Sot. Sci. Med. Vol. 19, No.

Printed in Great Britain

7, pp. 699-703.

027779536/84 $3.00 + 0.00

Pergamon Press Ltd

1984

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
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 selfmedication was practised by members of a community 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 selfmedicating 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 facilities were adequate and easily accessible, the prevalence 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, Maternal 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].

Due to an agro-based economy, 80% of the population 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) doctors 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 General 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 peripheral 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,
doctor : population,
nurse : population
and Ayurvedic
doctor: population
ratios of 1: 6000, 1: 570 and
1 : 25000 respectively.

699

0. A.

700

ABOSEDE

Kalutara South, the Public Health Midwife (PHM)

area chosen by random sampling for this study is said
to be approximately
representative
of the other PHM
areas. It had 370 homes in both urban (town like) and
rural (village with huts) setting.
Western and traditional
drugs are available for
purchase
as the Government
recognises
and promotes Ayurvedic (traditional)
medicine.
Drugs available
for sale over-the-counter
and
those imported to all parts of the country are under
control of the State Formulary
Corporation
while
those available for use in Estate Hospitals are under
control of the National Formulary
Committee.

MATERIALS

Table

Dejinition of terms
(I) Illiterate-had
no formal schooling
or had
functional education only.
(2) Literate-can
read and write English or the
local language.
(3) Ayurvedic doctor-one
who practices the traditional type of health care (Ayurveda).

Characteristics

of respondents
O0 Respondents

Characteristics

LIterate

Illiterate

25.0
42.5
30.0
2.5
100.0

25.0
47.5
25.0
2.5
100.0

61.5
32.5
100.0

70.0
30.0
100.0

97.5
2.5
100.0

95.0
5.0
100.0

52.5
47.5
100.0

75.0
25.0
100.0

85.0
5.0
10.0
100.0

82.5
7.5
10.0
100.0

Age group
Z&29
3&39
4w9
70+
Total
Sex
Female
Male
Total
Ethnic group
Sinhalese
Tamil
Total
Occupation
Housewife
Semi-skilled
Total
Religion
Buddhist
Christian
Moslem
Total

AND METHODS

Two questionnaires
were used for the study. One
was designed to obtain information
by interview on
the practice of self-medication
while the other was a
short test on the participants
knowledge
of the
management
of common
ailments
and the drugs
commonly
used or stored at home. Out of 370
families in the community,
200 were chosen randomly
and 80 comprising 40 literate and 40 illiterate categories finally selected in an attempt to control for age,
sex, ethnic group, occupation
and religion. A family
was categorized
illiterate
if the household
head
and/or decision maker on health matters was illiterate.
Homes were inspected
to determine
how safely
drugs were kept and what types and amount were
kept.
To minimize
bias, 2 student-health
personnel
rather than the areas normal health personnel helped
as interpreters
and collected data. One of them spoke
Sinhala while the other was Tamil.
Interviews and the short test were conducted in the
community on a public holiday and Saturdays as this
gave opportunity
to meet employed people at home.
It was important
to interview whoever was the decision maker on matters of health in each family.
Variables included literacy level, number of visits
of times
self-medication
number
to doctors,
attempted,
amount of drugs kept, knowledge of drug
usage and storage and scores on the short test.
Statistical
methods
used in analysis of the data
included
calculation
of percentages,
cross tabulations, correlations
and tests for significance
of
correlations.
Limitations
of the study included the fact that the
area used is not totally representative
of the whole
country. Kalutara is an area that has for many years
been used as a practice area for preventive medicine
and has a high population
of Public Health Staff
unlike many parts of the country. Also, the use of
interpreters
might have influenced responses.

I.

*Hindus.
though
they constitute
17.6 of the
countrys total population
live mostly in the
north and were not represented in the sample.

Choice

qf health care resource

Of the 7 options of health care resources listed, the

Western trained doctor was the most popular with a
majority (70-80~) of both categories of respondents
(Table 2). The illiterates had made more visits to the
doctor and made lesser attempts at self medication in
the previous 6 months (Tables 4 and 5).
Reasons for se[f-medication
Respondents
gave the following reasons for treating themselves instead of consulting qualified medical
professionals
(i) no time to see the medical practitioner
(literates,
10%; illiterates O%), (2) need to
wait for long periods (literates 35% illiterates 09,) (3)
belief in Ayurvedic medicine (literates 5p;, illiterates
5%).
Other reasons such as lack of privacy, financial
constraints,
distance of clinics/hospitals
and professionals inability to understand
problems
were not
considered
inhibitory.
Both categories
preferred
to
consult Western trained doctors and were reluctant to
consult their primary health care personnel.
But the
overall correlation
of their choice of health care
resources was not highly significant. P = 0.35 (Table
2). Self-treatment
was more popular with literates.
Hoarding of drugs
Asked what respondents
did with drugs left over
from a prescription,
the responses agreed with the
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
there was no significant difference between them and
the illiterates.
According to the inspection findings, literates kept
more drugs while the illiterates had fewer drugs that
had recently been prescribed in the clinic or hospital.
Most of these were still being used. Also. most homes
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
Health care resource

Rank

Western trained doctor

Nurse
Self
Pharmacist
Traditional (Ayurvedic) healer
Assistant Medical Practitioner
Other (relation or friend)
Total

32
1
2
0
2

I
2
40

Literate
F

Rank

28
0
7
0
4

1
7
2
5.5
3
4
5.5

70.0
0
17.5
0
IO
2.5
0
100.0

9,
80.0
2.5
5.0
0
5.0
2.5
5.0
100.0

5.5
3
7
3
5.5
3

F = frequency.
Correlations (using Spearman rank coefficient) illiterate/literate

I
0
40

p = + 0.35.

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

Educational
Primary health care
personnel

Family health
worker (or PHM)
Public health nurse
Public health Inspector
Any of the above
None of the above*
No response
Total

3
I
3
3
24
6
40

*May mean consultation

treatment.

Knowledge

about drugs kept

Table 4. Educational level and consultation of doctors in the

last 6 months
Consulted
doctor

Illiterate

Yes
28
No
I2
Total
40
d.f. = I: )! = 3.30; P < 0.05.
Table 5. Educational
Selftreatment
attempted
Yes

Illiterate

18
No
22
Total
40
d.f. = 1: 1 = 5.16; P <O.Ol.

7.5
2.5
7.5
7.5
60.0
15.0
100.0

Literate
N

% of Total

5
7
2
5
21
0
40

12.5
17.5
5.0
12.5
52.5
0
100.0

10.0
10.0
6.2
10.0
56.3
7.5
100.0

a relation/neighhour

or self-

taken for indigestion and there were some allpurpose Ayurvedic tablets.
Many simply continued to buy drugs that had
previously been prescribed for them for example,
Valium which an elderly literate lady had been taking
every night since prescription 1 year earlier or Lasix
that a similar respondent had used on and off for 3
years (when she felt weak).
DISCUSSION

Compulsory education up to the age of 15 years

commenced in Sri-Lanka in 1953. This is probably
Table 6. Hoardine of drums
What respondent
does with left
over drugs

Educational
Illiterate

Literate

Total

Keep
Throw away
Total

27
IO
37

22
I5
37

49
25
74

purchased

without

category

d.f. = I; y2 = 14.95; P > 0.01.

category
Literate

Total

20
20
40

48
32
80

level and practice of self-medication

Educational

of Ayurvedic doctors, pharmacist,

Most respondents, regardless of their educational

level showed deficiencies in their knowledge of drugs.
Of the illiterates 55% did not know the names of the
their drugs, 75.5% the side effects, 92.5% how to store
them and 100% had no idea when the drugs will
expire.
Most literates (62.5%) knew the names of their
drugs but like the illiterates did not know their side
effects or what dates they will expire (55% knew their
usefulness, 309/, the side effects, 22.5% the storage
methods and 0% the expiry dates).
The questionnaire
(short test) c&firmed
the
deficiencies in both categories knowledge about
drugs and home remedies. The purposes for which
they used some of their drugs were far from being
medically acceptable. For example, Tetracycline was

Educational

category

Illiterate

category
Literate

Total

28
12
40

46
34
80

Table 7. Sources of information on drugs

prescription
Illiterate
Source of information
I. Advertisement
2. Parents/friends/
neighbours
3. The chemist
4. The Ayurvedic
practitioner
5. Health worker
6. School/health
training center
7. Other
8. No response
Total

Literate

0,

10

25.0

10
10.0

2
0

5.0
0

6
16

15.0
40.0

2
4

5.0
10.0

2
8

5.0
20.0

0
4
18
40

0
10.0
45.0
100.0

4
0
0
40

10.0
0
0
100.0

702

0. A.

why fewer illiterates than before fell into the less than
30 year groups. With the literacy rate now about
SOT,&Sri-Lanka in a few years will boast of almost
lOOo/, literacy. From findings of the study, it may be
inferred that an increasing number of people will be
confident
to treat themselves
at home for certain
ailments rather than consult primary
health care
oersonnel (Tables 4 and 5).
The docior-population
;atio in Sri-Lanka in 1979
was 1 :3830 (Ministrv of Health. Sri-Lanka) but this
had increaseh by 19il to abou; 1: 6000 bdcause of
the alarming rate of emigration
of doctors to other
countries. The decreasing number is likely to worsen
attendant
rate of literates who unlike the illiterates
were already complaining
of the need to wait for long
periods at the hospital
(35%) and difficulty with
excusing themselves from work (10%).
More literates kept and used left-over drugs and
bought a greater variety of drugs from the pharmacies without a doctors prescription.
Rejection of other cadres of health personnel other
than the doctor may as stated by respondents
(Tables
2 and 3) be due to the fact that they were aware of
the limitations of such health personnel and therefore
seemed to have more confidence treating themselves
than accepting care from the latter. This finding may
not be a true reflection of actual use of resources but
should it be, then delay in receiving appropriate
medical attention whenever necessary will be a grave
problem.
Gould [6] in 1957 described such delay in seeking
medical treatment
in a study he carried out in the
North Indian village of Sherapur.
Even where medical facilities are readily available
lay diagnosis and management
persist. Bermondsey
and Southwark boroughs in London, served by Guys
hospital (a well equipped and well staffed hospital)
were examined
in a study on choice of treatment
during illness by Wadsworth
er al. [7]. They found
that in spite of a higher percentage visiting physicians
for complaints,
when it came to medication,
a higher
percentage had taken drugs which were not medically
prescribed for some period before consulting a doctor. Twenty to fifty per cent had used self-prescribed
drugs and more than 60/, had been diagnosed
by
non-medical
persons.
Traditional
care is also preferred to care from the
health personnel
(Table 2). This is similar to the
finding of Colson [8] in a study carried out in a rural
Malay village. He also recorded a high percentage of
people who preferred self-medication
and traditional
treatment.
His findings on 520 illness episodes and
the resource employed were (1) use of Government
health services, 26.5%; (2) native health services,
18.1%; (3) private physicians,
5.6%; (4) medicine
vendors, 7.5/,; (5) self-treatment
16%; (6) no treatment 4%; (7) combinations
22.3%
Shukla [9] in India, Wanigaratne
[IO] in Sri-Lanka,
Maclean [I I] and Ademuwagun
[12] in Nigeria have
also found in rural and urban settings that traditional
medicines are commonly
used by both literates and
illiterates.
Halon and Ampofo [13] think it wrong to dismiss
use of herbal preparations
simply because sometimes
it is not possible to analyse or synthetize
them
scientifically.

AB~SEDE

Safety of self-medication and self-reliance

Illiteracy is not synonymous
with ignorance but the
findings of this study showed the literate to be more
competent,
even though not adequately in managing
minor ailments at home. Many of them probably
learnt first aid measures in the elementary
school.
Self-medication
where done appropriately
is desirable. Cargill [14] and the United Kingdom Office
of Health Economics [ 151 among others have argued
for increased self-care. They recommended
that the
medical profession
review its attitude towards selfmedication,
with a view to becoming slightly more
permissive. Cargill in fact argued that as an aid to
easing the burden of work of a general practitioner.
some types of antibiotics should be made available as
patent medicine.
Medical professionals
have argued against such a
permissive attitude and their stand can be supported
on legal and ethical grounds. Certain questions need
to be answered for example, (I) What criteria will
determine the effective limits of self-care and professional care? (2) What problems may arise from over
medication?
(3) What are the ethical implications
of
imposing self-care on a society considering
the fact
that just a little knowledge is often dangerous? One
may go on and on but if self-reliance
is being
preached by the World Health Organization,
one is
compelled
to go along with Mahler [16] who said:
If health does not start with individuals, the home, the
family, the working place and the schools, then we will never
get to the goal of health for all. Even if we take the example
of industrialised
countries, self-care. self responsibility,
self
coping in the individual family and community represent
50-60% of all care.
Self-care is believed to b= cheaper than hospital and
other types of care. A study on the cost effectiveness
of self care for Colds in A.merica by Zapka and Averil
[ 171 showed a marked decrease in the number of visits
to medical practitioners
and a decrease in the cost of
treatment per person as a result of a self-care centre
with prepaid
ambulatory
service for 21,500 subscribers and their dependents.
Need for education of consumers and drug sellers
Self-medication
in spite of different legislations on
drugs is practised at dangerous levels throughout
the
world. There are several cases of drug misuse and
abuse which can be prevented through education of
the community.
What should be taught? Some have
advocated
for limiting self-medication
to symptom
treatment.
Artzliche [ 181said:
Self medication should be exclusively
treatments.

Provided

that the chemist

limited to symptom
properly informs the

consumer, self medication assumes a prominent part within

the education of the population to a reasonable use of
medicine.
Most developed countries
have control of overthe-counter
sales while dangerous
drugs such as
sedatives,
hormones
etc. are hawked freely in the
developing ones. Misuse of drugs is increasing at an
alarming
rate as there are increasing
numbers
of
quack doctors. Antiobiotics
are given as single-dose
injections or a few capsules mixed into native potions
and the holy healing water.

Self-medication:

an important

Drugs purchased
or previously
obtained
from
clinics/hospitals
are hoarded and carelessly kept and
cases of accidental ingestion resulting in death have
been reported.
Consumers
certainly need to know
basic facts about drugs they use. These are not
thoroughly
explained in the package inserts presently
used by many pharmaceutical
companies. Herman et
al. [ 171 have suggested what minimum information
is
needed in package inserts for prescribed
medicines.
They include informations
on what the medicine
does, taking the medicine (important
details), storing
the medicine, possible problems and solutions, long
term treatment and what to do in case of accidental
overdose.
Not only consumers need to be educated. The drug
sellers need it even more, though the chemists pharmacists
were not highly rated as a health care
resource especially by the illiterates. This is unlike the
findings in some other countries
like Nigeria for
example where Gesler [20] found that chemists or
sellers of patent medicines in small shops were the
preferred
resources
for most of the sample population. This he associated with the fact that there were
not enough clinics or hospitals in the area of study
and drug sellers were more accessible.
Many chemist shops have attendants
who prescribe medicine according
to symptoms
and many
times conditions
are misdiagnosed
and wrong treatment prescribed. Amichi et al. [21] found this in Iran
in 1978 where pharmacy attendants
dispensed drugs
without prescription.
Much as many Governments
do not want to
encourage chemists/pharmacists
to function as doctors, it is vital that they as primary care givers, be
educated on management
of the minor illnesses and
serve as a link in the referral system.
Getting
information
about drugs across to the
people can be achieved through the mass media and
health workers. Advertisements
were a major source
of information
for the illiterates
while it was the
Chemist for the literates in Kalutara (Table 7). One
expects similar finding in many countries.
CONCLUSION

Von Trosche

[22] has rightly

said:

a majority of every-day complaints and disturbances of

well being will not induce a patient to consult a doctor, self
medication in the lay manner being the rule.
It was therefore
concluded
from this study that:
(1) Self-medication
be emphasized as a component
in primary health care and that more health education programs be designed to educate communities
on safer practices.

aspect

of primary

health

care

(2) All countries be encouraged

to
of package inserts with the essential
every drug prescribed
for patients.
uction will be less if an Essential
adhered to.

703

enforce the use

information
for
Cost of prodDrugs List is

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