Promoting Healthy Reading Strategies as a Self-Care Alternative to Self-Medication among University Students in Sub-Saharan Africa: A Systematic Review

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However, the lack of it among university students often leads to immense academic demands and pressures, particularly during examinations. This could result in self-medication and nonmedical use of drugs to cope with pressure and could negatively affect their physical and mental health, well-being, as well as academic performance. There is also the risk of the long-term effects of medication dependence, addiction, and decreased cognitive function. Therefore, establishing healthy reading habits is essential to student self-care and holistic well-being. This study used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), guidelines, and protocols to review published data between 2010 and 2024 from Sage Journals, African Journal Online, ProQuest Dissertations, Scopus, and Google Scholar. Twelve selected articles were thematically analysed, and social cognitive theoretical lenses guided interpretation and analysis. The review revealed the prevalence of medication misuse among university students, risk factors for drug misuse, interventions to reduce medication misuse, and the role of policymaking in supporting drug misuse among university students. Based on the findings, recommendations were made to address self-medication and promote healthy reading habits and students’ well-being." } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/13-1332/v1", "name": "Promoting Healthy Reading Strategies as a Self-Care Alternative to..." } } ] } Home Browse Promoting Healthy Reading Strategies as a Self-Care Alternative to... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Ogbodu OM and Adekola AP. Promoting Healthy Reading Strategies as a Self-Care Alternative to Self-Medication among University Students in Sub-Saharan Africa: A Systematic Review [version 1; peer review: 1 approved with reservations] . F1000Research 2024, 13 :1332 ( https://doi.org/10.12688/f1000research.158366.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Systematic Review Promoting Healthy Reading Strategies as a Self-Care Alternative to Self-Medication among University Students in Sub-Saharan Africa: A Systematic Review [version 1; peer review: 1 approved with reservations] Olubunmi Margaret Ogbodu https://orcid.org/0000-0002-2488-2963 1 , Ayobami Precious Adekola https://orcid.org/0000-0001-5073-9012 2 Olubunmi Margaret Ogbodu https://orcid.org/0000-0002-2488-2963 1 , Ayobami Precious Adekola https://orcid.org/0000-0001-5073-9012 2 PUBLISHED 07 Nov 2024 Author details Author details 1 Department of Anaesthesiology and Critical Care, Walter Sisulu University, Mthatha, Eastern Cape, 5099, South Africa 2 Department of Gender and Sexuality Studies, University of South Africa, Pretoria, Gauteng, 0003, South Africa Olubunmi Margaret Ogbodu Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Project Administration, Resources, Writing – Original Draft Preparation Ayobami Precious Adekola Roles: Data Curation, Formal Analysis, Methodology, Project Administration, Validation, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract Healthy reading habits can improve concentration, critical thinking, information retention, and educational success skills. However, the lack of it among university students often leads to immense academic demands and pressures, particularly during examinations. This could result in self-medication and nonmedical use of drugs to cope with pressure and could negatively affect their physical and mental health, well-being, as well as academic performance. There is also the risk of the long-term effects of medication dependence, addiction, and decreased cognitive function. Therefore, establishing healthy reading habits is essential to student self-care and holistic well-being. This study used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), guidelines, and protocols to review published data between 2010 and 2024 from Sage Journals, African Journal Online, ProQuest Dissertations, Scopus, and Google Scholar. Twelve selected articles were thematically analysed, and social cognitive theoretical lenses guided interpretation and analysis. The review revealed the prevalence of medication misuse among university students, risk factors for drug misuse, interventions to reduce medication misuse, and the role of policymaking in supporting drug misuse among university students. Based on the findings, recommendations were made to address self-medication and promote healthy reading habits and students’ well-being. READ ALL READ LESS Keywords Reading habits, University students, Self-medication, Self-care, Academic performance, Examination periods Corresponding Author(s) Ayobami Precious Adekola ( [email protected] ) Close Corresponding author: Ayobami Precious Adekola Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2024 Ogbodu OM and Adekola AP. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Ogbodu OM and Adekola AP. Promoting Healthy Reading Strategies as a Self-Care Alternative to Self-Medication among University Students in Sub-Saharan Africa: A Systematic Review [version 1; peer review: 1 approved with reservations] . F1000Research 2024, 13 :1332 ( https://doi.org/10.12688/f1000research.158366.1 ) First published: 07 Nov 2024, 13 :1332 ( https://doi.org/10.12688/f1000research.158366.1 ) Latest published: 07 Nov 2024, 13 :1332 ( https://doi.org/10.12688/f1000research.158366.1 ) Introduction University students often face immense academic demands and pressures, particularly during examinations. Self-medication by university students to combat academic stress has been described by different authors ( Khalifah et al., 2023 ; Orayj et al., 2021 ). During these stressful times, maintaining healthy reading habits and avoiding the misuse of medications is crucial for their well-being and academic performance. The dangers of academic stress among students, including unrealistic academic goals, were described in a study conducted in Ghana ( Adom et al., 2020 ) with recommendations of organising workshops and seminars to sensitise the members of higher institutions on the dangers of academic stress, including medication misuse and effective approaches in curtailing them. Similarly, Parmar et al. (2024) posit that educating university students to modify their attitudes toward self-medication is an effective strategy for curbing medication misuse. The proper use of self-medication holds immense benefits for the individual’s health and is recognised by the WHO as part of self-care, as it can help treat minor ailments that do not require medical consultation ( Zewdie et al., 2020 ). Similarly, Hailemichael et al., 2016 described self-care as what people do to themselves to establish and maintain health and prevent and deal with illness. Healthy reading habits, such as regular balanced reading activities, benefit university students, including character-building for their future ( Labo-Popoola, 2018 ; Alsaeedi et al., 2021 ). Reading habits are crucial for shaping the academic performance and overall well-being of university students in Sub-Saharan Africa. Numerous studies have described the prevalence of self-medication by university students during academic sessions and examination periods as a self-care measure to cope with academic stress ( Alshahrani et al., 2019 ; AlRasheed et al., 2017 ). At the same time, some studies have emphasised the significant impact of reading habits as a self-care practice on students’ academic achievements, such as a study conducted at Afe Babalola University in Nigeria highlighted a positive correlation between reading habits and academic success ( Oriogu et al., 2017 ). Similarly, research has shown that maintaining regular reading habits and studying skills positively influences students’ academic performance ( Abid et al., 2023 ; Kasyoka, 2023 ). Studies have also indicated a strong correlation between students’ reading habits and academic success, with positive reading habits leading to better learning outcomes ( Wani, 2024 ; Yildiz, 2020 ). This relationship has been explored in various contexts, such as ESL classrooms, secondary schools, and preparatory schools, underscoring the universal significance of cultivating good reading habits for academic success ( Hassan et al., 2021 ). Reading can improve concentration, critical thinking, and information retention, valuable skills for academic success; as Oriogu et al. (2017) suggested, reading develops an individual’s affective, cognitive, and psychomotor traits. Owusu-Acheaw and Larson’s (2014) study revealed that reading has a positive influence on academic performance, corroborated by Alsaeedi et al. (2021) , who asserted that the habit of reading is one of the strongest predictors of academic success because it improves thinking ability, provides new concepts and ideas, and enhances vocabulary and language. Reading for pleasure can also be an effective stress management tool, allowing students to decompress and recharge between study sessions ( Balan et al., 2019 ). Reducing academic stress among students through stress management measures as coping strategies, including reading for pleasure and counselling and extra-curricular activities, have also been advocated by Parmar et al. (2024) . Healthy reading habits are essential for student self-care and holistic well-being ( Ikwara et al., 2024 ; Kawuma et al., 2021 ). Teachers and parents as significant others play essential roles in modelling positive behaviours in their children and wards ( Ogbodu et al., 2023 ) and developing and nurturing students’ reading habits to improve their academic performance ( Bano et al., 2018 ). Universities, policymakers, and relevant stakeholders have crucial roles to play in implementing measures and structures such as counselling services, campaigns against self-medication and drug abuse, stress management workshops, and sleep hygiene programs to address challenges associated with self-medication in university students ( Fareo, 2012 ). In conclusion, campaigns against drug abuse and counselling services on the adoption of healthy self-care options of study and reading habits to discourage self-medication behaviours and risky sexual practices and achieve academic success by university students in Sub-Saharan Africa are advocated to address the complex and multifaceted dimensions of self-medication, reading habits and achieving academic performance. Addressing these issues requires a comprehensive approach integrating interventions promoting positive reading habits, safe healthcare practices, and responsible sexual behaviours. By understanding the factors influencing these behaviours and implementing targeted interventions, stakeholders can work towards improving the academic performance and overall well-being of university students in the region. Research problem The pressure to perform well during examination periods can lead to stress, anxiety, and burnout, causing students to seek shortcuts, such as medication, to manage their symptoms ( Ogbodu et al., 2024 ). Healthy reading habits are essential for academic success, and university students are no exception. University students often face immense academic demands and pressures, particularly during examinations. In these stressful times, maintaining healthy reading habits and avoiding the misuse of medications can be crucial for students’ well-being and academic performance. Healthy reading habits, such as engaging in regular, balanced reading activities, have provided numerous benefits for university students. Reading can improve concentration, critical thinking, information retention, and valuable academic success skills. Reading habits and self-medication among university students in Sub-Saharan Africa are critical factors that can significantly impact academic performance and overall well-being. The prevalence of self-medication with over-the-counter (OTC) drugs, including analgesics, is notably high in this region ( Kawuma et al., 2021 ). This behaviour can have adverse effects on student’s health and academic outcomes. Additionally, risky behaviours such as inconsistent condom use and engaging in sexual activities with multiple partners are prevalent among university students in Sub-Saharan Africa ( Lungu et al., 2022 ). These behaviours can lead to various health risks, including the spread of sexually transmitted infections like HIV. Encouragingly, interventions based on social cognitive theory have shown promise in reducing risky sexual behaviours among university students in Sub-Saharan Africa ( Heeren et al., 2012 ). When tailored to the region’s specific context, such interventions can play a crucial role in promoting safer practices among students. Moreover, transitioning from secondary school to university is a critical period significantly impacting students’ preparedness and academic success ( Too et al., 2022 ). Despite efforts to expand educational opportunities in Sub-Saharan Africa, enhancing students’ skills and competencies is still necessary to improve academic performance. Furthermore, reading for pleasure can be an effective stress management tool, allowing students to decompress and recharge between study sessions. Establishing healthy reading habits, therefore, is an essential component of student self-care and holistic well-being ( Ikwara et al., 2024 ). This rising prevalence of self-medication among university students is a concern because it can lead to negative consequences on students’ academic performance, physical and mental health, as well as overall well-being ( James et al., 2022 ) with long-term effects of self-medication to cope with examination pressure can lead to dependence, addiction, and weakened cognitive function. The authors opine that educational institutions and healthcare providers can play pivotal roles in shaping students’ behaviours and attitudes. On the other hand, self-medication practices among university students in Sub-Saharan Africa can have adverse effects on their well-being and academic performance. While self-management interventions have been studied in the context of diabetes patients in the region, self-medication behaviours can harm individuals’ health ( Carter et al., 2021 ; Stephani et al., 2018 ; Dd et al., 2015 ). According to Khalifah et al., (2023) and Orayj et al., (2021) examination periods come with attendant pressure on university students, as they can feel overwhelmed by the volume of coursework, assignments, and study materials and resort to medication misuse to study for longer hours and reduce anxiety associated with preparing for examinations. Another study by Quintero and Nichter (2011) alludes to self-medication by students as a quick fix to stay awake to study, and improve their focus, concentration, and memory, even when intoxicated after a social outing, by taking psychoactive substances and stimulants. Additionally, students have indulged in self-medication during examination periods to resolve insomnia and sleep disorders so students can become refreshed to study for longer hours ( Goodhines et al., 2017 ). Self-medication could have detrimental effects, such as impaired mental health, cognitive function, mood disturbances, and decreased motivation for students. Weyandt (2014) noted that the misuse of stimulants and prescription drugs meant to treat Attention Deficit Hyperactivity Disorder (ADHD) has become a growing concern among university students, even though it remains unclear whether drug use for cognitive enhancement in individuals with undiagnosed ADHD is self-treatment or misuse ( Maier et al., 2015 ). While university students’ objectives for taking these medications are to cope with examination pressure, improve cognitive performance, and remain alert, the use of these drugs without a prescription could lead to various adverse health consequences, such as anxiety, insomnia, cardiovascular problems, and addiction. Additionally, it could also have legal implications for students. In the context of self-medication, particularly among university students, understanding the determinants and prevalence of this practice is essential for promoting safe healthcare behaviours ( Al-Zoubi et al., 2023 ). Studies have shown a concerning prevalence of self-medication among university students in the Middle East and North Africa region, highlighting the need for interventions to address this issue. Moreover, the burden of adverse drug reactions (ADRs) in Sub-Saharan Africa, exacerbated by the high HIV prevalence in the region, underscores the importance of early detection and appropriate management of ADRs ( Asio et al., 2023 ). In Sub-Saharan Africa, where there is a high demand for healthcare workers, the emigration of physicians poses a significant challenge to addressing the population’s healthcare needs ( Chaet et al., 2021 ). Understanding the factors driving medical student emigration intentions is essential for developing strategies to retain healthcare professionals within the region. Furthermore, training institutions in Sub-Saharan Africa must align their programs with the needs of the healthcare workforce to effectively retain graduating medical students ( Sawatsky et al., 2014 ). When these factors are addressed, countries in the region can work towards building a sustainable healthcare system, and healthcare systems must prioritise strategies that mitigate the risks associated with self-medication and ADRs to safeguard the population’s well-being. Research focus University students’ pressures and challenges during examinations can impact their physical and mental health. Poor reading habits and self-medications may provide temporary relief, but these behaviours could eventually harm students’ long-term well-being and academic success. Understanding the dynamics and implications of these issues is crucial to better supporting university students in maintaining a healthy and productive approach to their studies. Likewise, self-medication could also have health, social, security, and economic implications, including decreased productivity, financial burdens, and strained relationships with friends and family, underscoring the importance of global interventions for preventing drug abuse, including its impact on health, governance, and security ( Jatau et al., 2021 ). Frequent self-medication practices among university students can lead to dependency and addiction, which can harm their future ( United Nations Office on Drugs and Crime, 2018 ). Besides the potential individual consequences of self-medication, wider implications for public health and society as a whole have been described. Self-medication may contribute to developing drug-resistant bacteria, thus posing a major threat to global health ( World Health Organization, 2019 ). In conclusion, fostering positive reading habits among university students in Sub-Saharan Africa is essential for enhancing their academic performance and overall well-being rather than medication misuse and self-medication for cognitive enhancement purposes ( Fareo, 2012 ). Collaboration among educators, policymakers, and healthcare providers is crucial to promoting a reading culture and discouraging harmful self-medication practices among students to ensure their success and health. According to Gras et al. (2020) , identifying risk factors of self-medication facilitates the implementation of actions by educational institution actors to reduce the prevalence on the university campus. Academic stress, amongst other factors such as gender, educational level of father, and alcoholic consumption, was cited by Lukovic et al. (2014) . Educational institutions and healthcare providers can play pivotal roles in shaping students’ behaviours and attitudes ( James et al., 2022 ; Al Kubaisi, 2019 ; Bustanji et al., 2024 ). Self-care choices that promote healthy reading habits and reduce self-medication among university students through counselling services provided by universities, policymakers, and other stakeholders should implement several strategies. For instance, Fareo (2012) suggested that universities can provide access to academic support services, including tutoring, mentoring, and study skills programs. Similarly, Ikwara et al., (2024) and Ibrahim & Lua (2016) concur that universities should promote a culture of campaigns and counselling on healthy self-care choices of study habits, effective time management, goal-setting, and stress management techniques. In conclusion, raising awareness about the dangers of self-medication through campaigns and providing counselling services that include promoting positive reading habits among university students in Sub-Saharan Africa is essential for enhancing their academic performance and overall well-being. Research aim and research objectives This systematic review aims to address the issue of self-medication among university students during examination periods and to investigate the protective benefits of healthy reading habits. This review synthesised the existing body of knowledge to understand the relationship between reading habits, self-medication, and academic performance. This could guide the development of contextually relevant interventions to enhance students’ well-being and academic success. In addition, this review seeks to contribute to the discussion of university students’ use of prescription stimulants. This could positively influence universities’ counselling services and institutional policies. Therefore, the objectives of this are: • To determine effective strategies for promoting healthy reading habits among university students during examinations. • To determine the risk factors and consequences of self-medication among university students during examination periods. • To identify intervention programmes that have been shown to reduce self-medication and promote healthy reading habits among university students. Theoretical frameworks Social cognitive theory As proposed by ( Bandura, 1991 ), the social cognitive theory emphasises the role of observational learning, self-efficacy, and self-regulation in shaping behaviour. When applied to university students in Sub-Saharan Africa, this theory can offer valuable insights into understanding and modifying behaviours related to reading habits, self-medication, risky sexual practices, and academic performance. Heeren et al. (2012) demonstrated that interventions based on social cognitive theory could effectively reduce risky sexual behaviours among university students in Sub-Saharan Africa. By incorporating elements such as modelling positive behaviours, building self-efficacy, and providing opportunities for skill development, interventions can empower students to make healthier choices. This aligns with the emphasis on the importance of self-efficacy in behaviour change. Regarding reading habits and academic performance, social cognitive theory suggests that individuals learn through observation and modelling. Encouraging students to observe positive reading behaviours in their peers, instructors, or role models can enhance their reading habits ( Wani, 2024 ; Ali et al., 2023 ). By fostering a sense of self-efficacy in their reading abilities and academic performance, students are more likely to engage in consistent reading practices that positively impact their educational outcomes. Moreover, social cognitive theory can also be extended to address self-medication behaviours among university students in Sub-Saharan Africa. Understanding the factors influencing self-medication, such as perceived benefits and self-regulation, can inform interventions that promote safe healthcare practices ( Al-Zoubi et al., 2023 ). By enhancing students’ self-efficacy in seeking professional medical advice and improving their health literacy, interventions can mitigate the risks associated with self-medication. The social cognitive theory provides a valuable framework for understanding and addressing various behaviours among university students in Sub-Saharan Africa. By leveraging concepts such as observational learning, self-efficacy, and self-regulation, interventions can be designed to promote positive reading habits, safe healthcare practices, and responsible sexual behaviours, ultimately enhancing academic performance and well-being among students in the region. Therefore, we used Bandura’s social cognitive theory to interpret the study findings, emphasising the influence of observation, self-efficacy, and self-regulation in shaping behaviours ( Hilton et al., 2010 ). When applied to university students in Sub-Saharan Africa, this theory offers valuable information on how reading habits and self-medication practices impact academic performance and well-being. Students could learn by observing their peers. If their peers demonstrate positive reading habits or avoid self-medication, they are more likely to adopt these behaviours. Self-efficacy, or the belief in one’s ability to succeed, is crucial in whether students develop healthy reading habits and refrain from self-medication. Self-regulation is another important component of Bandura’s theory ( Bandura, 1991 ). By developing strong self-regulation skills, students can manage their reading habits and make informed decisions about self-medication. Setting goals, monitoring progress, and adapting based on feedback can significantly enhance academic performance and overall well-being. Additionally, the social cognitive theory recognises the power of collective agency ( Usher & Ford, 2022 ). This underscores the influence of group dynamics on individual behaviour. Encouraging a culture of positive reading habits and discouraging self-medication practices at the university level can create a supportive environment promoting students’ academic success and health. By fostering a culture that encourages positive reading habits and discourages self-medication, universities can create a supportive environment that promotes academic success and health among students. This theory can be applied to understand how students’ exposure to diverse reading materials, modelled behaviours of peers and educators, and their own self-efficacy beliefs influence their reading practices ( Hilton et al., 2010 ). Observational learning plays a significant role in shaping reading habits, as students may emulate the reading behaviours they observe in others. By creating environments that promote a culture of reading, universities in Sub-Saharan Africa can leverage social cognitive theory to encourage positive reading habits among students, ultimately enhancing their academic performance and intellectual development. Applying social cognitive theory offers valuable insights into understanding and addressing reading habits, self-medication practices, and their impact on academic performance and well-being among university students in Sub-Saharan Africa. By considering the constructs of this theory, stakeholders can design targeted interventions that promote positive behaviours and support students in achieving academic success and maintaining their health. Methods Sample As part of our study, we (the two authors) systematically reviewed published studies, analysing discussions, arguments, and evidence on the relationship between reading habits, prescription misuse, and academic achievement. A systematic review is designed to summarise all accessible primary research in response to a specific research question ( Clarke, 2011 ). This methodological technique was ideal and appropriate to achieve our study objectives. This study’s inclusion and exclusion criteria are detailed in the table below. We have meticulously defined each criterion to ensure clarity and precision. A comprehensive outline of the parameters for inclusion and exclusion in this study is shown in Table 1 . Table 1. Inclusion and exclusion criteria selected for the research. Inclusion criteria Exclusion criteria Study Type • Empirical studies using qualitative, quantitative, or mixed-method approaches. • Systematic reviews and meta-analyses relevant to the research topic. Topic Relevance • Studies explicitly examining the relationship between reading habits, medication misuse, and academic performance among university students. • Research examining the relationship between reading habits and academic performance • Research focusing on the impact of examination periods on student behaviour and well-being. • Articles that investigate interventions and strategies aimed at promoting healthy reading habits. • Articles that examine the guidelines for reducing medication use among university students during examinations. Population • Studies involving university or college students. • Research was conducted in various cultural and geographic contexts, provided the primary focus was on university students. Time Frame • Studies published between 2010 and 2024. Language • Studies published in English. Non-Empirical Publications • Financial reports, hospital newsletters, and financial reports from organisations like the Nigeria Medical Association (NMA). • Court reports and inductions related to medical associations. • General reports, correspondence, and meeting outcomes not directly related to the research topic. • Medical-related comments, editorials, opinion pieces, and anecdotal reports. Irrelevant Topics • Studies focusing on primary or secondary school students. • Research examining medication misuse without addressing its impact on academic performance. • Studies focusing solely on reading habits without linking them to academic performance or well-being. Population • Research involving populations other than university or college students, such as high school students or non-student adults. • Research involving only university students in medical and health sciences disciplines Time Frame • Studies published before 2010 Language • Studies published in languages other than English. Duplicate Publications • Duplicate studies or redundant publications from the same research project without significant new findings. Instrument and procedure Data collection and research materials for this study adhered to the guidelines and protocols of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), as illustrated in supplementary Figure 1 (Refer extended data). The narrative review primarily utilised data from databases such as Sage Journals, African Journal Online, ProQuest Dissertations, Google Scholar, and Academia Publications. Studies published between 2010 and 2024 were included. The search focused on keywords and sub-topics related to promoting healthy reading habits, developing guidelines for healthy reading habits, motives for self-medication, and reducing self-medication among university students during examinations. The articles were sourced from journals in various sectors, including health, corporate, clinical, biological, medical, public health, mainstream, and political sectors, recognising the broad societal impact of health. Systematic reviews have the potential for plagiarism due to their reliance on existing findings ( Marschan-Piekkari, & Welch. (2011) , this study took precautions to avoid it. Furthermore, the study focussed on relevant articles, thus promoting its clarity and conciseness. Data analysis We ensured transparency of this systematic review by following the PRISMA framework outlined by Page et al. (2021) . Guided by the four phases of the framework, namely identifying, screening, eligibility, and inclusion, we systematically reviewed all relevant research on the relationship between reading habits and self-medication and reported accurately. We did the thematic analysis of 12 eligible articles as described by Braun and Clarke (2006) and McLeod (2024) . This method involved reading and re-reading the selected articles thoroughly to gain an in-depth understanding of the content and context of each selected study. We then identified and labelled relevant data segments and created initial codes related to reading habits and self-medication. We clustered the initial codes into potential themes by observing patterns and relationships within the data. These themes were reviewed and refined to make sure they accurately represented the data. Finally, we defined each theme carefully to reflect the key aspects of the data. This approach makes this study data analysis rigorous and transparent, leading to valuable insights into the relationship between reading habits and self-medication among university students and achievement of academic success. Results Our article selection process and data analysis led to a comprehensive review of relevant literature for this study. For each of the twelve articles, we recorded the author’s name, year of publication, research aims, research design, research strategy, data analysis method, research outcomes, and recommendations. The findings from the systematic analysis of all the reviewed papers are shown in Supplemenary Tables 1 and 2 (Refer extended data). The selected studies were predominantly of cross-sectional design (8), three qualitative research designs, and a systematic review. Discussion The analysis produced four emergent themes, as shown in Supplementary Table 2 (Refer extended data), which are discussed below: • Prevalence of medication misuse by university students • Risk factors of medication misuse • Interventions to reduce medication misuse and support services by university management • Role of Policymaking to Support reduced medication misuse among University students Prevalence of self-medication The examined literature highlights a pervasive and potentially hazardous practice: self-medication among college students is concerningly common in different countries. A high prevalence of 81.1% in Nigeria, 70% in Ghana, 70% in Ethiopia, and 61.1% of self-medication was reported in Zambia ( Esan et al., 2018 ; Donkor et al., 2012 ; Hailemichael et al., 2016 ; Banda et al., 2021 ). This research demonstrates the scope of this problem in the African setting. These results imply that among college students, self-medication is a typical coping strategy. An Ethiopian study that suggested that students view self-medication as a component of self-care supports the existing findings of the prevalence of self-medication as a coping method ( Soroush et al., 2018 ). Because of the rigorous demands of university life, especially during test periods, students may look for easy fixes for common problems like headaches, anxiety, and exhaustion. Furthermore, Khalifah et al. (2023) and Orayj et al., (2021) allude that examination periods come with attendant pressure on university students, as they can feel overwhelmed by the volume of coursework, assignments, and study materials and resort to medication misuse to study for longer hours and reduce anxiety associated with preparing for examinations. These students frequently resort to using prescription pharmaceuticals that they obtained without a legitimate prescription or over-the-counter medications in the absence of proper education and professional supervision. This assertion was corroborated by Zewdie et al., (2020) . The high rate of self-medication among college students necessitates immediate action from academic institutions and medical professionals. Risk factors for self-medication The evaluated research found some risk variables for university students who self-medicate. These studies show that students’ propensity to self-medicate is greatly influenced by high levels of academic stress, which are frequently made worse by poor study practices. Stress, anxiety, and sleep deprivation are factors described by different authors as the primary causes of student self-medication ( Simpson, 2018 ; Hashmi et al., 2022 ). Factors uncovered by this review include long wait times and queues at clinics and a lack of time to visit clinics due to academic workload ( Esan et al., 2018 ; Banda et al., 2021 ); year of study and course of study were predictors of self-medication ( Bunduki et al., 2017 ; Zelalem et al., 2020 ). Poor time management as a concern for students was alluded to by Adom et al. (2020) , who stated that procrastination and poor time management were predictors of academic stress for students. The consequences are obvious: students who are under much stress and don’t have good coping skills are more prone to turn to self-medication, especially as the students described self-medication as a time-saving measure rather than visiting health facilities to seek medical care for their ailments ( Ikwara et al., 2024 ; Bunduki et al., 2017 ). This behaviour is frequently an ill-advised self-care attempt to control or lessen the psychological and physical effects of their academic obligations as students. Academic workload and academic stress, therefore, are precursors to the irrational use of medications, described as self-medication in this context. A major risk factor of time-saving described by participants in different studies by Ikwara et al. (2024) , Banda et al. (2021) , and Bunduki et al. (2017) underscores the overwhelming burden of academic stress and workload. The need for effective time-management strategies through the development of healthy study habits was opined by Ogbodu et al. (2024) and Sikhwari et al. (2019) in a Nigerian and South African study, respectively, where university students described academic stress as one of the factors implicated in self-medication. According to Zelalem et al. (2020) and Donkor et al. (2012) , study findings from Ethiopia and Ghana revealed that non-medical and health science students were found to indulge more in self-medication practices, most probably due to low awareness of the dangers and consequences of self-medication. Another interesting factor revealed by this review is the year of study and adolescent age of less than 20 years as described by authors in different sub-Saharan countries of Ethiopia and the Democratic Republic of Congo ( Zelalem et al., 2020 ; Bunduki et al., 2017 ; Hailemichael et al., 2016 ). This finding is further underscored by Ogbodu et al. (2024) , who posit that most university students as undergraduates belong to the adolescent age bracket, where adolescents are more prone to experimentation and risk-taking. Interventions to reduce self-medication Several interventions suggested to reduce self-medication included health awareness campaigns on university campuses and providing counselling and support services in response to the study’s identification of measures to address the growing problem of self-medication among college students. According to the review, health education initiatives such as organising campaigns on the rational use of drugs by students as a coping mechanism for academic stress can be extremely important in increasing public knowledge of the dangers of self-medication, as suggested by ( Ikwara et al., 2024 ; Obi et al., 2023 ; Fentesa et al., 2021). This was corroborated by Okyay and Erdoğan (2017) as a recommendation for a study that assessed the habits related to drug use among Turkish students; even in a non-sub-Saharan African region, the authors found that the awareness of rational drug use among university students was inadequate. Additionally, some authors opined that the provision of counselling services by the college and university authorities would go a long way to aid the self-care choices of destressing by students ( Fetensa et al., 2021 ). The de-stressing choices recommended other than self-medication include engagement in a healthy lifestyle, such as exercise and support services ( Simpson, 2018 ). Corroboratively, Ogbodu et al. (2024) and Sikhwari et al. (2019) stated that cultivating effective study habits and self-discipline by students aids in coping with academic stress whilst reducing the resort to self-medication as a coping, self-care measure. Oriogu et al. (2017) , in a study conducted at Afe Babalola University, Nigeria, underscored the significance of cultivating a reading culture and offering academic assistance services to improve students’ academic performance. Healthy habits such as reading for leisure and pleasure have contributed to relieving academic stress and resulted in academic achievement for students ( Hilton et al., 2010 ), while Kasyoka (2023) found a correlation between study habits and academic achievement. A previous study by Fareo (2012) also suggests that good study habits can be strengthened without the use of medications to keep students artificially awake if they combine healthy study habits with enough time for relaxation The author also recommended that Drug Awareness Units be established to assist students in resolving the socio-psychological issues related to self-medication. In addition to improving academic performance, students can lessen their likelihood of self-medication by providing support services and encouraging good reading habits. As a result, we advise using a multifaceted approach to combating university students’ self-medication. Universities are in a position to encourage good reading habits among students and lessen reliance on self-medication by integrating health education, stress management, reading skills programs, counselling services, mindfulness programs, and academic support services. The findings highlight the urgent need for thorough health education curricula designed specifically for college students. To effectively address the peculiar challenges which students face, these programs must incorporate training on stress management, mental health awareness, and good coping methods. Universities also, need to prioritise offering easily available counselling services and aggressively encourage a help-seeking culture. Promoting the use of these materials among students can help to create a welcoming learning atmosphere. To counteract self-medication for academic purposes, for instance, Ogbodu et al.’s study from 2023 emphasised the significance of developing productive study habits and putting regular public health campaigns into action. The study also emphasised how important social support is for reinforcing students’ positive behavioural changes. Peer networks and mentoring programs are examples of social support systems that can be quite helpful in assisting students in navigating the demands of their studies and their health. Similarly, Hailemichael et al., 2016 ) suggest that increasing students’ awareness and knowledge of the possible risks associated with self-medication practices is one way to reduce or eliminate self-medication among students. This suggests that the university administration should offer support systems for university students. Universities ought to think about including health literacy in the curriculum in addition to counselling and health education. Through this combination, students can gain a deeper understanding of health-related concerns as well as the long-term effects of self-medication. Universities can influence and enable students to make better decisions and lessen their dependence on self-medication by creating an atmosphere that values and encourages health literacy. Given this, Fareo (2012) supports developing drug education programs and their integration into all educational levels. Adom et al. (2020) , in a Ghanaian study, recommended that the organs of government, such as the Ministry of Education and the regulatory bodies of higher institutions in Ghana, ensure the setting of guidance and counselling units as well as task welfare committees to periodically organise workshops and seminars to sensitise the members of the higher institutions on the dangers of academic stress and effective approaches in curtailing them. A study by Sikhwari et al., (2019) conducted in South Africa specifically called for intentional campaigns and programs to accommodate students in their first year of study on campus, another indicator of the high propensity to take risks during adolescent years. This South African study further described personal motivation, self-discipline, study habits, and self-efficacy as factors influencing students’ academic achievement, a justification of the importance of self-efficacy as a component of human behaviour theory to guide behaviour change and health promotion interventions. Enhancing health literacy and offering strong support services are crucial elements of a holistic strategy to tackle self-medication among college students. Universities may establish a safe space that supports good health habits and academic achievement by implementing focused health education programs, enhancing counselling services, and encouraging a help-seeking culture. Role of policy making to support reduced medication misuse among university students The critical role that policymakers have to play in formulating and implementing policies that promote the rational distribution of drugs in different countries of the world has been expounded by several studies ( Fetensa et al., 2021 ; Bunduki et al., 2017 ; Hailemichael et al., 2016 ). These authors concisely described policymakers’ roles in supporting and promoting the reduction of self-medication practices. The enactment of policies to promote safe and responsible healthcare behaviours among students was specifically proposed by Fetensa et al. (2021) , Bunduki et al. (2017) , and Donkor et al. (2012) opined that healthcare policymakers should provide a strict policy on selling without prescription medicine, to act as a deterrent to defaulters and policymakers have a crucial role of providing strategic guidance on drug distribution and availability in countries, respectively. Interpretation and analysis through a social cognitive theory lens The study findings highlight the widespread issue of self-medication among university students, revealing the influence of observational learning, self-efficacy, and environmental factors on this behaviour. The Social Cognitive Theory has been used to guide behaviour change and health promotion interventions hence its suitability for this study. Observational learning The high prevalence of self-medication suggests that students may be observing and imitating the behaviour of their peers who self-medicate to cope with stress and academic pressure. Normalising this practice within the student community can create a social environment where self-medication is acceptable. Furthermore, identifying stress and poor reading habits as significant risk factors highlights the impact of the academic environment on students’ behaviours. Observing others struggle with stress and resorting to self-medication can reinforce this coping mechanism as a viable option, emphasising the observational learning construct which stresses that if individuals see a successful demonstration of a behaviour, they can also complete the behaviour. Self-efficacy The negative association between poor reading habits and self-medication suggests that students with lower self-efficacy in their academic abilities may be more likely to self-medicate to manage the resulting stress and anxiety. The success of reading skills programmes in reducing self-medication demonstrates the positive impact of improving students’ self-efficacy. By enhancing their academic skills and confidence, students may be less likely to turn to self-medication as a coping mechanism. This reinforces a person’s confidence in his or her ability to successfully perform a behaviour. Environmental factors The high levels of academic stress experienced by students underscore the role of the environment in influencing self-medication behaviour. The lack of adequate support services and stress management programmes can contribute to an environment where self-medication is considered a necessary coping mechanism. The effectiveness of health education programmes, counselling services, and mindfulness programmes suggests that modifying the environment can promote healthier coping mechanisms and reduce dependency on self-medication. Therefore, universities should create an environment that fosters positive health behaviours by providing students with the necessary skills and support. A key environmental factor is policy-making which shapes the context of the distribution and availability of medications, stipulating the indications for rational drug use and the sale of prescription medications only on the production of a valid prescription by a qualified medical practitioner. This will reduce the ease of access and availability of drugs without prescription as such availability impacts self-medication and abuse. Policy implications for Universities in Africa The study’s findings emphasise a number of crucial policy implications for African institutions and highlight the necessity of focused initiatives to address the pervasive problem of student self-medication. First and foremost, academic institutions ought to establish all-encompassing health education initiatives that augment students’ health literacy. These programs ought to be specifically designed with university students’ needs in mind and should include workshops on mental health awareness, stress management, and healthy coping techniques. Universities have the propensity and backing by constitution to drastically lower the prevalence of self-medication by providing students with the information, structures and abilities they need to make wise health decisions. In addition, it is critical to build easily accessible and widely advertised counselling services. In order to ensure that students are aware of and have easy access to mental health and counselling options, universities should foster a culture of asking for help. To help kids deal with stress related to school and other issues that may cause them to turn to self-medication, these services ought to provide them with individualised support and direction. Universities should include health literacy in their curricula as well. Students will gain a broader awareness of health-related concerns and the long-term effects of self-medication as a result of this integration. University programs that incorporate health education can foster a positive atmosphere that promotes healthy habits and lessens the need for self-medication. The necessity of regular public health campaigns that address self-medication and encourage healthy reading habits is another crucial policy conclusion. All students should be the target audience for these initiatives, which should educate them about the dangers of self-medication and offer helpful coping mechanisms for the stress of school. In conclusion, it is imperative to reinforce social support networks through regular public health campaigns, create platforms to educate and counsel students on embracing healthy lifestyles and offer mentorship initiatives. These networks of support can be extremely helpful to students in overcoming both health and academic obstacles. Universities can increase student resilience and reduce self-medication risk by creating a supportive community. From a social cognitive theoretical lens, universities should promote positive role models by highlighting and promoting students who successfully manage stress and academic pressures without self-medication. These positive role models can inspire and encourage other students to adopt healthier coping mechanisms. In addition, implementing programmes that improve academic skills, such as reading skills programmes, can enhance students’ self-efficacy and reduce their reliance on self-medication to manage academic stress. Likewise, universities should prioritise creating a supportive environment that addresses the root causes of stress and promotes healthy coping mechanisms. This can include providing easily accessible counselling services, stress management programmes, and health education initiatives. In the same vein, the University should foster a Culture of Help-Seeking: By actively promoting support services and creating a culture where seeking help is encouraged, universities can empower students to address their challenges healthily and constructively. Conclusions This study emphasises a strong link between university students’ decreased self-medication during the academic semester and exams as a self-care choice and their healthy reading habits in achieving academic success. The results underline the protective significance of excellent reading habits by showing that students who regularly and successfully practice reading and have an organised reading schedule are less prone to abuse drugs. Educational institutions can enhance academic performance and encourage healthier habits among students by cultivating these behaviours. The study assesses programs that successfully lower self-medication and successful tactics to encourage self-care practices such as good reading habits. These programs and interventions showed promise in reducing the risk factors related to medicine abuse and assisting pupils in forming long-term reading habits. Generally speaking, encouraging good study habits as a self-care practice and raising awareness about the dangers of self-medication on university campuses show promise as a strategy to enhance both academic performance and health outcomes among college students. Study limitations The study is limited to articles written in English; therefore, some relevant studies might have been omitted due to the language barrier. Suggestions for future research Future research should continue to explore the mechanisms underlying this relationship and investigate the long-term benefits of reading skills programmes and effective study habits in improving academic performance in university students. Data availability statement Underlying data No data are associated with this article. Extended data Figshare: Promoting Healthy Reading Strategies as a Self-Care Alternative to Self-Medication among University Students in Sub-Saharan Africa: A Systematic Review, DOI: https://doi.org/10.6084/m9.figshare.27292476.v3 ( Adekola & Ogbodu, 2024 ). The project contains the following extended data: • Table 2: Profile of selected articles • Table 3: Emerging themes from analysis of selected articles Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). Reporting guidelines Figshare: PRISMA checklist for ‘Promoting Healthy Reading Strategies as a Self-Care Alternative to Self-Medication among University Students in Sub-Saharan Africa: A Systematic Review’. DOI: https://doi.org/10.6084/m9.figshare.27292476.v3 ( Adekola & Ogbodu, 2024 ). The project contains the following reporting guidelines: • PRISMA_2020_checklist ogbodu et al.docx • Extended data_F1000research.docx (Flow chart) Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). Acknowledgements None. References Abid N, Aslam S, Alghamdi A, et al. : Relationships among students’ reading habits, study skills, and academic achievement in English at the secondary level. Front. Psychol. 2023; 14 . PubMed Abstract | Publisher Full Text | Free Full Text Adekola AP, Ogbodu OM: Extended data_F1000research.docx. Dataset. figshare. 2024. 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PubMed Abstract | Publisher Full Text | Free Full Text Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 07 Nov 2024 ADD YOUR COMMENT Comment Author details Author details 1 Department of Anaesthesiology and Critical Care, Walter Sisulu University, Mthatha, Eastern Cape, 5099, South Africa 2 Department of Gender and Sexuality Studies, University of South Africa, Pretoria, Gauteng, 0003, South Africa Olubunmi Margaret Ogbodu Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Project Administration, Resources, Writing – Original Draft Preparation Ayobami Precious Adekola Roles: Data Curation, Formal Analysis, Methodology, Project Administration, Validation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (1) version 1 Published: 07 Nov 2024, 13:1332 https://doi.org/10.12688/f1000research.158366.1 Copyright © 2024 Ogbodu OM and Adekola AP. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Ogbodu OM and Adekola AP. Promoting Healthy Reading Strategies as a Self-Care Alternative to Self-Medication among University Students in Sub-Saharan Africa: A Systematic Review [version 1; peer review: 1 approved with reservations] . F1000Research 2024, 13 :1332 ( https://doi.org/10.12688/f1000research.158366.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 07 Nov 2024 Views 0 Cite How to cite this report: Javaid ZK. Reviewer Report For: Promoting Healthy Reading Strategies as a Self-Care Alternative to Self-Medication among University Students in Sub-Saharan Africa: A Systematic Review [version 1; peer review: 1 approved with reservations] . F1000Research 2024, 13 :1332 ( https://doi.org/10.5256/f1000research.173942.r384380 ) The direct URL for this report is: https://f1000research.com/articles/13-1332/v1#referee-response-384380 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 26 Dec 2025 Zartashia Kynat Javaid , Government College University Faisalabad, Faisalabad, Punjab, Pakistan Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.173942.r384380 This study is a good way to work on alternatives to medication through reading. There are some suggestions for improvement. Study should add recent literature search as there is no literature from 2025. Compare studies of Africa to other regions. ... Continue reading READ ALL This study is a good way to work on alternatives to medication through reading. There are some suggestions for improvement. Study should add recent literature search as there is no literature from 2025. Compare studies of Africa to other regions. Clearly state research questions and link in discussion as well. Findings need expansion. Are the rationale for, and objectives of, the Systematic Review clearly stated? Yes Are sufficient details of the methods and analysis provided to allow replication by others? Yes Is the statistical analysis and its interpretation appropriate? Not applicable Are the conclusions drawn adequately supported by the results presented in the review? Partly If this is a Living Systematic Review, is the ‘living’ method appropriate and is the search schedule clearly defined and justified? (‘Living Systematic Review’ or a variation of this term should be included in the title.) Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Psychology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Javaid ZK. Reviewer Report For: Promoting Healthy Reading Strategies as a Self-Care Alternative to Self-Medication among University Students in Sub-Saharan Africa: A Systematic Review [version 1; peer review: 1 approved with reservations] . F1000Research 2024, 13 :1332 ( https://doi.org/10.5256/f1000research.173942.r384380 ) The direct URL for this report is: https://f1000research.com/articles/13-1332/v1#referee-response-384380 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 07 Nov 2024 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 Version 1 07 Nov 24 read Zartashia Kynat Javaid , Government College University Faisalabad, Faisalabad, Pakistan Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Javaid Z. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 26 Dec 2025 | for Version 1 Zartashia Kynat Javaid , Government College University Faisalabad, Faisalabad, Punjab, Pakistan 0 Views copyright © 2025 Javaid Z. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This study is a good way to work on alternatives to medication through reading. There are some suggestions for improvement. Study should add recent literature search as there is no literature from 2025. Compare studies of Africa to other regions. Clearly state research questions and link in discussion as well. Findings need expansion. Are the rationale for, and objectives of, the Systematic Review clearly stated? Yes Are sufficient details of the methods and analysis provided to allow replication by others? Yes Is the statistical analysis and its interpretation appropriate? Not applicable Are the conclusions drawn adequately supported by the results presented in the review? Partly If this is a Living Systematic Review, is the ‘living’ method appropriate and is the search schedule clearly defined and justified? (‘Living Systematic Review’ or a variation of this term should be included in the title.) Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Psychology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Javaid ZK. Peer Review Report For: Promoting Healthy Reading Strategies as a Self-Care Alternative to Self-Medication among University Students in Sub-Saharan Africa: A Systematic Review [version 1; peer review: 1 approved with reservations] . F1000Research 2024, 13 :1332 ( https://doi.org/10.5256/f1000research.173942.r384380) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-1332/v1#referee-response-384380 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions Adjust parameters to alter display View on desktop for interactive features Includes Interactive Elements View on desktop for interactive features Competing Interests Policy Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. 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