Abstract
Minor illnesses are usually treated in home and community contexts. Despite, or perhaps because of, their commonness, responses to minor illness are poorly researched, especially outside developed countries. The aim of this study was to qualitatively explore the range of everyday symptoms and minor illnesses that people in Pakistan might experience and types of responses they make to minor illnesses. The information gathered was to inform the design of a larger project to prospectively explore the responses of people to minor illnesses. Twenty-four participants, aged between 18 and 55 years, were approached through snowball sampling and social networking to take part in in-depth interviews or focus groups. Participants reported a wide range of everyday symptoms, which were then classified based on human physiological systems. Self-care, self-medication, use of home and herbal remedies and spiritual healing were found to be the most common responses to these symptoms. Factors affecting participants’ treatment decision-making included past experience, friends’ or relatives’ experience and advice, family practice, presence of a health professional in the family or circle of friends, and cultural practice. Consulting with a doctor was not a preferred option in treating minor illness. An understanding of how people experience illness and how they make decisions about their responses can inform health services and health policy.
1. Introduction
Minor aches and transient symptoms are part of everyday life. Different people respond differently to a given symptom, and responses can range from totally ignoring the symptom to immediately seeking medical help. Self-care, using home remedies and consuming traditional and alternative medicines are common responses to symptoms.
Responses to symptoms, or illness behaviour, is the differential perception, evaluation and consequent response to specific symptoms (Mechanic, Citation1962). Early work explored factors that influence individuals' decisions to seek medical help for a given illness. These included cultural and family background, social networks, psychological distress, access to healthcare, interpretation of the symptom, the intensity of the symptom, prior illness and medical care experiences, illness beliefs, as well as many other individual and social variables (Berkanovic & Telesky, Citation1982; Egan & Beaton, Citation1987; Ford, Citation1983; Mechanic, Cleary, & Greenley, Citation1982; Tanner, Cockerham, & Spaeth, Citation1983).
Historically, minor ailments have been little researched. However, in recent years there has been increased interest in studying people's responses to different illnesses including minor illnesses and the process by which they seek medical help (Hunte & Sultana, Citation1992; Porteous, Ryan, Bond, & Hannaford, Citation2006; Reeve, Citation2000). Little of this work has looked at developing countries.
Developing countries have more pluralistic health systems than developed countries and, consequently, an even greater range of options for responding to symptoms. For example, in Pakistan, in addition to typical public and private sectors (Hakim, Citation1997), there are also homeopaths, traditional/spiritual healers, Greco-Arab healers, herbalists and bonesetters. The interactions between formal and informal healthcare is little known or documented. An understanding of people's responses to symptoms is important if health promotion programmes and the healthcare system are to be effective. Despite growing literature on these topics in the context of developing countries (ICDDR, Citation2008; Leyva-Flores, Luz Kageyama, & Erviti-Erice, Citation2001; Ngokwey, Citation1995; Van der Geest & Hardon, Citation1990) very few studies have been seen in Pakistan, with little work on responses to minor illnesses (Anwar, Green, & Norris, Citation2012).
This qualitative study aimed to produce a near complete list of possible symptoms and minor illnesses that people in Pakistan might experience in everyday life, as well as the possible range of responses that might be made to each symptom or illness. The current study was conducted in part to inform the design of a larger project to prospectively explore the responses of people to minor illnesses using quantitative daily diary methods. The data gathered from that larger project are currently being analysed and written up for publication.
2. Methods
2.1. Study design
This qualitative study used interviews and focus group discussions. Prior to conducting this study ethical approval was obtained from the Human Ethics Committee, University of Otago, New Zealand. Ethics approval is not required by National Bioethics Committee (NBC) Pakistan to conduct observational research.
2.2. Participants
Potential participants were approached through snowball sampling and social networks in Wah Cantt, a small town in the northern part of the province of Punjab, Pakistan. Ten participants were recruited for the in-depth interviews and 14 for the focus groups, as summarised in . Each participant was compensated with 100 Rupees (approx. US$1) as a token of appreciation for their time.
Table 1. Demographic characteristics of participants.
2.3. Procedure
Ten individual in-depth interviews and two focus groups (one male, one female) were conducted. Due to cultural, traditional, and religious limitations it was not possible to have focus groups with both male and female participants. A qualified female research assistant was trained to conduct the interviews and the focus group with the female participants. Interviews and focus groups with males were conducted by the first author. Individual interviews were conducted following an interview schedule, and focused on participants’ recent experience of any minor illness, their responses to the illness, factors affecting decision-making pertaining to the treatment and reasons for or against consulting with a qualified healthcare professional. Each focus group was conducted in two halves, the first half focusing on listing the most commonly experienced symptoms and minor illnesses that people might experience in everyday life, with the second half having a detailed discussion on each of the reported symptoms as to how people possibly respond to these symptoms. Though occasionally some chronic conditions were also discussed in both interviews and focus groups, these are not discussed in this paper.
All the interviews and focus groups were conducted in Urdu (the national language of Pakistan) and were recorded. Written informed consent was gained from each participant, prior to the start of the interview/focus group. The audio recordings were then transcribed and translated into English by the first author. Symptoms were grouped by physiological systems, and then potential responses were listed under those headings. Preliminary analysis was completed by the first author, and then discussed with other authors.
3. Results
3.1. Findings of interviews
3.1.1. Symptoms experienced and responses
The most recently experienced symptoms as reported by the participants included nasal bleeding along with cold and flu-like symptoms, persistent cough (later diagnosed as tuberculosis), headache with fever, backache and ear infection, long term flu-like symptoms along with general body pain, sore throat, diarrhoea with vomiting and fever, diarrhoea with fever, diarrhoea only, and menstrual pain along with flu and fever. Three of the participants reported only one symptom and the rest reported more than one.
In order to treat nasal bleeding the participant reported that she had washed her head with cold water attributing the symptom to hot weather.
P1: It might be because of hot weather so I washed my head with cold water but it did not help. Then I went to see the doctor who gave one stitch inside my nose and gave me some tablets and nasal drops.
The participant who experienced persistent cough reported seeking medical help from a primary healthcare centre without trying any home remedy. At the healthcare centre he was given some cough syrup.
P2: I went to the public dispensary (primary healthcare centre) where symptomatic treatment is provided and they do not go in depth. They gave me a cough syrup which I used for many days but it did not help so I went to them again and they referred me to the hospital where I was diagnosed with tuberculosis.
Headache and fever were reported to be treated with analgesics and antipyretics such as paracetamol and mefenamic acid. However one of the participants reported seeking help from a homoeopathic practitioner after he found that paracetamol was not working for him.
P3: I took paracetamol hoping that it will help in my fever but it didn't so I went to a homoeopathic practitioner who gave me some medicine that really helped.
Another participant who had diarrhoea along with fever attributed the fever as a symptom of infection (diarrhoea in his case) and started using an antibiotic without consulting with a doctor in order to treat diarrhoea, believing that fever will go once the diarrhoea was cured.
P7: I did not take paracetamol but only ciprofloxacin as I know fever is because of some infection.
Backache was reported by one of the participants as an ongoing problem, which was treated by a home remedy that includes mixing egg with boiling milk and drinking this mixture. This provided relief for some time. The participant indicated that his profession (plumbing) was the reason for the backache and he would have to bear with it the rest of his life. He preferred ayurvedic over conventional medicines to treat his problem.
P4: When I have to take medicine I go for ayurvedic as I do not like Angrezi dawa [translated as ‘English medicine’ and refers to allopathic medicine]. I used the medicine for about one month and I was perfectly alright but when I stopped taking the medicine it started again.
Joshanda (a commercially available herbal mixture; ingredients of a typical example are: Glycyrrhiza glabra, Judticia adhatoda, Hyssopus officinalis, Camellia sinensis, Ephedra sinica, Mentha x piperita, Foeniculum vulgare and Eucalyptus globulus) was reported to be used for treating flu-like symptoms by one of the participants. Another participant who experienced the same symptoms used black tea. One of the participants reported having long-term cold and flu-like symptoms that were affecting her eyesight and causing generalised body pain. She went to see the doctor who suggested an x-ray that she did not go for in order to save money. She further indicated that she was thinking of switching to the homoeopathic mode of treatment which might be less expensive.
The participant who experienced sore throat reported treating it with paracetamol and gargling with saline water.
Diarrhoea was recently experienced by three of the participants. One of them tried to treat his condition by taking metronidazole, ciprofloxacin, and oral rehydration therapy.
P7: It started with pain in my stomach so I took metronidazole. I took three doses and the pain was gone but when I ate okra curry it started again and I got severe diarrhoea with loose motions.
P7: I took ispaghola husk with yogurt. Also someone told me to roast the cumin seed and eat them. I tried that as well.
Another participant who experienced diarrhoea used a decoction of mint, fennel, and Bishop Weed (Ajwain in local language). However one of the participants was brought to the hospital where he was given emergency treatment. He reported that he hardly used any kind of remedy including home remedies when he gets minor symptoms as they get better on their own.
Menstrual pain was reported to be treated by mefenamic acid and a home remedy that included boiling together and drinking certain herbs such as black tea leaves, mint, glycyrrhiza (also known as Chinese liquorice), and black cardamom.
3.1.2. Factors affecting decision-making on treatment
Some of the factors found to affect participants’ decision-making pertaining to the treatment of minor ailments included past experience, friends’ or relatives’ experience and advice, family practice, presence of a health professional in the family or circle of friends and cultural practice. Involvement of these factors in the treatment-seeking quest is evident from the following quotes:
P1: I used the same nasal drops that the doctor gave me the first time to stop nasal bleeding
P3: Mostly I go to see the homoeopathic practitioner as he lives nearby and he is kind of a family friend.
P3: My mother often tells me about home remedies.
P3: My aunt always tells us when to take which tablet as her husband owns a medical store.
P4: My father brought me some allopathic medicine for back ache.
P6: My mum as she herself uses this remedy.
P7: [Roast] Cumin [seed] was told by my cousin's sister and yogurt and Ispaghol, you know it's very common in our culture.
P10: My aunty told me about it [decoction of mint, fennel and Bishop Weed].
3.1.3. Consultation with a doctor
Seeking professional help for minor conditions was not a preferred choice. The majority of the participants stated that they would try to fix the condition on their own first by using traditional remedies and/or over-the-counter (OTC) products but if the condition got worse and persisted for a long period of time or interferes with their normal routine they would consider seeking help from a doctor. The high cost of diagnostic tests, perceived side effects associated with allopathic medicines and dislike of injections were reasons to avoid consulting a doctor.
P5: They asked me to go for an X-ray but I never went as it will cost me a lot.
P4: Allopathic medicines have side effects while homoeopathic medicines do not have any
P10: Actually the first thing they do is they give infusion and then ask for different tests and give medications of high potency that make your condition even worse. Also I prefer not to take any medicine in injection form so I prefer not to go and see the doctor.
Homoeopathic and ayurvedic systems of treatment were also found to be the preferred choice for some respondents.
P5: Now I am thinking to consult with a homoeopathic practitioner.
P3: Mostly I go to see the homoeopathic practitioner who lives nearby.
P4: When I have to take medicine I go for ayurvedic as I do not like Angrezi dawa [allopathic medicine].
In contrast, one participant claimed that he believed only in the allopathic system of treatment as it is research based and that homoeopathic practitioners are ill qualified.
P2: Homoeopathic system may work for minor ailments but for serious and complicated conditions allopathic system is better as they have more research, also they have surgery and different diagnostic tests.
P2: I have many friends of mine who completed 10 years of education and got into homoeopathic course and now they are called doctors. So for condition like mine I do not think homoeopathic can work.
3.1.4. Knowledge and beliefs about symptoms and medication
Some participants' beliefs aligned with allopathic medicine.
P2: If a cough persists for more than 3 days and does not respond to OTC products one should consult the doctor.
P7: One should complete the full course of antibiotics.
However, one of the participants claimed that the ear infection he was having is actually a kind of pimple in his brain that should release the pus; otherwise it may progress into some kind of cancer; one should not get any treatment for this other than pain killers.
3.2. Findings of focus group discussions
Participants highlighted 29 symptoms which they thought people experienced in everyday life.
3.2.1. Respiratory symptoms
Participants highlighted four respiratory symptoms that people might experience in everyday life along with possible responses (), along with asthma which as a chronic condition is not included in the results. Use of honey, ginger, and gargling with saline water were reported to be the common responses to respiratory symptoms. However participants also reported using antibiotics for sore throat, without consulting with a doctor. Homoeopathic medication and commercially available herbal mixture Joshanda were reported to be used for treating the symptoms of flu.
Table 2. Respiratory symptoms and responses.
3.2.2. Musculoskeletal symptoms
A total of five musculoskeletal symptoms were highlighted by the participants (). Arthritis and osteoporosis were reported by the participants but are not described here due to their chronic nature. Pain killers and massage were found to be the most common responses to such symptoms. Spiritual healing that included the recitation of few initial Quranic verses was reported as a response to headache.
Table 3. Musculoskeletal symptoms and responses.
3.2.3. Gastrointestinal symptoms
Two possible gastrointestinal symptoms were reported by the participants (). Some of the responses to gastric symptoms included use of certain juices such as that of onion, pumpkin, and lemon, use of carbonated drinks, consuming light soft food such as yogurt, and taking ispaghola husk. Participants also reported using antimicrobials such as metronidazole in order to treat diarrhoea.
Table 4. Gastrointestinal symptoms and responses.
3.2.4. Dermatological symptoms
Eight common dermatological symptoms were highlighted during the discussions (). Use of certain oils, creams, lotions, and shampoos were found to be the most common responses to such symptoms. Some other possible responses included waxing for female facial hair, using prickly heat powder for prickly heat, applying aloe vera pulp for rashes and using anti-dandruff shampoo for hair dandruff. Honey was reported not only to be used in certain respiratory symptoms but also in attempts to stop hair loss.
Table 5. Dermatological symptoms and responses.
3.2.5. Mental/psychological symptoms
Three mental/psychological symptoms were also highlighted by the participants which were anxiety/depression, lack of focus, and phobia. Spiritual healing, such as reciting Quranic verses and offering prayers, was found to be the most common response to these symptoms. Other responses to treat anxiety/depression included getting more sleep, talking with friends, listening to music, and taking sleeping pills. Lack of focus was reported to be a symptom that might be caused by some social problem and would be relieved once the problem is solved. The only response to phobia as reported by the participants was offering prayers.
3.2.6. Miscellaneous symptoms
Some of the miscellaneous symptoms included eye infection, fever, jaundice, evil eye (a look that is believed by many cultures to be able to cause injury or bad luck for the person at whom it is directed for reasons of envy or dislike), and wax/dryness in ear (). Some other chronic conditions were excluded, such as hypertension, hypercholesterolemia, and diabetes.
Table 6. Miscellaneous symptoms and responses.
4. Discussion
Participants reported a variety of responses to combat minor illnesses. These responses included getting more rest, spiritual healing, trying home remedies, using homoeopathic and herbal medicines, and using allopathic medicines (sometimes without consulting a physician).
‘Home-based treatment’ also termed ‘self-care’ was a commonly reported response to a wide range of symptoms, although it is one of the least studied forms of health seeking behaviour (Bledsoe & Goubaud, Citation1985; Kroeger, Citation1983; Risse, Citation1977; Ritchie, Herscovitch, & Norfor, Citation1994; Silverman, Lee, & Lydecker, Citation1982). The World Health Organization (Citation2009) defines self-care as ‘the ability of individuals, families and communities to promote health, prevent disease, and maintain health and to cope with illness and disability with or without the support of a health-care provider’. One of the integral parts of ‘self-care’ is ‘self-medication’ which is defined as ‘the selection and use of medicines (including herbal and traditional remedies) by individuals to treat self-recognized illnesses or symptoms’ (World Health Organization, Citation1998). The participants of this study reported the use of all forms of medications as a part of a self-care process. Consistent with the findings of other studies conducted on specific conditions in different geographical areas of Pakistan this study suggests that self-medication is the most common initial response to any illness (Chandio et al., Citation2000; Haider & Thaver, Citation1995; Hassan, Citation1981; Hunte & Sultana, Citation1992; Sadiq & Muynck, Citation2001; Shaikh, Haran, & Hatcher, Citation2008). People use both homemade and commercially prepared remedies, which are mostly herbal in nature.
Self-medication is a common practice both in industrialised as well as developing countries but is hardly equivalent qualitatively or quantitatively (Van der Geest & Hardon, Citation1990). In industrialised countries it is less of a necessity and is mostly guided by information gained by books, magazines, package inserts, and other media, and drug legislation and enforcement means that access to many medicines is restricted by prescription. In developing countries like Pakistan, however, self-medication is more necessary due to poverty and lack of access to formal healthcare (Van der Geest & Hardon, Citation1990). Consumers from developing countries mostly rely on advice from family and friends, overprescribing physicians, unqualified drug sellers, and the marketing campaigns of the pharmaceutical companies (Kunin, Citation1985; Tan, Citation1988; Yusuff & Wassi Sanni, Citation2011). The current study also found that family and friends were important influences on responses to illness.
The majority of the home remedies in this study were herbal and traditional in nature. This is consistent with the findings of other studies conducted in developing countries such as Ghana, Mali, Nigeria, and Zambia (Hasan, Ahmed, Bukhari, & Loon, Citation2009). The use of traditional medicines outside their traditional culture (especially in developed countries) can be termed Complementary and Alternative Medicine (CAM) (World Health Organisation, Citation2000a). In this sense, the high level of traditional medicine use is not dissimilar to some developed countries. For example, about 46% of respondents in the UK are expected to use one or more CAM therapies in their lifetime (Thomas, Nicholl, & Coleman, Citation2001) with a similar level in South Australia (MacLennan, Myers, & Taylor, Citation2006). In developing countries like Pakistan, in addition to using home-based and commercially available traditional medicines people consult with traditional healers also known as Hakeem, homeopaths, spiritual and faith healers, bonesetters, and traditional birth attendants (Dais). This informal sector accounts for more than 70% of the consultations in the country (Karim & Mahmood, Citation1999). In this medical pluralism where formal and informal sectors operate hand in hand, ‘healer shopping’ can be a common practice. As is evident from the findings of other studies people tend to change healers quickly because they want quick results (Hunte & Sultana, Citation1992; Kundi, Anjum, Mull, & Mull, Citation1993). However the findings of this study suggest that using all kinds of remedies without any consultation is the first immediate response to almost all the minor illnesses reported.
Antibiotics were used without medical advice for certain medical conditions. These are most likely sourced from drug retail-shops, commonly known as medical stores, which are often the public's first point of contact with the healthcare system (Kafle et al., Citation1996). In Pakistan all drugs are sold as over-the-counter products that do not require any prescription (Arshad, Ijaz, & Hussain, Citation2007–Citation2010). Rao and Soomro (Citation2004) explored the role of pharmacy in health-seeking behaviour in Karachi. Reasons for going to the pharmacy included it being a common practice in society, the higher cost of other treatments, extra cost of doctors, long waiting times, doctors not being available 24 hours a day, doctors’ knowledge not being up to standard, confidence in their own knowledge of medicine, and pharmacists being more up-to-date sources of knowledge about drugs. The last reason is questionable as only a few reputable pharmacy chain stores have qualified pharmacists at the front desk; the majority of pharmacies are operated by non-qualified lay persons who get their knowledge of drugs from experience of running their own business or working in some other retail pharmacy prior to starting their own business.
Similar to Shaikh and Hatcher (Citation2005), the type and duration of symptoms experienced for the illness are major determinants of health-seeking behaviour and choice of care provider. In case of a mild single symptom such as fever, home remedies or folk prescriptions are used, whereas with multiple symptoms and a longer period of illness, an allopathic health provider is more likely to be consulted (Islam & Malik, Citation2001; Sadiq & Muynck, Citation2001). Social networks including family and friends were also found to be significantly shaping people's responses to symptoms. Advice of the elder women in the house is also instrumental and cannot be ignored (Delgado, Sorensen, & Van der Stuyft, Citation1994). Household economics also limit the choice and opportunity for health seeking (Hunte & Sultana, Citation1992; World Bank, Citation2002). In countries like Pakistan where 70% of health expenditure is out-of-pocket payments, poverty excludes people from benefits of the healthcare system (Shaikh & Hatcher, Citation2005; World Health Organisation, Citation2000b).
Being an Islamic state, religion has an integral part in people's everyday life. This is evident from the finding that use of certain Quranic verses is a common practice to alleviate certain sicknesses. However, unlike the findings of some other studies in rural areas of Pakistan where illness was often related to evil eye and spirit possession (Hunte & Sultana, Citation1992; Mull & Mull, Citation1988; Shaikh et al., Citation2008), the respondents of this study did not report the same, though they did mention evil eye as a condition in and of itself, which may be treated by reciting certain Quranic verses. The disparity between the findings might be due to the variation in educational background of the participants. The aforementioned studies were conducted in remote areas of Pakistan with low literacy rates whereas the participants of the current study were moderately educated. Higher education might have influenced their understanding and awareness. However, it was not clear whether the spiritual healing is preferred over conventional treatment or if they are used together. According to Muslim belief there are various verses of the Quran which are helpful in treating different conditions especially the first few verses of the Quran which are regarded as ‘Verses of cure’. Islam also encourages people to use conventional treatments, although one should have a belief that whichever mode of treatment is used (Quranic verses or conventional treatment) the ultimate cure is given by Allah (God).
Focus group discussions are a qualitative research method that has become increasingly popular in healthcare and medical research due to the fact that most health-related conditions are created by social environments and made within the social context (Carter & Henderson, Citation2005). Focus groups, unlike individual interviews, provide the added dimension of the interactions among members (Wong, Citation2008). Thus, focus groups are a popular method for assessing public experience and understanding of illness (Kitzinger, Citation1993; Ritchie et al., Citation1994). As the aim of the study was to explore possible everyday life symptoms that people might experience and possible responses to these symptoms, focus groups were the most suitable method to gather the data of interest. However, domination by one or two group members, shyness at describing sensitive topics, and possible inconsistency between what people say and what actually they do are some of the limitations of focus groups. These limitations were countered with the addition of in-depth interviews.
Self-care offers unique opportunities for health promotion, disease prevention, and for staying healthy. To revitalise self-care effectively, beneficial lay/traditional self-care practices can be integrated into alternative community-based self-care interventions (World Health Organization, Citation2009). A project in Nepal based on these concepts has shown promising results (Haider & Thaver, Citation1995; Kafle & Gartoulla, Citation1993). Mass-level health awareness programmes coupled with integration of the traditional and informal sector into the mainstream and development, implementation, and enforcement of laws about prescription only medicine status may attenuate the problems associated with self-medication and improve the overall quality of healthcare.
5. Conclusions
Home-based treatments, including self-care, self-medication, use of CAM and spiritual healing, were found to be the first line of action for alleviating minor illnesses in Pakistan. Family and social connections were key influences, especially for the use of traditional remedies.
Acknowledgements
We thank Mrs. Afshan Rani for her invaluable contribution to this study by interviewing and conducting a focus group with female participants.
Disclosure statement
No potential conflict of interest was reported by the authors.
ORCID
Mudassir Anwar http://orcid.org/0000-0003-4714-6130
James A. Green http://orcid.org/0000-0002-7309-0751
Pauline Norris http://orcid.org/0000-0003-1656-871X
Nadeem I. Bukhari http://orcid.org/0000-0001-5710-9574
Related Research Data
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