Patterns of Self-medication Practices by Caregivers to Under-five Children in South-Western Nigeria

ABSTRACT

Self-medication has generated a serious public health concern with its accompanied unhealthy practices. In Nigeria, the prevalence of self-medication is on the increase. Globally, the use of medicines for children is of serious concern as children are considered to be vulnerable group. Despite the full range of self-medication practices, not much is known about its extension to the most vulnerable of under-five children in Nigeria. This paper examined the patterns of self-medication practices among the caregivers to under-five children in south-western Nigeria. Two local government areas from Lagos and Osun states were selected for the study based on their cosmopolitanism and non-cosmopolitanism nature. Eighty-six caregivers to under-five children within the communities participated in the discussions. Purposive snowballing technique was used to select the participants in the study area with the aid of people of influence in the community for the FGDs. Twelve FGDs were conducted and stratified into younger caregivers and older caregivers. Data were collected with the aid of FGD guide for the caregivers of U-5 children and with the assistance of audio-tape recorder to obtain relevant information from those involved in the practice of self-medicating to their U-5 children. Data were analyzed based on thematic analysis. This was developed by the use of codes based on the identified variables from the fieldwork. Data were transcribed verbatim and classified into different themes. Analysis was done with the aid of Nvivo 11.0, a software designed for the analysis of qualitative data. The pattern of self-medication identified from this study included various combinations of herbal medicine, western medicine and faith-based medicaments. Also, the social factors associated with these patterns included, age of the caregivers, level of education, religion and relationship of the caregivers to their under-five children.

KEYWORDS:

• Caregiver
• self-medication
• under-five children
• herbs
• faith-based medicine
• pattern
• self-medication practice

Introduction

The use of medicines without a physician's prescription to treat a self-recognized or well-known ailment or symptoms is a phenomenon of public health importance globally. This practice is otherwise called self-medication. The World Health Organization (WHO) operational definition for the self-medication is

use of pharmaceutical or medicinal products by the consumer to treat self-recognized disorders or symptoms, the intermittent or continued use of a medication previously prescribed by a physician for chronic or recurring disease or symptom, or the use of medication recommended by lay sources or health workers not entitled to prescribe medicine.

Self-medication includes the utilization of therapeutic items by the buyer to treat self-perceived turmoil, indications, intermittent sickness or minor medical issue (Afolabi, 2008).

Studies have indicated different issues related to self-medication such as the increased risk of adverse drug reaction, drug-drug interaction, drug resistance, and even sudden demise in specific cases (WHO, 2010). In most homes, the first response to childhood illnesses is the use of non-prescribed drugs, but when this continued unabated, there could be a risk to the life of the child. Studies exploring the influence of socio-cultural and economic issues such as traditional child-rearing practices, beliefs, family types, taboos, norms and values, demographic factors on caregivers’ self-medication practice to under-five children are sparse in Nigeria.

Despite the full range of self-medication practices, not much is known about its extension to the most vulnerable and vital group of as under-five children in Nigeria. The healthcare actions or practices done to under five children are not within their volition. It is therefore worthy of note to ascertain the patterns of self-medication practice among caregivers to under-five children.

Literature review

The various forms or types of the self-medication practices performed or observed by the caregivers to their under-five children as means of alleviating or treating their illnesses or disease need to be assessed. Different types of self-medication practices among household include modern and traditional self-medicine (Shafie, Eyasu, Muzeyin, Worku, & Martín-Aragón, 2018). Additionally, the utilization of over-the-counter (OTC) drugs accessible without a doctor's remedy through drug stores (Mourya, Mary, James, Jose, & Srinivasan, 2019), the sporadic usage of an endorsed medication or the utilization of unused medications from past illnesses. It is observed that in the process of child care, different methods of treatment approach to childhood ailment were involved. Understanding the social milieu enveloping parental administration of OTC medications to children would ensure parents to be aware of the purpose and side effects of the OTC in their children (Martin-Perez et al., 2016). Also, the type of self-medication practice that was done depended on the severity of the illnesses. The practice was also noted to be associated with a strong belief in the spiritual causes of illnesses. The traditional self-medication practices include the utilization of an extensive variety of Complementary and Alternative Medicine (CAM), for example, natural medicines (herbs or homegrown arrangements), wholesome enhancements, customary items, and home cures (WHO, 2019). Self-drug does not mean the utilization of present-day medications but rather likewise of herbs (Al-Worafi, 2020) . However, (Salami & Adesanwo, 2015) who investigated the practice of self-medication among mothers of under in Ibadan reported that 53.4% mothers of under-five children who fell sick two weeks prior to the survey applied self-medication as the first action but never explored the types of self-medication practices that was done. This still connotes the fact that the caregivers evidently undertake self-medication practices.

In the South-Western region of Nigeria, the form of self-medication practices follows the same trend as in the North-east region. This may be because most caregivers in these climes are interested in quick recovery from illness or disease ravaging their children (Orimadegun & Ilesanmi, 2015). In their study to investigate the treatment practices for childhood malaria by mothers in a rural community of Ise-Orun, Nigeria reported the combination of herbal remedies with orthodox medicine which are obtained without doctor's prescription in the management of childhood malaria by mothers. Various traditional or local means were highlighted as methods of preventing childhood malaria. These include “burning of dry orange peel,” “burning of cow dungs,” “burning of herbs” and a “sprinkling of kerosene and water.” The extent of the efficacy of such methods, however, remain unproven.

Also (Oluwasogo, Henry, Abdulrasheed, Olawumi, & Olabisi, 2016) who evaluated caregivers practice regarding malaria treatment among under-five in the rural community in Nigeria affirmed that 37% of the caregivers preferred to use herbs while 40% use self-prescribed palliative drug combination over the counter drugs in treating malaria. Inadequate knowledge and misconception of childhood illnesses contributed to the type of self-medication practices the caregivers, hence need to be considered to improve on the effective management of under-five childhood illnesses. Similarly, 96.5% of mothers in Koko community in Ibadan, while assessing their knowledge on the hazards of antibiotics self-medication were noted to practice self-medication with antibiotics to their under-five children (Akinlade, Akinyemi, & Fawole, 2015). Most of the antibiotics were revealed to be purchased over the counter. Usage of paracetamol, buy over the counter was reported among caregivers of under-five, but misuse and over dosage were associated with its usage (Martin-Perez et al., 2016). This brings into the fore the need for knowledge about medicine used.

Assessment of the prevalence of self-medication practices in school children by their parents in Enugu affirmed that self-medication prevalence in school children by their parents was high 75.8%; majorly by over the counter. This shows that the practice is of a significant health problem which needs intervention,(Nworie et al., 2018), nevertheless the various sociological indices underpinning the practice must first be explored in order to plan the efficient intervention.

Objective

To determine patterns of self-medication practices among the caregivers to under-five children in south-western Nigeria.

Research design

Study locations

Considering the nature of this research study design and the research questions, for the study to have a general representation of the states in south-western Nigeria, two states were selected for the study based on the cosmopolitanism and non-cosmopolitanism nature of the states. The south-western (SW) Nigeria comprises of six states which are predominantly of the Yoruba tribe. The language generally speaking in this region is major, Yoruba language. Culturally these states are homogenous. However, there are some features which differentiate the states such as level of commercialization, population density, religion, land mass, and different cultural practices. The six states in this region are Lagos, Ogun, Oyo, Osun, Ekiti, and Ondo states. Among them, Lagos and Osun states were selected for the study.

Study population

This study engaged the caregivers to under-five children within the household. The caregivers in this study refer to any individual that is directly involved in the treatment of the under-five children during illness or diseased period in the house. This may be mothers, fathers, siblings, housemaid, grandparents, neighbors, foster parents, relatives or as it exists during the study.

Sampling technique

A purposively snowballing technique was used to select the respondents in the study area with the aid of people of influence in the community for the FGDs. Considering the nature of the study design, this technique produced exactly the required targeted study population that would produce the necessary information for the study. This may make the outcome skewed towards the under-five child-raring age group caregivers. The 12 FGDs were stratified into younger caregivers and older caregivers. Each FGD consisted of 6–8 caregivers, and the sessions were conducted until the level of saturation was attained.

Inclusion criteria for the study relied mainly on individual directly responsible for the care of any children under the age of 5 years that are in the community. Also, the exclusion criteria used was non-inclusion of any individual caring for the children that are above five years and with no experience of childrearing.

Data collection

In the study of this nature, data were collected using the FGD with the aid of FGD guide for the caregivers of U-5 children and with the assistance of audio-tape receiver to obtain relevant information from those involved in the practice of self-medicating to the caregivers of the U-5 children.

Data analysis

The data was analysed based using a thematic analysis. This was developed by the use of codes based on the identified variables from the fieldwork. FGD and the interview were transcribed verbatim and classified into different themes. The data or information from the qualitative design was analysed with the aid of Nvivo 11.0, a software designed for the analysis of qualitative data.

Ethical permission

Ethical considerations are paramount to investigation of this nature. The following safeguards were employed to protect the informants or participants’ rights. The research objectives were articulated verbally and in writings so that they are clearly understood by the informant. Written permission to proceed with the study as articulated was received from the informant. Ethical permission was sought from the Ethical and Research Committee in the Institute of Public Health, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria. The informant was informed of all data collection devices and activities. The final decision regarding informant anonymity rested with the informant Table 1.

Table 1. Socio-demographic profiles of focus group discussion participants.

Caregivers profile	(N = 86) (Number)
Local Government Area
Alimosho LGA	43
Ife East	43
Age group
19–29	24
30–39	49
40–49	9
50–59	3
Sex
Male	26
Female	60
Marital status
Never married	12
Married	74
Number of Children
<2	10
4-Feb	65
5 and above	11
Ages of Children
<1 years	30
1–2 years	41
3–4 years	59
5 years and above	54
Family size
3	11
6-Apr	67
7 and above	8
Religion affiliation
Christian	46
Muslims	40
Highest Education Qualification
No formal education	5
Primary school	11
Junior high school	7
Senior high school	37
University	26
Occupation
Official	12
Self-employed	59
Housewife	8
Unemployed	7
Place of residence
Urban	41
Rural	45
Distance to clinic (minutes)
<10	4
10	13
20	16
30	21
40-1hr	32`
Family monthly income
< ₦10,000	11
₦10,000-₦30,999	33
₦31,000- ₦60,999	27
₦61,000- ₦90,999	11
₦91,000- ₦120,999	3
₦121,000 and above	1
Medical insurance
Yes	5
No	81
Existence of chronic disease
Yes	3
No	83

Result

Twelve sessions of FGDs were with eighty-six caregivers. Forty-three of the participants were from Alimosho LGA in Lagos State as well as forty-three participants from Ife East LGA in Osun State. The age group showed that 49 out of 86 discussants were around age 30–39 years. In terms of marital status, the discussants profile showed that 74 were married while a few of the participants were never married. Majority of the participants (65) had two to four children. With regard to ages of children, all of the discussants had at least one child that was under-5 years. In addition, 67 of the participants had a family size of four-six. Concerning the religion affiliations, 46 of the participants were Christians and 40 were Muslims.

Pertaining to their highest educational qualification obtained, 37 of the participants had a senior high school qualification while (26) of them had a university degree. By occupation, majority (59) of the discussants were self-employed, (12) were civil servants, (8) of them were fully engaged as full housewife and (7) were unemployed. Regarding family monthly income, thirty-three and twenty-seven discussants had income of N10,000–N30,999 and N31,000–N60,999 monthly respectively. Eighty-one participants did not have medical insurance.

The study examined various combinations of medicines/drugs or products used in self-medication by the caregivers to their under-five children. Different types and variants of means of self-medicating were identified which included; herbs, palm wine, eroo, bitter leaf, íhanturu, snail water, ogogoro, kafra, anointing oil, shea butter, éwe-imi esu’ etc. This was evident from these excerpts:

“ … we use traditional herbs which is effective and then massaged the baby with water … ”. (FGD2, Female, Lagos)

“ … child has measles they will ask you to look for bomubomu leaf and wash it, squeeze it and put small to his mouth, also to rub his body and if the child is having temperature and crying, there is this leaf called éwe imi esu, if you wash and squeeze it, put it in his mouth, rub the remaining on his body and the temperature will go down”. (FGD, Male, Osun)

However, some caregivers counter the above opinions as they do not believe in the use of herbs on the account of poor measurement and inefficacy:

“ … giving a child herbs that did not have measurement even the English drugs that has measurement do not work at times … ”. (FGD, Male, Osun)

But another participant was of opposing view as he explained the method of measuring the dose for the child:

“.. you see taking of measurement was done by our forefathers and till date, for example, if it was to be a new child they want to give the concoction, they will use their finger to give the baby the concoction, so you can see that our fathers have their own measurement before English come with their own measurement.” (FGD, Male, Osun)

Some discussants demonstrated strong efficacy of some herbal leaves in the management of childhood illnesses as shown below:

“Even a day old, one will look for cashier leaf, pawpaw leaf, ewuro leaf, efinrin leaf and ewe edini, you will cook them, a 3-year-old child will drink a spoon, in fact within 3 h he has taken it, the child will be playing actively around.” (FGD, Male, Osun)

A combination of both herbal and western medicines was noticed by few participants:

“ … efinrin, alcohol, ewuro I washed everything together and add gin to it and give him by the time we gave him like two times all the smell will stop and he excrete them out now, it is only the temperature that remains so in the afternoon I will give him paracetamol”. (FGD, Male, Osun)

“personally I use ‘ágbo iba’. You see I have belief that we should use medical drugs 100% and also use the local herbs 100% … .” (FGD, Female, Lagos).

Also, the use of individual faith (belief system), western medicine and the traditional medicine were observed among these discussants who demonstrated a strong belief in God as healer while at the same time aligned with the traditional medicine:

“ … I will use ogogoro and ewuro. I will give the child to drink and also use it to rub the body and God will take control”. (FGD, Female, Osun)

“ … I believe in anointed water and prayers and there is nothing in this world that prayers cannot answer. The kind of problems that prayers will not be able to solve will not happen to us. It has to do with our faith and the bible says we should decree because we are created with authority. You can put water down and pray into it as long as you have faith it will work.” (FGD, Female, Lagos)

“.. it depends on the type of the sickness, like the one that happened to my child three days ago, I pray to God and God healed him, so I don’t have to use any medicine again”. (FGD, Male, Osun)

“ … in addition to qur’anic citations, if a child has temperature or measles, we will prepare soap for the child to bath. And the one he will be drinking to cleanse the child from inside and the child will excrete it out”. (FGD, Male, Osun)

The use of honey, onion and lime as homemade remedies were highlighted by some discussants in the treatment of cough in children:

“ … in case of cough, I use honey and onion, it works well, you will grind the onion and mix it with honey, I just give my child a drop of it at regular intervals, the cough will leave”. (FGD, Female, Osun)

“ … if you notice the baby is coughing, mix honey with lime and give the child to lick or we pound bitter kola and take ‘ogede odo’ and squeeze its water and give the child to drink. This will assist the cough syrup to work”. (FGD, Female, Osun)

The use of variants of western medicines were discovered among the caregivers to be used for the under-five children. Examples are paracetamol, ibuprofen, septrin, bonababe syrup, babyrex, neofylin tonic. They are used for managing different perceived illnesses among the children. Some discussants when asked on common medications used in self-medicating during their children illnesses, their views go thus;

“ … one of the most common drugs that we use for them is paracetamol, once the temperature has reduced … . will think they are better not knowing that it is storing in their body.” (FGD, Female, Lagos)

“ … paracetamol, Ibuprofen, whenever the child complain that he is having body pain and I touch him the temperature is hot, this paracetamol is not close to my hand but ibuprofen is close to my hand. I will just take it and use it for him.” (FGD, Female, Lagos)

“ … the kind of drug I used are paracetamol, septrin, bonababe and baby rex because if teeth is not disturbing them they may be running temperature, So I give him paracetamol, bonababe just to cool the temperature”. (FGD, Female, Osun)

The discussants specified that they used herbs traditional medicine for self-medication of under-five children. Mostly, herbs were used when they noticed their child had lost appetite and general body weakness. The participants reported that they prefer herbs to western medicine because herbs are cheap; their family background influences the use of herbs, easily accessible and some sickness can only be cured traditionally. They further stated that herbs had been tested. Hence they are reliable. Also, they made use of the combination of herbs and modern medicine. Herbs can be used to bath a child to maintain body temperature and skin diseases. The caregivers detailed that they use herbs and spiritual water (prophetic medicines like carl water, zytun, habertu zaoda, tumeric and zemzem water) for self-medicating to their under-five children. They also stated that they prefer traditional medicine to western medicine because it’s cheap and easy to access. Furthermore, they noted that the reasons for combining traditional medicine with modern medicines are to achieve efficacy like completely removing umbilical cord; to promote quick recovery especially from an abdominal illness, and to prevent the disease from worsening such as body rashes.

Discussion

This study identified the various self-medication patterns among caregivers to under-five children in Lagos and Osun state, South-Western Nigeria. The participants revealed different types of products and methods as a form of self-medication to their under-five children. These forms were used either separately or combined in various ways. These include the use of herbal concoctions, spiritual water and western medicines. The pattern spread across the rural and urban settings involved in the study. Most of these products were used for prevention and curative purposes.

As the rural discussants had limited or no access to healthcare facilities, though these facilities were in non-existence, their pattern of self-medication were traditional medicines (herbal concoctions and leaves), western medicines (paracetamol, septrin, ibuprofen, babyrex, bonababe) and faith-based medicines (spiritual water, anointing oil, prayer and fasting). This finding is not unexpected because they ascribed their trend to cheap and easy access to these products. This is in contrary to (Shafie et al., 2018) who reported the reasons for self-medication to be mildness of the illness, previous knowledge about the drug and emergency of the illness. This might be as a result of variation in the socio-demographic of the population studied. Occasionally few caregivers mixed both herbs and orthodox medicines to prevent illnesses from worsening. This is corroborated by a report in the rural community of Ise-Orun of Ekiti state, where caregivers combined herbal remedies with orthodox medicine in self-medicating to their wards (Orimadegun & Ilesanmi, 2015). Also, the use of spiritual water obtained from the faith healing homes was reported by the caregivers in the rural communities, and this is in tandem with (Mourya et al., 2019) who highlighted the use of prayer healing which is being practiced by the caregivers.

In the urban environment that was engaged in this study, the pattern of self-medication tends towards the use of mostly paracetamol and herbal concoctions. Owing to the availability of health facilities, pharmacy shops, and chemists, the use of paracetamol was predominant among the caregivers to the under-five children. This is solely used in the treatment of fever. To corroborate this findings, (Mourya et al., 2019) identified paracetamol to be commonly used as self-medication drug among the majority of the population studied . (Shafie et al., 2018) affirmed the frequent use of paracetamol, traditional medicine and antibiotics in the management of common main ailments as form of self-medication practice. In other similar climes in the western world, paracetamol was identified as self-medication drugs to the children (Martin-Perez et al., 2016).

Medical pluralism is a common practice in social settings where biomedicine and traditional medical system co-exist (Shafie et al., 2018). It could be affirmed from the respondents’ revelations that self-medication practices done to their under-five children were multifaceted, that is, traditional medicines (herbal concoctions and leaves), faith-based medicines (spiritual waters, anointing oil, prayer and fasting, ihantutu) and western medicines (paracetamol, septrin, ibuprofen, syrups). Reasons majorly responsible are cost, affordability, accessibility and their native beliefs in these products. Evidence from this implies that, despite the availability of healthcare facilities and accessibility to these places, caregivers till prefer the use of locally made herbs, spiritual water to the use of western medicines in self-medicating to their children. It further showed that the practice of self-medication shows no boundary between either rural and urban stings as both settings demonstrated almost the same pattern of self-medication to their under-five children.

This study recognises that the practice of self-medication to under-five children in the southwestern Nigeria has not been sufficiently studied to date. It further revealed how caregivers valued child care practice of their under-five children and various societal context that intervenes with the practice. Apart from the national policy that prevents the sales of some medicines over-the counter, though which is not very effective in Nigeria, there is need for household-based policy that specifically targets the caregivers to under-five children where they are enlightened on the use of drugs irrationally on their children. This idea was supported by caregivers’ revelations rendered as part of the information gathering for this study. The goal is to ensure a safe responsible self-medication practice in order to reduce the cost of care, reduce child mortality rate and improve on the quality of healthcare to the under-five children.

Caregivers are still dominated by social and traditional norms of child care practices as well as some unhealthy and unsafe methods of administering medicaments to their under-five children. This calls for public orientation and sensitization of caregivers on childcare health education. This could be done in form of public health awareness campaign by various stakeholders in the communities.

The involvement of the Federal Ministry of Health is of immense importance in implementing and enforcing measures at all maternal and child care clinics in primary healthcare centres, secondary health care facilities and tertiary health establishments, that will guarantee a responsible safe self-medication practice to the under-five children. This could be done through organised periodic and incessant public sensitization and education of community members to enhance quick uptake of the information.

Conclusion

The study revealed different dimensions involved in the use of medicines and other several practices in approaching self-medication practices. From the various discussions done, it was observed that cultural values and belief system dominated their self-medication practices towards performing different modalities of medical pluralism to their under-five children.

Disclosure statement

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

Notes on contributor

Dr. Oluseye Ademola Okunola is a medical graduate of Obafemi Awolowo University College of Health Sciences, Ile-Ife with a strong passion for research activities in community/public health practice. He is a physician/ research fellow in Public Health and Medical Sociology. He presently works at Obafemi Awolowo University, Ile-Ife. He has a Ph.D. in Sociology and specialized in Sociology of Health, Health/Medical Systems, Social Policy and Development. He is a fellow of Consortium for Advanced Research Training in Africa (CARTA).

Additional information

Funding

This research was supported by the Consortium for Advanced Research Training in Africa (CARTA). CARTA is jointly led by the African Population and Health Research Center and the University of the Witwatersrand and funded by the Carnegie Corporation of New York (Grant No: B 8606.R02), Sida (Grant No: 54100113), the DELTAS Africa Initiative (Grant No: 107768/Z/15/Z) and Deutscher Akademischer Austauschdienst (DAAD). The DELTAS Africa Initiative is an independent funding scheme of the African Academy of Sciences (AAS)'s Alliance for Accelerating Excellence in Science in Africa (AESA) and supported by the New Partnership for Africa's Development Planning and Coordinating Agency (NEPAD Agency) with funding from the Wellcome Trust (UK) and the UK government.