self-medication practices pharmacy students

self medication practices pharmacy students review article topics 2024

PMID: 35300683

PMID: 35162213

PMID: 38069846

PMID: 40012022

PMID: 38853267

PMID: 34915938

mkdir -p /home/daytona/workspace/review-article

~/review-article/generate_review.py

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
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)

subtitle_style = ParagraphStyle(
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    alignment=TA_CENTER,
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)

journal_style = ParagraphStyle(
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    leading=13,
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    alignment=TA_CENTER,
    spaceAfter=14,
    fontName="Helvetica-Oblique",
)

section_heading = ParagraphStyle(
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body_style = ParagraphStyle(
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    fontName="Helvetica",
)

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abstract_box_style = ParagraphStyle(
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keyword_style = ParagraphStyle(
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# ── 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 = [
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        "AH", parent=styles["Normal"], fontSize=11,
        fontName="Helvetica-Bold", textColor=colors.white))],
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        "<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
    )],
]

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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))

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    [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)],
]

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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}")

python /home/daytona/workspace/review-article/generate_review.py

ls -lh /home/daytona/workspace/review-article/