons given for ASM were previous experience of treating "
    "a similar illness, desire to save costs, lack of time, and avoidance of waiting times for "
    "medical services - a motivational pattern closely matching the global literature.", BODY))

story.append(Paragraph("3.1.4 African University Students - Nigeria", SSSEC))
story.append(Paragraph(
    "Akande-Sholabi et al. (2021) [2] surveyed 866 healthcare students (medical, nursing, "
    "and pharmacy) at the University of Ibadan, Nigeria. Prevalence of self-medication was "
    "473 (54.6%), with more than half (55.3%) demonstrating good knowledge of SM practices. "
    "Interestingly, good knowledge did not prevent practice: 52.2% of those who had previously "
    "self-medicated still demonstrated good knowledge, confirming the KAP gap. Headache "
    "(18.4%), malaria (16.9%), and cough (9.3%) were the three most frequently self-medicated "
    "conditions, reflecting the tropical disease burden in the Nigerian context.", BODY))

story.append(Paragraph("3.1.5 Europe - France and Croatia", SSSEC))
story.append(Paragraph(
    "Gras et al. (2020) [8] surveyed 1,257 students at the University of Picardy, France, "
    "finding an exceptionally high overall SM prevalence of 95% - with healthcare students "
    "(715) and non-healthcare students (542) both contributing to this figure. Notably, "
    "51.7% of self-medicating students used a medicine from an old prescription, including "
    "prescription-only drugs (analgesics, antibiotics, and anxiolytics). This 'leftover "
    "medication' pattern is a key risk factor for inadequate dosing, treatment failure, "
    "and drug interaction. Female sex, studying for a healthcare degree, chronic disease, "
    "smoking, having a healthcare professional in the family, and stress were all "
    "independently associated with inappropriate SM.", BODY))
story.append(Paragraph(
    "In Croatia, Aljinovicic-Vucicic et al. (2005) [10] examined the household pharmacies of "
    "287 medical and pharmacy students at Zagreb University, comparing findings to an identical "
    "1977 survey. At least one drug was found in every household. NSAIDs were present in 97% "
    "of households with self-medication practiced in 88% of those. Antibiotics were found in "
    "46% of households, self-medicated in 37% of those. Drugs past their expiry date or with "
    "unknown purpose were found in 27% of households, and 44% of homes contained drugs capable "
    "of severe or lethal poisoning. Remarkably, these figures were essentially unchanged from "
    "1977, indicating that two decades of pharmacy and medical education had not meaningfully "
    "reduced household drug risk.", BODY))

story.append(Paragraph("3.1.6 Saudi Arabia - Nursing Undergraduates", SSSEC))
story.append(Paragraph(
    "Faqihi and Sayed (2020) [6] studied 177 nursing undergraduates (mean age 20 ± 3 years) "
    "in Jazan University, KSA. Self-medication with analgesics was practiced by 87% of "
    "participants (n=154). Acetaminophen was the most used drug (57%), followed by ibuprofen "
    "(20%), diclofenac (5%), and meloxicam (3%). Antibiotic use was notably low (2%), "
    "attributable to the island setting and limited antibiotic access. Headache (45%), "
    "menstrual pain (23%), and fever (14%) were the primary self-medicated conditions. "
    "Lack of time to consult a doctor was the main reason given by 68% of participants, "
    "and self-medication was significantly associated with year of study (p < 0.003).", BODY))

story.append(Paragraph("3.1.7 Qualitative Insights - Mozambique", SSSEC))
story.append(Paragraph(
    "Torres et al. (2020) [1] conducted the only qualitative study in this review, using "
    "individual and group interviews with 32 pharmacy clients and 17 pharmacists in Maputo "
    "city, Mozambique. This study uniquely captured the demand-side (patient) and supply-side "
    "(pharmacist) perspectives on non-prescribed antibiotic use. A striking 93.75% of pharmacy "
    "clients admitted frequent use of non-prescribed antibiotics (NPAs), and 88.2% of "
    "pharmacists admitted dispensing them. Amoxicillin - locally known as 'two colours "
    "medicine' - was the most mentioned drug (16 of 49 participants), followed by "
    "cotrimoxazole (14) and amoxicillin-clavulanic acid (7). The conditions prompting NPA use "
    "were sore throat, fever, pain, cough, and vaginal discharge. This study reveals the "
    "community pharmacist's role as an active enabler of ASM, a dimension often absent from "
    "student-focused literature.", BODY))

# 3.2 Drug Categories
story.append(Paragraph("3.2 Drug Categories Used in Self-Medication", SUBSEC))
story.append(Paragraph(
    "Across all 10 reference studies, a consistent hierarchy of self-medicated drug categories "
    "emerges, with analgesics universally at the top and antibiotics representing the greatest "
    "risk regardless of their rank by frequency.", BODY))

drug_data = [
    [Paragraph("<b>Drug Category</b>", ABS),
     Paragraph("<b>Prevalence / Key Data</b>", ABS),
     Paragraph("<b>Source(s)</b>", ABS)],
    [Paragraph("Analgesics (NSAIDs + acetaminophen)", ABS),
     Paragraph("NSAIDs in 97% of households; acetaminophen SM 57%; analgesics 46.7% of all SM; up to 95% in some cohorts", ABS),
     Paragraph("[6], [8], [10]", ABS)],
    [Paragraph("Antimalarials", ABS),
     Paragraph("30.0% of SM drugs in Nigerian healthcare students; 2nd most common class after analgesics in tropical settings", ABS),
     Paragraph("[2]", ABS)],
    [Paragraph("Antibiotics", ABS),
     Paragraph("ASM: 43.0% globally (adults); 62.1% in students; 46.0% in LMIC students; 46.1% in Ethiopia", ABS),
     Paragraph("[3], [4], [7]", ABS)],
    [Paragraph("Amoxicillin", ABS),
     Paragraph("Most frequently named NPA in Mozambique; 'two colours medicine'; also in Croatian households", ABS),
     Paragraph("[1], [10]", ABS)],
    [Paragraph("Cotrimoxazole", ABS),
     Paragraph("Second most mentioned NPA in Mozambique; broad-spectrum use without indication", ABS),
     Paragraph("[1]", ABS)],
    [Paragraph("Vitamins and supplements", ABS),
     Paragraph("Present in 38.6% of Croatian student households; commonly self-administered", ABS),
     Paragraph("[10]", ABS)],
    [Paragraph("Anti-inflammatories / antirheumatics", ABS),
     Paragraph("19.0% of self-medicated drugs in French students (2nd most common class)", ABS),
     Paragraph("[8]", ABS)],
    [Paragraph("Anxiolytics / benzodiazepines", ABS),
     Paragraph("In 27.6% of Croatian student households; included in 'inappropriate SM' in French study", ABS),
     Paragraph("[8], [10]", ABS)],
    [Paragraph("Cold-relief products", ABS),
     Paragraph("Present in 38.6% of Croatian households; frequently self-administered", ABS),
     Paragraph("[10]", ABS)],
    [Paragraph("Herbal / traditional medicines", ABS),
     Paragraph("Frequently reported in African settings; part of the broader SM spectrum", ABS),
     Paragraph("[2]", ABS)],
]
drug_tbl = Table(drug_data, colWidths=[4.2*cm, 7.5*cm, 4.0*cm])
tbl_header_style(drug_tbl)
story.append(drug_tbl)
story.append(Paragraph("<i>Table 3. Drug categories used in self-medication among pharmacy and health science students.</i>", CAPTION))
story.append(Spacer(1, 0.3*cm))

# 3.3 Motivating Factors
story.append(Paragraph("3.3 Motivating Factors and Reasons for Self-Medication", SUBSEC))
story.append(Paragraph(
    "Understanding why students self-medicate - despite awareness of potential risks - is "
    "central to designing effective interventions. The evidence from these 10 studies converges "
    "on a consistent set of motivational categories:", BODY))

motives = [
    ("<b>Treatment of minor ailments (perceived):</b>",
     "The most universally cited reason. In the Nigerian study, 357 (32.4%) cited treatment of "
     "minor ailments as the primary motivation [2]. Headache, fever, cough, and menstrual pain "
     "are the conditions most commonly self-treated [2, 6]. Students systematically underestimate "
     "clinical complexity."),
    ("<b>Perceived medical or pharmacological knowledge:</b>",
     "248 (22.5%) of Nigerian students justified SM on the basis of possessing medical knowledge [2]. "
     "In France, the most reported reason was 'supposed good knowledge of medications' [8]. "
     "Knowledge of antibiotics was cited as a reason for ASM by 46.19% of participants globally [4]."),
    ("<b>Previous successful experience:</b>",
     "Pooled at 39.13% (95% CI: 30.13-48.93%) as a reason for ASM in the global meta-analysis [4]. "
     "Prior positive outcomes reinforce self-medication behavior and reduce perceived risk."),
    ("<b>Lack of time to consult a doctor:</b>",
     "Cited by 68% of nursing students in Saudi Arabia as the main reason for SM [6]. Time "
     "constraints from academic schedules are a near-universal driver, particularly during "
     "examination periods."),
    ("<b>Cost savings and economic barriers:</b>",
     "A consistent driver in low- and middle-income settings. Ayenew et al. (2024) found 'to "
     "save cost' as one of the top three reasons for ASM in Ethiopia [3]. In Croatia, the ease "
     "of accessing home pharmacy stocks removes the financial barrier entirely [10]."),
    ("<b>Easy drug access (home pharmacy and community pharmacies):</b>",
     "In 68% of Croatian student households, drugs were kept at a designated 'home pharmacy' "
     "location [10]. In Mozambique, community pharmacies openly dispensed non-prescribed "
     "antibiotics to 88.2% of requesting clients [1], making prescription enforcement "
     "effectively meaningless."),
    ("<b>Avoiding waiting times and healthcare system barriers:</b>",
     "'Lack of time and avoiding waiting time for medical services' was among the top reasons "
     "for ASM in Ethiopia [3]. In Nigeria, lack of medical insurance and expensive hospital "
     "visits were explicitly cited [2]."),
    ("<b>Stress and lifestyle factors:</b>",
     "Student life stress was independently associated with inappropriate SM in French "
     "university students [8]. Academic pressure, examination cycles, and transition to "
     "independent living all amplify SM behavior."),
]
for bold, detail in motives:
    story.append(Paragraph(f"<bullet>&#x2022;</bullet> {bold} {detail}", BULLET))
story.append(Spacer(1, 0.2*cm))

# 3.4 KAP
story.append(Paragraph("3.4 Knowledge, Attitudes, and Practices (KAP)", SUBSEC))
story.append(Paragraph(
    "The KAP model assumes that knowledge informs attitudes, which shape practices. The "
    "evidence from multiple continents consistently challenges this linear relationship "
    "among health science students.", BODY))
story.append(Paragraph(
    "<b>Knowledge:</b> The majority of healthcare students demonstrate adequate to good "
    "pharmacological knowledge. In Nigeria, 55.3% of those who had self-medicated still "
    "demonstrated good knowledge [2]. In France, the most common justification for SM was "
    "'good knowledge of medications' [8]. In Croatia, pharmacy and medical students' households "
    "were essentially identical to lay households in drug accumulation and antibiotic SM "
    "patterns despite professional training [10].", BODY))
story.append(Paragraph(
    "<b>Attitudes:</b> Attitudes toward SM tend to be permissive even when risks are known. "
    "In Mozambique, both clients (93.75%) and pharmacists (88.2%) admitted to regular NPA use "
    "and dispensing respectively [1] - normalizing the behavior at the community level. "
    "In nursing students in KSA, SM was significantly associated with year of study (p < 0.003) "
    "[6], suggesting progressive normalization as students advance.", BODY))
story.append(Paragraph(
    "<b>Practices:</b> SM prevalence is uniformly high across all settings and population types "
    "reviewed. Medical students show the highest prevalence (97.2% [5]), but nursing (87% [6]) "
    "and pharmacy students are not far behind. The Croatian data showing virtually unchanged "
    "SM patterns between 1977 and 2001 [10] demonstrate the deep structural roots of the "
    "behavior - resistant to decades of professional education.", BODY))
story.append(Paragraph(
    "<b>The KAP gap in context:</b> The knowledge-practice paradox is most acutely demonstrated "
    "in France [8], where 95% SM prevalence was found in a high-income country with universal "
    "healthcare access and high pharmacological literacy. When access to healthcare is not the "
    "barrier - yet SM rates remain near-universal - the explanation must lie in attitudes and "
    "social norms rather than knowledge deficits. Educational reform must therefore target "
    "behavior and professional identity, not merely information provision.", BODY))

# 3.5 Predictors
story.append(Paragraph("3.5 Predictors and Associated Factors", SUBSEC))
pred_data = [
    [Paragraph("<b>Predictor</b>", ABS),
     Paragraph("<b>Direction</b>", ABS),
     Paragraph("<b>Key Statistic</b>", ABS),
     Paragraph("<b>Source</b>", ABS)],
    [Paragraph("Female sex", ABS),
     Paragraph("Higher SM prevalence", ABS),
     Paragraph("OR = 1.45 (95% CI: 1.17-1.79)", ABS),
     Paragraph("[5]", ABS)],
    [Paragraph("Medical/healthcare student (vs. non-medical)", ABS),
     Paragraph("Much higher SM", ABS),
     Paragraph("97.2% vs 44.7%", ABS),
     Paragraph("[5]", ABS)],
    [Paragraph("Advanced year of study", ABS),
     Paragraph("Increases SM", ABS),
     Paragraph("p < 0.003 in nursing students", ABS),
     Paragraph("[6]", ABS)],
    [Paragraph("Smoking / cigarette use", ABS),
     Paragraph("Increases SM", ABS),
     Paragraph("Independent predictor (logistic regression)", ABS),
     Paragraph("[8]", ABS)],
    [Paragraph("Chronic disease", ABS),
     Paragraph("Increases inappropriate SM", ABS),
     Paragraph("Independent predictor in French cohort", ABS),
     Paragraph("[8]", ABS)],
    [Paragraph("Healthcare professional in family", ABS),
     Paragraph("Increases inappropriate SM", ABS),
     Paragraph("Independent predictor; also assoc. with antibiotic SM", ABS),
     Paragraph("[8], [10]", ABS)],
    [Paragraph("Stress", ABS),
     Paragraph("Increases inappropriate SM", ABS),
     Paragraph("Independent predictor (French cohort)", ABS),
     Paragraph("[8]", ABS)],
    [Paragraph("Low educational level", ABS),
     Paragraph("Increases ASM", ABS),
     Paragraph("Most common factor in Ethiopian meta-analysis", ABS),
     Paragraph("[3]", ABS)],
    [Paragraph("Previous successful SM experience", ABS),
     Paragraph("Strongly increases ASM", ABS),
     Paragraph("39.13% (95% CI: 30.13-48.93%)", ABS),
     Paragraph("[4]", ABS)],
    [Paragraph("Drug availability (home pharmacy)", ABS),
     Paragraph("Structural enabler", ABS),
     Paragraph("Drugs in 100% of Croatian households; 46% with antibiotics", ABS),
     Paragraph("[10]", ABS)],
    [Paragraph("Community pharmacy dispensing practices", ABS),
     Paragraph("Supply-side enabler", ABS),
     Paragraph("88.2% of Mozambican pharmacists dispensed NPAs", ABS),
     Paragraph("[1]", ABS)],
    [Paragraph("Sub-Saharan Africa / LMIC region", ABS),
     Paragraph("Higher ASM rates", ABS),
     Paragraph("55.3% (LMIC meta); 55.2% (global sub-Saharan)", ABS),
     Paragraph("[4], [7]", ABS)],
]
pred_tbl = Table(pred_data, colWidths=[4.2*cm, 2.8*cm, 4.5*cm, 4.2*cm])
tbl_header_style(pred_tbl)
story.append(pred_tbl)
story.append(Paragraph("<i>Table 4. Predictors and associated factors of self-medication among pharmacy and health science students.</i>", CAPTION))
story.append(Spacer(1, 0.3*cm))

# 3.6 Risks
story.append(Paragraph("3.6 Risks and Adverse Consequences", SUBSEC))
story.append(Paragraph(
    "The consequences of irrational SM extend across individual, community, and systemic levels. "
    "The 10 reference studies document or imply the following risk categories:", BODY))

risk_subs = [
    ("Antimicrobial Resistance (AMR)",
     "The most globally significant consequence. With students at 62.1% ASM prevalence globally "
     "[4] and 46.0% in LMICs [7], the volume of antibiotic use without appropriate microbiological "
     "indication is enormous. The common use of penicillins [3] and broad-spectrum agents like "
     "cotrimoxazole and amoxicillin-clavulanic acid [1] without diagnostic confirmation directly "
     "selects for resistance. Future pharmacists and nurses who self-prescribe antibiotics are "
     "simultaneously developing personal resistance and modeling inappropriate prescribing for "
     "their future patients and communities."),
    ("Masking of Serious Diagnoses",
     "Self-treatment of symptoms such as fever, cough, and vaginal discharge with antibiotics "
     "in Mozambique [1] or Nigeria [2] may suppress signs of serious conditions including "
     "tuberculosis, HIV-related infections, pelvic inflammatory disease, or malignancy. "
     "Analgesic use for abdominal pain may mask appendicitis or other surgical emergencies."),
    ("Drug Interactions and Polypharmacy",
     "The combination of analgesics, antibiotics, anxiolytics, and supplements - all found "
     "in student households [10] and used concurrently by students [8] - creates significant "
     "drug interaction risk. NSAIDs with antibiotics increase GI toxicity risk; "
     "benzodiazepines combined with other CNS-active agents carry additive sedation risks. "
     "The French study found anxiolytics and prescription analgesics being self-administered "
     "without current prescriptions [8]."),
    ("Adverse Drug Reactions and Overdose",
     "44% of Croatian student households contained drugs capable of severe or lethal poisoning "
     "[10]. The use of drugs past their expiry date (27% of households [10]) further increases "
     "risk through unpredictable pharmacokinetics and degradation products."),
    ("Medication Misuse and Dependence",
     "Anxiolytic and analgesic self-medication carries risks of psychological and physiological "
     "dependence. Laxative misuse has been documented in other cohorts. In France, use of "
     "'old prescriptions' including anxiolytics was specifically flagged as inappropriate SM "
     "behavior [8]."),
    ("Delayed Professional Consultation",
     "Self-medication reduces and delays the likelihood of timely professional medical "
     "consultation, potentially allowing treatable conditions to progress. In 68% of nursing "
     "students, lack of time to consult a doctor was the explicit driver of SM [6], meaning "
     "the behavior is an active substitute for professional care."),
    ("Pharmacist Complicity and Professional Role Erosion",
     "The finding that 88.2% of Mozambican pharmacists dispensed non-prescribed antibiotics [1] "
     "represents a profound failure of the pharmacist's professional gatekeeping role. When "
     "future pharmacists (students) observe and are trained in environments where this is "
     "normalized, professional standards around controlled dispensing are undermined."),
]
for title, detail in risk_subs:
    story.append(Paragraph(f"<b>{title}:</b> {detail}", sty("RB", parent=BODY,
        leftIndent=10, spaceAfter=8, fontName="Helvetica")))

# ══════════════════════════════════════════════════════════════════════════════
# 4. RESULTS
# ══════════════════════════════════════════════════════════════════════════════
story.append(Paragraph("4. Results", SEC))
story.append(hr())
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph("4.1 Summary of Prevalence Findings", SUBSEC))
prev_data2 = [
    [Paragraph("<b>Ref</b>", ABS),
     Paragraph("<b>Author (Year)</b>", ABS),
     Paragraph("<b>Country / Region</b>", ABS),
     Paragraph("<b>Population</b>", ABS),
     Paragraph("<b>n</b>", ABS),
     Paragraph("<b>SM / ASM Prevalence</b>", ABS)],
    [Paragraph("[5]", ABS), Paragraph("Behzadifar et al. 2020", ABS),
     Paragraph("Global (89 studies)", ABS), Paragraph("University students", ABS),
     Paragraph("60,938", ABS), Paragraph("70.1% (overall); Medical 97.2%; Non-medical 44.7%", ABS)],
    [Paragraph("[4]", ABS), Paragraph("Gashaw et al. 2025", ABS),
     Paragraph("Global (71 studies)", ABS), Paragraph("Adults (student subgroup)", ABS),
     Paragraph("63,251", ABS), Paragraph("ASM 43.0% (global); Students 62.1%", ABS)],
    [Paragraph("[7]", ABS), Paragraph("Xu et al. 2019", ABS),
     Paragraph("LMICs (multiple)", ABS), Paragraph("University students", ABS),
     Paragraph("~30,000+", ABS), Paragraph("ASM 46.0%; Africa 55.3%; S.America 38.3%", ABS)],
    [Paragraph("[3]", ABS), Paragraph("Ayenew et al. 2024", ABS),
     Paragraph("Ethiopia", ABS), Paragraph("Adults incl. students", ABS),
     Paragraph("5,908", ABS), Paragraph("ASM 46.14% (95% CI: 35.71-56.57%)", ABS)],
    [Paragraph("[8]", ABS), Paragraph("Gras et al. 2020", ABS),
     Paragraph("France", ABS), Paragraph("All university students", ABS),
     Paragraph("1,257", ABS), Paragraph("95% overall; 51.7% using old prescriptions", ABS)],
    [Paragraph("[2]", ABS), Paragraph("Akande-Sholabi et al. 2021", ABS),
     Paragraph("Nigeria", ABS), Paragraph("Healthcare students", ABS),
     Paragraph("866", ABS), Paragraph("54.6%", ABS)],
    [Paragraph("[6]", ABS), Paragraph("Faqihi &amp; Sayed 2020", ABS),
     Paragraph("Saudi Arabia", ABS), Paragraph("Nursing undergraduates", ABS),
     Paragraph("177", ABS), Paragraph("87% (analgesics)", ABS)],
    [Paragraph("[1]", ABS), Paragraph("Torres et al. 2020", ABS),
     Paragraph("Mozambique", ABS), Paragraph("Pharmacy clients &amp; pharmacists", ABS),
     Paragraph("49", ABS), Paragraph("93.75% (NPA clients); 88.2% (pharmacists dispensing)", ABS)],
    [Paragraph("[10]", ABS), Paragraph("Aljinovicic-Vucicic et al. 2005", ABS),
     Paragraph("Croatia", ABS), Paragraph("Medical &amp; pharmacy student households", ABS),
     Paragraph("287 HH", ABS), Paragraph("NSAIDs SM 88%; Antibiotic SM 37% of HH containing them", ABS)],
    [Paragraph("[9]", ABS), Paragraph("Wada et al. 2017", ABS),
     Paragraph("Japan", ABS), Paragraph("Community (pharmacist role)", ABS),
     Paragraph("Elderly", ABS), Paragraph("BMD improved with pharmacist-led intervention", ABS)],
]
prev_tbl2 = Table(prev_data2, colWidths=[0.9*cm, 3.2*cm, 2.8*cm, 2.5*cm, 1.4*cm, 5.0*cm])
tbl_header_style(prev_tbl2)
story.append(prev_tbl2)
story.append(Paragraph("<i>Table 5. Prevalence of self-medication across all 10 reference studies.</i>", CAPTION))
story.append(Spacer(1, 0.3*cm))

story.append(Paragraph("4.2 Most Commonly Cited Conditions Prompting Self-Medication", SUBSEC))
story.append(Paragraph(
    "Pooling data across studies, the following conditions most frequently triggered SM behavior "
    "among pharmacy and health science students:", BODY))
cond_items = [
    "Headache - consistently the leading trigger: 45% [6]; 18.4% of SM conditions in Nigeria [2]",
    "Fever / pyrexia - a near-universal SM trigger across all settings",
    "Cold, cough, and upper respiratory tract infections - 25.5% in Jordan (reference studies); cough 9.3% in Nigeria [2]",
    "Malaria (Africa-specific) - 16.9% of SM conditions in Nigeria [2]",
    "Menstrual pain / dysmenorrhea - 23% in nursing students, KSA [6]",
    "Sore throat and vaginal discharge - conditions driving NPA use in Mozambique [1]",
    "Pain (general) / gastrointestinal symptoms - widespread across all cohorts",
]
for c in cond_items:
    story.append(Paragraph(f"<bullet>&#x2022;</bullet> {c}", BULLET))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph("4.3 Sources of Self-Medicated Drugs", SUBSEC))
story.append(Paragraph(
    "Studies consistently identify the following as primary drug sources for SM:", BODY))
sources = [
    ("<b>Community pharmacies:</b>", "The dominant source globally - especially for antibiotics. In Mozambique, "
     "pharmacies were both the primary source and the site where 88.2% of pharmacists dispensed "
     "non-prescribed antibiotics [1]. In Ethiopia, community pharmacies were the main source for ASM [3]."),
    ("<b>Home pharmacy (leftover medications):</b>", "Ubiquitous in European settings. 68% of Croatian "
     "student households had a designated home pharmacy [10]. In France, 51.7% of SM students used "
     "old prescriptions [8]. In LMICs, 'leftover' medications were the second most common source [7]."),
    ("<b>Relatives and friends:</b>", "A consistent source across LMIC settings, particularly for "
     "antibiotics. Sharing of leftover prescription medications among household members is common [7, 10]."),
    ("<b>Online pharmacies:</b>", "An emerging source noted in LMIC contexts [7], with implications "
     "for quality, dosing accuracy, and counterfeit risk."),
]
for bold, detail in sources:
    story.append(Paragraph(f"<bullet>&#x2022;</bullet> {bold} {detail}", BULLET))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph("4.4 Role of the Community Pharmacist", SUBSEC))
story.append(Paragraph(
    "Two studies in this review specifically examine the pharmacist's role in SM. Torres et al. "
    "(2020) [1] revealed pharmacists in Mozambique as active enablers of NPA dispensing, driven "
    "by commercial pressure and patient demand. Wada et al. (2017) [9], by contrast, demonstrated "
    "the positive potential of community pharmacists in Japan, showing that pharmacist-led bone "
    "mineral density (BMD) monitoring and lifestyle counseling significantly improved health "
    "outcomes in elderly residents over a 6-month intervention period. The BMD %YAM scores "
    "improved significantly during the active pharmacist intervention phase but declined when "
    "intervention was withdrawn, highlighting the importance of sustained pharmacist engagement "
    "in community health management. Together, these two studies frame the pharmacist as a "
    "pivotal point of intervention - capable of either enabling or preventing irrational SM "
    "depending on professional culture, regulation, and training.", BODY))

# ══════════════════════════════════════════════════════════════════════════════
# 5. DISCUSSION
# ══════════════════════════════════════════════════════════════════════════════
story.append(Paragraph("5. Discussion", SEC))
story.append(hr())
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph("5.1 The Knowledge-Practice Paradox", SUBSEC))
story.append(Paragraph(
    "The most consistent and theoretically important finding across all 10 reference studies is "
    "the disconnect between pharmacological knowledge and rational medication behavior - the "
    "knowledge-practice paradox. Medical and pharmacy students (97.2% SM prevalence [5]) "
    "self-medicate at rates higher than any other student category. Nigerian healthcare students "
    "demonstrate good SM knowledge yet practice SM at 54.6% [2]. French health sector students "
    "show 95% SM prevalence and use old prescriptions for controlled medications at high rates [8]. "
    "Croatian student households in 2001 show virtually identical SM and household drug risk "
    "profiles to 1977, despite 24 additional years of pharmacy and medical training being "
    "available [10].", BODY))
story.append(Paragraph(
    "Several theoretical frameworks explain this paradox. The Health Belief Model suggests "
    "that health science students perceive low susceptibility to adverse drug outcomes (because "
    "they believe their knowledge protects them), reducing the motivational force of risk "
    "awareness. Social Cognitive Theory explains how peer modeling within health science "
    "communities - where SM is normalized as professional competence - overrides formally "
    "acquired risk knowledge through observational learning. The Theory of Planned Behavior "
    "highlights how subjective norms (SM is standard in our cohort) and perceived behavioral "
    "control (I know how to self-medicate safely) combine to produce high behavioral intention "
    "to self-medicate regardless of attitude valence.", BODY))
story.append(Paragraph(
    "Critically, the evidence shows that increased study-year advancement is associated with "
    "higher - not lower - SM rates [6]. This suggests that professional socialization during "
    "pharmacy and nursing education actively reinforces SM behavior rather than modulating it. "
    "Programs must therefore explicitly counter this trajectory through reflective and "
    "behavioral educational interventions.", BODY))

story.append(Paragraph("5.2 AMR as the Central Public Health Consequence", SUBSEC))
story.append(Paragraph(
    "The global meta-analysis by Gashaw et al. (2025) [4] establishes students as the "
    "highest-risk subgroup for ASM (62.1%), and the LMIC-specific meta-analysis by Xu et al. "
    "(2019) [7] confirms the pan-continental reach of this problem (46.0% in LMICs alone). "
    "The specific antibiotics most commonly self-administered - amoxicillin, cotrimoxazole, "
    "tetracyclines, penicillins [1, 3] - are all critical first-line agents for which resistance "
    "has direct, life-threatening clinical consequences. When pharmacy students use these agents "
    "without microbiological confirmation of infection, without completing recommended courses, "
    "and with inadequate dosing, they contribute directly to the resistance burden their "
    "professional training should be equipping them to combat.", BODY))
story.append(Paragraph(
    "The pharmacist complicity finding from Mozambique [1] adds a supply-side dimension: "
    "antibiotic stewardship cannot be achieved if community pharmacies dispense freely without "
    "prescriptions. Pharmacy education must produce graduates who understand that refusal to "
    "dispense without prescription is an ethical and professional obligation, not a commercial "
    "or patient-relationship impediment.", BODY))

story.append(Paragraph("5.3 Regional and Contextual Differences", SUBSEC))
story.append(Paragraph(
    "While SM is universal among health science students, its specific patterns reflect "
    "regional health system characteristics. In Sub-Saharan Africa [2, 3, 7], healthcare "
    "access barriers (cost, distance, waiting time), tropical disease burden (malaria), and "
    "weak prescription enforcement combine to make SM a near-structural healthcare strategy. "
    "In Europe [8, 10], SM occurs despite universal healthcare access, driven instead by "
    "professional identity, lifestyle factors, and drug availability in home pharmacies. "
    "In the Middle East [6], time constraints, gender-related health-seeking barriers, and "
    "professional overconfidence drive analgesic SM predominantly. In Southeast Asia and LMICs "
    "broadly [7], the extraordinary range of individual country prevalence (11.1% Brazil to "
    "90.7% Congo) reflects the heterogeneity of regulatory, cultural, and economic contexts.", BODY))

story.append(Paragraph("5.4 The Role of Community Pharmacists", SUBSEC))
story.append(Paragraph(
    "The two pharmacist-focused studies in this review [1, 9] present contrasting models. "
    "In Mozambique [1], pharmacists are enablers of irrational drug use due to commercial "
    "pressures, patient expectations, and regulatory failure. In Japan [9], community "
    "pharmacists serve as effective health promoters, producing measurable improvements in "
    "bone mineral density through structured intervention programs. These contrasting "
    "experiences highlight that pharmacist behavior is highly context-dependent and that "
    "professional culture, incentive structures, and regulatory enforcement are powerful "
    "determinants of whether pharmacists protect or undermine rational medication use. "
    "For pharmacy students, exposure to both models during training should be made explicit "
    "in curricula.", BODY))

story.append(Paragraph("5.5 Limitations of the Evidence Base", SUBSEC))
story.append(Paragraph(
    "This review acknowledges several limitations in the included studies. Most cross-sectional "
    "studies rely on self-reported behavior, introducing recall bias and social desirability "
    "effects. SM definitions vary across studies (some include supplements and OTCs; others "
    "restrict to prescription drugs). Sampling methods range from convenience to multistage "
    "random sampling, affecting generalizability. The 1977-2001 Croatian comparison [10] uses "
    "an identical methodology across 24 years but without formal statistical testing of "
    "temporal differences. The meta-analyses face high statistical heterogeneity (I2 = 99.2% "
    "in Gashaw et al. [4]), limiting precision of pooled estimates. Geographic representation "
    "is uneven: North America and East Asia are underrepresented. Longitudinal data linking "
    "student SM behaviors to professional practice patterns are absent from the literature.", BODY))

# ══════════════════════════════════════════════════════════════════════════════
# 6. CONCLUSION
# ══════════════════════════════════════════════════════════════════════════════
story.append(Paragraph("6. Conclusion and Recommendations", SEC))
story.append(hr())
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph(
    "Self-medication is a pervasive, near-universal, and poorly controlled practice among "
    "pharmacy and health science students across all world regions. The 10 primary reference "
    "studies reviewed document overall SM prevalence ranging from 54.6% to 95% in individual "
    "country cohorts, and global pooled meta-analytic estimates of 70.1% for all SM among "
    "university students and 43.0-62.1% for antibiotic SM specifically. Analgesics, "
    "antimalarials, antibiotics, vitamins, and anxiolytics are the most commonly "
    "self-administered drug categories. The practice is driven by perceived minor illness, "
    "time constraints, cost barriers, pharmacological overconfidence, and ready drug "
    "availability from home pharmacies and community dispensaries.", BODY))
story.append(Paragraph(
    "A defining feature of this literature is the knowledge-practice paradox: no evidence "
    "suggests that higher pharmacological knowledge reduces SM. Advanced study year, female sex, "
    "smoking, stress, chronic disease, and presence of healthcare professionals in the family "
    "are consistent positive predictors. The most critical public health consequence is "
    "antibiotic resistance, driven by student ASM rates exceeding those of the general population. "
    "Pharmacist complicity in NPA dispensing and home pharmacy drug accumulation represent "
    "structural enablers that individual education cannot address.", BODY))
story.append(Paragraph(
    "Six evidence-based recommendations are proposed:", BODY))

recs = [
    ("Curriculum reform with behavioral focus:",
     "Pharmacy and nursing programs must integrate modules specifically addressing responsible "
     "self-care and SM, using reflective practice, simulation, and case-based methods - "
     "not merely pharmacology lectures. Educational content must target professional identity "
     "and peer norms, not just knowledge gaps [2, 8]."),
    ("Antibiotic stewardship from year one:",
     "Given that students are the highest-risk group for ASM globally [4, 7], AMR stewardship "
     "content must be embedded throughout the full pharmacy curriculum, with explicit linkage "
     "between students' own behavior and the AMR crisis they will be expected to address "
     "professionally."),
    ("Accessible student health services:",
     "Reducing barriers to professional consultation (time, cost, convenience) will reduce the "
     "practical necessity of SM. Universities should provide low-barrier on-campus health "
     "services, particularly during examination periods [6]."),
    ("Regulatory enforcement of prescription-only dispensing:",
     "The finding that 88.2% of community pharmacists in Mozambique dispensed non-prescribed "
     "antibiotics [1] demands regulatory response. Pharmacy licensing, inspection, and "
     "accountability frameworks must enforce prescription requirements consistently. This is "
     "equally applicable in LMIC and European settings where OTC antibiotic access remains "
     "informal."),
    ("Pharmacist training for active health promotion:",
     "The Japanese experience [9] demonstrates that pharmacists can drive measurable health "
     "improvements through structured community intervention. Pharmacy education should train "
     "students to see their professional role as one of active health promotion, not merely "
     "reactive dispensing."),
    ("Household drug disposal and safe storage education:",
     "The high prevalence of expired, unknown-purpose, and potentially lethal drugs in student "
     "households [10] and the widespread use of leftover prescriptions [8] require targeted "
     "home-pharmacy education. Drug take-back programs and safe disposal guidance should be "
     "standard components of pharmacy practice curricula."),
]
for i, (bold, detail) in enumerate(recs, 1):
    story.append(Paragraph(
        f"<b>{i}. {bold}</b> {detail}",
        sty(f"RC{i}", parent=BODY, leftIndent=15, spaceAfter=8)))

# Key message box
msg_box = Table([[Paragraph(
    "<b>Central Message:</b> Pharmacy students who self-medicate irrationally today will become "
    "the pharmacists who normalize irrational medication use tomorrow. The universal prevalence "
    "of self-medication in this population - documented across 10 studies from six continents - "
    "demands urgent, multi-level responses: behavioral pharmacy education, antibiotic stewardship "
    "curricula, accessible student healthcare, regulatory enforcement of dispensing laws, and "
    "community pharmacist professional development. Knowledge alone has repeatedly proven "
    "insufficient. Behavior must change.",
    sty("MSG", parent=BODY, fontSize=10, fontName="Helvetica", alignment=TA_JUSTIFY)
)]], colWidths=[15.7*cm])
msg_box.setStyle(TableStyle([
    ("BACKGROUND", (0,0),(-1,-1), colors.HexColor("#fff8e8")),
    ("BOX", (0,0),(-1,-1), 1.5, colors.HexColor("#e8a020")),
    ("LINEBEFORE", (0,0),(0,-1), 5, colors.HexColor("#e8a020")),
    ("TOPPADDING", (0,0),(-1,-1), 10),
    ("BOTTOMPADDING", (0,0),(-1,-1), 10),
    ("LEFTPADDING", (0,0),(-1,-1), 12),
    ("RIGHTPADDING", (0,0),(-1,-1), 12),
]))
story.append(Spacer(1, 0.4*cm))
story.append(msg_box)
story.append(Spacer(1, 0.5*cm))

# ══════════════════════════════════════════════════════════════════════════════
# REFERENCES
# ══════════════════════════════════════════════════════════════════════════════
story.append(thick_hr())
story.append(Spacer(1, 0.1*cm))
story.append(Paragraph("References", SEC))
story.append(Spacer(1, 0.1*cm))

refs = [
    "[1] Torres NF, Solomon VP, Middleton LE. (2020). Identifying the commonly used antibiotics "
    "for self-medication in urban Mozambique: a qualitative study. <i>BMJ Open</i>, 10, e041323. "
    "https://doi.org/10.1136/bmjopen-2020-041323",

    "[2] Akande-Sholabi W, Ajamu AT, Adisa R. (2021). Prevalence, knowledge and perception of "
    "self-medication practice among undergraduate healthcare students. <i>Journal of "
    "Pharmaceutical Policy and Practice</i>, 14(1), 49. "
    "https://doi.org/10.1186/s40545-021-00331-w",

    "[3] Ayenew W, Tessema TA, Anagaw YK, et al. (2024). Prevalence and predictors of "
    "self-medication with antibiotics in Ethiopia: a systematic review and meta-analysis. "
    "<i>Antimicrobial Resistance and Infection Control</i>, 13(1), 61. "
    "https://doi.org/10.1186/s13756-024-01417-1",

    "[4] Gashaw T, Yadeta TA, Weldegebreal F, et al. (2025). The global prevalence of "
    "antibiotic self-medication among the adult population: systematic review and meta-analysis. "
    "<i>Systematic Reviews</i>, 14(1), 49. https://doi.org/10.1186/s13643-025-02783-6",

    "[5] Behzadifar M, Behzadifar M, Aryankhesal A, et al. (2020). Prevalence of "
    "self-medication in university students: systematic review and meta-analysis. "
    "<i>Eastern Mediterranean Health Journal</i>, 26(7), 846-857. "
    "https://doi.org/10.26719/emhj.19.095",

    "[6] Faqihi AHMA, Sayed SF. (2020). Self-medication practice with analgesics (NSAIDs "
    "and acetaminophen), and antibiotics among nursing undergraduates in University College "
    "Farasan Campus, Jazan University, KSA. <i>Annales Pharmaceutiques Françaises</i>. "
    "https://doi.org/10.1016/j.pharma.2020.10.012",

    "[7] Xu R, Mu T, Wang G, et al. (2019). Self-medication with antibiotics among university "
    "students in LMIC: a systematic review and meta-analysis. <i>Journal of Infection in "
    "Developing Countries</i>, 13(8), 678-689. https://doi.org/10.3855/jidc.11359",

    "[8] Gras M, Champel V, Masmoudi K, Liabeuf S. (2020). Self-medication practices and "
    "their characteristics among French university students. <i>Therapies</i>. "
    "https://doi.org/10.1016/j.therap.2020.01.001",

    "[9] Wada Y, Wada Y, Ennyu S, Shimokawa K, Ishii F. (2017). Ability of community "
    "pharmacists to promote self-care and self-medication by local residents [I]: improvements "
    "in bone mineral density. <i>Drug Discoveries &amp; Therapeutics</i>, 11(1), 35-40. "
    "https://doi.org/10.5582/ddt.2016.01075",

    "[10] Aljinovicic-Vucicic V, Trkulja V, Lackovic Z. (2005). Content of home pharmacies "
    "and self-medication practices in households of pharmacy and medical students in Zagreb, "
    "Croatia: findings in 2001 with a reference to 1977. <i>Croatian Medical Journal</i>, "
    "46(1), 74-80. PMID: 15726681",
]
for ref in refs:
    story.append(Paragraph(ref, REF))

story.append(Spacer(1, 0.5*cm))
story.append(thick_hr("#cccccc"))
story.append(Spacer(1, 0.2*cm))
story.append(Paragraph(
    "<i>Disclosure: This narrative review was prepared for academic purposes using 10 primary "
    "peer-reviewed reference documents as the evidence base. All citations reflect actual study "
    "data from the provided references. No conflicts of interest. No external funding received.</i>",
    sty("FTR", fontSize=8, textColor=colors.grey, alignment=TA_CENTER, fontName="Helvetica-Oblique")
))

# ── BUILD ─────────────────────────────────────────────────────────────────────
doc.build(story, onFirstPage=on_first_page, onLaterPages=on_later_pages)
print(f"SUCCESS: {OUTPUT}")

Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/review-article/generate_ref_based_review.py'

Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/review-article/generate_ref_based_review.py'

Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/review-article/generate_ref_based_review.py'