Sot. Sci. Med. Vol. 19, No. 7, pp. 699-703. 1984 027779536/84 $3.00 + 0.

00
Printed in Great Britain Pergamon Press Ltd

SELF-MEDICATION: AN IMPORTANT
ASPECT OF PRIMARY HEALTH CARE
0. A. ABOSEDE
Institute of Child Health and Primary Care, College of Medicine, Idi-Araba, Lagos, Nigeria

Abstract-The main objective of this study was to determine the degree to which individuals practised
self-medication in relation to their educational status. Kalutara, a small town in Sri-Lanka is semi-urban
and has a good mixture of literates and illiterates.
Important findings include the fact that knowledge of drugs was grossly inadequate, literates
self-medicated far more than illiterates and a high percentage of the total sample population by-passed
other health personnel in preference for Western trained doctors.
Self-medication, though desirable, can be dangerous and should be emphasized as a component of
primary health care because (i) it is commonly practised even where health professionals are easily
accessible, (ii) it encourages self-reliance for curative, preventive, promotive and rehabilitative care and
(iii) literacy, which seems to enhance its practice, is increasing worldwide.

INTRODUCTION Due to an agro-based economy, 80% of the popu-

The struggle to improve health on a World-wide basis
(Alma Ata declaration, Geneva 1978) has prompted
many countries to find alternatives to health care
relevant to their own situations. It has set in motion
a gradual change of emphasis from health-care-giver
centred services to self-reliance. This welcome change
is the motivating factor behind this study whose main
purpose was to find out the extent to which self-
medication was practised by members of a commu-
nity and to what extent their educational level
influenced this. It sought to examine reasons for
resorting to self-medication, the drugs commonly
used and attitudes to primary health care facilities.
The rationale for carrying out the study was to
make health planners, especially those in developing
countries aware of the possibility of people self-
medicating and/or by-passing some types of health
care facilities. This type of study is important because
it highlights the relationship between educational
level and attitude to primary health care facilities.
The piactice of self-medication, its advantages and
disadvantages have been studied by several authors
[l-3]. They have found that even where health facil-
ities were adequate and easily accessible, the preva-
lence of inappropriate self-medication remained high.
Sri-Lanka, the country in which the study was
carried out is a small island with a population of 14.9
million, of which an average of 80% is literate (83.2%
males and 70.7p6 females) and 67.4% are Bhuddists.
In spite of a low Gross National Product per capita
(E80 sterling or US$204), this country by virtue of its
health indices is on a much better standing than many
of the other developing countries. It has been able to
reduce Infant Mortality rate to 42.2 per 1000, Mater-
nal Mortality rate to 0.8 per 1000 and increase Life
Expectancy at birth to an average of 65 years [4]. Its
Physical Quality of Life Index (PQLI) is one of the
highest in the world and is much higher than those
of some richer developing countries (Sri-Lanka 82,
Nigeria 27, Bangladesh 32, India 41) [5].
699
lation is dispersed in rural areas and is clustered in
more than 22,000 villages. Sinhalese form the largest
group (71.9%) in Sri-Lanka. Others are Tamils
(20.6x), Moors (6.7%) and smaller groups including
Bughers, Euraseans, Malaysians (0.8%).
Health personnel, other than doctors are increasing
rapidly and in addition, Ayurvedic (traditional) doc-
tors outnumber the Western trained ones (ratio 9: 1).
The number of Western trained doctors continues to
decrease due to emigration.
Kalutara, the small district town in which the study
was carried out is located 26 miles south-west of
Colombo, the capital city. It falls within the 52 square
miles area with a population of 200,000 used as
practice area by the National Institute of Health
Sciences (NIHS). This Institute, in keeping with the
primary health care concept of the World Health
Organization has 37 basic health units (Maternal and
Child Health clinics) called Public Health Midwife
clinics. Each unit has a staff of 2 Public Health
Midwives and 1 Public Health Inspector and serves
a population of about 5000. One medical officer
supervizes 5-6 basic units.
In addition to these basic units, Kalutara is
endowed with several other health facilities organized
to function in such a way not duplicated by any other
part of the country. They include (a) Kalutara Gen-
eral Hospital with 490 beds and a staff strength of 10
doctors, 23 midwives, 118 Nurses; (b) a district
hospital of 40 beds with 2 doctors, 3 midwives and 9
nurses; (c) a rural hospital of 15 beds staffed by a
Registered Medical Practitioner and 6 dispensers; (d)
2 central dispensaries with 2 dispensers; (e) a periph-
eral unit comprising 1 dispensary and a maternity
centre with 34 beds staffed by 3 midwives and a
visiting Assistant Medical Practitioner. Ayurverdic
(traditional) doctors number over 80 in Kalutara
alone. Kalutara, therefore has roughly, doc-
tor : population, nurse : population and Ayurvedic
doctor: population ratios of’ 1: 6000, 1: 570 and
1 : 25000 respectively.
700 0. A. ABOSEDE

Kalutara South, the Public Health Midwife (PHM) Table I. Characteristics of respondents
area chosen by random sampling for this study is said O0 Respondents
to be approximately representative of the other PHM
Characteristics LIterate Illiterate
areas. It had 370 homes in both urban (town like) and
rural (village with huts) setting. Age group
Z&29 25.0 25.0
Western and traditional drugs are available for 3&39 42.5 47.5
purchase as the Government recognises and pro- 4w9 30.0 25.0
motes Ayurvedic (traditional) medicine. 70+ 2.5 2.5
Total 100.0 100.0
Drugs available for sale ‘over-the-counter’ and
Sex
those imported to all parts of the country are under Female 61.5 70.0
control of the State Formulary Corporation while Male 32.5 30.0
those available for use in Estate Hospitals are under Total 100.0 100.0
control of the National Formulary Committee. Ethnic group’
Sinhalese 97.5 95.0
Tamil 2.5 5.0
Total 100.0 100.0
Occupation
MATERIALS AND METHODS
Housewife 52.5 75.0
Semi-skilled 47.5 25.0
Two questionnaires were used for the study. One Total 100.0 100.0
was designed to obtain information by interview on Religion
the practice of self-medication while the other was a Buddhist 85.0 82.5
short test on the participants’ knowledge of the Christian 5.0 7.5
Moslem 10.0 10.0
management of common ailments and the drugs Total 100.0 100.0
commonly used or stored at home. Out of 370
*Hindus. though they constitute 17.6”” of the
families in the community, 200 were chosen randomly country’s total population live mostly in the
and 80 comprising 40 literate and 40 illiterate catego- north and were not represented in the sample.
ries finally selected in an attempt to control for age,
sex, ethnic group, occupation and religion. A family
was categorized illiterate if the household head Choice qf health care resource
and/or decision maker on health matters was illiter- Of the 7 options of health care resources listed, the
ate. Western trained doctor was the most popular with a
Homes were inspected to determine how safely majority (70-80’~) of both categories of respondents
drugs were kept and what types and amount were (Table 2). The illiterates had made more visits to the
kept. doctor and made lesser attempts at self medication in
To minimize bias, 2 student-health personnel the previous 6 months (Tables 4 and 5).
rather than the area’s normal health personnel helped
as interpreters and collected data. One of them spoke Reasons for se[f-medication
Sinhala while the other was Tamil. Respondents gave the following reasons for treat-
Interviews and the short test were conducted in the ing themselves instead of consulting qualified medical
community on a public holiday and Saturdays as this professionals (i) no time to see the medical prac-
gave opportunity to meet employed people at home. titioner (literates, 10%; illiterates O%), (2) need to
It was important to interview whoever was the deci- wait for long periods (literates 35% illiterates 09,) (3)
sion maker on matters of health in each family. belief in Ayurvedic medicine (literates 5p;, illiterates
Variables included literacy level, number of visits 5%).
to doctors, number of times self-medication Other reasons such as lack of privacy, financial
attempted, amount of drugs kept, knowledge of drug constraints, distance of clinics/hospitals and profes-
usage and storage and scores on the short test. sionals’ inability to understand problems were not
Statistical methods used in analysis of the data considered inhibitory. Both categories preferred to
included calculation of percentages, cross tabu- consult Western trained doctors and were reluctant to
lations, correlations and tests for significance of consult their primary health care personnel. But the
correlations. overall correlation of their choice of health care
Limitations of the study included the fact that the resources was not highly significant. P = 0.35 (Table
area used is not totally representative of the whole 2). Self-treatment was more popular with literates.
country. Kalutara is an area that has for many years
been used as a practice area for preventive medicine Hoarding of drugs
and has a high population of Public Health Staff Asked what respondents did with drugs left over
unlike many parts of the country. Also, the use of from a prescription, the responses agreed with the
interpreters might have influenced responses. findings of home inspections that a high percentage
of both categories kept them (Table 6). The literates
seemed to have a greater tendency to hoard drugs but
Dejinition of terms there was no significant difference between them and
(I) Illiterate-had no formal schooling or had the illiterates.
functional education only. According to the inspection findings, literates kept
(2) Literate-can read and write English or the more drugs while the illiterates had fewer drugs that
local language. had recently been prescribed in the clinic or hospital.
(3) Ayurvedic doctor-one who practices the tra- Most of these were still being used. Also. most homes
ditional type of health care (Ayurveda). kept traditional medicines.
 Self-medication: an important aspect of primary health care 701

Table 2. Choice of health care resources in relation to education category

Educational category
Illiterate Literate
Health care resource F Rank 9, F Rank %
Western trained doctor 32 I 80.0 28 1 70.0
Nurse 1 5.5 2.5 0 7 0
Self 2 3 5.0 7 2 17.5
Pharmacist 0 7 0 0 5.5 0
Traditional (Ayurvedic) healer 2 3 5.0 4 3 IO
Assistant Medical Practitioner I 5.5 2.5 I 4 2.5
Other (relation or friend) 2 3 5.0 0 5.5 0
Total 40 100.0 40 100.0
F = frequency.
Correlations (using Spearman rank coefficient) illiterate/literate p = + 0.35.

Table 3. Health personnel preferred in the absence of a doctor

Educational category
Primary health care Illiterate Literate
personnel N % N % % of Total
Family health
worker (or PHM) 3 7.5 5 12.5 10.0
Public health nurse I 2.5 7 17.5 10.0
Public health Inspector 3 7.5 2 5.0 6.2
Any of the above 3 7.5 5 12.5 10.0
None of the above* 24 60.0 21 52.5 56.3
No response 6 15.0 0 0 7.5
Total 40 100.0 40 100.0 100.0
*May mean consultation of Ayurvedic doctors, pharmacist, a relation/neighhour or self-
treatment.

Knowledge about drugs kept taken for indigestion and there were some ‘all-
Most respondents, regardless of their educational purpose’ Ayurvedic tablets.
level showed deficiencies in their knowledge of drugs. Many simply continued to buy drugs that had
Of the illiterates 55% did not know the names of the previously been prescribed for them for example,
their drugs, 75.5% the side effects, 92.5% how to store Valium which an elderly literate lady had been taking
them and 100% had no idea when the drugs will every night since prescription 1 year earlier or Lasix
expire. that a similar respondent had used on and off for 3
Most literates (62.5%) knew the names of their years (when she felt weak).
drugs but like the illiterates did not know their side
effects or what dates they will expire (55% knew their DISCUSSION
usefulness, 309/, the side effects, 22.5% the storage Compulsory education up to the age of 15 years
methods and 0% the expiry dates). commenced in Sri-Lanka in 1953. This is probably
The questionnaire (short test) c&firmed the
deficiencies in both categories’ knowledge about Table 6. Hoardine of drums
drugs and home remedies. The purposes for which What respondent Educational category
they used some of their drugs were far from being does with left
medically acceptable. For example, Tetracycline was over drugs Illiterate Literate Total
Keep 27 22 49
Throw away IO I5 25
Table 4. Educational level and consultation of doctors in the Total 37 37 74
last 6 months d.f. = I; y2 = 14.95; P > 0.01.
Educational category
Consulted Table 7. Sources of information on drugs purchased without
doctor Illiterate Literate Total prescription
Yes 28 20 48
No I2 20 32 Illiterate Literate
0,
Total 40 40 80 Source of information F % F 10
d.f. = I: )!’ = 3.30; P < 0.05. I. Advertisement 10 25.0 4 10.0
2. Parents/friends/
neighbours 2 5.0 6 15.0
Table 5. Educational level and practice of self-medication 3. The chemist 0 0 16 40.0
4. The Ayurvedic
Self- Educational category
treatment practitioner 2 5.0 2 5.0
attempted Illiterate Literate Total 5. Health worker 4 10.0 8 20.0
6. School/health
Yes 18 28 46 training center 0 0 4 10.0
No 22 12 34 7. Other 4 10.0 0 0
Total 40 40 80 8. No response 18 45.0 0 0
d.f. = 1: 1’ = 5.16; P <O.Ol. Total 40 100.0 40 100.0
702 0. A. AB~SEDE

why fewer illiterates than before fell into the less than Safety of self-medication and self-reliance
30 year groups. With the literacy rate now about Illiteracy is not synonymous with ignorance but the
SOT,&Sri-Lanka in a few years will boast of almost findings of this study showed the literate to be more
lOOo/, literacy. From findings of the study, it may be competent, even though not adequately in managing
inferred that an increasing number of people will be minor ailments at home. Many of them probably
confident to treat themselves at home for certain learnt first aid measures in the elementary school.
ailments rather than consult primary health care Self-medication where done appropriately is de-
oersonnel (Tables 4 and 5). sirable. Cargill [14] and the United Kingdom Office
The docior-population ;atio in Sri-Lanka in 1979 of Health Economics [ 151 among others have argued
was 1 :3830 (Ministrv of Health. Sri-Lanka) but this for increased self-care. They recommended that the
had increaseh by 19il to abou; 1: 6000 bdcause of medical profession review its attitude towards self-
the alarming rate of emigration of doctors to other medication, with a view to becoming slightly more
countries. The decreasing number is likely to worsen permissive. Cargill in fact argued that as an aid to
attendant rate of literates who unlike the illiterates easing the burden of work of a general practitioner.
were already complaining of the need to wait for long some types of antibiotics should be made available as
periods at the hospital (35%) and difficulty with patent medicine.
excusing themselves from work (10%). Medical professionals have argued against such a
More literates kept and used left-over drugs and permissive attitude and their stand can be supported
bought a greater variety of drugs from the pharma- on legal and ethical grounds. Certain questions need
cies without a doctor’s prescription. to be answered for example, (I) What criteria will
Rejection of other cadres of health personnel other determine the effective limits of self-care and profes-
than the doctor may as stated by respondents (Tables sional care? (2) What problems may arise from over
2 and 3) be due to the fact that they were aware of medication? (3) What are the ethical implications of
the limitations of such health personnel and therefore imposing self-care on a society considering the fact
seemed to have more confidence treating themselves that ‘just a little knowledge is often dangerous’? One
than accepting care from the latter. This finding may may go on and on but if self-reliance is being
not be a true reflection of actual use of resources but preached by the World Health Organization, one is
should it be, then delay in receiving appropriate compelled to go along with Mahler [16] who said:
medical attention whenever necessary will be a grave
problem. If health does not start with individuals, the home, the
Gould [6] in 1957 described such delay in seeking family, the working place and the schools, then we will never
medical treatment in a study he carried out in the get to the goal of health for all. Even if we take the example
of industrialised countries, self-care. self responsibility, self
North Indian village of Sherapur.
coping in the individual family and community represent
Even where medical facilities are readily available
50-60% of all care.
lay diagnosis and management persist. Bermondsey
and Southwark boroughs in London, served by Guy’s Self-care is believed to b= cheaper than hospital and
hospital (a well equipped and well staffed hospital) other types of care. A study on the cost effectiveness
were examined in a study on choice of treatment of self care for Colds in A.merica by Zapka and Averil
during illness by Wadsworth er al. [7]. They found [ 171 showed a marked decrease in the number of visits
that in spite of a higher percentage visiting physicians to medical practitioners and a decrease in the cost of
for complaints, when it came to medication, a higher treatment per person as a result of a self-care centre
percentage had taken drugs which were not medically with prepaid ambulatory service for 21,500 sub-
prescribed for some period before consulting a doc- scribers and their dependents.
tor. Twenty to fifty per cent had used self-prescribed
Need for education of consumers and drug sellers
drugs and more than 60”/, had been diagnosed by
non-medical persons. Self-medication in spite of different legislations on
Traditional care is also preferred to care from the drugs is practised at dangerous levels throughout the
health personnel (Table 2). This is similar to the world. There are several cases of drug misuse and
finding of Colson [8] in a study carried out in a rural abuse which can be prevented through education of
Malay village. He also recorded a high percentage of the community. What should be taught? Some have
people who preferred self-medication and traditional advocated for limiting self-medication to symptom
treatment. His findings on 520 illness episodes and treatment. Artzliche [ 181said:
the resource employed were (1) use of Government
Self medication should be exclusively limited to symptom
health services, 26.5%; (2) native health services,
treatments. Provided that the chemist properly informs the
18.1%; (3) private physicians, 5.6%; (4) medicine consumer, self medication assumes a prominent part within
vendors, 7.5”/,; (5) self-treatment 16%; (6) no treat- the education of the population to a reasonable use of
ment 4%; (7) combinations 22.3% medicine.
Shukla [9] in India, Wanigaratne [IO] in Sri-Lanka,
Maclean [I I] and Ademuwagun [12] in Nigeria have Most developed countries have control of ‘over-
also found in rural and urban settings that traditional the-counter’ sales while dangerous drugs such as
medicines are commonly used by both literates and sedatives, hormones etc. are hawked freely in the
illiterates. developing ones. Misuse of drugs is increasing at an
Halon and Ampofo [13] think it wrong to dismiss alarming rate as there are increasing numbers of
use of ‘herbal preparations simply because sometimes quack doctors. Antiobiotics are given as single-dose
it is not possible to analyse or synthetize them injections or a few capsules mixed into native potions
scientifically. and the ‘holy’ healing water.
 Self-medication: an important aspect of primary health care 703

Drugs purchased or previously obtained from (2) All countries be encouraged to enforce the use
clinics/hospitals are hoarded and carelessly kept and of package inserts with the essential information for
cases of accidental ingestion resulting in death have every drug prescribed for patients. Cost of prod-
been reported. Consumers certainly need to know uction will be less if an Essential Drug’s List is
basic facts about drugs they use. These are not adhered to.
thoroughly explained in the package inserts presently
used by many pharmaceutical companies. Herman et
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