Knowledge, Attitude, And Practice Regarding Over-The-Counter Analgesic Use Among the General Population: A Cross-Sectional Study

Pain is one of the most frequent health concerns globally, affecting people of all ages. Headache, fever, musculoskeletal pain, low back pain, dysmenorrhea, and tooth pain are among the most commonly reported painful conditions. Low back pain is the greatest cause of disability worldwide, accounting for about 149 million disability-adjusted life years (DALYs) every year, whereas tension-type headache affects approximately 42% of the world's adult population [1,2]. Pain negatively impacts quality of life by lowering physical function, interrupting sleep, limiting social involvement, and affecting psychological well-being. It also causes huge economic losses due to absenteeism and low working productivity. [3] Notably, a large proportion of people estimated at 40-60% of adults manage pain symptoms without seeking medical attention, primarily by using over-the-counter (OTC) analgesics. Self-medication is described as the use of medicinal goods to address self-diagnosed diseases or symptoms rather than seeking medical guidance. OTC analgesics are non-prescription pharmacological medicines that are approved for the short-term treatment of mild to moderate pain and fevers. Common over-the-counter painkillers include: Acetaminophen (Paracetamol) is a centrally acting analgesic and antipyretic used as a first-line treatment for mild to moderate pain, Ibuprofen is an NSAID with analgesic, antipyretic, and anti-inflammatory effects, Aspirin, an older NSAID with antiplatelet properties, is less popular due to its gastrointestinal adverse effects, Naproxen is a long-acting NSAID frequently used to treat musculoskeletal disorders and dysmenorrhea. People choose over-the-counter drugs for their ease of availability, low cost, time-saving convenience, and autonomy in managing minor ailments without having to navigate the healthcare system [4]. When taken correctly, OTC analgesics provide quick relief for mild symptoms, decrease the pressure on healthcare facilities, and are a cost-effective therapeutic alternative. They also encourage patient autonomy and active self-care, as recommended by the World Health Organization [5]. Irrational usage of OTC analgesics poses considerable hazards. Incorrect dose, drug interactions, and the masking of serious underlying diseases are all well-known risks. Key undesirable effects include: Paracetamol overdose is a leading cause of acute liver failure, especially for chronic alcohol users and those with pre-existing liver impairment, NSAIDs can cause gastrointestinal toxicity by inhibiting mucosal-protective prostaglandins, increasing the risk of peptic ulcer disease and bleeding, Prolonged NSAID use can reduce renal prostaglandin synthesis, potentially leading to acute kidney injury or worsening chronic kidney disease. Reading product labels and rigorously following stated dosage directions is crucial for reducing these hazards. However, studies show that a large number of OTC consumers do not read or comprehend package information leaflets [6,7].

NSAIDs are among the most extensively consumed drug classes worldwide, with over 36 million Americans consuming over-the-counter formulations each year, a trend that is paralleled in South Asian communities, including India [8]. Current NSAID exposure has a pooled odds ratio of 1.73 for AKI in the general population, rising to 2.51 in the elderly and up to 5.25 in those with pre-existing CKD, with AKI accounting for about 1.7 million fatalities globally each year [9]. In India, NSAIDs account for 21% of all drug-induced AKI patients, making them the second most common pharmacological cause, with a reported increase in NSAID-induced CKD reports via the national pharmacovigilance system [10,11]. In terms of hepatotoxicity, NSAIDs account for approximately 10% of all drug-induced liver injury (DILI) cases worldwide, with an incidence of 0.29 to 9 per 100,000 patients per year; up to 15% of users exhibit subclinical liver enzyme elevations, and fatal outcomes such as fulminant hepatitis have been documented, particularly with diclofenac and sulindac, both widely available OTC in India. The combination of unregulated OTC availability, widespread self-medication, low pharmacovigilance awareness, and a high burden of comorbidities such as hypertension and diabetes create a particularly vulnerable epidemiological context in the Indian setting, necessitating immediate regulatory and clinical attention [12,13]. Several studies have looked at OTC analgesic use in diverse populations. Globally, self-medication prevalence rates range from 12.7% to 95%, with paracetamol and ibuprofen constantly ranking as the most often used medications [14]. Studies have also found that the top indications are headache, fever, and musculoskeletal pain, with simple availability and prior pleasant experience being the most important motivators. Across populations, knowledge of side effects and dose limitations is inadequate. Fosnocht et al. discovered that fewer than 30% of participants correctly recognized the maximum recommended daily dose of paracetamol, and that using numerous paracetamol-containing items concurrently increases the risk of substantial overdose, which is prevalent and largely unrecognised. Irrational usage patterns, including as dose escalation, polypharmacy, and medication sharing, have been regularly recorded in low-, middle, and high-income contexts [15].  Although various studies have assessed self-medication behaviors, the majority have focused on university students or hospital outpatients in high-income nations, limiting the generalizability of the findings. [15] There is currently limited data available on OTC painkiller using trends, knowledge, and safety awareness among individuals in our study group. Furthermore, few studies have examined usage behavior, pharmacological knowledge, and awareness of adverse consequences in the same population an integrated approach required for creating successful therapies. This research is justified by a number of public health concerns. The global consumption of over-the-counter analgesics has expanded significantly, owing to population expansion and the widespread availability of non-prescription medications [16]. Irrational usage can cause considerable injury, such as liver failure, gastrointestinal hemorrhage, and renal impairment, which is clinically significant but underappreciated by users. Pharmacist-led education has been demonstrated to improve consumer understanding and reduce harmful practices; however, such initiatives must be based on locally relevant data [17].

MATERIALS AND METHODS

The purpose of this cross-sectional, questionnaire-based survey was to investigate the general population's knowledge, attitude, and behaviors (KAP) about over-the-counter (OTC) painkiller use. The survey was conducted online using Google Forms and took place in Hyderabad, Telangana, India, in May 2026. The study included persons aged ≥18 who could read and understand English and agreed to participate. A convenience sample strategy was utilized, with the survey link sent via social media platforms and messaging apps, allowing members of the broader population to participate. The final analysis includes 121 respondents who completed all of the core KAP items. The questionnaire has six sections: participant consent, demographics, OTC consumption trends, knowledge, attitude, and practices. For the knowledge domain, each correct response was worth one point, while incorrect or "don't know" responses were worth zero, resulting in a total knowledge score of 0-6. Respondents were classified as having poor, moderate, or good knowledge based on their overall score using specified cut offs (poor: 0-3, moderate: 4, good: 5-6). Attitude was measured using three Likert-scale items ranging from 1 (strongly disagree) to 5 (strongly agree). Prior to analysis, the negatively phrased item (A3) was reverse-coded, resulting in higher scores indicating more favorable sentiments regarding safe OTC analgesic use. The item scores were then added together to yield a total attitude score, with higher values indicating more favorable attitudes. Respondents were grouped into bad, moderate, and good attitude groups based on Bloom's cut-off, with good scores ranging from 80-100%, moderate scores ranging from 60-79%, and poor scores below 60%. The practice was evaluated using measures that assessed the frequency of OTC analgesic use as well as self-reported behaviors such as label reading, adherence to suggested doses, and other safe-use practices. Composite practice scores were generated and classified into low, moderate, and good practice levels using predetermined grading criteria.  The attitude scale's internal consistency was evaluated using Cronbach's alpha. The initial three-item attitude scale had a Cronbach's alpha of 0.452, and item total data were used to identify underperforming items; after removing one item (A3), the two-item scale exhibited increased internal consistency (Cronbach's alpha = 0.632). Jamovi version 2.7.12 was used for reliability analysis. Responses were automatically gathered in Google Forms and saved to Microsoft Excel before being integrated into Jamovi. Data were reviewed for completeness and consistency, and records with missing core KAP items were removed from the final analysis set. Statistical analyses were carried out using jamovi (version 2.7.12). Descriptive statistics were used to characterize participant characteristics and KAP variables, with continuous variables provided as mean and standard deviation (SD) and categorical data as frequencies and percentages. As previously indicated, Cronbach's alpha was used to examine the attitude scale's internal consistency. The associations between categorical factors (sex and occupation) and KAP outcome categories (poor, moderate, good) were investigated using chi square tests of independence, and Cramer's V was used to calculate effect size. To account for potential variable heterogeneity, differences in mean age across knowledge, attitude, and practice outcome categories were analyzed using Welch one-way analysis of variance (ANOVA). We used Spearman's rank correlation to investigate the link between age and total KAP scores. Partial Spearman correlation was utilized to investigate correlations between knowledge, attitude, and practice scores, with the alternative hypothesis predicting a positive relationship. A one-way Welch ANOVA was also used to compare attitude scores across practice result categories, followed by Games-Howell post hoc tests for pairwise comparisons as needed. A p-value < 0.05 was considered statistically significant.
Participation was voluntary, and all respondents provided electronic informed consent before accessing the questionnaire. No personally identifiable information was gathered, and data were evaluated in aggregate to protect anonymity.

RESULTS

A total of 121 respondents completed the survey on knowledge, attitude, and practice (KAP) regarding over‑the‑counter (OTC) analgesic use. Most participants were female (66.9%, n=81), followed by males (32.2%, n=39), with one respondent preferring not to disclose sex (0.8%). Students constituted the largest occupational group (62.8%, n=76), followed by those employed in non‑healthcare sectors (16.5%, n=20) and healthcare professionals (10.7%, n=13), with smaller proportions of homemakers, retired individuals, and unemployed respondents. (Table 1) Regarding utilization frequency, the majority of participants reported using OTC painkillers less than once a month (80.2%, n=97), whereas 18.2% (n=22) used them 1–3 times per month and 1.7% (n=2) reported use 3–6 times per week. Paracetamol was the most commonly used OTC analgesic (68.6%, n=83), followed by ibuprofen (9.9%, n=12), diclofenac (9.1%, n=11), and naproxen (3.3%, n=4), while 9.1% (n=11) were unsure which OTC painkiller they used. (table 2)

KAP scores and outcomes

The mean knowledge score was 4.17 (SD 1.76; range 0–6), the mean attitude score was 8.97 (SD 2.08; range 3–15), and the mean practice score was 9.10 (SD 1.81; range 3–12) across the sample. Based on predefined cut‑offs, 26.4% of respondents (n=32) had poor knowledge, 20.7% (n=25) had moderate knowledge, and 52.9% (n=64) demonstrated good knowledge regarding OTC analgesic use. For attitude, 40.5% (n=49) were classified as having poor attitude, 47.1% (n=57) moderate attitude, and 12.4% (n=15) good attitude. In terms of practice, 9.9% (n=12) showed poor practice, 43.0% (n=52) moderate practice, and 47.1% (n=57) good practice related to OTC analgesic use. (table 3)

Reliability of the attitude scale

The three‑item attitude scale demonstrated an initial Cronbach’s alpha of 0.452, indicating suboptimal internal consistency. Item‑level analysis showed that item A3 had a low item–rest correlation (0.0831), and removal of A3 increased the overall Cronbach’s alpha to 0.6318, with item–rest correlations of approximately 0.47 for the remaining items (A1 and A2), indicating an improvement in internal consistency after item reduction. (table 4)

Associations between sex and KAP outcomes

Chi‑square tests revealed no statistically significant association between sex and knowledge outcome categories (χ²=4.50, p=0.343), although good knowledge was more frequent than poor or moderate knowledge in both sexes. Similarly, there was no significant association between sex and attitude outcomes (χ²=1.48, p=0.830) or between sex and practice outcomes (χ²=3.20, p=0.525), suggesting that KAP levels did not differ meaningfully by sex in this sample. (table 5)

Associations between occupation and KAP outcomes

Occupation was not significantly associated with knowledge outcome categories (χ²=8.46, p=0.584) or attitude outcome categories (χ²=4.90, p=0.898). In contrast, a statistically significant association was observed between occupation and practice outcomes (χ²=21.81, p=0.016), with the distribution of poor, moderate, and good practice varying across occupational groups such as healthcare workers, non‑healthcare employees, students, homemakers, retired, and unemployed participants. (table 5)

Age and KAP outcomes

One‑way Welch ANOVA indicated no significant differences in mean age across knowledge outcome categories (F=0.34, p=0.713); participants with poor, moderate, and good knowledge had mean ages of 26.7, 25.4, and 24.9 years, respectively. Likewise, no significant age differences were found across attitude outcome categories (F=0.77, p=0.469), with mean ages of 26.6, 24.9, and 23.7 years among those with poor, moderate, and good attitudes, respectively. Practice outcomes also did not differ significantly by age (F=1.60, p=0.220), although the poor‑practice group tended to be slightly older on average than the moderate‑ and good‑practice groups. (table 5)

Consistent with the ANOVA findings, Spearman correlation analysis showed no significant correlations between age and total knowledge score (ρ=−0.028, p=0.762), age and total attitude score (ρ=−0.130, p=0.155), or age and total practice score (ρ=−0.057, p=0.531), indicating that KAP scores were largely independent of age in this sample. (table 5)

Correlations among KAP domains

Partial Spearman correlation analysis between K, A, and P totals revealed that knowledge was not significantly correlated with attitude (ρ=0.064, p=0.241) or with practice (ρ=0.086, p=0.173). In contrast, attitude showed a statistically significant positive correlation with practice (ρ=0.248, p=0.003), suggesting that more favourable attitudes towards OTC analgesic use were associated with better reported practices. (table 5) To further explore this association, a one‑way Welch ANOVA was conducted with practice outcome (poor, moderate, good) as the grouping variable and total attitude score as the dependent variable, which demonstrated a significant effect (F=6.06, p=0.006). Participants classified as having good practice had the highest mean attitude score (mean 9.61, SD 2.16), compared with those with moderate practice (mean 8.29, SD 1.76) and poor practice (mean 8.83, SD 2.17), and Games–Howell post‑hoc tests indicated a significant difference in attitude scores between the moderate‑ and good‑practice groups (p=0.002). (table 5)

Table 1: Sociodemographic characteristics of respondents (n = 121)

Table 2: Utilization patterns of over‑the‑counter (OTC) analgesics (n = 121)

Table 2a: Frequency of OTC painkiller use

Table 2b: OTC analgesic most often used

Table 3: Knowledge, attitude, and practice outcome categories (n = 121)

Table 4: Internal consistency of the attitude scale