An integrative review of the prevalence, patterns and predictors of self-medication in Ghana

Abstract

Within healthcare literature, evidence-based practice, which is born out of research (particularly reviews and critical appraisals) is increasingly becoming important. This has birthed new research into the synthesis of existing knowledge on different health issues. Having acknowledged the importance of evidence synthesis in evidence-based practice, this study was conceived to critically synthesize literature on the prevalence, patterns, and the determinants of self-medication among different segments of the Ghanaian population. The integrative review methodology was employed as the study's methodological foundation. Evidence was synthesized from the twelve articles that met the inclusion and exclusion criteria. High incidence of self-medication was identified among various segments of the Ghanaian population (pregnant women, persons diagnosed with HIV/AIDS, older people and students among other groups). Furthermore, various factors that influenced self-medication (demography, self-rated health, and cost of healthcare, in addition to health system factors) were identified, and these reflect those espoused by the theories underlying the study (the Theory of Planned Behaviour and the Health Belief Model). The study, therefore, has implications for policy on self-medication and the general delivery of healthcare in Ghana. Amongother things, the study recommends that the Ministry of Health and the Ghana Health Service, in collaboration with other related agencies and departments step up education and awareness programmes on the effects of self-medication. Additionally, there should be strict enforcement of regulations on the sale of drugs in open markets, chemical shops and pharmacies.

Keywords:

• drugs
• health
• health behaviour
• predictors
• self-medication

PUBLIC INTEREST STATEMENT

Self-medication is a widespread practice that may contribute to the antibiotic resistance of human pathogens. The negative effects of such health behaviour should always be highlighted to the community, along with actions to curb them. Without medical supervision, widespread irrational use of drugs or medicines can raise the risk of improper, inaccurate, or excessive medication, missed diagnoses, delays in seeking treatment, pathogen resistance, and increased morbidity. This review focused on the prevalence and influencing factors of non-prescription drug use among Ghanaians. Demographic, self-rated health, cost of healthcare services, and inefficiencies in the delivery of healthcare were found to be predictors of self-medication among Ghanaians. To encourage prudent and safe self-medication practices, it is necessary to increase awareness on safe self-care and self-medication practices, while legislations are and passed to regulate the sale of drugs on the open market. A better understanding of self-medication may lead to reasonable use, which would curb microbial resistance problems.

1. Introduction

Although it has been part of human existence, self-care, a practice that primarily denote discretionary actions taken by individuals to sustain and maintain their health, prevent and treat diseases is increasing in recent times. It denotes a wide-range concept encompassing lifestyle choices, hygiene, self-medication, socioeconomic influences and others (Galato et al., 2009; James et al., 2006). Self-medication is an indispensable component of every health care system. It is also a vital form of self-care, and its practice is widespread (Vidyavati et al., 2016). Self-medication comprises obtaining medications without instruction, resubmitting previous prescriptions to buy medications, sharing drugs with relatives or members in one’s social group or using excess medicines stored at home. “Self-medication drugs” are mainly termed “non-prescription medications or over-the-counter (OTC) drugs.” These medicines can be obtained from pharmacies and are also available in “supermarkets or convenience stores” in a lot of countries (Morgan et al., 2022; Gutema et al., 2011; Loyola Filho et al., 2004). For governmental institutions and agencies, this can lessen costs while affording health professionals the luxury to focus on more precarious health problems (Galato et al., 2009), when people treat themselves with self-prescribed drugs. While well-administered self-medication could be effective in treating various health conditions, ”irrational” self-medication could lead to abuse and other health complications.

Some common drugs used for self-medication include; analgesics, antipyretics, antacids, antidiarrheal, skin ointments, antibiotics, vitamins, blood tonics etc. Factors predicting the practice of self-medication in earlier studies include age, educational attainment, family attitudes, legislation, drug advertisements, drugs accessibility, past experiences with the signs of a disease, and the importance ascribed to the disease (James et al., 2006; Pan et al., 2012), availability of home-kept prescription drugs (Klemenc-Ketis & Kersnik, 2010) and financial strength or capacity of individuals. Depression and anxiety could likewise be linked with the practice of self-medication (Hofmeister et al., 2010). Significant problems connected with self-medication are waste of resources, a higher adaptation of pathogens, “drug-resistance” and adverse health effects, for example, a severe reaction and protracted suffering (Mekonnen et al., 2018). Self-medication increases the likelihood of drug abuse (Pan et al., 2012) and drug dependence. It similarly masks the symptoms and signs of underlying diseases, thereby confounding the issue, producing drug resistance, and procrastinating diagnosis (Hofmeister et al., 2010; Klemenc-Ketis & Kersnik, 2010). Globally, the extent of use is alarming; up to 68% in European countries, while much higher in the developing countries with rates going as high as 92% in the adolescents of Kuwait, 59% in Nepal and 31% in India. In the majority of economically deprived countries, nearly 60–80% of health-related problems are treated through self-medication as a lower-cost alternative (Zafar et al., 2008).

Studies within some countries of which Ghana is part pictures a high prevalence of self-medication and unjustifiable medicine intake, where the prevalence in Ethiopia, Nigeria, and Nepal have been respectively reported to be 43.2%, 73% and 59% (Asiedu et al., 2016; Bamgboye et al., 2006; Donkor et al., 2012; Oppong, 2019; Sarahroodi & Mikaili, 2012; Shankar et al., 2003; Yadav & Rawal, 2015). The prevalence is projected to be three times higher than the global rate in Ghana, where 70% of the population is reported use medicines on their volition (Donkor et al., 2012), with this concurring the finding in Iran where up to 83% of the population is estimated to practice self-medication (Heidarnia, 2011; Sarahroodi & Mikaili, 2012). Among all groups, the elderly tend to use higher amounts of non-prescribed medicine (Sarahroodi & Mikaili, 2012), because they suffer more from illnesses and a wide collection of psychological distress, chronic conditions and multimorbidities (Banerjee, 2015; Gyasi et al., 2019; McCracken & Phillips, 2017) which possibly increases their demand for healthcare. And these older people in developing countries are often victims of poverty (Gyasi et al., 2019; Samsudin & Abdullah, 2017), leading to varying utilisation of healthcare services (Adeoye, 2015).

In Ghana, self-medication is the easiest and most widespread means through which individuals deal with diseases such that one in every two Ghanaian self-medicates during periods of ill health. Conservatively, pregnancy is not regarded as a condition of ill health or disease, nevertheless, it persists as a threat to health (Marwa et al., 2018; Shulman et al., 2018), influencing and predisposing individuals to self-medicate. There are countless physiological and medical challenges concomitant with pregnancy, making drug usage almost unavoidable during pregnancy. In Ghana, studies on self-medication are growing, owing to the increasing attention to the issue. Some of these explored self-medication among students (Asiedu et al., 2016; Donkor et al., 2012; Oppong, 2019), self-medication practice in a rural setting (Mensah et al., 2019), and self-medication for the treatment of HIV/AIDS (Laar et al., 2017). These studies are scattered and do not auger well with evidence-based practice. In evidence-based practice, synthesising evidence from various studies on a particular issue is important to better understand, and identify strategies to address the emerging challenges. While primary evidence on self-medication abounds, there is no synthesis of the literature on self-medication practices among various segments of the Ghanaian population. Due to the importance of such reviews, this study relied on the integrative review approach and examined the prevalence of self-medication and the factors that are associated with the health behaviour among various segments of Ghana’s population. The evidence from the study could assist health actors and authorities, like the Ghana Health Service (GHS), Ministry of Health (MoH) and other stakeholders to know the factors precipitating the practice of self-medication, and focus on some policy recommendations that can curtail or control the “indiscriminate practice of self-medication”.

2. Theoretical framework

The Health Belief Model (HBM) and the Theory of Planned Behaviour (TPB) underpinned the study.

2.1. The Health Belief Model (HBM)

The Health Belief Model (HBM) was propounded in the 1950s to explain the reason for people’s behaviour towards the detection and prevention of diseases or health complications (Hochbaum, 1958; Rosenstock, 1960). Embedded in the HBM are many factors that determine why people will put in measures to control, screen and prevent ill conditions. These are susceptibility, seriousness, perceived benefits, perceived barriers, self-efficacy (Glanz et al., 2008). Healthy behaviour according to the theory connotes actions taken by persons who perceive their health to be in good condition whereas illness behaviour denotes actions taken by persons who perceive their health to be in a bad condition (Rosenstock, 1974). Perceived susceptibility, one of the dimensions of the theory, is concerned with the belief about the possibility of contracting a disease (Conner, 2010). For instance, if an individual believes he can contract an illness, that individual will be interested in engaging in a health behaviour say, self-medicate or go to the hospital than an individual with lower perceived susceptibility. Perceived seriousness explains the severity or consequences of not treating a health condition (Janz & Becker, 1984).

The other dimensions of the theory include perceived benefits which lead to increased performance or motivation for undertaking the desirable health behaviour which in this case is self-medication (Glanz et al., 2008; Rosenstock, 1974); and perceived barriers that can prevent an individual from engaging in that health behaviour despite the demand (Janz & Becker, 1984). These barriers include cost, perceived inconvenience and fear of side effects from a medical procedure (Rosenstock, 1974). Cues to action, another dimension of the theory centres on the individual’s preparedness to take action (Rosenstock, 1974). The HBM was modified to include self-efficacy (Rosenstock et al., 1988), which implies an individual’s mindset to successfully perform the behaviour. Originally, the model was created to explain one-time health-related behaviour but has been modified to a more substantial, long-term behaviour change (Rosenstock et al., 1988). Since this theory captures an array of factors that influence the decision of individuals to undertake or perform a health activity or behaviour, the theory is considered appropriate in examining the factors that contribute to self-medication among various segments of Ghana’s population. The applicability of the theory in this study was also contingent on its suitability in determining factors influencing health behaviour among certain clusters of the population studied by these scholars (Henshaw & Freedman‐Doan, 2009; Leavitt, 1979).

2.2. Theory of Planned Behaviour (TPB)

The Theory of Planned Behaviour (TPB) was propounded by sociologist Icek Ajzen in 1985 through his article “From intentions to action: A theory of planned behaviour.” This theory has been used extensively to understand and appreciate the healthy behaviour of people (Conner, 2010; Conner et al., 2002). It is thus one of the highly utilized health behaviour theories (HBT). According to the TPB, the intention of behaviour is the single most important indicator of behaviour. This theory thus explain the linkages between behaviour, beliefs and intentions (Conner, 2010). The intentions to engage or exhibit a certain behaviour and the total perceived control over the behaviour are considered as the determinants of behaviour. The TPB considers intentions as motivations to undertake an activity while perceived behaviour control relates to the belief that one has control over the intended action. Thus, by employing the TPB in this study, it is hypothesized that the probability of an individual with an underlying or a predisposing health condition to practice self-medication on the perceived outcome of improvement in health status determines self-medication practices. However, the TPB has limited consideration for the perceived barriers to healthcare accessibility. Nonetheless, employing it alongside the HBM provides the prospect for the two theories to harmonize their strength and weaknesses.

3. Methodology

3.1. Search strategy

To accomplish the objectives of the study, the study relied only on secondary materials that were published on self-medication in Ghana. The choice of this approach stems from the extended review method that the study adopted. By this evidence was extracted from existing literature on the practice of self-medication in Ghana. The search strategy, therefore, represented the process employed to retrieve the materials from the different bibliographic databases. The amalgamation of diverse key terms produced results that included studies from a multiplicity of disciplines, for instance, health and social sciences. These articles represented different issues from prevalence and patterns of self-medication, associated factors and the effects of self-medication, among others. The initial electronic literature search involved electronic searches of popular academic databases between October and November 2020. The academic databases include CINAHL, Cochrane Library, EMBASE, Ingenta, Proquest, Medline/PubMed, SAGE and Scopus. These databases were searched for published peer-reviewed research. However, due to the ever-changing content and undependability of sources of articles from Google Scholar, the academic database was consequently let off from the list of selected bibliographic databases from which articles were searched (Giustini & Boulos, 2013). Beyond the electronic search, the use of hand searches and snowballing sampling which comprised a search through the reference lists of some downloaded materials was done to identify other materials that were missed during the electronic database search. Employing the hand search approach provided complimentary and relevant literature alongside some keywords for further search. Using a hand searching or snowballing approach to retrieve additional articles enhanced access to published and unpublished materials on any subject matter of interest (Hawker et al., 2002). Additionally, the use of search engines like Google, Bing, the Kwame Nkrumah University of Science and Technology (KNUST) Library Databases, and other methods including looking at websites of agencies related to the research topic or conducting manual searches were employed to find additional grey literature. Table 1 presents the key search terms with Boolean Operators used to retrieve the articles from the relevant databases.

Table 1. Key Search Terms with Boolean Operators

Keywords	“Self-medication” “Non-prescription drugs” OR “Over-the- counter (OTC) drugs” OR “Self-medication and self-treatments” OR “Self-care” OR “Prevalence” OR “Determinants” AND “its effects.” AND OR “Ghana”
	“Non-prescription Drugs” OR “Determinants” OR “Predictors” And “Effects” AND “Ghana”
	“Self-medication” OR “Incidence” AND “its impacts.”
Advanced Search Terms	“Self-medication with non-prescription Drugs” OR “Associated factors” AND “Older adults.” OR “Ghana”
	“Self-medication” OR “Determinants” AND “Effects” AND “Ghana”
	“Non-prescription Drugs” OR “Associated factors” AND “impacts.” AND “Ghana”

3.2. Results and refinement of the search

The preliminary search of the databases produced one hundred and fifty-five articles in total. Fifty-one studies were discarded from the downloaded or searched items as they were duplicate articles. By operationalizing the “snowballing and hand search” techniques (to retrieve studies from reference lists of some of the retrieved papers), fourteen supplementary articles of much relevance were retrieved, thus bringing the total number of articles to one hundred and eighteen. Out of this, an aggregate of eighty-four articles was omitted after sifting for title relevance, country context and year of publication of the articles. The remaining thirty-two articles were initially included for review. The abstracts and introductions, in addition to the full texts of these remaining articles, in some cases, were subsequently read, and an additional twenty-two articles were expunged. The excluded articles were either comprised of systematic or literature reviews or had insufficient details on self-medication and its associated factors among different segments of the Ghanaians population. Thus, the final number of papers contained within the review from the databases searched was twelve studies. Additional details of the downloaded articles are presented in Figure 1.

Figure 1. Flow diagram of the integrative review.

Source: Adapted from PRISMA, 2009 and Andrew et al. (2015)

3.3. Article selection

Altogether full-length articles, editorials, reviews, original articles, and short communications that have been published in the English language dealing with self-medication among different segments of the Ghanaian population were reviewed and those that met the inclusion criteria were included. Self-medication was conceptualized as obtaining and consuming drugs without the advice of a physician to treat a self-recognized illnesses or symptoms (World Health Organization. [WHO], 2014; WHO, 1998). All studies published between 2000 and 2020 were included in the review, whereas studies spanning periods before the year 2000 were excluded. The justification for this year range stems from the viewpoint of Bollu et al. (2014) that, the issue of self-medication has risen to prominence since the turn of the millennia. Studies that focused on self-medication but are outside the jurisdiction of Ghana were excluded from the review articles.

3.4. Data abstraction

The data abstraction process was done by the authors in conjunction with two other researchers (with extensive knowledge, and experience in qualitative studies, and extended literature reviews of various kinds) who helped to appraise the methodological rigour and the quality of evidence in the twelve selected articles. The authors together with the other independent appraisers screened the twelve selected articles in line with the inclusion and exclusion criteria. The focus was on the country where the work was conducted (in this instance, the emphasis was on Ghana), the sampled population, the year of publication and data with regard to the study objectives (prevalence and determinants of self-medication).

3.5. Assessment of methodological quality

To evaluate the literature, the three article appraisal procedures recommended by Boyle (1998) was adopted to that effect. The guide by Boyle relates to sampling procedures, measurement of variables and data analysis framework (Boyle, 1998). The twelve studies were appraised in the light of the probability of the adopted survey design to produce representative samples after a clear delineation of the population of interest. With regards to the measurement, the emphasis was on the probability of the survey instruments to produce dependable and valid measures of the variables and constructs. Relating to the data analysis, the attention was on the features of the sampling design and confidence interval. All twelve articles passed or qualified in all three categories. The appraisal results of the individual appraisers were discussed, and the final appraisal confirmed. Differences in results were resolved through discussion. The thematic analysis approach was adopted to synthesize and extract data from the selected articles. The thematic analysis comprised noting patterns and themes, identifying plausibleness, crowding, totalling, making associations and contrasts, discerning shared and uncommon trends, subsuming details into general, noting relations between variability, finding intervening factors and creating a logical chain of evidence (Hopia et al., 2016; Whittemore & Knafl, 2005). The thematic data analysis approach enabled for the reflection of agreement or discrepancy across the literature concerning the issue under investigation and reconnoitred which issues caused or fashioned the observed conclusions (Braun & Clarke, 2006; Denscombe, 2017; Russel & Ryan, 2003).

4. Results

Twelve articles were included in the study after they passed the inclusion criteria. These articles were published over the periods between 2012 and 2020. The studies were conducted among different segments of the Ghanaian population and cuts across different regions and districts within the country as well. The prominent groups of people among which the studies of self-medication were conducted included pregnant women, students (tertiary students only) and other clusters of the Ghanaian population, including rural folks. Following the operationalisation of the analytical framework, the following themes were identified in the selected articles. Prevalence and patterns of self-medication; and factors influencing self-medication were the identified themes. In the subsequent sessions, a detailed discussion of these themes are presented.

4.1. Prevalence and patterns of self-medication

The papers largely reported on the prevalence of self-medication among the various population segments they studied. From the results, different prevalence rates of self-medication were reported by the articles reviewed. In separate studies conducted among pregnant women, Gbagbo and Nkrumah (2020), Nkrumah and Gbagbo (2019), and Adama (2017) reported prevalence rates of 69%, 69% and 74.1% respectively. The study of Nkrumah and Gbagbo (2019) was conducted among pregnant women aged between 15 years and 46 years and above (with 1.5% of the respondents falling within the age range of 46 and above) within the Effutu and Agona West Municipalities, located in the Central Region of Ghana. The study of Adama (2017), on the contrary, was conducted in the Wa Municipality of the Upper West Region, among pregnant women aged between 18 years and 45 years. Although the study of Nkrumah and Gbagbo reported a high prevalence of self-medication, 88% of the participants frequently attend or visit antenatal clinics while the study of Adama did not report on this variable.

Studies that explored the perceptions and prevalence of self-medication practices among students (tertiary students) also reported varied prevalence of the health behaviour. Asiedu et al. (2016), Donkor et al. (2012), Gbadago (2017), and Oppong (2019)found prevalence rates of self-medication among tertiary students to be 25.2%, 70%, 48% and 94.2% respectively. While the study of Asiedu et al. was conducted among undergraduate students in the University of Cape Coast, the study of Donkor et al. was conducted among students from the Accra Polytechnic (now Accra Technical University), Central University, Korle-Bu Medical campus and the Methodist University College, Ghana. Oppong (2019) conducted his study among the School of Medicine and Dentistry students in Korle Bu, whereas Gbadago (2017) conducted his study among undergraduate students at the University of Ghana. While largely the studies reported a high prevalence of self-medication, Oppong (2019) reported the highest incidence of 94.2%.

Mensah et al. (2019) reported a self-medication rate of 73.2% among rural residents in Akuse, while in Accra, Agblevor (2016) in a qualitative study on self-medication practices among households reported high indulgence in self-medication among the respondents (which cuts across different socio-economic classes). Among adults living with HIV/AIDS within the Bolgatanga Municipality of Ghana’s Upper East Region, Saffoh (2019) found the prevalence of self-medication to be 38.8% among the respondents. A similar result was reported in a study by Laar et al. (2017), where one out of three respondents (out of a sample of 540 respondents) used non-prescription drugs every three months. They (Laar et al., 2017) further asserted that these non-prescription drugs were mainly locally made, and comprised concoctions from Christian prayer centres. They, however, concomitantly use the non-prescription drugs with antiretroviral medications (ARVs). In another qualitative study on self-medication and access to healthcare in Ghana, Bonti (2017)found that self-medication in Ghana is prevalent (specifically within the Greater Accra and the Ashanti regions). In all, the studies reported a high prevalence of self-medication across different segments of the Ghanaian population. The highest incidence was, however, recorded among students from health institutions (precisely school of medicine and dentistry students in Korle Bu) by Oppong (2019). An occurrence the author attributed to high awareness of self-care and medication. Additionally, we found that both traditional and orthodox medicines were used by the respondents to self-medicate.

4.2. Determinants or predictors of self-medication

From the articles reviewed, some factors were categorised as the determinants of self-medication. These factors include demography (predisposing), self-rated health (need factors), cost (enabling factors) and health system factors. These factors act in synergy or in isolation to influence the decision of the respondents in each case to practice self-medication. A detailed account of the determinants of self-medication is presented in the next paragraphs.

4.2.1. Demography or predisposing factors

Among pregnant women, Gbagbo and Nkrumah (2020) found that education and religion were determinants of self-medication. The highly educated pregnant women were more likely to self-medicate due to the supposed awareness of certain medications and access to the internet, where they surfed and searched for information. On the other hand, the pregnant women whose religious beliefs and practices encouraged them to take local herbs and concoctions were more likely to self-medicate as compared to persons whose religious beliefs and practices do not encourage the use of concoctions and herbs. Adama (2017), however, found that pregnant women with lower levels of education were more likely to self-medicate compared to those with higher education. Pregnant women who were married had a lower likelihood of engaging in self-medication than those who were single, while those cohabiting had a higher propensity to self-medicate. Both studies (Adama, 2017; Gbagbo & Nkrumah, 2020), however, found no association between age and likelihood to engage in self-medication among pregnant women.

Donkor et al. (2012) discovered in their study on self-medication practices among tertiary students in Accra that female students had a higher likelihood to self-medicate in the short term, while male students had a higher likelihood of practising self-medication over a prolonged period. That is to say in the short term, female students highly self-medicate, whereas male students do so in the long run. Asiedu et al. (2016) also reported a higher prevalence of self-medication with over the counter topical ophthalmic medication among females than males. This study was conducted among undergraduate students at Cape Coast University. The higher tendency of females to self-medicate with over the counter topical ophthalmic medication was attributed to higher gritty sensation and blurred vision among females compared to males.

Among adults living with HIV/AIDS, Saffoh (2019) discovered that older people were more likely to self-medicate as compared to younger people. Additionally, the study reported a higher prevalence of self-medication among males, people with tertiary education and non-Christians, than their respective counterparts. Saffoh (2019) further discovered a lower prevalence of self-medication among married people diagnosed with HIV/AIDS, while a higher prevalence was reported among students diagnosed with HIV/AIDS. Laar et al. (2017), however, discovered that males diagnosed with HIV/AIDS were more likely to self-medicate as compared to their female counterparts and non-Christians also have a higher propensity to self-medicate. Respondents with non-tertiary education were more likely to self-medicate while respondents in urban areas and younger were less likely to self-medicate as compared to their corresponding counterparts. Pregnant women were more likely to self-medicate than non-pregnant women, while lactating mothers were less likely to self-medicate. The studies of both Saffoh (2019) and Laar et al. (2017) reported a higher prevalence of self-medication among older people and males diagnosed with HIV/AIDS. There were, however, no disparities in the results as some demographic variables were not measured by each of the studies.

4.2.2. Self-rated health or need factors

Persons with perceived poor health status are likely to undertake health behaviour than those with good self-rated health, from the theoretical foundation of the study. Nine of the articles reviewed reported need factors as determinants of self-medication among the various population cohorts they studied. Gbagbo and Nkrumah (2020) and Nkrumah and Gbagbo (2019) in their studies on self-medication among pregnant women, identified self-care and poor health status as factors that drive the decision of pregnant women to self-medicate. By this, the tendency to rate their overall health as poor or not in good health status motivates them to self-medicate. Adama (2017) and Bonti (2017) also revealed that perceived illness and prior experience with self-medication were determinants of self-medication. Oppong (2019), in his study among the School of Medicine and Dentistry students in Korle Bu, identified perceived poor health status as a determinant of self-medication. Other studies also reported similar findings where the respondents who felt they have poor self-rated health were more likely to self-medicate (Agblevor, 2016; Gbadago, 2017; Mensah et al., 2019; Saffoh, 2019).

4.2.3. Cost and availability of medicines or enabling factors

Of all the articles reviewed, ten of them reported that lower cost of self-administered drugs as against seeking healthcare services from health facilities influenced the respondents to self-medicate (Adama, 2017; Agblevor, 2016; Bonti, 2017; Donkor et al., 2012; Gbadago, 2017; Gbagbo & Nkrumah, 2020; Mensah et al., 2019; Nkrumah & Gbagbo, 2019; Oppong, 2019; Saffoh, 2019). The articles revealed that the cost involved in purchasing drugs from chemical stores (shops), open markets and pharmaceuticals was lower as compared to the cost involved in accessing healthcare from health facilities (vis-a-vis cost of health services and associated transport cost). These costs were also reported to be higher when the participants visit health facilities without health insurance. Aside from the lower cost of drugs and medicines, easy accessibility of drugs was also a determinant of self-medication (Adama, 2017; Bonti, 2017; Gbadago, 2017; Nkrumah & Gbagbo, 2019; Saffoh, 2019). With chemical shops, pharmaceutical stores, and open markets dotted all over the country, access to drugs without prescriptions is easy. By that, it is more convenient to self-medicate with over the counter drugs than visit a health facility.

4.2.4. Health system factors

Health system factors are factors within the health system such as availability of health facilities, quality of healthcare services, and availability of essential drugs in addition to the attitude of healthcare workers. The favourability of these factors demotivate individuals from engaging in self-medication, whereas non-favourability of these health system factors motivate people to self-medicate. The unavailability of health facilities was identified as a motivator of self-medication (Adama, 2017; Nkrumah & Gbagbo, 2019; Oppong, 2019). With unavailable health facilities to service the health needs of people, they rely on self-medication to meet their medical needs. In instances where health facilities exist, long waiting time at health facilities was reported as a factor that influence their decision to self-medicate (Adama, 2017; Donkor et al., 2012; Gbagbo & Nkrumah, 2020; Mensah et al., 2019; Nkrumah & Gbagbo, 2019; Oppong, 2019; Saffoh, 2019). Additionally, unavailability of essential drugs at the health facilities and poor satisfaction with healthcare services in general influences their decision to self-medicate (Adama, 2017; Oppong, 2019; Saffoh, 2019). The unavailability of essential drugs at health facilities was largely reported by respondents who accessed health facilities under the national health insurance scheme. Linked to the overall satisfaction with care received from health facilities, the poor attitude of healthcare workers was also a determinant of self-medication among older people with HIV/AIDS and pregnant women respectively (Adama, 2017; Saffoh, 2019).

5. Discussion of results

5.1. Prevalence of self-medication

The increasing practice of self-medication has necessitated several kinds of research into the subject matter on the prevalence, causes and effects of the practice, in addition to predicting factors. Evidence from this review support the claims of increasing rateof self-medication. The studies reported a high prevalence of self-medication among the various segments of the Ghanaian population. This confirms the findings of earlier studies where the prevalence rates were noted to be high throughout the world; up to 68% within European countries, while a much higher prevalence exists in the developing countries with rates going as high as 92% in the adolescents of Kuwait, 59% in Nepal and 31% in India. Studies in some other countries show high rates of self-medication and unreasonable medicine intake, where the prevalence of self-medication in Ethiopia, Nigeria, and Nepal have been reported to be 43.2, 73 and 59%, respectively (Bamgboye et al., 2006; Sarahroodi & Mikaili, 2012; Shankar et al., 2003; Yadav & Rawal, 2015). In the majority of economically deprived countries, nearly 60–80% of health-related problems are treated through self-medicated as a lower-cost alternative (Zafar et al., 2008).

The excessively high prevalence of self-medication among people in economically deprived economies has been ascribed to a lot of factors of which poor health infrastructure, low awareness of health effects of self-medication amidst low cost and easy accessibility of drugs. While the prevalence was generally high, medical students recorded a higher prevalence of self-medication, and this has been attributed to growing knowledge of self-care. This extremely high prevalence of self-medication could be attributable to the fact that the study was conducted among students from the School of Medicine and Dentistry of the University of Ghana. Medical practitioners and students alike have been reported as persons who often engage in self-medication as a result of a high interest in self-care and knowledge of drugs. This supports the views of Naveed et al. (2014) where growing empowerment, resulting from improvement in educational levels and greater access to information, combined with an increased individual interest in personal health, is resulting in the growing demand for direct participation in healthcare decisions.”

5.2. Predictors of self-medication

5.2.1. Predisposing factors

The demographic factors, either known as predisposing factors, relate to some traits of the individual that makes them liable to engage in a certain behaviour as compared to people without the said traits. Older people were reported to be more likely to self-medicate as compared to younger people, due to the higher demand for healthcare needs; most at times sometimes, amidst low financial capabilities (Gyasi et al., 2019; Samsudin & Abdullah, 2017). The findings allude to evidence from previous studies where older people were reported to have a higher tendency to self-medicate as compared to younger people (James et al., 2006; Pan et al., 2012). Increasing barriers to healthcare use among older people is noted for this this occurrence. An individual’s level of education was correlated with the tendency to self-medicate. While some studies reported a higher prevalence of self-medication among people with higher education, some other studies reported that people with a lower level of education had a higher tendency to self-medicate. This supports evidence that one’s level of education influences their decision to self-medicate (Jafari et al., 2015; James et al., 2006; Naveed et al., 2014; Pan et l., 2012). Higher education could stimulate self-care behaviours where one seeks self-treatment or seek treatment from health professionals, for fear of side effects associated with self-medication.

Additionally, non-Christians have a higher propensity to self-medicate, while married people had a lower tendency to self-medicate. Studies reveal that religion is a determinant of self-medication (Aziato et al., 2016; WHO, 2016). In terms of gender, female students had a higher likelihood to self-medicate in the short term, while male students had a higher likelihood of practising self-medication over a prolonged period. This was, however, different in another study where the higher incidence of self-medication was reported among males diagnosed with HIV/AIDS. Mekonnen et al. (2018) discovered that males have a higher tendency to practice self-medication than their female counterparts, and additionally, Jafari et al. (2015) found a correlation between gender and self-medication; necessitating the inclusion of gender issues into self-medication control strategies.

5.2.2. Perceived health status

Self-rated health factors are related to perceived health status of the individual and how that influence the individuals’ health behaviour. Persons who rate their health status as poor were more likely to self-medicate. This stems from the need to improve their health. Persons who have perceived good self-rated health were less likely to self-medicate, owing to the perceived low need to improve their health. Particularly among pregnant women, those with perceived their health status as poor engaged in self-medication more than those with a good self-rated health. Evidence abounds that people with poor health conditions are more likely to self-medicate (Conner, 2010; Mekonnen et al., 2018), and this tendency is higher when the people are far from health facilities (Arikpo et al., 2010; Awad et al., 2006). This implies that self-rated health ultimately motivates people to self-medicate.

5.2.3. Cost and availability of drugs

Cost and availability factors relating to self-medication has to do with the issues or elements that enable the individual to engage in the said health behaviour. Healthcare cost remains a major barrier to formal healthcare utilisation (Gyasi et al., 2019; Samsudin & Abdullah, 2017), particularly for vulnerable groups. Consequently, many people resort to alternative means to seek redress for their various health conditions. Self-medication, particularly with over the counter drugs, was reported by the studies as less costly than seeking formal healthcare from health facilities. In this instance, the findings confirm other studies where self-medication becomes the first point of contact when it comes to seeking redress for health problems (Mekonnen et al., 2018; Vidyavati et al., 2016; Zafar et al., 2008). Additionally, easy access to drugs and herbal medicines have also contributed to the tendency to self-medicate, as has been reported in other studies (Galato et al., 2009; Zafar et al., 2008).

5.2.4. Health system factors

Quite a lot of health system factors such as unavailability of health facilities, high cost of healthcare services, unsatisfactory healthcare services and attitude of healthcare professionals amongst others influenced self-medication practices among Ghanaians. The absence of health facilities or long distance, coupled with transportation problems demotivate people to seek healthcare services in these facilities, by rather engaging in self-medication. The unavailability of health facilities pushed people to self-medicate drugs (Pagan et al., 2006; Sharma et al., 2005). The low satisfaction with healthcare services especially the unavailability of essential drugs (mainly reported by respondents who accessed healthcare under the national health insurance scheme) and attitude of healthcare workers also demotivated the respondents to seek formal healthcare and rely on self-medication to treat the health conditions they frequently encounter. This also supports the claims made by Gutema et al. (2011) that low satisfaction with healthcare services make people engage in self-medication.

6. Limitations of the study

The primary studies that were included in the review used a variety of methods for data collection and reporting, which had some limitations. The included studies’ varying levels of quality, operational definitions of self-medication, analytical framework, recall, selection, and social desirability all raised the possibility of bias. These factors always impact primary studies. For instance, while some research did not disclose the length of the recall period utilized during data collection, the majority of studies employed recall periods of more than six months. In a prior study (Arnold et al., 2013), a recollection duration longer than one month was found to be strongly linked with the probability of recall bias. Most surveys used non-random participant recruiting techniques and did not validate the data collection tools, which might have an impact on the study’s results. The significant degree of variation in the research under consideration may be related to the absence of defined survey data gathering standards. Our efforts to shed light on the prevalence and the contributing factors to self-medication behaviour were severely hampered by a lack of access to some of the most widely used databases in the field, a lack of time to search through all possible sources for pertinent publications (cross-referencing), and a failure to look further for unpublished research reports. The findings of this review should be interpreted cautiously since the main findings of each study have been carefully examined to create a more comprehensive picture of self-medication practices among Ghanaians.

7. Conclusion

The study employed an integrative review methodology as provided by Whittemore and Knafl (2005) to synthesise the prevalence and determinants of self-medication in Ghana. The findings of the study reflect a rather high prevalence of the health behaviour among various segments of the Ghanaian population (pregnant women, persons diagnosed with HIV/AIDS, older people and students among other groups). Further, the various factors that influence self-medication (demography, self-rated health, and cost, in addition to health system factors) reflect the basic tenets of the theories underlying the study. These factors reflect the HBM and the TPB, where some factors predispose and enable people to serve as a determinant of health behaviour, which in this case is self-medication. Largely, the study contributes to the literature on self-medication and holds prospect to influence decision making regarding healthcare delivery and the promotion of self-care and responsible self-medication. The study, therefore, has implications for policy on general healthcare delivery and self-medication.

By way of recommendations, the Ministry of Health (MoH) and the Ghana Health Service (GHS), together with other stakeholders must step up education and awareness programmes on the effects of self-medication, and the institution of such where no programmes exits. The Pharmacy Council of Ghana in association with the GHS should formulate strategies and likewise enforce these strategies to prevent chemical sellers, private pharmacists and drug peddlers from supplying drugs to the general population (especially some vulnerable groups like pregnant women and older adults) without prescription from physicians. Commensurate sanctions must be applied against persons who indiscriminately sell non-prescription drugs in the open market, in addition to the sale and dispensing of prescription drugs without valid prescriptions. Finally, the inconveniences in healthcare delivery such as long waiting time, non-availability of drugs at health facilities that make people indulge in irresponsible self-medication must be addressed.

Authors’ contributions

JC contributed to conception and design, acquisition and analysis of data, and manuscript drafting. AKM contributed to the study conception, design and proofreading of the manuscript. All authors read and approved the manuscript.

Declaration

The authors declare no conflict of interest.

Acknowledgements

We acknowledge the authors of the various articles used in the review.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The authors did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Notes on contributors

Anthony Kwame Morgan

Anthony Kwame Morgan holds a Master of Science Degree in Development Policy and Planning and a Bachelor of Arts Degree in Geography and Rural Development from Kwame Nkrumah University of Science and Technology, Ghana. Currently, he is a Freelance Research Assistant who is committed to investigating issues related to public Health, Health Services Research, Ageing, Rural Development, and Poverty and Livelihood Studies. The author’s work contributes to the literature on the development space, as he hopes to influence policy discourse and practice towards creating a more equitable, value-driven, and sustainable society for all, particularly for the vulnerable. In this paper, the prevalence and the determinants of self-medication was addressed from an integrative review perspective, with contribution to policy and research.