Self-medication practice for dental problems: A cross-sectional study among adults in Kuantan, Pahang in Peninsular Malaysia

Azlini Ismail; Muhammad Nazmi Abdul Majid; Muhammad Nabil Mohd Haron; Mohd Firdaus Akbar Abdul Halim; Mohamad Shafiq Mohd Ibrahim; Zurainie Abllah

doi:10.4103/jioh.jioh_173_22

ORIGINAL RESEARCH

Year : 2023 | Volume : 15 | Issue : 2 | Page : 184-193

Self-medication practice for dental problems: A cross-sectional study among adults in Kuantan, Pahang in Peninsular Malaysia

Azlini Ismail¹, Muhammad Nazmi Abdul Majid², Muhammad Nabil Mohd Haron³, Mohd Firdaus Akbar Abdul Halim⁴, Mohamad Shafiq Mohd Ibrahim⁵, Zurainie Abllah⁵
¹ Department of Fundamental Dental and Medical Sciences, Kulliyyah of Dentistry, International Islamic University Malaysia, Kuantan, Pahang, Malaysia
² School of Dental Sciences, Hospital Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
³ Ministry of Health Malaysia, Kota Bharu, Kelantan, Malaysia
⁴ Faculty of Computer and Mathematical Sciences, Universiti Teknologi MARA Kelantan Branch, Kota Bharu, Kelantan, Malaysia
⁵ Department of Paediatric Dentistry and Dental Public Health, Kulliyyah of Dentistry, International Islamic University Malaysia, Kuantan, Pahang, Malaysia

Date of Submission	03-Aug-2022
Date of Decision	07-Jan-2023
Date of Acceptance	13-Jan-2023
Date of Web Publication	28-Apr-2023

Correspondence Address:
Dr. Azlini Ismail
Department of Fundamental Dental and Medical Sciences, Kulliyyah of Dentistry, International Islamic University Malaysia, Indera Mahkota, Kuantan, 25200 Pahang
Malaysia

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jioh.jioh_173_22

Abstract

Aim: To investigate the prevalence, attitude, and pattern of self-medication practice for dental problems among adults in Kuantan, the state capital of Pahang, Malaysia. Materials and Methods: This cross-sectional study was conducted among adults over 18 years of age who live in Kuantan via self-administered online- and paper-based bilingual questionnaires. Descriptive statistics and chi-square analysis were run using IBM SPSS^® Version 26 software. Results: From 275 respondents, one-fifth of respondents (21.8%) practised self-medication for dental problems and most of them obtained a mean attitude score of 21.7 ± 2.5% out of 25. Most self-medicating respondents were from the age group of 18–27 years (78.3%), females (55%), singles (78.3%), resides urban area (75.0%), and students (71.7%), with a household income of <MYR 3860 (46.7%), have no dental insurance (66.7 %), and did not have any family relationship with dental personnel (90.0%). Only gender has significant association with self-medication practice, X² (1, N = 275) = 4.916, P < 0.05. Most of self-medicating respondents gained information related to self-medication from internet (62.0%) and obtained medication from pharmacy (78.0%). The major dental problem that triggered them to self-medicate was toothache (76.0%), and the majority used paracetamol for pain relief (62.0%). Their main reason for self-medication was the perceived mildness of the dental problems (60.0%). Conclusion: Adult populations in Kuantan, Pahang have moderate prevalence (21.8%) in self-medicating practice for dental problems which was mainly caused by toothache and was primarily treated with over-the-counter pain-relief medication. They also have good attitude toward appropriate self-medication.

Keywords: Attitude, Dental, Pattern, Prevalence, Self-Medication

How to cite this article:
Ismail A, Abdul Majid MN, Mohd Haron MN, Abdul Halim MF, Mohd Ibrahim MS, Abllah Z. Self-medication practice for dental problems: A cross-sectional study among adults in Kuantan, Pahang in Peninsular Malaysia. J Int Oral Health 2023;15:184-93

How to cite this URL:
Ismail A, Abdul Majid MN, Mohd Haron MN, Abdul Halim MF, Mohd Ibrahim MS, Abllah Z. Self-medication practice for dental problems: A cross-sectional study among adults in Kuantan, Pahang in Peninsular Malaysia. J Int Oral Health [serial online] 2023 [cited 2023 Jun 1];15:184-93. Available from: https://www.jioh.org/text.asp?2023/15/2/184/375361

Introduction

Self-medication refers to the act of using any nonprescription drugs, either modern or traditional, for self-treatment without prior consultation with any medically qualified physician.^[1] Self-medication practice is considered a part of an individual’s health-seeking behavior for self-management of common minor ailments such as headache, fever, cough, and pain.^[2],[3] This practice provides benefits by reducing the burden imposed on medical services, reducing the frequency of patient’s visits to the physician, thus reducing the patient’s expenditure for medical consultation.^[4]

In Malaysia, the prevalence of self-medication in general was reportedly high among few study populations in the west coast region of Peninsular Malaysia, in the range of 50–65%.^[5],[6],[7] Most of these local studies have discussed on the general self-medication which includes fever, headache, flu, etc., but none had discussed specifically on the self-medication practices for dental problems. Globally, specific studies on self-medication for dental problems have been conducted among other populations in which the prevalence were found to be moderate by 21.7% in Brazil^[8] and 30% in certain coastal region in Karnataka, India^[9], while other studies found a much higher prevalence of 45.5% in Nigeria,^[10] 50.4% in Saudi Arabia,^[11] 69.9% in Karachi, Pakistan,^[12] 70.2% in Turkey,^[13] and 81% in Mumbai city of India.^[14] The common dental problems that were explored in these studies include toothache, gingival swelling, gingival bleeding, tooth mobility, halitosis, and others. Self-medication practice by using nonprescribed analgesics for toothache was identified to be a common practice among dental patients.^[3],[11] Previous studies also reported an improper self-medication practice which was the unintentional overdose of analgesics use secondary to acute dental pain.^[15],[16] In addition to that, improper self-medication practice may lead to antimicrobial resistance, specifically upon self-medicating with the antibiotics, as well as prompting adverse drug reactions and toxicity related to drug–drug interactions.^[17] These adverse drug reactions and toxicity resulting from the improper self-medication practice may have increased the burden of the healthcare system.

Since there are currently no studies that have explored the self-medication practice specifically for dental problems in the east coast region of Malaysia, we aimed to investigate the extent of self-medication practice for dental problems among adults in Kuantan, the capital state city of Pahang, Malaysia, specifically by determining the prevalence, pattern, and the attitude of this study population toward self-medicating practice for dental problems.

Materials and Methods

Ethical approval

Ethical approval was received from the International Islamic University Malaysia (IIUM) Research Ethical Committee on 19 March 2019, with an approval number of IREC 2019-059. Participants’ data were stored in a file that was accessible only to the researchers.

Informed consent

The respondents signed informed consent form for the paper-based self-administered questionnaire and clicked “Agree” to proceed upon given information about this study information and consent page for the online-based questionnaire.

Study design

This was a cross-sectional descriptive study.

Study duration

Data collection for the pilot study among 54 respondents was conducted from August to October 2019; meanwhile, for the main study among 275 respondents, the data were collected from November 2019 to January 2020.

Study population, sample size, and sampling

This study was conducted among adults aged 18 years and above who lives in Kuantan, Pahang. Kuantan is the capital city of Pahang, measuring about 324 km² in size, and is situated in the east coast Malaysia with an estimated total adults’ population of 332,100 based on 2014/2015 statistic. There was no published information about the latest statistics of adult population in this region upon the conduct of this study in 2019. For our main study, the sample size was calculated using the following formula:

where n = sample size, Z = Z statistic for a level of confidence (1.96), P = expected prevalence of proportion (P = 0.84, based on the previous study in a Malaysian population^[18]), and D = precision (0.05).

At 95% confidence level, Z = 1.96, P = 0.84, d = 0.05, the minimum calculated sample size was 207. With the addition of 10% nonresponse, the final sample size was 228. However, since this study utilized the convenience sampling method and the survey was distributed through an online platform, we received 275 respondents for the main study.

Inclusion and exclusion criteria

Inclusion criteria include adults aged 18 years and above that can understand Malay or English and live in Kuantan during the study period. Individuals who reside outside Kuantan were excluded from this study.

Questionnaire design

The questionnaire was designed based on a general self-medication study conducted among one local Malaysian subpopulation^[7] with some modifications to cater to dental problems based on few other studies conducted outside Malaysia.^{[9],[19],[20]} The questionnaire was designed in English, but it was translated to Malay by the research team, then the Malay version of the questionnaire was submitted for back-translation to English by a certified linguist lecturer from the Centre for Languages and Pre-University Academic Development (CELPAD), IIUM.

Questionnaire items

The questionnaire consisted of 27 items and was separated into four sections. The first section comprised nine items regarding demographic factors: age, gender, marital status, residential area, highest education level, occupation, monthly household income, dental insurance coverage, and whether respondent’s occupation or family’s occupation was related to the dental profession.

The second part consisted of three items such as previous experience of dental problems, availability of medication prescribed by medically qualified physicians for the dental problem, and medication usage without prior consultation with the physician or the dentist for the problem (indicative for self-medication).

The next part of the questionnaire consisted of three positive and two negative statements to evaluate the respondent’s attitude towards self-medication practice. A 5-point Likert scale was used, which consists of “strongly disagree,” “disagree,” “neutral,” “agree,” and “strongly agree,” with scores of “1,” “2,” “3,” “4,” and “5” were allocated, respectively, for the positive statements. This scoring system was reversed for the two negative statements. With the total maximum score of 25, the total score was then tabulated to find the median and the mean score.

There were nine items in the final part concerning the pattern of self-medication practice for dental problems. Only respondents that self-medicate for their problems were required to answer this part of the questionnaire. The items include whether prior information was obtained before self-medication, source of information, source of medication, type of dental problems that trigger self-medication, reasons for self-medication, type of medication, frequency of consumption, experience after self-medication, subsequent action if the problem does not relieve, and occurrence of side effect after self-medication.

Data collection

The questionnaire was then distributed as a self-administered offline (paper-based) survey and online (web-based) using Google Form. The paper-based questionnaire is bilingual with English and Malay statements. Two URL links were provided for the online-based questionnaire with two versions of either Malay or English. The invitation to participate in this study was distributed through social media platforms such as Facebook Page for the local community of Kuantan and few WhatsApp groups for residents of housing areas in Kuantan, Pahang. The respondents were free to select their preferred versions of the questionnaire, either English or Malay version. An additional question of the postcode of respondents’ current living place was asked to confirm that only Kuantan residents were included in this study for the online-based questionnaire.

Face-to-face validation and pilot study

Before the pilot study, face-to-face validation of the questionnaire was performed on three respondents. Any confusing elements such as doubtful word and misleading instruction were improvised based on the suggestions from the respondents. A total number of 54 respondents were then collected for the pilot study. The internal consistency of the questionnaire was checked by determining the Cronbach’s alpha coefficient value using the items with five-point Likert scale in the Attitude section. A Cronbach’s alpha coefficient value of 0.711 was obtained for this pilot study, and it was in the acceptable range.^[21]

Statistical analysis

Data analysis was run using SPSS software version 26.0. Descriptive statistics were used to describe the sociodemographic characteristics of respondents, the prevalence, and the patterns of self-medication practice for dental problems. In addition, the chi-square test was used to test the association between the sociodemographic characteristics and self-medication practice for dental problems. A P value of less than 0.05 was considered statistically significant.

Results

Sociodemographic characteristics of the respondents

The sociodemographic characteristics of respondents in this study are listed in [Table 1]. Most respondents in this study were 18–27 years old (82.7%), with females (66.9%) outnumbered males. Majority of the respondents are currently undergoing or have completed tertiary level of education of at least diploma (73.1%). The respondents mainly came from urban area (70.5%) and were single (85.1%). Most respondents (46.5%) were from the bottom 40% category or known as B40. The B40 category is indicated for families with a monthly household income of less than MYR 3860. This B40 income figure was derived based on the Household Income and Expenditure Survey (HIES) 2014 conducted by the Department of Statistics, Malaysia.^[22] More than half (69.1%) of the respondents have dental insurance, and the majority of the respondents (88%) did not have any family relationship with dental personnel.

Table 1: Association of sociodemographic characteristics with self-medication practice for dental problems among adults in Kuantan, Pahang

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Prevalence of self-medication practice for dental problems among Kuantan adults’ population and their sociodemographic profiles

From 275 respondents, only one-fifth (21.8%) practised self-medication for their dental problems [Table 1]. The majority that practised self-medication aged 18–27 years(78.3%), females (55%), single (78.3%), resides urban area (75.0%), currently undergoing or have completed tertiary level of education of at least diploma (75.0%), and were students (75.0%). Most respondents that practised self-medication for their dental problems have a monthly household income of less than MYR 3860 (46.7%), have no dental insurance (66.7%), and did not have any family relationship with dental personnel (90.0%). Among all the sociodemographic characteristics, gender has a significant association with self-medication practice for dental problems, X² (1, N = 275) = 4.916, P < 0.05) [Table 1].

Attitude toward self-medication practice for dental problems among Kuantan adults’ population

The attitude of 275 respondents toward self-medication practice for dental problems is depicted in [Table 2]. Most of the respondents (70.2%) strongly agreed that it was essential to inform the doctor, dentist, or pharmacist about other medications or supplements they are taking upon consultation with them. No respondents reported that they were afraid to consult a doctor or dentist if their dental problems persist after self-medicate. Most of the respondents (76.7%) were aware that reading the medication label is important. Most of the respondents strongly agreed (77.1%) that they will take medication according to the label or as directed by the healthcare practitioners. 42.9% of the respondents strongly disagreed with irrespective self-medication practice despite the seriousness of dental problems. The respondents showed a median score of 22.0 out of 25.0 and a mean score of 21.7 ± 2.5% for this attitude section.

Table 2: The attitude of respondents towards self-medication practice for dental problems (n = 275)

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Pattern of self-medication practice for dental problems among Kuantan adults’ population

Only 60 respondents that self-medicate for their dental problems were required to answer the final part of the questionnaire. The respondents were usually triggered to self-medicate when they had dental problems such as toothache (76%), ulcers (54%), swelling (28%), bad breath (18%), and tooth decay (16%) in which the primary source of information regarding this practice was primarily retrieved from the internet (62%) and following the advice from family, friends, or neighbors (60%) [Figure 1]. Most frequently, the respondents self-medicate with paracetamol (62%), followed by salt (60%) and other painkillers (30%), and unfortunately, some respondents also reported self-medication with the antibiotics (12%) [Figure 2]. When asked about the source of medications, most of them reported buying from the pharmacy (78%), and almost half of the respondents (46%) obtained the medication from their friends, family, or neighbors [Figure 2]. The respondents decided to self-medicate for various reasons, but the primary reason is due to the mild nature of their dental problem (60%), as well as to avoid long waiting time to get dental treatment (50%), and for personal convenience (50%) [Figure 3]. More than half of the respondents self-medicated for dental problems only when necessary (66%), and the majority reported relief after self-medicating (90%), with none of them that experience any worsening dental problems after self-medicating [Figure 3]. Most respondents (96%) would visit a dentist as a subsequent measure if the symptoms did not relieve after self-medication [Figure 3]. It was also found that only a minority of respondents who self-medicated for their dental problems (2%) reported side effect upon self-medicating.

Figure 1: The types of triggering dental problems and the source of information regarding self-medication for dental problems

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Figure 2: The types and sources of medications used to self-medicate for dental problems

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Figure 3: The reasons to self-medicate for dental problems, the frequency and respondents’ experience, as well as their expected action once self-medication fails in solving the problems

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Discussion

This study showed that the prevalence of self-medication for dental problems was moderate (21.8%) among adults in Kuantan, Pahang. This moderate prevalence can be explained by the fact that most respondents in this study were young- to middle-aged adults, with majority of them were currently undergoing and/or have completed tertiary level of education of at least diploma, and most importantly, they live in an urban area in Kuantan, Pahang, with good access to dental facilities. As the state’s capital city, Kuantan has a generally good oral healthcare system, which is heavily subsidized to the Malaysian citizens at the government dental clinics. On top of that, the oral healthcare system was heavily supported by many private dental clinics in this city.

Till this date, there was no previous study on self-medication practice specific to dental problems in Malaysia. However, the prevalence percentage in this study was comparable to those of other populations in different countries, for example, 30% in coastal Karnataka, India,^[9] and 21.7% in Brazil.^[8] However, few other studies that have been conducted in other countries found much higher prevalence; for instance, the prevalence was at 45.5 % in Nigeria,^[10] 50.4% in Saudi Arabia,^[11] 69.9% in Karachi, Pakistan,^[12] 70.2% in Turkey,^[13] and 81% in Mumbai city of India.^[14] The different prevalence across regions can be contributed by many regional factors, including the healthcare standard and regulatory policy, drug’s accessibility and control measures, and public access to healthcare facilities.^[23]

On top of that, the sociodemographic characteristics such as age and gender of the study population can be among other factors contributing to the self-medication prevalence. Only gender was significantly associated with self-medication practice for dental problems among this study population, whereby we found that most self-medicating respondents were females. This finding was in line with two previous studies conducted among adults in Riyadh, Saudi Arabia,^[3] and Nigeria.^[10] In addition, the odds of practising general self-medication were reported to be about two times higher among females than males.^[23] The possible cause for the higher prevalence of this practice in females is probably due to the higher occurrence of orofacial pain in females compared to males.^[24]In addition, females have lower pain threshold and lesser pain tolerance as compared to males,^[25],[26] and they also have greater fear of seeking dental treatment as compared to males.^[27] However, the actual underlying factors should be explored with further research in the future.

Besides gender, age was also mentioned to contribute to the self-medication practice. A previous study by Fekadu et al.^[23] reported that younger adults were about 4.5 times more likely to practice self-medication than adults at ≥40 years of age. However, our study did not show any significant association between age and the practice, perhaps because of the minimal number of elderly adults in Kuantan that respond to this study compared to the younger adults. Recruiting elderly respondents using an online survey was challenging as modern technology may not be convenient for elderly respondents.

Nonetheless, the respondents’ attitude toward self-medication practice for dental problems in this study was deemed satisfactory as the respondents’ mean score was above 17.5, out of the total score of 25 (equivalent to >70%). This supposition was based on a previous study by Jawahir and Abd Aziz^[7] that considered a score of 70% and above as an indicator for having a good attitude toward self-medication practice. In addition, we found that most respondents in this study possessed a good attitude since most of them strongly agreed with the importance of informing the relevant authorities, either doctor or dentist or pharmacist, about other medications or supplements that they are currently taking upon consultation with them. This action is essential as proper prescription can avoid unwanted effects such as drug–drug interaction, overdosage, and even under-dosage. Drugs overdosage can lead to the risk of side effects, while drugs underdosage can reduce the desired therapeutic effect.^[28]

Furthermore, most respondents strongly disagreed that they were afraid to consult a doctor or a dentist if their dental problems persist after self-medication. Their refute on this statement inferred the respondents as having a good attitude in practising self-medication. It is undeniably true that timely consultation is valuable in receiving adequate treatment to treat any dental problems.^[4] For instance, a minor untreated dental decay might lead to a more severe problem in the future if no intervention was done at the early stage. Apart from that, this study also showed that more than half of the respondents strongly agreed that it was important to read the medication label and take the medication according to the label or as directed by the healthcare practitioners. These practices, in particular, are also very crucial to avoid hazardous side effects of overdosage or underdosage.^[29] The act of self-medicating irrespective of the seriousness of dental problems was not agreed upon by most respondents. Again, the respondents’ rebut on this statement indicates a good attitude as proper consultation and management for dental problems should be sought when the symptoms worsen.^[4]

This study was also extended to examine the pattern of practice among those self-medicating respondents. Our study findings conform with the findings from other previous studies. For instance, we found in this study that the two primary sources of information for the respondents to practice self-medication were actually from the internet and the advice received from their close social circles, including their family, friends, and neighbors. A similar finding was previously reported whereby most respondents heavily relied on mass media and the experience of their friends and relatives to obtain information on self-medication.^[30] Pharmacy became the primary source to obtain medication among the respondents in this current study. This result was in line with other study findings whereby 66% of respondents in Saudi Arabia^[3]; 86% in India,^[4] and 46% in Brazil^[8] preferred pharmacy as their primary source to obtain the medication. The pharmacy was reported as one of the most reliable sources, especially for over the counter (OTC) drugs. In addition, most pharmacy retailers have a pharmacist in charge of brief counselling and consultation, and on top of that, no consultation fee was charged upon buying from the pharmacy.^[31]

In addition to that, this study found that dental problems that triggered the respondents to self-medicate were mainly toothache, followed by ulcer, and gum swelling. Toothache was reported as a common dental problem that triggers respondents to self-medicate, as found in many studies, including those conducted in few other countries like India,^[4] Saudi Arabia,^[3] and Cameroon.^[20] Dental pain of tooth and gum origins was prevalent, as reported in a study conducted among dental students in Malaysia.^[32] Most people preferred to self-medicate when encountered with a mild toothache as they believed that dentist’s consultation was required only in severe toothache cases.^[33] Besides toothache, ulcer was also reported as another main dental problem that triggers self-medication.^[34] In addition, almost all community pharmacies have stocked OTC products for toothache and mouth ulcers, enabling the easy access of these drugs to the public, which contributed to the self-medication practice.^[35] Because the most common dental problem faced by those self-medicating respondents was toothache, we found that the most common medication they took was the analgesic acetaminophen. Alternatively, most of the respondents also preferred natural remedy such as salt. A study conducted among adults in Riyadh reported a similar finding whereby salt in hot water and acetaminophen were the most frequent choices to relieve the pain.^[3] Acetaminophen is the most widely used OTC drugs for pain relief readily available in community pharmacies, local supermarkets, and even convenience stores. Meanwhile, natural remedy such as salt is generally regarded as safe as it has no apparent risks of side effects and complications.^[33]

It is also noteworthy to mention that some minority of the respondents still practice self-medication with antibiotics, and this issue actually warrants specific concern since irrational and misuse of antibiotics may lead to menacing problems like antibiotic resistance.^[36] Community pharmacist should play a key role in addressing the issue related to self-medication as the retail pharmacy is their primary source of medication. A well-educated patient will have a sound judgment on when to practice self-medication and the limit of self-medication. Further awareness campaign of proper self-medication practice may help in reducing irrational drugs usage among the local community.

In terms of frequency of self-medication practice, most of the respondents will self-medicate only when necessary, and they reported relief of dental problems upon self-medication. After practising self-medication, most of the respondents did not notice any side effects from this practice, similar to what was observed among the Saudi population in Riyadh (86.9%).^[3] It is also found that the respondents’ main reasons to self-medicate were mainly because of their perception that their dental problem was mild and that they want to avoid the long waiting time for proper dental treatment. AlQahtani et al.^[2] also reported the same reasons given by their study respondents. However, when asked if the self-medication practice fails, most of our respondents preferred to go to the dentist or doctor. Only a minority of the respondents were still persistent and will continue self-medicating despite the failure. These measures were almost similar to the studies conducted among respondents in Bangalore^[4] and Karnataka, India.^[30]

Study limitations

Our study on the pattern of medication did not explore in detail the specific types of medications that were used as we assume that this community will not be able to recall the specific types of medications that they have consumed. Only general terminology like painkillers were used on this regard. The approach might be different if the target groups are among the dental, medical, or health sciences students, lecturers, or professionals. Other than that, there was also a possibility of recall bias among respondents since this study was conducted as a self-administered questionnaire. In addition to that, the findings in this study may be limited to the practice of the younger generation of adults in Kuantan and may not best represent the older adults’ community in Kuantan as most of our respondents were mainly obtained from online surveys through the social media platform that were profoundly dominated by the young- to middle-aged adults.

Conclusion

Self-medication practice for dental problems is reasonably common among adults in Kuantan, Pahang. Mainly, their self-medicating practice was caused by toothache and was primarily treated with over-the-counter pain-relief medication. Overall, they have good attitude toward practising a proper self-medication practice.

Future Scope/Clinical Significance

This study has revealed the pattern, the attitude, and the actual self-medication practice for dental problems among this community. This may help the relevant authorities to further design a more targeted approach as a part of the continued public education effort in eradicating the irrational drugs usage especially in this community. Future study can perhaps extend the survey to the older adult’s community using interview-administered survey rather than the self-administered online questionnaire.

Acknowledgements

We are thankful to Madam Hanifah Hydel, a linguistic lecturer from the Centre for Languages and Pre-University Academic Development (CELPAD), IIUM, for her kind assistance during the questionnaire preparation.

Financial support and sponsorship

This study did not receive any specific grant from any funding agencies. However, the publication fee was funded by the International Islamic University Malaysia (IIUM).

Conflicts of interest

Nil.

Author contributions

Study concepts and design by Azlini Ismail, Mohd Firdaus Akbar Abdul Halim, and Zurainie Abllah; Investigation by Muhammad Nazmi Abdul Majid and Muhammad Nabil Mohd Haron; Data analysis by Mohamad Shafiq Mohd Ibrahim and Mohd Firdaus Akbar Abdul Halim; Manuscript writing and review by Azlini Ismail, Muhammad Nazmi Abdul Majid and Muhammad Nabil Mohd Haron.

Ethical policy and institutional review board statement

Ethical approval was received from the International Islamic University Malaysia (IIUM) Research Ethical Committee on 19 March 2019, with an approval number of IREC 2019-059. Participants’ data were stored in a file which was accessible only to the researchers. All the procedures have been performed as per the ethical guidelines as stipulated in Declaration of Helsinki (2013).

Patient declaration of consent statement

The respondents signed informed consent form for the paper-based self-administered questionnaire and clicked “Agree” to proceed upon given information about this study information and consent page for the online-based questionnaire. All the procedures have been performed as per the ethical guidelines as stipulated in Declaration of Helsinki (2013).

Data availability statement

The data set used in the current study is available upon reasonable request to Dr. Azlini Ismail at the email address: [email protected].

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