Available online at www.sciencedirect.

com

Health Professions Education 4 (2018) 16–26

www.elsevier.com/locate/hpe

Prevalence of Self-prescribing Propranolol Among Medical

and Dental Students in Riyadh, Saudi Arabia: A Cross-
sectional Study
Omar A. Al-Mohreja, Waad M. Al-Banib, Nouf S. AlShaalanb, Rawan A. Aldahasha,
Anas M. Alyamania, Hind S. Almodaimeghc,n
a
College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
b
College of Dentistry, King Saud University, Riyadh, Saudi Arabia
c
College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
Received 25 July 2016; received in revised form 12 October 2016; accepted 18 October 2016
Available online 22 October 2016

Abstract

Purpose: The life of students is full of stressors that might have an impact on their mood and academic performance. These
stressors are exaggerated among medical and dental students, as they have to worry more about financial, social, and academic
issues. The study aimed to estimate the prevalence and predictors of inappropriate self-prescribing of propranolol (Inderals)
among medical and dental students at King Saud bin Abdulaziz University for Health Sciences (KSAU-HS) Riyadh, Saudi Arabia.
Methods: A cross-sectional study using consecutive sampling was carried out among Saudi medical and dental students, who
were enrolled in KSAU-HS during the study period. A validated newly developed English questionnaire was sent via E-mail to all
eligible participants with response rate of 86.9%. Chi-square test was used to compare between groups, whereas multivariate
logistic regression analysis was carried out, where the variables that were included in the model were the ones that showed
statistical significance at the bivariate level.
Results: Around 30% of the sample used propranolol (Inderals) during their college years. Propranolol use predictors showed
that females from both specialties were less likely to use propranolol (OR ¼ 0.11, 95% CI¼0.06–0.24, P-value o .001), whereas
medical students were more likely to be propranolol users (OR¼ 12.38, 95% CI ¼4.89–31.35, P-value o.001). Notably, junior
students were less likely to use the drug (OR ¼ 0.08, 95% CI¼0.01–0.49, P-value ¼ .006).
Conclusions: The overall results showed a slightly high rate of propanol misuse among medical and dental students. The majority
of users are aware of the risks and potential side effects of self-prescribing medications, however; the anxiety relieving effect of
propranolol increased its use prior to oral exams and presentations. Educational activity targeting students must be implemented.
& 2016 King Saud bin AbdulAziz University for Health Sciences. Production and Hosting by Elsevier B.V. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Keywords: Propranolol; Beta blockers; Self-prescription; Medical students; Dental students

n
Correspondence to: Hind Almodaimegh, PharmD, BCPS-AQ Cardiology, FISMP, FCCP, Assistant Dean, College of Pharmacy-Female branch,
King Saud Bin Abdulaziz University for Health Sciences King Abdulaziz Medical City, PO BOX 22490, Riyadh, 11426.
Fax: þ 96618011111x12557.
E-mail address: modaimeghh@ksau-hs.edu.sa (H.S. Almodaimegh).
Peer review under responsibility of AMEEMR: the Association for Medical Education in the Eastern Mediterranean Region

http://dx.doi.org/10.1016/j.hpe.2016.10.001
2452-3011/& 2016 King Saud bin AbdulAziz University for Health Sciences. Production and Hosting by Elsevier B.V. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 O.A. Al-Mohrej et al. / Health Professions Education 4 (2018) 16–26
1. Introduction
The life of students is full of stressors that might
have an impact on their mood and academic perfor-
mance. These stressors are exaggerated among medical
and dental students as they have to worry more about
financial, social, and academic issues. Therefore, these
students tend to seek different stress reliving techni-
ques. The most commonly used technique is the use of
drugs, such as beta-blockers, to overcome performance
anxiety.1 Generally, medical students use these medi-
cations in order to improve the concentration, focus,
and alertness or to help study harder before tests.
Students may get these medications either by a
physician's prescription, from friends, or the Internet,
and use it in different routes; crushing the pills then
sniffing them or inhaling the powder, or injecting the
drug. Students keep intravenously looking for more
efficient and intense ways of using the drugs.
In 1958, Propranolol (Inderals), a beta-adrenergic
blocking drug, was developed by James Black.2 It helps
minimizing the effects of excessive adrenaline release by
slowing the heart rate even in healthy individuals.3
Propranolol is used to control symptoms of heart and
circulatory conditions such as angina, tremors, hyperten-
sion, heart rhythm disorders.4,5 However, its uses nowa-
days clinically are mainly restricted to thyroid patients, and
a prophylaxis in migraine headaches.6 It was also shown in
well controlled double-blinded trials that propranolol has a
favorable effect in anxiety management.7,8
Schutsky et al. findings, however, were likely
pertinent to situations in which stress worsen human
cognition.9 Tasks that are based on the recall of
recently learned or studied information such as exams
and public speaking are more sensitive to the negative
effects of stress, therefore an anticipatory arousal and
stress can disrupt the performance. Interestingly, pro-
pranolol is described to improve intellectual tractability
and exam performance.10–12 However, it is crucial to
evaluate patients medically before prescribing a beta
-blocker. In addition, tolerability testing before the
actual performance is of great value in inspecting side
effects.13,14 Propranolol, 10 mg about 1 h before the
performance, is most often prescribed.15
A nationwide, non-random online poll for the non-
medical uses of prescription drugs by Nature, reported
that prescription drugs were used in 20% of partici-
pants to enhance their concentration for a particular
task.16 Among those 20% participants, 15% said they
had taken beta blockers such as propranolol.
A study that was performed among Dutch university
students showed that 2.4% of respondents reported the
17
use of prescription drugs for several times for a non-
medical purpose. Out of those, 61.1% students reported
the use of beta-blockers.17 The use of beta- blockers for
the purpose of improving ones’ study results was
reported by 38.9% students, out of those users 19.4%
used the medications without prescription.
In another cross-sectional study18 among students of
several universities in Switzerland, with responses
reached 6275 students who completed the survey,
methylphenidate was reported at the top of the most
frequently used drugs reaching 4.1%, followed by
sedatives (2.7%), then beta-blockers (1.2%). Another
cross-sectional study included 1260 Iranian university
students, showed that 60 (4.7%) participants had used
propranolol.19 Of those, 50 participants were female.
Regarding marital status, 54 participants were single
while 56 were living in university's dorm.
Medical knowledge among the students and the easy
access to propranolol in pharmacies increase the
potential for self-treatment. Considering the side effects
of propranolol, it is essential to understand medica-
tional self-prescription behavior among the students, so
that prevention strategies can be developed and imple-
mented.13,14 Since there is a lack of studies in the
region that is conducted for the identification of
prevalence and predictors of self-prescribing proprano-
lol among students, the present study would help to
establish a baseline data in regard to the self-
medication prescriptions among medical and dental
students. Keeping in mind the drug safety concerns
among the Saudi medical and dental students, the study
aimed to estimate the prevalence and predictors of
inappropriate self-prescribing of propranolol among
medical and dental students in one of the universities
in Riyadh, Saudi Arabia.
2. Subjects and methods
This cross-sectional study was carried out in King
Saud bin Abdulaziz University for Health Sciences
(KSAU-HS) which is located in the capital city of
Riyadh, Saudi Arabia.
Saudi medical and dental students, both males and
females who were enrolled in the colleges of medicine
and dentistry at KSAU-HS during the study period
were included. A consecutive sample was used since
the questionnaire was sent via E-mail to all medical and
dental students who were studying at one of the two
mentioned schools during the study period. The
response rate reached 86.9%.
Due to the paucity of studies in this topic, a new
English questionnaire was developed by the research
18 O.A. Al-Mohrej et al. / Health Professions Education 4 (2018) 16–26

team. Painstaking revision of the questionnaire was Table 1

made to ensure that it covers the objectives of the Baseline characteristics of the respondents.
study. The questionnaire consisted of four sections; Variables Categories N %
First section was mainly about baseline characteristics
of study participants (age, gender, college, and aca- Age Mean ( 7SD) 22.2 ( 72.2)
demic year). Second section focused on the past Gender Female 186 55.7%
medical history of the participant. Third section was Male 148 44.3%
about the history and patterns of using propranolol. We College Medicine 239 71.6%
asked about the reasons to use propranolol (peer Dentistry 95 28.4%
pressure, anxiety, stress, or others). Also, a propranolol Academic level Preparatory years 39 11.7%
usage pattern was identified when comparing taking the Basic sciences 114 34.1%
drug more commonly before oral presentations, written years
exams, or both. Fourth section was about the indivi- Clinical years 181 54.2%
dual's attitude and knowledge about propranolol and its Diseases None 289 86.5%
usage (the taken dose, efficacy, medication side effects Diseased 45 13.5%
and complications). The questionnaire was subjected to Smoking No 286 85.6%
the process of content validation. The content valida- Yes 48 14.4%
tion of questionnaire was done by two clinical phar- Usage of propranolol at any time No 234 70.1%
macologists (college of pharmacy, KSAU-KS), two during college years Yes 100 29.9%
medical education specialists (college of medicine,
KSAU-KS) and two epidemiologists (King Abdullah
time. A cover page, which illustrated the purpose of the
International Medical Research Centre). A pilot study
study, accompanied the online questionnaire, reassur-
of randomly selected 40 students was conducted in
ing respondents of the confidentiality of the survey.
another university in Riyadh. Then, the items of the
Ethical approval was obtained from the IRB of the
questionnaire were checked for vagueness, and indivi-
King Abdullah International Medical Research Centre,
duality in responses. Testing the content validity
National Guard Health Affairs, Riyadh, Saudi Arabia.
revealed clarity and no confusion in the questions, face
validity was done by two faculties specialized in
pharmacology and public health. During the pilot phase 3. Results
respondents were found to understand all the questions
without any confusion. Using Cronbach's α for testing Of KSAU-HS students, 65% are male and 35% are
the internal consistency for the sections was done. female. Comparing college of medicine to college of
Cronbach's α, which has been ranged from 0.6 to 0.8, dentistry, 79% of the population are medical students
has been applied separately to each section. The result compared to 21% dental students. The total responses
of Cronbach's α for the study questionnaire was .81. reached 334 participants, the baseline characteristics of
For the present study to manage data and process the questionnaire showed that 186 (55.7%) of the
analysis, the Statistical Package for Social Sciences questionnaire respondents were female with a mean
(SPSS) version 21 (IBM Corp. Released 2013. IBM age of 22.2 (7 2.2). Of whom, 239 (71.6%) were
SPSS Statistics for Mac, Version 21.0. Armonk, NY: medical students. The sample included participants
IBM Corp) was used. Descriptive analyses were carried from all academic years. Of participants, 12% were
out by reporting the frequencies, percentages mean and in the preparatory years, 34% in the basic sciences
standard deviations for the categorical and continuous years, and 54% in the clinical years. There were 48
variables. Chi-square test and Fisher exact test were (14.4%) smokers among the sample. Of note, 45
used to compare between groups, whereas multivariate (13.5%) of the participants were found out to be
logistic regression analysis was carried out, where the diagnosed with chronic diseases. Around 30% of the
variables that were included in the model were the ones sample used propranolol (Inderals) during college
that showed statistical significance at the bivariate years. As shown in details in (Table 1).
level. For this, 95% of confidence interval (CI) and As (Table 2) shows, 78 (78.0%) of propranolol users
odds ratio (OR) were reported. All the tests were done were male. Of the propranolol users, 29 (29.0%)
at the level of a p-value of .05 or less. participants were smokers. Interestingly, 93 (93.0%)
Participation in the study was voluntary, and each of the participants who used propranolol were medical
participant was able to withdraw from the study at any students in compare to 7 (7.0%) dental students only.
 O.A. Al-Mohrej et al. / Health Professions Education 4 (2018) 16–26 19

Table 2
Baseline characteristics of propanol users and non-users.

Have you used propranolol (Inderals) at any time during your college years?

Variable Categories No Yes P-Value

N % N %

Gender Female 164 70.1% 22 22.0% o .001

Male 70 29.9% 78 78.0%
College Medicine 146 62.4% 93 93.0% o .001
Dentistry 88 37.6% 7 7.0%
Academic Level Preparatory 39 16.7% 0 0.0% o .001
years
Basic sciences years 91 38.9% 23 23.0%
Clinical years 104 44.4% 77 77.0%
Diseases None 204 87.2% 85 85.0% .593
Diseased 30 12.8% 15 15.0%
Smoking No 215 91.9% 71 71.0% o .001
Yes 19 8.1% 29 29.0%

Table 3 A number of 98 participants (64.1%) used the drug to

Multivariate analysis of propranolol use predictors. relief anxiety, while 23 participants (15.0%) used it
Variables β 95% C.I. Odd Ratio P-Value
because of peer pressure. Remarkably, 86 (86%) of the
respondents used the drug without physician consulta-
Lower Upper tions. Regarding the dosage, 29 participants (29%)
answered as “the dose depends on the activity” while
Gender  2.167 0.06 0.24 0.11 o .001
College 2.516 5.12 31.15 12.62 o .001 31 participants (31%) answered as 20 mg. However, 50
Academic year  2.480 0.18 0.68 0.35 .002 participants (50%) have increased the dose for various
reasons. Of those, 57(50.4%) increased the dose due to
oral exams such as OSCEs. The majority of the drug
users (94%) found propranolol very effective for
None of propranolol users were at the first or second anxiety relief, making 65 participants (67.7%) advise
year, while 60 (60.0%) participants were studying at their colleagues to use because of its effectiveness in
the third and fifth year. Fifteen (15.0%) participants reducing anxiety symptoms. Of those who would not
who were diagnosed with chronic diseases, such as advise their colleagues to use it, 8 participants (61.5%)
asthma, used the drug to reduce anxiety. mentioned that side effects were the main reason for
(Table 3) details the multivariate analysis of propra- not advocating propranolol use. Surprisingly, 97 parti-
nolol use predictors. It has been found that females cipants (97%) were aware of the complications result-
were less likely to use propranolol (OR ¼ 0.11, 95% ing from taking propranolol without medical
CI ¼ 0.06–0.24, p-value o .001), whereas medical supervision. In addition, when asked some questions
students were more likely to be propranolol users regarding the drug side effects and complication, all of
(OR ¼ 12.38, 95% CI ¼ 4.89–31.35, p-value o.001). the respondents were able to answer the questions
As expected, junior students were less likely to use the correctly. Regarding complications, 20 participants
drug (OR ¼ 0.08, 95% CI¼ 0.01 to 0.49, p- (20%) had complications. Hypotension was the com-
value ¼ .006). monest complication followed by erectile dysfunction.
Of note, 15 (15.6%) participants used propranolol (Table 4) details the characteristics of propranolol using
for 10 times or more. Fortunately, 58 (57.4%) stopped among the sample.
using the drug, this can be due to the side effects Medical students were significantly using the drug
exhibited by 20 (20%) of participants. The majority, more frequently, 5–10 times or more, than dental
around 90%, of the propranolol users take the drug students (P-value o .001). Medical students found
before oral exams (OSCE), poster or oral presentations. the drug very effective in reducing anxiety more than
20 O.A. Al-Mohrej et al. / Health Professions Education 4 (2018) 16–26

Table 4
Characteristics of propranolol use among the sample.

Variables Categories N %

Dose 5 times or less 61 63.5

10 times or less 20 20.8
more than 10 times 15 15.6

Do you still use propranolol (Inderal)? No 58 57.4

Yes 43 42.6

When do you use the propranolol (Inderal) the most?a Before oral exams (OSCE) 66 43.1
Before poster or oral 69 45.1
presentations
During final exams period 13 8.5
Others 5 3.3

What are the reasons to use propranolol (Inderal)?a Medical 2 1.3

To relief anxiety 98 64.1
Peer pressure 23 15.0
others 30 19.6

Who prescribed propranolol (Inderal) for you? Yourself 48 48.0

Your colleague 38 38.0
Your physician 14 14.0

What is your usual dose of propranolol? o20 mg 21 21.0

20 mg 31 31.0
40 mg 18 18.0
80 mg 1 1.0
Dose depends on the activity 29 29.0

Have you increased your dose at any time? No 50 50.0

Yes 50 50.0

What activity requires you to use higher than your usual dose?a Before oral exams (OSCE) 58 50.4
Before poster or oral 46 40.0
presentations
During final exams period 4 3.5
others 3 2.6
None 4 3.5

Have you noticed that you needed to increase the dose over the time? No 53 53.5
Yes 46 46.5

Did you find it effective to reduce anxiety? No 6 6.0

Yes 94 94.0

Would you recommend it for other colleagues? No 12 12.0

Yes 88 88.0

why wouldn’t you advise your colleague to use it?a Side effects 8 61.5
Ineffective 4 30.8
Illegal 1 7.7
 O.A. Al-Mohrej et al. / Health Professions Education 4 (2018) 16–26 21

Table 4 (continued )

Variables Categories N %

why would you advise your colleague to use ita Very effective in reducing 65 67.7
anxiety
Great feeling 19 19.8
Makes you feel high 12 12.5

Are you aware of the complications resulting from taking propranolol without medical No 3 3.0
supervision? Yes 97 97.0

What were the complications you are aware of?a Wrong 0 0.0
Correct 97 100.0

Have you ever had some of propranolol's side effects/complications No 80 80.0

Yes 20 20.0

what were the complications you had? Hypotension 18 72.0

Erectile dysfunction 5 20.0%
Shortness of breath 2 8.0%
a
Counted as multiple responses.

dental students (P-value¼ .009). Consequently, the
majority of medical students would recommend the
drug for other colleagues in comparison to dental
students (P-value ¼ .009). (Table 5) summarizes the
differences between medical and dental students
regarding propranolol use.
4. Discussion
This cross-sectional study which was done using
consecutive sampling was carried out among Saudi
medical and dental students, who were enrolled in
KSAU-HS during the study period. A validated newly
developed English questionnaire was sent via E-mail to
all eligible participants. Around 30% of the sample
used propranolol (Inderals) during their college years.
Propranolol use predictors showed that females from
both specialties were less likely to use propranolol
(OR ¼ 0.11, 95% CI ¼ 0.06–0.24, P-valueo .001),
whereas medical students were more likely to be
propranolol users (OR ¼ 12.38, 95% CI ¼ 4.89–31.35,
P-value o .001). Notably, junior students were less
likely to use the drug (OR ¼ 0.08, 95% CI ¼ 0.01–
0.49, P-value ¼ .006).
This is the first known study to be conducted in
Saudi Arabia, and probably in the Middle East region
to comprehensively demonstrate prevalence, patterns,
attitude and knowledge of the use of propranolol
among medical and dental students for anxiety and
stress relief.
The present findings provide a baseline data of
patterns of attitude and knowledge of using propranolol
among medical and dental students. The result of this
study is a representation of the adequacy of the present
community educational campaigns about propranolol
adverse effects and complications. It is expected that
these findings will yield further perception in providing
future variable interventions targeting specific areas to
foster rational propranolol use, and fill up the knowl-
edge and attitude gaps to overcome propranolol misuse
especially among students.
It has been shown in different studies that nonme-
dical uses of propranolol are generally common among
medical students. Although the prevalence of propra-
nolol differs among different studies, the usage of the
drug in the current sample is thought to be the highest,
around 30% of the sample used propranolol during
college years. Showing a relatively higher rates of
propranolol use compared to those reported in Iran,
Switzerland and Netherlands.17–19
Of propranolol users in the sample, 78.0% were male
while females were less likely to use propranolol. In
contrary, female students had higher rates of propanol
use compared to the male students in the Iranian
22 O.A. Al-Mohrej et al. / Health Professions Education 4 (2018) 16–26

Table 5
Comparison between medical and dental students who use propranolol.

Variables Categories Medicine Dentistry P-Value

N % N %

Dose 5 times or less 54 60.7% 7 100% o .001

10 times or less 20 22.5% 0 0.0%
More than 10 15 16.9% 0 0.0%
times

Do you still use No 53 57.0% 5 62.5% .762

propranolol (Inderal)? Yes 40 43.0% 3 37.5%

When do you use the Before oral 62 44.0% 4 33.3% .399

propranolol (Inderal) exams (OSCE)
the most? Before 62 44.0% 7 58.3%
presentations
During final 12 8.5% 1 8.3%
exams period
Others 5 3.5% 0 0.0%

What are the reasons to Medical 2 1.4% 0 0.0% .514

use propranolol To relief 91 64.5% 7 58.3%
(Inderal)? anxiety
Peer pressure 22 15.6% 1 8.3%
Others 26 18.4% 4 33.3%

Who prescribed Yourself 45 48.4% 3 42.9% .957

propranolol (Inderal) Your colleague 35 37.6% 3 42.9%
for you? Your physician 13 14.0% 1 14.3%

What is your usual dose o20 mg 20 21.7% 1 12.5% .940

of propranolol? 20 mg 28 30.4% 3 37.5%
40 mg 16 17.4% 2 25.0%
80 mg 1 1.1% 0 0.0%
Dose depends 27 29.3% 2 25.0%
on the activity

Have you increased No 47 50.5% 3 42.9% .695

your dose at any time? Yes 46 49.5% 4 57.1%

What activity requires Before oral 54 51.4% 4 40.0% .012

you to use higher than exams (OSCE)
your usual dose? Before 43 40.9% 3 30.0%
presentations
During final 4 3.8% 0 0.0%
exams period
Others 2 1.9% 1 10.0%
None 2 1.9% 2 20.0%

Have you noticed that No 50 53.8% 3 50.0% .858

you needed to increase Yes 43 46.2% 3 50.0%
the dose over the time?

No 4 4.3% 2 28.6% .009

 O.A. Al-Mohrej et al. / Health Professions Education 4 (2018) 16–26 23

Table 5 (continued )

Variables Categories Medicine Dentistry P-Value

N % N %

Did you find it effective Yes 89 95.7% 5 71.4%

to reduce anxiety?

Would you recommend No 9 9.7% 3 42.9% .009

it for other colleagues? Yes 84 90.3% 4 57.1%

why wouldn’t you Side effects 7 70.0% 1 33.3% .262

advise your colleague Ineffective 2 20.0% 2 66.7%
to use it? Illegal 1 10.0% 0 0.0%

why would you advise Very effective 64 71.1% 1 16.6% .001

your colleague to use it in reducing
anxiety
Great feeling 16 17.7% 3 50.1%
Makes you feel 10 11.1% 2 33.3%
high

Are you aware of the No 1 1.1% 2 28.6% o .001

complications resulting Yes 92 98.9% 5 71.4%
from taking propranolol
without medical
supervision?

What were the Wrong 0 0.0% 0 0.0% –

complications you are Correct 92 100.0% 5 100.0%
aware of?

Have you ever had No 74 79.6% 6 85.7% .695

some of propranolol's Yes 19 20.4% 1 14.3%
side effects/
complications

what were the Hypotension 17 70.8% 1 100.0% .900

complications you had? Erectile 5 20.8% 0 0.0%
dysfunction
Shortness of 2 8.3% 0 0.0%
breath

study.19 This finding could have resulted from the
stigma of risky behaviors that is generally common
among females in Saudi Arabia.20-21 It is also relevant
to say that the family and society load could be a
reason for women to avoid taking such a risk.
Medical students showed higher rates of using
propranolol compared to dental students since 93
(93.0%) of the participants who used propranolol were
medical students. In addition, it was found that 7
(100%) of dental students used the drug for 5 times
or less, in comparison to 35 (39.4%) of medical
students who used it above 5 times. This could be
explained by the knowledge that medical students have
about the drug uses in compare to dental students. This
was also confirmed by the results that indicated 98.9%
of medical students were aware of the complications of
using the drug without medical supervision in compare
to 71.4% of dental students. This can be evident by the
fact that the level of knowledge, attitude, and percep-
tion of medical students regarding medications were
24 O.A. Al-Mohrej et al. / Health Professions Education 4 (2018) 16–26
much higher than that of dental students as shown in a
study comparing antimicrobial medications.22
None of propranolol users were at the first or second
year, while 60 (60.0%) participants were studying at
the third and fifth year. This could be related to the
escalating pressure throughout the studying years and
the difficulty of the curriculum in the final years. As
found in Germany, older students are affected more by
test anxiety.23 Also, they reported a higher substance
consumption/abusive behaviour and often more con-
sumption of drugs that required prescription such as
beta-blockers. Another systematic review study con-
firmed high levels of stress and a significant occurrence
of exhaustion and depressive symptoms among medical
students.24 Final year students, in particular, revealed
higher levels of stress, burnout and depressive
symptoms.25
The majority of propanol users, constituting
around 90%, take the drug before oral exams (OSCE),
poster or oral presentations, which could be an
indication of higher levels of social anxiety. Moreover,
in compare to dental students, medical students
increased the dose for many reasons not limited to oral
exams (OSCE) or presentations (P-value ¼ .012). This
can be attributed to the effective anxiety reduction
stated by 89 (95.7%) of medical students in compare to
5 (71.4%) of dental students who found it effective.
This was also seen in 67.9% of medical students in a
previously conducted study who felt that OSCE was
very stressful to them.26 This finding is consistent with
the findings reported by Dadgar et al. who documented
62.9% of the students felt stressed before OSCE.27
Anxiety and stress adversely affect self-efficacy and
confidence of students that could be reflected nega-
tively upon their grades. In a previously conducted
study, second year medical students who had a high
degree of anxiety at the time of OSCE were less
confident about their ability to take the examination
compared to their less anxious counterparts.28 Higher
anxiety level associated with OSCE contributes to less
efficacy and a low confidence level of the students
taking this examination compared to those appearing in
traditional examinations like multiple choice
questions.29
The effect of peer pressure as a cause of propranolol
use was higher among medical students 22 (15.6%)
compared to 1 (8.3%) between dental students. This
finding can be clarified by the higher percentage of
colleagues’ recommendations among medical students
due to effective anxiety reduction stated by 64 (71.1%)
of medical students in compare to 2 (66.7%) of dental
students who will not recommend it due to less
effective results in anxiety reduction. The higher
effective results exhibited by medical students can be
attributed to the higher expectations, the placebo effect,
since medical students are more aware about the drug
potentials. On the other hand, 19 (20.4%) of medical
students exhibited drug side effects in compare to 1
(14.3%) of dental students. None of dental students had
shortness of breath and erectile dysfunction, whereas 2
(8.3%) and 5 (20.8%) of medical students had short-
ness of breath and erectile dysfunction respectively,
which is expected due to the higher participation in the
study by medical students.
Propranolol, used by patients suffering from perfor-
mance anxiety, represents another example of ethical
obscurity with respect to medication abuse. The reason
behind such obscurity is that the ethical evaluation of
medication abuse is formed by societal views, many of
which are based on unquestioned speculations we make
about our world. These inferred meanings often present as
vague images and ideas based on, if at all, weak evidence.
Furthermore, societal images may portray opposing and
contending meanings that add to the obscurity of a moral
evaluation of medication and their use.
Our study has a number of limitations that may have
to lead to a very vigilant interpretation of our data.
First, although we reached very high response rates,
reducing the possibility of a response bias, data
sampling was non-random since all students were
surveyed. Furthermore, it is clear that although the
use of propranolol is mostly examined in medical and
dental student populations, it is probably not possible
to generalize this to other populations. However, efforts
were made to overcome these limitations. Also, our
sample is from one single university, larger studies
including students from different universities might be
more helpful and might give more accurate data about
the behaviour of medical and dental students of Saudi
Arabia.
Future studies should extend the scope of this study
to investigate the prevalence of using propranolol and
other types of drugs in the general population to define
whether only health sciences students use prescription
drugs or whether employees and students of other fields
do the same. Also, further studies should focus on
attitudes of using such drugs and whether students
think if such behaviour is a justifiable, depending on
subject characteristics and context.
The study was conducted among medical and dental
students who were aware of the risks of medications
self-prescribing showed increased misuse of proprano-
lol, which necessitates determines the prevalence
among non-medical population to further work on
 O.A. Al-Mohrej et al. / Health Professions Education 4 (2018) 16–26
increasing public awareness. Further studies exploring
the prevalence of other more dangerous drugs used
among medical students to overcome performance
anxiety is of importance to be conducted in our culture
to determine its commonness and improve the educa-
tional and awareness campaigns in the community.
5. Conclusion
The overall results showed slightly high rate of
propanol inappropriate use among medical and dental
students. Despite the fact that the majority are aware
about the risks and potential side effects of self-
prescribing medications, the anxiety relieving effect
that follows the administration of propranolol increased
its use prior to oral exams and presentations. With the
majority admitting that they would recommend it for
their colleagues, this should trigger wider education
about the medical consequences that could result from
inappropriate use of propranolol.
Authors’ contributions
OAM: Study concept, study design, Data acquisi-
tion, data analysis and interpretation, statistical analy-
sis, manuscript preparation. WAB and NSS: Data
acquisition, manuscript preparation. RAD and AMY:
manuscript preparation, manuscript editing, manuscript
review. HSM: Study design, manuscript editing, manu-
script review. All authors read and approved the final
manuscript.
Disclosure
Ethical approval was obtained from the IRB of the
King Abdullah International Medical Research Centre,
National Guard Health Affairs, Riyadh, Saudi Arabia.
Competing interests
The authors declare that they have no competing
interests.
Funding
This research did not receive any specific grant from
funding agencies in the public, commercial, or not-for-
profit sectors.
25
Availability of data and materials
All data related to this study are available upon
request.
Acknowledgements
The authors would like to duly express their heart-
felt appreciation and gratitude to Ms. Lujain A. Al-
Yamani for her countless support throughout the
project.
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