An Investigation into Consumer Attitudes and Perception towards Self-Medication in Pakistan in light of the Cultural Dimension of Uncertainty Avoidance

Submitted by Khawaja Saleem Ahmed (1058138) Fatima Haider (1058117) Yousuf Zahid (1058156) Asma Zuberi (1058108)

For the course Research Project EMBA 66 (6)

Submitted to Faryal Salman on Thursday, February 14, 2013 Faculty of Management Sciences, SZABIST

Shaheed Zulfikar Ali Bhutto Institute of Science & Technology (SZABIST) Karachi

Table of Contents
Acknowledgement ........................................................................................................................................ 4 Abstract ......................................................................................................................................................... 5 1. INTRODUCTION ................................................................................................................................ 6 1.1 Background of the Study............................................................................................................... 6

1.2 Problem Statement .............................................................................................................................. 7 1.3 Research Gap ...................................................................................................................................... 8 1.4 Research Objectives ............................................................................................................................ 9 1.5 Research Questions ........................................................................................................................... 10 1.6 Theoretical Framework ..................................................................................................................... 11 1.7 Significance and Scope of the Study................................................................................................. 12 1.8 Limitations of the Study.................................................................................................................... 13 2. LITERATURE REVIEW ................................................................................................................... 14 2.1 Self-Medication: Definition .............................................................................................................. 14 2.2 Self-Medication: Spread and Frequency ........................................................................................... 14 2.3 Self-Medication: Reasons and Ailments Treated.............................................................................. 15 2.4 Self-Medication: Consumer Behavior .............................................................................................. 15 2.5 Self-Medication: Effect of Population Spread, Income and Literacy ............................................... 16 2.6 Self-Medication: Perception of Risk ................................................................................................. 17 2.7 The National Cultural Dimensions of Hofstede ................................................................................ 18 2.8 Pakistan: The Cultural Dimension of Uncertainty Avoidance .......................................................... 19 2.9 Hofstede: Criticism ........................................................................................................................... 20 3. RESEARCH METHODOLOGY ........................................................................................................ 21 3.1 Research Design................................................................................................................................ 21 3.1.1 Qualitative Research .................................................................................................................. 21 3.1.1.1 Focus Group ........................................................................................................................... 21 3.1.2 Quantitative Research ................................................................................................................ 23 3.1.2.1 Desk Research ......................................................................................................................... 23 3.1.2.2 Survey and Questionnaire Design........................................................................................... 23

3.2 Sampling Procedure and Design ....................................................................................................... 25 3.2.1 Sampling Frame ......................................................................................................................... 25 3.2.2 Sampling Size and Selection ...................................................................................................... 25 3.3 Field Work for the Survey ................................................................................................................ 27 3.4 Research Hypothesis ......................................................................................................................... 28 4. DATA ANALYSIS ............................................................................................................................. 29 4.1 Reliability Analysis ........................................................................................................................... 29 4.2 Instrument Validity ........................................................................................................................... 31 4.3 Demographics ................................................................................................................................... 32 4.3.1 Frequency Tables ....................................................................................................................... 32 4.3.2 Bar Charts .................................................................................................................................. 35 4.4 Behavioral Analysis .......................................................................................................................... 39 4.5 Confirmatory Factor Analysis........................................................................................................... 41 4.6 Pearsons Correlation Matrix ............................................................................................................ 45 4.7 Hypothesis Testing............................................................................................................................ 46 5. CONCLUSION AND RECOMMENDATIONS .................................................................................... 49 5.1 Conclusion ........................................................................................................................................ 49 5.2 Recommendations ............................................................................................................................. 51 AREAS OF FURTHER STUDY ................................................................................................................ 52 BIBLIOGRAPHY ....................................................................................................................................... 53 APPENDIX ................................................................................................................................................. 57 a. b. Focus Group Guide ......................................................................................................................... 57 Survey Questionnaire ...................................................................................................................... 61

Acknowledgement
The authors of the study express a sincere gratitude to Ms. Faryal Salman for providing guidance throughout the semester and especially on the continuous improvement of data collection and its compilation.

A profound appreciation also goes out to all our classmates who had been instrumental in extending support in their respective organizations for collection of data through the survey questionnaire.

Special thanks are conveyed to Mr. Asad Subzwari for taking out time and assisting the authors during coding and data entry of the survey on the software of SPSS 17 and PASW Statistics 18.

Abstract

The purpose of the research study is to investigate the perception and attitudes of consumers towards self-medication in light of Hofstedes cultural dimension of uncertainty avoidance. The study had been conducted in Karachi and a sample size of 200 had been utilized for the purpose. Analysis of data obtained from specially designed questionnaire had been fed into statistical software to acquire descriptive statistics together with confirmatory factor loading and correlation matrix analysis. The empirical findings showed that the consumers are risk averse but will be willing to practice self-medication based upon the specific situation they may face in life or due to operational variables which they may be exposed to at any given time e.g. cost of medicine being too high or unavailability of time to wait at a doctors clinic. Additionally, the consumer may engage into self-medication based upon good past experience or group influence. Studies in Pakistan have been undertaken on self-medication but not in juxtaposition with any cultural dimension. Future researches on different cultural dimensions of Hofstede vis--vis selfmedication and for other risk-taking and risk-averse behavior can be conducted in light of this research.

1. INTRODUCTION
1.1 Background of the Study

The people of Pakistan have been observed to take risks, knowingly and unknowingly, in every walk of life. The authors in light of their everyday observation have seen countless people take a risk while undertaking a specific action. These actions arise from an attitude that the people have created due to a wide range of reasons. Without contemplating on the reasons as to why people have developed such attitudes, consider the people who take risks while riding motorcycles without helmets, violating traffic signals on the red light, attempting to cheat in exams, swimming at the seaside without knowing how to swim, talking on the cell phone while driving, making an expensive lease-based investment but without a plan of how future payments will be made, providing children at home with computer and internet facilities and then not keeping a check and control over their activities, procrastinating at workplace despite being aware of work deadlines and visiting public places during times of public unrest and turmoil. The list of such activities in which an apparent risk-taking behavior is observed is endless but then risk is a subjective term and what is considered to be a risk for one person may not be so for another. This is where perceptions of people come into interplay. The authors of the study have attempted to narrow the focus on the apparent risk-taking behavior of people in the act of self-medication. Self-medication is not only common in Pakistan but all over the world as well and it is practiced due to a large number of reasons; reasons which encourage people to avoid consulting the physician. Regardless of the reasons, it is a human behavior which requires to be studied in order to determine the factors which play a role in developing perception and attitudes among people.

1.2 Problem Statement

According to the cultural dimension of uncertainty avoidance put forth by Hofstede (geerthofstede.com), the people of Pakistan have been found as risk-averse and with a considerably high uncertainty avoidance index. On the contrary, the act of self-medication as per common knowledge and based upon general scientific evidence is a risk-taking behavior. This contradiction is the essence of the problem because on one hand, Pakistanis refrain from taking risks and on the other, indulge in treatment of ailments through self-medication without seeking professional advice from doctors.

1.3 Research Gap

The research conducted in Pakistan almost thirty years ago (Hofstede & Bond, 1984), had established the basis of the society as high on uncertainty avoidance but the authors intend to conduct a study because of some apparent gaps that have been identified in the research. a) Has the societys risking-taking attribute changed and evolved over the years? b) Is the society still risk-averse and had the original research missed out key aspects which had failed to show the larger picture? c) Do other cultural dimensions of Hofstede influence or have started to influence the uncertainty avoidance index of Pakistanis? d) Is it just a perception or a fact that self-medication is dominantly practiced amongst the educated people? e) Is the consumer behavior of self-medication influenced by personality characteristics of an individual and by formal/informal reference groups? The research being undertaken will eventually benefit to understand and identify the hidden reasons of this specific consumer behavior and bring to light possible other aspects besides Hofstedes theory when it comes to declaring the Pakistani society as high on uncertainty avoidance.

1.4 Research Objectives

The primary objective of the study is to learn how consumers develop perceptions and form an attitude towards the act of self-medication and whether consumers take this risk willingly or unknowingly. At the same time, the study will also assist in the determination and analysis of reasons behind this act in contrast with the cultural dimension of uncertainty avoidance.

1.5 Research Questions

The core research questions arising as a result from the research objectives and the research gap are: a) How do the people in Pakistan perceive risk when it comes to management of health matters? b) Despite being a risk-averse nation, why do the people in Pakistan practice selfmedication? c) Which attributes contribute in forming an attitude towards the specific consumer behavior of self-medication? d) If and whether socio-economic factors play a role in motivating people to practice self-medication?

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1.6 Theoretical Framework

The practice of self-medicating students has reached a significantly high percentage despite the fact that the majority of students understand that self-medication practice is incorrect (Zafar et al., 2008). This means that people take a risk even after knowing the fact that it is a risk. This postulation has been clarified in the theoretical framework which incorporates the research hypothesis in light of the uncertainty avoidance index and the different variables.

Figure 1. The theoretical framework

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1.7 Significance and Scope of the Study

The research study strives to identify reasons by means of which consumers develop an inclination towards risk-averse or risk-taking behavior in the practice of self-medication based upon the perceptions that are developed leading to attitude formation. Findings of the study will possibly pave the way for managerial implications in terms of identifying ways and means of implementing stringent pharmacy regulations, stabilizing the cost of medicines and sustaining the quality of health care otherwise a strong probability exists that consumers will continue to jeopardize individual and family health care through self-medication practices. Subsequently, tactical measures by all concerned stake holders will ensure that a larger strategy is formulated which also incorporates the aspect of imparting awareness on self-medication towards the people. In order to conduct the research, specific units have been considered and which constitute of male and female adults hailing from different income groups and belonging to different age segments. These units are students and working individuals both in terms of profession.

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1.8 Limitations of the Study

The study is restricted to the research of consumer behavior on self-medication only with a focus on Karachi that represents the major urban areas of Pakistan. The drawn sample size is however not sufficient as it may not represent the total population of the city and the other principle urban hubs of the country. The other cultural dimensions of Hofstede besides uncertainty avoidance have not been considered and which may establish an-interplay among all the dimensions in order to analyze consumer perception and attitude. An element of bias may also exist in the replies received by the respondents due to individual perception and attitude towards the personal subject of health care. Other factors that have not been considered in the study include elements of religion and locus of control by means of which people govern their lives in Pakistan. Personalities also play a role and which motivates a person to develop an attitude and behave in a particular manner; this dimension also has not been taken into consideration. Based upon the lines of the study undertaken, additional in-depth research is required which may bring to light hidden variables that act as trigger points when it comes to understanding consumer behavior and the cultural dimensions of Pakistan.

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2. LITERATURE REVIEW

2.1 Self-Medication: Definition

The act treating an ailment either for diagnosis or prescription, by purchasing and consuming medicines without consulting an authorized doctor is called self-medication (Montastruc et al., 1997) The methods of self-medication are several and include purchase of drugs without a doctors prescription, using old prescriptions to acquire medicines, consuming in-stock medicines at home or workplace and exchanging, sharing and recommending drugs with friends, family members and colleagues (Filho et al., 2004). Self-medication is a widespread international occurrence and it has been around since ages because human beings have a natural disposition to reduce and eradicate health related issues with some medicine (Baig, 2012). Self-medication has been recognized at the highest level as well and the World Health Organization has pronounced the act as one where a person, during sickness will choose and consume a drug for self-treatment (WHO, 1998).

2.2 Self-Medication: Spread and Frequency

The impulsive use of medicines based upon self-conceived notions and through influencing references has been a matter of all-round concern (Filho et al., 2004) Self-medication as an act is spread all over the world and has considerably high rates of occurrence; up to 68% in European countries (Bretagne et al., 2006). The developing countries have an even higher rate (Shankar et al., 2002); up to 92% in Kuwait (Abahussain et al., 2005). India has 31% (Deshpande & Tiwari, 1997) whereas Nepal has a prevalence rate of 59% (Shankar et al., 2002). In Pakistan, however, just a few undertakings have come to light which elucidate the spread of self-medication but which have nonetheless confirmed a high rate of 51% spread in the country (Haider & Thaver, 1995).

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2.3 Self-Medication: Reasons and Ailments Treated

In a research that had been undertaken among Karachi-based university students, it was discovered that up to 76% students have engaged in the act of self-medication (Zafar et al., 2007). The study disclosed a number of reasons based upon which students self-medicate; most notable among which were the past experience of respondents with similar health indications (50.1%) and the perception itself of the petty nature of the problem (48.3%). Ailments for which the students practiced self-medication included headaches (72.4%), fever (55.2%) and common cold (65.5%). Accordingly, the respondents consumed medicines for relief and which fell into the category of painkillers (88.3%), fever relieving medicines (65.1%), anti-allergics (44.1%) and antibiotics (35.2%). These drugs had been mostly purchased from pharmacies (64.6%) or/and consumed from available medicines stored at home (64.4%) or acquired from class mates and friends (9.7%). It had also been reported in the study that more than one-third (43.3%) students who had approached a physician had later modified the dosage of the prescribed medicine on their own accord.

2.4 Self-Medication: Consumer Behavior

Self-medication is practiced by students in all academic disciplines and its commonness is more or less equal among medical and non-medical students (Zafar et al., 2007). Traditionally, it is assumed that non-medical students do not engage in the practice of selfmedication in comparison with medical students due to the possession of limited knowledge of medicines but the research findings proved otherwise. In contrast, another research shows an exceptionally higher rate of self-medication among medical students and professionals (James et al, 2006).

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A study that had been carried out on women and specifically mothers in Pakistan brought to light that positive past experience (61.3%) with drugs had been the primary reason for selfmedication (Haider & Thaver, 1995) Such consumer attitudes are developed through perception that is reinforced by gaining good experience through repeated acts of selfmedication but it is negative in outlook and identifies that people, despite being educated remain ignorant of possible problems that may arise through self-medication.

2.5 Self-Medication: Effect of Population Spread, Income and Literacy

Self-medication in Pakistan is practiced more in the urban as compared to rural areas and that its prevalence ratio goes up with the gradual increase in literacy levels (Baig, 2012). The households in urban and rural areas together constitute 64.2% in terms of presence of contemporary medicines at home with urban household leading within the percentage (Hussain et al., 2011). Results from a research puts skilled labor over unskilled labor (by 21%) when it comes to practicing self-medication (Baig, 2012). The research also showed that respondents (76.6%) earning a monthly income of above Rs. 10,000 self-medicated more than those (57.2%) with a monthly income of less than Rs. 10,000 per month. Another study presented interesting facts which proved the common knowledge that illiterate people abide by basic rules more than literate people; rules that govern specific situations in life. The results of the study revealed that literate people have a greater tendency to selfmedicate in comparison with illiterates (Klemenc-Ketis et al., 2010; Henry et al., 2006).

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2.6 Self-Medication: Perception of Risk

A research study discovered that in Pakistan, a very low proportion of university students consult a physician for ailments and that the reason for not consulting a doctor includes a number of factors besides the issue of cost of treatment. The study shows that the risk and hazard perception of the students towards self-medication is considered as inconsequential (Mumtaz et al., 2006). According to the Australian Council for Safety and Quality in Health Care, the specific consumer behavior of borrowing and sharing of medicines prescribed by physicians is recognized as a risk factor by the health and medical field stakeholders exclusively in medication errors which subsequently result in adverse drug events (Runciman et al., 2003). This specific patient behavior negatively affects the quality use of medicine (Bolton et al., 2002) and that there is a risk of underestimating the impact of this behavior on the incidence of adverse drug events which include drug-drug interactions, poisoning and the development of antibiotic resistant strains of pathogens (Ellis, 2009). In another study conducted at two medical and two non-medical universities, it was discovered that the frequency of self-medication had been as high as 76 percent (Zafar et al., 2008). Within the research it had been noted that 87.4% of the respondents were aware of the risks to health through self-medication. The respondents had accepted the fact that selfmedication is harmful and this shows the aspect of absence of knowledge. A similar result had also come to light in a research carried out in Turkey where it was found out, that despite majority of the students (89%) understood the reason of consulting a doctor before consuming antibiotics, 45% nonetheless continued the practice of self-medication (Buke et al., 2005).

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2.7 The National Cultural Dimensions of Hofstede

Despite being common in all segments of society, the factors which encourage a person to indulge in self-medication are still not clear and the risks arising from this practice continue to bring forth serious dangers to health (Baig, 2012). The awareness of health and its management in contemporary times by ordinary people is a result of the difference between culture and language, and the socioeconomic ranks together with the capacity of a person to comprehend and act on a doctors advice which depends upon cultural beliefs on the broad subject of health (Shaw et al., 2008). In a study conducted in United States of America, it was found that African-Americans consume medicines for symptoms like headaches, nosebleeds and hallucinations by taking decisions based upon culturally-informed experiences (Schoenberg and Drew, 2002). There is a definite influence of cultural dimensions on the behavior of a person at the time of an illness and upon the subsequent consumption of drugs (Deschepper et al., 2008). The scrutiny of differences in culture is carried out by a number of different models and from which the most-well renowned is Hofstedes National Cultural Dimensions. Hofstede defines culture as the collective programming of the mind that distinguishes the members of one human group from another (Hofstede & Bond, 1984). Based upon moderating variables such as education, the following of people of each other will increase the possibilities of perceiving the social environment and sharing of a subjective culture all from the same or a similar window (Hofstede & Bond, 1984).

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2.8 Pakistan: The Cultural Dimension of Uncertainty Avoidance

Hofstede has labeled the people of Pakistan as risk averse in the cultural dimension of uncertainty avoidance (geert-hofstede.com). With a score of 70, Pakistan is categorized as high in uncertainty avoidance or where people have a high preference for avoiding uncertainty. It means that Pakistanis adhere to specific codes of belief; are intolerant of unorthodox behavior and ideas; have an emotional need for rules; give importance to time; have an urge to work hard; resist innovation at times; observe punctuality as a norm and individual motivation is driven by security (geert-hofstede.com). In other words, on the uncertainty avoidance index, the people of Pakistan feel threatened by unknown, ambiguous, uncertain or unstructured situations. According to Hofstede, the people in Pakistan possess an emotional need for rules even if these rules do not seem to work (geert-hofstede.com). On the other hand, rules and regulations exist in Pakistan to govern the functioning of a pharmacy but in Karachi alone, all kinds of drugs are available at a chemist without prescription. This fact proves Hofstedes point but the medicines at these pharmacies are being sold because there are customers who will purchase them. It is a two-way intentional violation of the governing rule for a pharmacy to function (Strum et al., 1997). However, in a study on the cultural diversity in Pakistan (Shah & Amjad, 2011), the results showed that the Pakistani society by and large does not feel threatened by uncertainty, unknown, ambiguous or unstructured situations. From the study, it is interesting to note that the findings on uncertainty avoidance index are amidst terrorist attacks, political instability and increasing stagflation in Pakistan, and calls for more research into this phenomenon (Shah & Amjad, 2011).

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2.9 Hofstede: Criticism

Hofstedes cultural dimensions have been criticized as not being a valid instrument to determine cultural differences because of the almost thirty years that have lapsed since 1984 and the study is far too obsolete and could not be implemented in contemporary times of fast evolving environment, convergence and globalization (Shariq et al., 2011). A number of researchers have put forth compelling argument against Hofstede. The argument includes Hofstedes variables varying in sensitivity from one culture to another (Schwartz, 1999); the original study by Hofstede had been based on an assessment of individuals and then applied in large on the overall community, which skewed the results (Dorfman & Howell, 1988); culture is not necessarily bounded by national borders therefore entire nations cannot be the valid unit of analysis (McSweeney, 2000); Hofstedes research had been conducted on the data collected from one company in different countries and a the findings of one company in each country could not be implemented on the entire nation to determine cultural dimensions. (Graves, 1986; Olie, 1995);

Therefore, the purpose of this study is to learn how consumers develop perceptions and form an attitude towards the act of self-medication and whether consumers take this risk willingly or unknowingly. This study also undertakes to discover the behavior of consumers in Pakistan; their level of awareness and the factors which trigger the specific act of selfmedication.

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3. RESEARCH METHODOLOGY
3.1 Research Design

The development of the study is based on applied research with an approach encompassing cross-sectional and snap-shot research parameters. Quantitative and qualitative research methodologies have been implemented in order to explain the contradiction in actual consumer behavior towards the risk-bearing act of selfmedication and the risk-averse label suggested on the people of Pakistan in light of the cultural dimension of uncertainty avoidance as formulated by Hofstede. The research design for the study will subsequently assist in bringing forth an analysis that will allow suggesting logical recommendations.

3.1.1 Qualitative Research 3.1.1.1 Focus Group

The focus group analysis had been designed and implemented in order to assess the perception and attitude of the three identified respondent clusters viz., students, households and corporate professionals. A focus group is used as a tool to manage, conduct, write and record the feedback received from a specific group of people who are selected as per pre-defined criteria. The focus group participants are managed by a moderator who asks questions and probes deeper to obtain a true understanding of the replies provided by the participants (Prince and Davies, 2001). For the undertaken research, a focus group had been conducted to obtain a better understanding of opinions and attitudes of consumer behavior towards the act of self-medication in light of the underlying cultural dimension variable. The discussion guide for the focus group consisted of unstructured questions according to the information needed to extract responses through a conversation.
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The sample size for the focus group constituted of seven individuals and which represented educated and different socio-economic classes specifically hailing from the clusters of corporate sector, household and students. The overall age group was between 20-35 years with average house hold income of Rs. 100,000 per month. The major findings which came forth elucidated that the participants have practiced selfmedication due to five main reasons viz., (a.) time constraints (b.) avoiding the queue time at a clinic/hospital (c.) non-accessibility to a qualified physician (d.) negligence of doctors in terms of imparting service as per general perception (d.) non-availability of quality doctors at the time when treatment of an ailment had been required. According to participants perspective, self-medication is a risk towards health by which various negative consequences can occur and which often leads to serious complications in the form of side effects and even causing death. The participants opined that factors exist which can motivate an individual to take a calculated or blind risk in terms of self-medication and in life in general. These factors interplay with an individuals personality based upon aspects of recognition in society, a powerful external locus of control and group influence. The participants also disclosed that they will avoid an uncertain situation as and where logically possible. The focus group findings disclosed that homogeneity in approach existed among the three respondent clusters towards the act of self-medication. Accordingly, the outcome of the focus group determined the constructs for the quantitative survey.

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3.1.2 Quantitative Research 3.1.2.1 Desk Research

Research in Pakistan has been undertaken in the past on self-medication but not in light of the cultural dimension of uncertainty avoidance. With regard to the act of self-medication, consumer behavior including consumer knowledge, perception and attitude has either not been measured in depth or has been missed out altogether. A thorough study of different literature has been conducted to develop an understanding of the consumer behavior in this study and to ascertain if the Pakistani people are genuinely risk averse as declared by Hofstede. Secondary data has been collected from different data bases of trustworthy and genuine research journals of medicine, consumer behavior, psychology and sociology.

3.1.2.2 Survey and Questionnaire Design

In terms of applied research, a self-monitored questionnaire based survey has been deployed in light of a cross-sectional study in Karachi. The survey has been designed to measure the consumer perception and attitude in terms of behavioral intention, uncertainty avoidance, perceived risk and risk aversive behavior towards self-medication. The questionnaire has been designed to provide simplicity, understandability and comprehensiveness for the respondent and for the ease in post survey proceedings. The structure of the statements in the survey had been supported by the likert scale had been developed to determine the strength of opinion of the respondents. The scale had been balanced in terms of favorable and unfavorable responses and was non-comparative in nature.

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According to the conceptual model of the undertaken research, uncertainty avoidance serves as the independent variable and the consumer attitude and behavior as the dependent variables. The underlying operational elements of medicine cost, waiting time for treatment, consumers awareness, external legal environment, consumers locus of control and physicians service quality shaped up the questionnaire statements and which also included constructs to ascertain the influence of reference groups on consumer behavior. In the questionnaire, specific constructs also carried the rank-order scale to measure ailments most commonly treated through self-medication the situations which encourage a consumer to opt for self-medication. The profile of the respondent had also been developed based upon scales requesting for data pertaining to gender, age group, education, employment status and household income.

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3.2 Sampling Procedure and Design

3.2.1 Sampling Frame

The focus group findings brought to light that there is no significant difference in opinion among the three clusters of corporate, household and student representatives. Therefore, the sample of respondents had been chosen from the corporate sector and university students. Homogeneity within these clusters may exist but the respondent background within the clusters will lead to heterogeneity due to diversity in income and age groups, corporate position, marital status and gender. For the respondents, the city of Karachi had been selected because of its universal influence on other cities of Pakistan and thereby it would depict an appropriate representation of the major urban areas.

3.2.2 Sampling Size and Selection

The sample size constituted of 200 educated respondents residing in different localities of Karachi. The principle criterion for selecting the sample was based on probability of stratified random sampling. This is type of sampling technique is where every individual has an equal and known chance of being selected (Sekaran, 2000). The respondents had been selected on a chance-basis from the population of those available at the point of contact at the time of approach. At the private firms and university, the contact persons had been advised to pre-qualify the respondents on behalf of the authors vis--vis willingness of the respondents to participate neutrally in the survey and by considering the ability of a respondent to comprehend the importance of the research survey and articulate the replies accordingly.

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The respondents from the students cluster had been approached in the BBA and MBA programs of Shaheed Zulfiqar Ali Bhutto Institute of Science and Technology whereas the working professionals (as respondents) had been approached in a number of private companies which included MCB, HBL, Habib Metro, Bayer, Habib Public School, AKUH, Multinet and Ibrahim Fibers.

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3.3 Field Work for the Survey

The authors of the study had approached the private firms in two teams by contacting the resource individuals and obtaining necessary permission. It took 16 days from first contact till the receipt of completed survey forms. Research quality had been assured by maintaining a Chinese wall (wikipedia.org) during all communication to ensure that the element of bias is kept at the lowest possible level.

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3.4 Research Hypothesis

The study puts forth specific hypothesis for empirical testing in light of the research objectives and with the help of secondary data and insights from focus group. Risk is perceived by self-medicating people in individual capacities and which leads the people to be either risk-averse or risk-takers. As a result, the people may be high or low on the uncertainty avoidance index which reflects on the specific (positive or negative) attitudes that are developed and which will eventually initiate or avoid the consumer behavior towards self-medication. The following hypotheses were generated: a. H0: The behavioral intention is significantly correlated to uncertainty avoidance H1: The behavioral intention is not significantly correlated to uncertainty avoidance b. H0: The behavioral intention is significantly correlated to perceived risk H1: The behavioral intention is not significantly correlated to perceived risk c. H0: The behavioral intention is significantly correlated to risk aversive behavior H1: The behavioral intention is not significantly correlated to risk aversive behavior d. H0: The uncertainty avoidance is significantly correlated to perceived risk H1: The uncertainty avoidance is not significantly correlated to perceived risk e. H0: The uncertainty avoidance is significantly correlated to risk aversive behavior H1: Uncertainty avoidance is not significantly correlated to risk aversive behavior f. H0: The perceived risk is significantly correlated to risk aversive behavior H1: The perceived risk is not significantly correlated to risk aversive behavior

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4. DATA ANALYSIS

The data collected from field survey of the study had been analyzed by means of four specific tests through SPSS 17 and PASW Statistics 18 software. The tests included the reliability analysis, instrument validity, factor analysis and correlation matrix. Subsequently, the hypothesis put forth will be concluded.

4.1 Reliability Analysis

The internal consistency of a test is expressed between 0 and 1 (Cronbach, 1951). The internal consistency measures the statements under each of the variables with respect to reliability i.e. if the constructs are reliable enough to measure what is intended to be measured. As the credibility estimate increases, the fraction of the test score which may be derived from a mistake should decrease (Nunnally and Bernstein, 1994). The Cronbach is a measurement of the credibility of a result and locates and assigns errors at specific respondent instead of on the researcher (Tavakol and Dennick, 2011). The four constructs of the research study presented acceptable reliability figures of 0.5 and greater Cronbachs alpha and depicted in the tables on the following page.

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Behavioral Intention
Cronbach's Alpha .775 Cronbach's Alpha Based on Standardized Items .775 N of Items 12

Uncertainty Avoidance
Cronbach's Alpha .643 Cronbach's Alpha Based on Standardized Items .646 N of Items 5

Perceived Risk
Cronbach's Alpha .813 Cronbach's Alpha Based on Standardized Items .818 N of Items 5

Risk Aversive Behavior

Cronbach's Alpha .824 Cronbach's Alpha Based on Standardized Items .825 N of Items 7

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4.2 Instrument Validity

The instrument for conducting research has to be checked for validity before implementation. The questionnaire deployed for the research had been replicated from that administered on self-medication with antibiotics from an international study (plosone.org). For the specific requirement of the research, the authors customized the original questionnaire to accommodate the four constructs of behavioral intention, uncertainty avoidance, perceived risk and risk aversive behavior. These constructs cumulatively accentuate the different research studies undertaken in Pakistan and internationally on self-medication, risk aversive behavior, cultural dimension of uncertainty avoidance, and consumer behavior. Face validity had also been acquired from course advisor to the extent that the said constructs and scales will amicably fulfill the purpose of measuring the needful.

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4.3 Demographics

The survey questionnaire constituted of items related to identify the basic demographic structure of the respondents. Six basic demographic dimensions had been used in the survey instrument, viz. (a) gender (b) marital status (c) age group (d) education (e) employment status (f) household income.

4.3.1 Frequency Tables

Gender
Frequency Valid Male Female 3 Total 132 67 1 200 Percent 66.0 33.5 .5 100.0 Valid Percent 66.0 33.5 .5 100.0 Cumulative Percent 66.0 99.5 100.0

Marital Status
Frequency Valid Single Married Total 135 65 200 Percent 67.5 32.5 100.0 Valid Percent 67.5 32.5 100.0 Cumulative Percent 67.5 100.0

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Age Group
Frequency Valid 18-20 21-26 27-32 33-38 39-34 45-50 50-55 Total 25 93 48 21 9 3 1 200 Percent 12.5 46.5 24.0 10.5 4.5 1.5 .5 100.0 Valid Percent 12.5 46.5 24.0 10.5 4.5 1.5 .5 100.0 Cumulative Percent 12.5 59.0 83.0 93.5 98.0 99.5 100.0

Education
Frequency Valid undergraduate Graduate Post Graduate Total 37 87 76 200 Percent 18.5 43.5 38.0 100.0 Valid Percent 18.5 43.5 38.0 100.0 Cumulative Percent 18.5 62.0 100.0

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Employment Status
Frequency Valid employed self employed unemployed 5 Total 96 18 85 1 200 Percent 48.0 9.0 42.5 .5 100.0 Valid Percent 48.0 9.0 42.5 .5 100.0 Cumulative Percent 48.0 57.0 99.5 100.0

Household Income
Frequency Valid 0 Rs. 50k-74k 75k-99k 100k-124k 125k-149k 150k+ Total 5 47 46 60 12 30 200 Percent 2.5 23.5 23.0 30.0 6.0 15.0 100.0 Valid Percent 2.5 23.5 23.0 30.0 6.0 15.0 100.0 Cumulative Percent 2.5 26.0 49.0 79.0 85.0 100.0

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4.3.2 Bar Charts

35

36

37

4.3.3 Findings

The demographic results of the study presented 66% male and 33% female respondents and out of the total sample size 67.5% were married and 32.5% single. Majority of the respondents i.e. 46.5% hailed from the age group of 21-26 years, followed by 27-32 years group at 24%. Age groups of 33-38 and up to 20 years old represented 10.5% and 12.5% respectively. With regard to education, 43.5% respondents were graduates, 38% postgraduates and 18.5% undergraduates. Nearly half the respondents were employed at 48%. The unemployment percentage was 42.5% and the reason for this high ratio was the fact that close to a hundred respondents had been students in their final semester. On the household income front, diverse readings came to light. Most notable was the 15% representation from the Rs. 150,000 plus income bracket. Rs. 50,000-74,000, Rs. 75,000-99,000 and Rs. 100,000124,000 per month household income groups were represented by 23.5%, 23% and 30% respectively.

38

4.4 Behavioral Analysis

The research had also incorporated two specific items to identify the behavior of respondents in terms of self-medication i.e. the situations under which they are motivated to selfmedicated and the ailments for which they engage into this practice. The empirical findings brought to light that 19% of the respondents practice self-medication in order to save the fee of a doctor. Another 21% self-medicate to avoid the waiting time at a doctors clinic or a health-care facility. The lack of trust on the competency and quality of a doctor constituted 10% whereas the most significant reason stood out as the easy of availability of medicines at a chemist without having to show a doctors prescription at 29%. A notable 21% of the respondents engage into self-medication because going over to the doctor is considered as a hassle.

Legend:

B1: Save doctors fee B3: Lack of trust on doctor B5: Hassle going to the doctor

B2: Avoid waiting at the doctors clinic B4: Ease of availability of medicines

39

The other questions asked from respondents regarding the ailments for which they usually self-medicate presented the fact that for perceived to-be minor ailments, self-medication practice is high among consumers whereas for ailments which are perceived to be serious or complex in nature, the practice of self-medication is considerably low.

The most common ailments for which consumers self-medicate include cold (18%), headaches (13%), cough and sore throat (11% each), nasal congestion (10%) and ordinary fever (9%). For serious ailments, the percentages were low which show the behavioral trend that consumers will prefer to visit a doctor. Lack of sleep, depression, nausea and diarrhea had represented less than 10% each.

40

4.5 Confirmatory Factor Analysis

Reducing from a large to an achievable choice of factors is factor analysis (Zikmund, 2002). In factor analysis, all variables are grouped together in order to display the capability of individual items to depict a specific construct. For all the four constructs i.e. behavioral intention, uncertainty avoidance, perceived risk and risk aversive behavior; factor analysis had been conducted separately. The Kaisr-Meyer-Olkin (KMO) measures the adequacy of the sample and presents an index (between 0 and 1) of the proportion of variants among the variables that might be common variant. A KMO close to 1.0 indicates a factor analysis and if it is less than 0.5 then it is not appropriate (Dr. Komata). KMO identifies the specific item which has to be discarded in factor loading. The final solution had been constructed and based upon the criteria that each factor must possess a minimum of three item loadings greater than 0.3 and that any item loading on more than one factor subject to acquiring the final solution, will be placed only in the factor on which it loads most highly. Since the data is based upon perceptions therefore for the constructs of behavioral intention, uncertainty avoidance, perceived risk and risk aversive behavior, the score of 0.3 as the baseline against each variable of the construct has been considered. This has been done due to the reason that perceptions cannot be accurate. A score of 0.5 on the other hand would have been considered if the findings had been healthier. The following tables present the communalities derived from factor analysis.

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Behavioral Intention
Initial If I am cured by a medicine through self-medication then I will not visit a doctor I take advice for self-medication from the chemist Based upon my past experience with medicines, I self-medicate on my own I use medicines based upon the references provided by my family and friends I favorably recommend medicines to family and friends which made me better I switch to another medicine on my own, if a doctor's prescription doesn't make me feel better I switch to any economical medicine brand if the one prescribed by the doctor is expensive If I run-out of medicine prescribed by the doctor, I switch to another alternative medicine available at home I switch to any other alternative medicine if side-effects are experienced from the doctors prescribed medicine I discontinue using a medicine without consulting the doctor I discontinue using a medicine on my own after the symptoms disappear I discontinue using a medicine after it runs out 1.000 1.000 1.000 .695 .676 .578 1.000 .606 1.000 1.000 .562 .592 1.000 1.000 1.000 1.000 1.000 1.000 Extraction .624 .400 .653 .550 .605 .515

Findings: For the construct of behavioral intention, twelve items had been loaded and all were accepted. The KMO had been determined at 0.782 whereas the approximate chi-square came out to be 658.054.

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Uncertainty Avoidance
Initial Through self-medication, the risk that I take is high There may be side-effects from the medicines I use through self-medication I may suffer harmful side-effects if I take an over/under dose of a medicine I may suffer from severe allergic reactions from the medicine I use through self-medication People practice self-medication because medicines are freely available (without prescription) 1.000 1.000 1.000 1.000 1.000 Extraction .603 .603 .735 .598 .378

Findings: Five items were loaded for the construct of uncertainty avoidance and all had been accepted. The KMO came out to be 0.678 and with a chi-square of 140,803 approximately.

Perceived Risk
Initial I always read the medicine pack/label even if the medicine has been prescribed by the doctor I always read the medicine information sheet (inside the pack) even if the medicine has been prescribed by the doctor I always follow the doctor's instructions while taking medicine I always discontinue using medicine after consulting the doctor Rules and regulations should be strictly implemented so that chemists sell medicines only through a doctor's prescription 1.000 1.000 1.000 .576 .553 .700 1.000 .653 1.000 Extraction .689

Findings: The perceived risk construct was loaded for a total number of five items and all of them had been accepted. KMO was derived at 0.800 and the approximate chi-square was 344.999.
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Risk Aversive Behavior

Initial I ensure that I always take medicines that are prescribed by the doctor When I take a medicine, I ensure that no health risks are involved I dont want to be unsure about the medicines I take I would be rather safe than sorry I only change medicine if my doctor tells me to do so I always take the exact dosage of medicine as prescribed by the doctor I always check the expiry date on medicine before consuming them 1.000 1.000 1.000 1.000 1.000 1.000 1.000 Extraction .500 .608 .388 .466 .582 .492 .395

Findings: The construct of risk aversive behavior had a total of seven items that had been loaded and all were accepted. Accordingly, the KMO came out to be 0.823 and with an approximate chi-square of 439.382.

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4.6 Pearsons Correlation Matrix

The correlation matrix of Pearson has been used to identify the correlation between no less than continuous factors. The worth of the correlation may fall between 0.00 (i.e. no correlation) and 1.00 (i.e. absolute best correlation). The different components corresponding to team size should resolve whether or not the correlation is important. In most cases, however, correlations about 0.8 are thought to be high.

Descriptive Statistics
Mean Behavioral Intention Uncertainty Avoidance Perceived Risk Risk Aversive Behavior 2.8858 3.3890 3.4270 3.7136 Std. Deviation .65836 .79652 .87962 .73327 N 200 200 200 200

Correlations
Risk Behavioral Intention Behavioral Intention Pearson Correlation Sig. (2-tailed) N Uncertainty Avoidance Pearson Correlation Sig. (2-tailed) N Perceived Risk Pearson Correlation Sig. (2-tailed) N Risk Aversive Behavior Pearson Correlation Sig. (2-tailed) N 200 -.233
**

Uncertainty Avoidance

Perceived Risk

Aversive Behavior

1 200 .282
**

.001 200 -.269

**

1 200 .418
**

.000 200 -.213

**

.000 200 .443

**

.002 200

.000 200

.000 200 200

**. Correlation is significant at the 0.01 level (2-tailed).

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4.7 Hypothesis Testing

In light of Pearsons Correlation Matrix, the hypothesis could now be concluded.

a. H0: The behavioral intention is significantly correlated to uncertainty avoidance H1: The behavioral intention is not significantly correlated to uncertainty avoidance Null hypothesis is accepted and believed that the two variables have some association in the population. The two variables are correlated significantly and correlate together due to the negative finding (-0.233). It is believed that the consumer behavior towards selfmedication is triggered with the uncertainty avoidance index. The consumer with a high uncertainty avoidance index will act in a safe manner and not take the risk to engage into self-medication and had the uncertainty avoidance been low then the consumers behavior would have been more towards a risk-taking attitude. As a situational need of a person comes to light it may diminish the high uncertainty avoidance index and the consumer will likely to be engaged in self-medication.

b. H0: The behavioral intention is significantly correlated to perceived risk H1: The behavioral intention is not significantly correlated to perceived risk Null hypothesis is accepted and believed that the two variables have some association in the population. The two variables are correlated significantly and negative in its empirical outcome (-0.269). It is believed that the consumer will act depending upon how risk is perceived. How a consumer perceives risk and whether it leads to a risk-taking or riskaversive behavior towards self-medication are linked together. Risk perception of a consumer could be either experiential or influenced by a group reference thereby increasing or decreasing the confidence and motivation to engage or refrain from selfmedication.

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c. H0: The behavioral intention is significantly correlated to risk aversive behavior H1: The behavioral intention is not significantly correlated to risk aversive behavior Null hypothesis is accepted and believed that the two variables have some association in the population. The two variables are correlated significantly but are negative in nature (0.213). It is believed that the intent of a consumer to behave towards self-medication is directly linked with the risk aversive behavior. A consumer will refrain from taking risk if the perception has been developed to avoid risk unless a specific situation arises which demands a person to practice self-medication. This situation may also be influenced upon a person.

d. H0: The uncertainty avoidance is significantly correlated to perceived risk H1: The uncertainty avoidance is not significantly correlated to perceived risk Null hypothesis is accepted and believed that the two variables have some association in the population. The two variables are correlated significantly. It is believed that with high perception of risk, the uncertainty avoidance index of consumers will also remain high and vice versa that is if the consumer perceives that there is no risk in the act of selfmedication then a low uncertainty avoidance index will be observed. This correlation acts inversely due to its positivity (0.282) and therefore the perception of risk will vary on the risk-aversive and risk-taking continuum.

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e. H0: The uncertainty avoidance is significantly correlated to risk aversive behavior H1: Uncertainty avoidance is not significantly correlated to risk aversive behavior Null hypothesis is accepted and believed that the two variables have some association in the population. The two variables are correlated significantly but the finding is positive in nature (0.443) and therefore as uncertainty goes up or down, the risk-aversive behavior increases or decreases accordingly. It is believed that consumers at the time of being risk aversive towards self-medication display a high uncertainty avoidance index.

f. H0: The perceived risk is significantly correlated to risk aversive behavior H1: The perceived risk is not significantly correlated to risk aversive behavior Null hypothesis is accepted and believed that the two variables have some association in the population. The two variables are correlated significantly but due to positive (0.418) in nature they move inversely. Therefore the higher the perception of risk, the higher will be the risk-aversive behavior and vice-versa. It is believed that consumers in accordance with their perception of risk behave in a risk aversive manner when it comes to selfmedication. If the consumers perceive that there exists a risk then they will avoid the act of self-medication.

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5. CONCLUSION AND RECOMMENDATIONS

5.1 Conclusion
The basic purpose of this research study was to gauge the perception and attitude of consumers towards self-medication in light of the cultural dimension of uncertainty avoidance. In addition to this an investigation was made to discover the relationship between the four survey constructs of behavioral intent, uncertainty avoidance, perceived risk and risk aversive behavior.
In a nutshell, with regard to self-medication, the assertion put forth by Hofstede that Pakistanis are risk-averse people due to a high index of uncertainty avoidance index is true. Regardless of the fact that the act of self-medication is considered as a risk-taking behavior, the people operate their

behavior with a two-prong strategy. On one hand, as evident from the focus group finding and acceptance of all null hypotheses, the people refrain from self-medicating because they are aware of the risks attached; at the same time they also engage into the practice of selfmedication due to (1) they lack complete knowledge about adverse drug reactions and (2) they justify their act by citing reasons which in their specific state of affairs holds true. Cost of medicines, competency of doctors and long waiting queues all play a role independently and together in motivating a person to self-medicate. This contradiction brings to light the elements of locus of control which according to research studies in case of Pakistanis is external (Shah & Amjad, 2011). The locus of control is also directly linked with the religious beliefs of a person. (Shah & Amjad, 2011) This aspect however demands a separate study. The demographic findings from the research bring to light the fact that educated people earning average and above average income though are risk-averse but are inclined towards self-medication as per situations which they face in their lives and that have been identified above. This fact establishes the rationale that people with education, who are employed and earning respectable income engage into this act (Klemenc-Ketis et al., 2010; Henry et al., 2006). But the study could not acquire a respondent base from a lower socio-economic class which could further justify that people from this group either do not self-medicate or do it nominally because of their strong affinity towards rules and regulations (Klemenc-Ketis et al., 2010; Henry et al., 2006).
49

From the literature that had been reviewed and the empirical findings it also came to light that the consumers are aware of the risks attached with self-medication but they still pursue the practice basically because of a positive past experience and the influence of credible reference groups, both of which encourages them to consider the self-medication issue as too petty. Additionally, the consumers do not perceive the act of self-medication itself to be one that involves risk. At the same time, where Pakistans uncertainty avoidance index states that people have an affinity towards rules and regulations then these same people at their own free accord purchase all types of medicines from a pharmacy. That the government regulations have not been implemented is one aspect but the consumers themselves have totally disregarded the rule. The universal fact remain that consumers develop a perception and then form an attitude leading either towards the act of self-medication or refraining from it. The risk consumers take towards self-medication is both willing and unknowingly. Its a matter of how the risk is perceived to be. The establishment of risk perception comes into action from operational variables which surround a consumer e.g. lack of regulations, cost of medicine, unawareness of the danger involved, competency of physicians, etc. Subsequently, the empirical findings of the research also concluded and accepted the null hypotheses that had been derived initially. The risk-taking attribute of the society may have changed over the years if a general observatory glance is given over the people but just as in selective ethics which a person may practice, in a similar way, situation-based and experience-based risk-taking behavior is displayed. Socio-economic factors play a role and so specific situations upon which a person may not have any control; therefore attitude formation takes place and selective risk-aversive behavior (e.g. in case of serious ailments such as diarrhea and sleeping disorder) and risktaking behavior (e.g. in case of minor ailments such as sore throat and cough) is witnessed.

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5.2 Recommendations

The primary understanding is that self-medication is not in benefit of a consumer unless it is an over-the-counter medicine like paracetamol which can be sold and purchased without the prescription of a physician. Things can be done to reduce self-medication in any country and it can also be done in third world countries like Pakistan. Educate, is the number one thing which pharmaceutical companies, the ministry of health and other stake holders need to plan and initiate. Another solution could be the reduction in price of medicines and to revisit the overall health care cost in Pakistan. Stringent implementation of pharmacy regulations is also long overdue. Finally, in light of the logical criticism of Hofstede, consumer perception and attitude has to be checked not only for different product and service categories, which can identify risktaking consumer behavior but also on the platform of social sciences and coupling it with all the cultural dimensions of Hofstede and not only uncertainty avoidance. Only then, after comparing multiple dimensions which a person is exposed to and experiences in life in general, will the actual uncertainty avoidance index by identified.

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AREAS OF FURTHER STUDY

At this time on an academic level, the authors have attempted to define the effects of perception and attitude on consumer behavior towards self-medication. The unanswered question of why they do it could be comprehended in totality if the dimensions of locus of control and religion are taken into account, both of which are strongly and deeply rooted in the Pakistani society and serve as a bench mark towards countless deeds and acts by the people from all walks of life. Additionally, all cultural dimensions put forth by Hofstede have to be measured parallel and not only uncertainty avoidance because these dimensions possess an interplay and based upon which consumers behave towards different objective and subjective elements.

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BIBLIOGRAPHY

1. Abahussain E, Matowe LK, Nicholls PJ. Self-reported medication use among adolescents in Kuwait. Med PrincPract 2005; 14: 161-4. 2. Baig S. Self medication practices. Professional Med J Aug 2012;19(4): 513-521. 3. Cronbach, L. J. 1951. Coefcient alpha and the internal structure of tests. Psychometrika 16:297334. 4. Deschepper R, Lundborg CS, Monnet DL, Scicluna EA, Birkin J, Haaijer-RuskampFM , SAR consortium (2007) Attitudes, beliefs and knowledge concerning antibiotic use and self-medication: a comparative 5. Deshpande SG, Tiwari R. Self-medication-a growing concern. Indian J Med Sci. 1997; 51: 93-6. 6. Dorfman, P. W. and J. P. Howell (1988). "Dimensions of National Culture and Effective Leadership Patterns: Hofstede revisited." Advances in International Comparative Management 3: 127-150. 7. Ellis, J., Mullan, J. (2009), Prescription medication borrowing and sharing: risk factors and management. Australian Family Physician, 38(10), 2009, 816-819. 8. Filho L, Antonio I, Lima-Costa MF, Uchoa E. Bambui Project: a qualitative approach to self-medication. Cad SaudePublica 2004;20:1661-9. 9. GEERT-HOSFTEDE. National Cultural Dimensions. Available at: http://www.geerthofstede.com/countries.html (Accessed on January 2, 2013) 10. Graves, D. (1986). Corporate Culture - Diagnosis and Change: Auditing and changing the culture of organizations. London, Frances Printer. 11. Haider S, Thaver IH (1995). Self medication or self care: implication for primary health care strategies. J. Pak. Med. Assoc., 45 (11): 297-298.

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12. Hofstede G, Bond MH (1988). The Confucius connection: From cultural roots to economic growth. 13. Hussain S, Malik. F, Hameed A, Riaz H (2010). Exploring health seeking behaviour, medicine use and self medication in rural and urban Pakistan. Southern Med. Rev., 3: 3234. 14. James, H., et al., Influence of medical training on self medication by students. International Journal of Clinical Pharmacology and Therapeutics, 2008. 46(1): p. 23-29. 15. Klemenc-Ketis, Z., Kersnik. J, Grmec S. The effect of carbon dioxide on near-death experiences in out-of-hospital cardiac arrest survivors: a prospective observational study. Critical Care 2010 14:R56. 16. Kometa, Dr. S., "How to perform and interpret factor analysis using SPSS Data Retrieved from: http://www.ncl.ac.uk/iss/statistics/docs/factoranalysis.php Date: January 15, 2013 17. Likert, R. (1931). A technique for the measurement of attitudes. Psychology. New York: Columbia University Press. Archives of

18. McSweeney B. Hofstede's model of national cultural differences and their consequences: a triumph of faith a failure of analysis. Human Relations 2002; 55: 89-118. 19. Montastruc JL, Bagheri H, Geraud T, Lapeyre MM (1997). Pharmacovigilance of selfmedication. Therapie, 52: 105-110 20. Mumtaz Z, Salway S, Waseem M, Umer N (2003). Gender-based barriers to Primary health care provision in Pakistan: the experience of female providers. Health Policy Plan, 18: 261269. 21. Nunnally, J. C., & Bernstein, I. H. (1994). Psychometric Theory (3rd ed.). New York: McGraw-Hill. 22. Olie, R. (1995). The 'Culture' Factor in Personnel and Organization Policies. International Human Resource Management: An integrated approach. A. Harzing and V. R. J. London, Sage Publications: 124-143.

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23. PEER REVIEWED OPEN ACCESS JOURNAL. File S1: Questionnaire for selfmedication with antibiotics. Available at: http://www.plosone.org (Accessed on January 22, 2013) 24. Prince, M. and Davies, M (2001) "Moderator teams: an extension to focus group methodology", Qualitative Market Research: An International Journal, Vol. 4 Iss: 4, pp.207 216 25. Runciman WB, Roughead EE, Semple SJ, et al. Adverse drug events and medication errors in Australia. Int J Qual Health Care 2003; 15 Suppl 1: i49-i59. 26. Schoenberg, N.E. & Drew, E.M. (2002). Articulating Silence: experiential certitude and biomedical controversies over hypertension symptomatology. Medical Anthropology Quarterly, 16(4), 458-475. 27. Schwartz, S. H. (1999). "A Theory of Cultural Values and Some Implications for Work " Applied Psychology 48(1): 23-47. 28. Sekaran, U. (2000). Research methods for business. New York: John Wiley & Sons, Inc. 29. Shah, M., Amjad, Dr. S. Cultural Diversity in Pakistan: National vs Provincial. Mediterranean Center of social and Educational Research 2011; 2:2:331-344 30. Shankar PR, Partha P, Shenoy N. Self-medication and non-doctor prescription practices in PokharaVaelley, Western Nepal: a questionary-based study. BMC FamPract 2002;3:17-23. 31. Sturm AW, van der Pol R, Smits AJ et al. Over-the-counter availability of antimicrobial agents, self-medication and patterns of resistance in Karachi, Pakistan. J AntimicrobChemother1997; 39:543547. European study. Pharmacoepidemiol and Drug Safety. 16:1234-43. 32. Tavakol, M. and Dennick, R. (2011) Making sense of Cronbachs alpha. International Journal of Medical Education; 2:53-55 33. WIKIPEDIA. Self-Medication. Available at: http://www.wikipedia.org/selfmedication (Accessed on December 19, 2012)

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34. WORLD HEALTH ORGANIZATION. The role of the pharmacist in self-care and selfmedication. Hangue: World Health Organization, 1998; 17. Available at:http://www.wsmi.org/pdf/boarddeclarationselfcare.pdf (Accessed on 7th January 2013) 35. Zafar SN, Syeed R, Waqar S, Zubairi AJ, Vaqar T, Shakh M, et al. Self-medication amongst university students of Karachi: Prevalence, Knowledge and attitudes. J Pak Med Assoc. 2008; 58(4): 214-17 36. Zikmund, W.G. (2002). Business Research methods (6th ed.). United States of America: Harcourt College Publishers.

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APPENDIX

a. Focus Group Guide

Thank you for agreeing to participate. We are very interested to hear your valuable opinions. The purpose of this study is to learn how consumers develop perceptions and form an attitude towards the act of self-medication and whether consumers take this risk willingly or unknowingly. We hope to learn about consumer behavior in Pakistan; their level of awareness and the factors which trigger the specific act of self-medication. The information you give us is completely confidential, and we will not associate your name with anything you say in the focus group. We will ask participants to respect each others confidentiality. We would like to record the focus group so that we can make sure to capture the thoughts, opinions, and ideas we hear from the group. No names will be attached to the focus group and the audio file will be destroyed as soon as they are transcribed. You may refuse to answer any question or withdraw from the study at anytime. Please check the boxes below to the best of your knowledge and to show that you agree to participate in this focus group. Gender: Age Group: Education: Employment Status: Household Income: Male 21-26 Female 27-32 Marital Status: 33-38 Graduate 39-44 Single Married 55+

45-50

50-55

Intermediate Employed

Masters Unemployed Rs. 100,000-124,000

Self-Employed

Rs. 50,000-74,000 Rs. 125,000-149,000

Rs. 75,000-99,000 Rs. 150,000 +

Family Members:

___ Adults ___ Children (up to 12 y.o) ___ Children (13-17 y.o)
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The focus group session will last for 60 minutes approximately and during which you should feel free to sit and walk, take notes or use the white board to express your thoughts. Beginning the Focus Group Session Welcome and introduce yourself and the note-taker, and send the Consent Form around to the group. Introducing the focus group with a review on: a) Who we are and what were trying to do? b) What will be done with this information? c) Why we asked you to participate? Explanation of the process. Ask the group if anyone has participated in a focus group before. Explain that focus groups are being used more and more often in consumer research. About focus groups a) We learn from you (positive and negative). b) Not trying to achieve consensus, were gathering information. c) No virtue in long lists: were looking for priorities. d) The reason for this focus group is that we can get more in-depth information from a smaller group of people. This allows us to develop the statements for the subsequent survey questionnaire.

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Ground Rules a) Everyone should participate. b) Information provided in the focus group must be kept confidential. c) Stay with the group and please dont have side conversations. d) Turn off cell phones. e) Turn on Audio Recording f) Ask the group if there are any questions before we get started, and address those questions. g) Participant Introductions (name, working where and as, born where, hobbies & family) Discussion begins, make sure to give people time to think before answering the questions and dont move too quickly. Use the probes to make sure that all issues are addressed, but move on when you feel you are starting to hear repetitive information. Focus Group Questions a) What are your thoughts about self-medication? (Your feelings and approach) Why and how? b) Which ailments do you think individual typically opt for self-medication? c) Which drugs are usually brought for self-medication purpose? d) Do you think its a risk or is it safe to self-medicate? e) Why do people prefer self-medication? (if people are in the habit to do so) f) Whos opinion matters in using drugs? g) How do you perceive risks in general, in your life? h) Why do people take risks? (helmet, swimming, CNG, overhead bridge, smoking)

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Underlying variables: a) Situation faced before self-medication b) Ailment treated c) Decision to do so past experience and/or under influence d) Medicines consumed e) Cost f) Time Probes for Discussion: a) Personal satisfaction b) Ego, self-concept and confidence c) Belief in your self d) Belief in fate and destiny e) Experiential perception f) Family traditions g) Knowledge based decisions That concludes our focus group. Thank you for coming and sharing your thoughts and opinions with us. If you believe that you have missed a certain point or fact which you wanted to share then please note it down on the sheet provided so that it may assist in compilation of the research.

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b. Survey Questionnaire

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62