University of Ghana http://ugspace.ug.edu.gh SCHOOL OF PUBLI C HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA, LEGON ASSESSMENT OF SELF-MEDICATION FOR URTIs AMONG CHILDREN IN TEMA EAST SUB-METRO IN THE TEMA METROPOLITAN ASSEMBLY. BY ANGELA ACHEAMPOMAA (10359741) THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF THE MASTER OF PUBLIC HEALTH (MPH) DEGREE. DECEMBER, 2018 University of Ghana http://ugspace.ug.edu.gh DECLARATION I hereby declare that with the exception of references made of other people’s work which have been duly cited in the study, this report is the result of my own research work and that it has not been submitted either in whole or part to any other institution for another degree. ACADEMIC SUPERVISOR …………………………… PROF MOSES AIKINS ANGELA ACHEAMPOMAA (ID: 10359741) i University of Ghana http://ugspace.ug.edu.gh DEDICATION I dedicate this work to my family in recognition of their prayers, encouragement and support for me throughout my study. ii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT My greatest gratitude goes to God Almighty for the grace and opportunity bestowed on me to pursue my master’s degree. I am grateful to my academic supervisor, Professor Moses Aikins of the School of Public Health, Legon for his direction and academic inputs. I am also grateful to all my lecturers who took time to teach and explain in detail aspects of Public Health. My gratitude goes to the Head of Department – Health Policy, Planning and Management, and the staff of School of Public Health who were very helpful in ensuring that I followed all administrative processes required by the University. My sincerest gratitude goes to the Metropolitan Director of Health Service and Sub-Metro Director who gave approval for data collection in the selected sub-metro for this research work. I am very grateful to all the data collectors for their time and sacrifice during the data collection period. My greatest gratitude goes to Mr. Hayford Kofi Oduro (my dear husband) for the financial and technical support. I am also grateful to my children, Heavelyn, Lordina, Godlives and Hayford Jnr for their love and care. I am very grateful to Mr. Steven Bonsoe of Abromex Consult for his technical support and coaching during the data analysis stage. I am also grateful to Ms. Irene Asamoah for all the reviews, comments, professional and technical support provided me during the write up. Your support cannot be quantified: Thank you! iii University of Ghana http://ugspace.ug.edu.gh To all those who made inputs during the various presentations in the formative stages of the study, I say ‘Thank you’; your inputs helped to shape the study. To everyone else who contributed in diverse ways during the development of this work, I appreciate every bit of contribution you made to bring the work to this point. May God bless us all! iv University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS DECLARATION ............................................................................................................................. i DEDICATION ................................................................................................................................ ii ACKNOWLEDGEMENT ............................................................................................................. iii TABLE OF CONTENTS ................................................................................................................ v LIST OF FIGURES/MAPS ......................................................................................................... viii LIST OF TABLES ......................................................................................................................... ix LIST OF ABBREVIATIONS ......................................................................................................... x DEFINITION OF TERMS ............................................................................................................ xi ABSTRACT .................................................................................................................................. xii CHAPTER ONE ............................................................................................................................. 1 INTRODUCTION .......................................................................................................................... 1 1.1 BACKGROUND ................................................................................................................... 1 1.2 PROBLEM STATEMENT ................................................................................................... 4 1. 3 OBJECTIVES ...................................................................................................................... 5 1.3.1 General objective: ........................................................................................................... 5 1.3.2 Specific objectives: ......................................................................................................... 5 1.4 RESEARCH QUESTIONS ................................................................................................... 6 1.5 JUSTIFICATION .................................................................................................................. 6 1.6 CONCEPTUAL FRAMEWORK ......................................................................................... 7 CHAPTER TWO .......................................................................................................................... 10 LITERATURE REVIEW ............................................................................................................. 10 2.1 THE CONCEPT OF SELF-MEDICATION ....................................................................... 10 2.1.1 Definition of Self-Medication .......................................................................................... 10 2.2 Types of self-medication ..................................................................................................... 12 2.2.1 Responsible self-medication ......................................................................................... 12 2.2.2 Irresponsible, Non-rational or Inappropriate self-medication ...................................... 13 2.3 Prevalence of self-medication among children ................................................................... 14 2.4 Benefit and risks of self-medication.................................................................................... 16 2.5 Factors influencing with self-medication among children .................................................. 17 2.5.1 Parental socioeconomic background ............................................................................ 17 2.5.2 Individual and personal/ Household / Societal norms and Cultural factors influencing self-medication ...................................................................................................................... 18 2.5.3 Provider factors............................................................................................................. 19 v University of Ghana http://ugspace.ug.edu.gh 2.5.4 Mass media ................................................................................................................... 20 2.6 Conclusion ........................................................................................................................... 20 CHAPTER THREE ...................................................................................................................... 22 METHODOLOGY ....................................................................................................................... 22 3.1 STUDY DESIGN ................................................................................................................ 22 3.2 STUDY AREA .................................................................................................................... 22 3.3 VARIABLES ...................................................................................................................... 23 3.3.1 Dependent variable ....................................................................................................... 23 3.3.1.1 Responsible Self-Medication .............................................................................. 23 3.3.1.2 Irresponsible Self-Medication ............................................................................. 24 3.3.1.3 Overall Self-Medication ...................................................................................... 24 3.3.2 Independent Variables .................................................................................................. 24 3.3.2.1 Socio-demographic characteristics ............................................................................ 24 3.3.2.2 Individual/Household/Societal factors ...................................................................... 24 3.3.2.3 Mass Media Factors ................................................................................................... 25 3.3.2.4 Provider Factors ......................................................................................................... 25 3.4 STUDY POPULATION ..................................................................................................... 25 3.4.1 Inclusion criteria ........................................................................................................... 25 3.4.2 Exclusion criteria .......................................................................................................... 26 3.5 SAMPLING ........................................................................................................................ 26 3.5.1 Sample size determination ............................................................................................... 26 3.5.2 Sampling Method ............................................................................................................. 27 3.6 DATA COLLECTION METHODS AND TOOLS ............................................................ 27 3.6.1 Data collection.................................................................................................................. 27 3.6.2 Data processing and analysis............................................................................................ 27 3.7 Background characteristics of parents/caregivers and children ...................................... 28 3.8 Determination of prevalence of self-medication ................................................................. 28 3.10 Quality control................................................................................................................... 29 3.10.1 Training of research assistance ................................................................................... 29 3.10.3 Supervision and checking ........................................................................................... 30 3.11 Ethical clearance ............................................................................................................... 30 3.11.1 Community entry ........................................................................................................ 30 3.11.2 Privacy, confidentiality and anonymity ...................................................................... 30 3.11.3 Compensation ............................................................................................................. 31 vi University of Ghana http://ugspace.ug.edu.gh 3.11.4 Risk and Benefits ........................................................................................................ 31 3.11.5 Voluntary withdrawal ................................................................................................. 31 3.11.6 Consenting process ..................................................................................................... 31 3.11.7 Data storage and usage ............................................................................................... 32 3.11.8 Declaration of conflict of interest ............................................................................... 32 CHAPTER FOUR ......................................................................................................................... 33 RESULTS ..................................................................................................................................... 33 4.0 Introduction ......................................................................................................................... 33 4.3 Prevalence of self-medication ............................................................................................. 36 4.4.1 Socio-demographic factors ............................................................................................... 37 4.4.2 Provider factors, personal/household/social and media factors ....................................... 40 CHAPTER FIVE .......................................................................................................................... 42 DISCUSSIONS ............................................................................................................................. 42 5.0 Introduction ......................................................................................................................... 42 5. 1 The prevalence of self-medication for URTI among children below 5 years .................... 42 5.2 The factors influencing self-medication .............................................................................. 43 5.2.1 Socio-demographic factors ............................................................................................... 43 5.5.2 Provider factors, personal/household/social and media factors .................................... 44 CHAPTER SIX ............................................................................................................................. 46 CONCLUSION AND RECOMMENDATIONS ......................................................................... 46 6.1 Conclusion ....................................................................................................................... 46 6.2 Recommendations ........................................................................................................... 46 REFERENCES ............................................................................................................................. 47 APPENDICES ................................................................................................................................. I Appendix A: Participant’s Consent Form .................................................................................... I Appendix B: Questionnaire ....................................................................................................... IV vii University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES/MAPS Figure 1.1: Conceptual framework of self-medication among under-five children…………..…22 Figure 3.1: Map of Tema Metropolitan Assembly........................................................................35 Figure 4.1: Place of URTI treatment…………………………………………………………….46 Figure 4.2: Prevalence of responsible and irresponsible self-medication……………………….47 viii University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 4.2: Background characteristics of parent/caregivers and children .................................... 34 Table 4.3: Socio-demographic factors influencing self-medication ............................................. 38 Table 4. 4 - Predictors of self-medication ..................................................................................... 40 ix University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATIONS ARI Acute Respiratory Infection CCM Cough and Cold Medications GHSERC Ghana Health Service Ethics Review Board MoH Ministry of Health NHIS National Health Insurance Scheme OECD Organization for Economic Co-operation and Development OTC Over- the-Counter TGA Therapeutic Goods Administration URTIs Upper Respiratory Tract Infections USA United States of America WHO World Health Organization WSMI World Self Medication Industry x University of Ghana http://ugspace.ug.edu.gh DEFINITION OF TERMS Self-medication Taking of medications without approval from medical professional Over-the-Counter Over-the-counter (OTC) medicine is a product that can be purchased medicines from pharmacies without a prescription Prescribed medicine Prescribed medicine is a product that may be dispensed from a pharmacy only with a prescription from a physician Responsible self- Responsible self-medication has been defined as the healthcare medication assumed by the patient where he or she has a greater degree of responsibility in the management of a symptom or illness, using a pharmaceutical product available over-the-counter (OTC) Irresponsible self- This is the inappropriate drug use which involves taking inadequate medication doses, sharing medicines, a short duration of treatment, and stopping treatment upon the improvement of disease symptoms xi University of Ghana http://ugspace.ug.edu.gh ABSTRACT Introduction: The burden of URTIs is common in children due to their weak immune systems leading to persistent morbidities such as pneumonia which increases the risk of mortality levels among children below five (5) years. The long hours spent at the health center discourages some care-givers from seeking professional help to diagnose and treat their children who are suffering from URTIs. Most caregivers therefore consider URTIs as minor ailments thus, they resort to home remedies using herbal medicines or antibiotics purchased Over the Counter (OTC). The aim of this study is to determine the prevalence of self-medication and the factors that influence self-medication among children less than five years in the Tema East sub- metropolis. Methods: Descriptive cross-sectional design was used with selected sample of 151. Parents/caregivers were randomly selected. Structured-questionnaire was used for data collection. Descriptive and logistic regression analyses was used. Results: The response rate was 83.4%. The overall prevalence of self-medication was 78.6%. Responsible and irresponsible self-medication were 41.4% and 58.6% respectively. Socio- economic factors were not significantly associated with self-medication. Provider factors was 0.1 times more at odds with self-medication among parents/caregivers than personal/household/social and media factors. Conclusion: This study concludes self-medication was high in the Tema East Sub-Metro especially irresponsible self-medication. This was mainly influenced by provider factors and not socio-economic factors. xii University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTION 1.1 BACKGROUND Self-medication, as a concept, has gained collective recognition worldwide. It generally encourages individuals to treat petty illnesses with effective and simple therapies and often preferred for combating the symptoms of diseases quickly. The World Health Organization (WHO, 2000) has defined self-medication as “the use of drugs to treat self-diagnosed disorders/symptoms, or the intermittent or continued use of a prescribed drug for chronic or recurrent diseases/symptoms”. Generally, this working definition effectively defines the very essence of self-medication. Self-medication is generally categorised into two forms, namely, responsible self-medication and irresponsible self-medication. Responsible self-medication involves treatment of self-diagnosed diseases and symptoms using drugs that are approved and properly used (Hughes, McElnay & Fleming (2001). On the other hand, irresponsible self- medication, according to Skliros et al (2010), involves taking inadequate doses, sharing medicines and stopping treatment upon improvement of disease symptoms. In addition, irresponsible self-medication is generally about using drugs to cure diseases, especially without medical advice. The World Self Medication Industry (WSMI) has identified self-medication as a major antidote for treating common illnesses which do not necessitate the doctor’s visit (Klemenc-Ketiš, Hladnik & Kersni, 2010). As further observed by WHO (2000), self-medication plays “an important role in healthcare” and enhances “people’s education, general knowledge and socio- economic status”. It is widely known that many healthcare systems worldwide have adopted self- medication in view of its benefits. 1 University of Ghana http://ugspace.ug.edu.gh Self-medication can contribute greatly in enhancing the health status of people. However, there is cause for concern, especially in the absence of a regulatory and legal framework to manage the practice of self-medication. For instance, WHO (2000) asserts that those who practice self- medication may obtain Over-The-Counter (OTC) drugs through self-prescription with a patient information leaflet but without instructions on drug use. This assertion confirms concerns raised about the irrational purchase and use of drugs, most especially in developing countries. Shanker, Partha and Shenoy (2002) observes that the proportion of drugs used for self-medication is higher than the use of prescribed drugs and this is usually due to the availability of a wide range of drugs and inadequate health services. Self-medication, though beneficial, has significant downside risks. One of the dangers of self- medication is the risk of worsening the pathology of an existing illness. Ameko, Achio and Alhasaan (2012) revealed that “pathogens isolated from the urine of patients who self-medicated indicated a high percentage of resistance than those isolated from urine samples of patients who did not self-medicate prior to the test”. In addition, inappropriate practice of self-medication as a result of inadequate knowledge of the efficacy of a drug could lead to the occurrence of several health conditions, most especially in lactation and during pregnancy (Shankar, Partha & Shenoy, 2002: Murray, Callahan, 2003). One of the factors that influence self-medication challenges is the prevalence of Over-The- Counter drugs. A study conducted in America indicated that 60% of self-treatment of ailments without professional help involved OTC drugs (Dabney, 2001). It is possible that the prevalence of OTC drugs is even higher in developing countries. As asserted by Khan (2011), about 60-80% of health problems are treated through self-medication as a lower cost alternative in most 2 University of Ghana http://ugspace.ug.edu.gh developing countries, including Ghana. It is public knowledge that OTC drugs are everywhere in Ghana due to proliferation of pharmacies and chemical shops. A number of studies have indicated that Upper Respiratory Tract Infections (URTIs) are the primary reason for self-medication. Research conducted in the United States of America and Europe also showed that self-medication is particularly well-known for colds and other URTI’s (Grigoryan et al, 2008). A report by the World Health Organization (WHO) revealed that “more than 50% of antibiotics worldwide are purchased privately from pharmacies or street vendors in the informal sector” without a prescription (Cars & Nordberg, 2005). It is also believed that self- medication is influenced mainly by OTC dispensing in pharmacies and past prescription drugs. As posited by Nichol, D’Heilly and Ehlinger, (2006), this occurs mostly in developing countries since the use of antibiotics without medical guidance is largely facilitated by inadequate regulation and sale of prescription drugs. Children form one of the major consumers of health care services in several developing countries and is usually reflected in their medication use (Santos, Barreto & Coelho, 2009). A study conducted by Cruz et at (2014) showed that self-medication among children is usually based on the assessment of the value, function and adaptation of the use of the drug in adults. Another study conducted in Brazil revealed a 56% prevalence of self-medication among children particularly those below two years of age. Some caregivers also resort to self-medication due to the lack of access to medical care. In a study conducted in six (6) Latin American countries, WHO (2000) showed that a “high percentage of drugs were being dispensed without medical prescription or follow-up and this was attributed to lack of access to medical care”. 3 University of Ghana http://ugspace.ug.edu.gh 1.2 PROBLEM STATEMENT Upper Respiratory Tract Infections (URTIs) are the most prevalent infections in several communities that cause about four (4) million deaths among children yearly, with majority of such deaths occurring in lower middle-income countries (Abdel-Salam & Abdel-Khalek, 2016). Children are at a higher risk of these infections due to their low immunity to infections leading to reduced activity days, school, work loss, school performance and increasing healthcare utilization (Nichol, D’Heilly & Ehlinger, 2008). The frequency of URTIs in children under-five years imposes excessive burden on parents, care givers and health care services with regards to the amount of time and money spent for diagnosis and treatment (WHO, 2000). Most parents and caregivers therefore self-diagnose and resort to self-medication practices by acquiring antibiotics from pharmacies, street vendors, or using left over drugs to treat children showing signs and symptoms of URTI such as common cold and otitis media. Care provided to children by caregivers, family and parents through self-medication may not be the most efficient way to treat URTIs. This very often leads to complications and other additional problems such as adverse drug reactions leading to hospital admissions of these children (Olivier et al., 2009; Lewinski et al., 2010), excessive and improper use of antibiotics (overuse/underuse), which is one of the causes of child mortality and bacterial resistance to drugs (Montasser, Helal & Rezq, 2012). Furthermore, caregivers use drugs without prescriptions in treating their children under five years with URTIs due to the misconceptions and misunderstandings about the appropriate applications and effectiveness of antibiotics. Self-medication has been studied as a concept by Ameko, Achios and Alhassan (2012), Osemene and Lamikanra (2012) and WHO (2000). However, the researcher submits that very few studies have been conducted on the factors influencing self-medication for URTI among children under 4 University of Ghana http://ugspace.ug.edu.gh five (5) years old in the Tema East sub-metropolis of the Greater Accra Region of Ghana. This study therefore seeks to determine the prevalence and factors of self-medication for URTIs among children under five (5) years old in the Tema East sub-metropolis in order to propose interventions that could contribute to reducing child mortality due to self-medication. The findings of the study could also be used by policy makers in formulating policy interventions to curtail self-medication among children as well as guide caregivers and service providers in mitigating self-medication for URTIs among children under five years. 1. 3 OBJECTIVES 1.3.1 General objective: The general objective of the study is to assess self-medication for URTI among children in the Tema Metropolitan Assembly. 1.3.2 Specific objectives: The specific objectives are: 1. To determine the prevalence of responsible self-medication for URTI among children less than five years in the Tema Metropolis 2. To determine the prevalence of irresponsible self-medication for URTI among children less than five years in the Tema Metropolis 3. To determine the prevalence of overall self-medication for URTI among children less than five years in the Tema Metropolis 4. To determine the factors influencing self-medication among children less than five years in the Tema Metropolis 5 University of Ghana http://ugspace.ug.edu.gh 1.4 RESEARCH QUESTIONS 1. What is the prevalence of responsible self-medication for URTI among children less than five years in the Tema Metropolis? 2. What is the prevalence of irresponsible self-medication for URTI among children less than five years in the Tema Metropolis? 3. What is the overall prevalence of self-medication for URTI among children less than five years in the Tema Metropolis? 4. What are the factors influencing self-medication among children less than five years in the Tema Metropolis? 1.5 JUSTIFICATION The issue of self-medication among children represents an emerging topic in the scientific research (Gualano et al., 2015). Studies have shown that there are risks and potential harm that can be caused by self-medication, yet self-medication among children is commonly reported to be prevalent and common pediatric OTC medications, such as cough and cold medicines (CCM) can lead even to serious adverse drug effects among self-medicating children (Du & Knopf, 2009). The phenomenon of self-medication of children is even widespread in developing countries such as Ghana. Therefore, an assessment of the extent of self-medication among children with upper respiratory infections in the Tema East Sub-metro will determine the prevalence of the phenomenon of self-medication of children and the factors driving this practice. This will provide baseline information to enable preventive measures to be taken in order to curb the practice. 6 University of Ghana http://ugspace.ug.edu.gh 1.6 CONCEPTUAL FRAMEWORK Self-medication of children primarily occurs through adult members of the family such as the biological parents or through other care takers. It is dependent upon several factors emanating from the persons responsible for the healthcare needs of the child. This shows that factors at the level of the parents can directly influence self-medication of children. As a result, socio- demographic factors of the parents such as educational level, age as well as occupation can influence the healthcare decisions taken in respect of the healthcare needs of the child. Also, geographical access to health services has the potential to influence self-medication of children by their parents. 7 University of Ghana http://ugspace.ug.edu.gh Figure 1.1 Conceptual framework of self-medication among under-five children Mother/ Caregiver/ Child Socio-demographic characteristics Age, Sex, Educational level, Income, Marital status. URTI Children (Last 2 weeks) Personal /Household/ Social Provider factors Mass media factors factors  Availability of OTCs  Advertisement  C ost of URT  Self-care orientation and  Ownership of treatment attitude towards medicine phone/radio/TV  Storage and use of left-over medicines at home  Provision of medicine by family/friends  Social norms  Beliefs and habits of self- medication Self-medication Behavior (Responsible and Irresponsible) 8 University of Ghana http://ugspace.ug.edu.gh Additionally, the economic status of the parents in terms of the income level of the family as well as availability of valid NHIS card can influence the self-medication of children since the ability of the parents to seek for medical consultation in the healthcare facility will depend largely on their economic status. Other factors of self-medication among children under five years with URTI include the mass media (advertisement, ownership of radio/TV), individual/household factors (provision of medicine by family and friends), provider factors (cost of URTI treatment and availability of OTC drugs) play a significant role in influencing the practice and prevalence of self-medication among children under-five years. 9 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO LITERATURE REVIEW 2.1 THE CONCEPT OF SELF-MEDICATION 2.1.1 Definition of Self-Medication There is no one single definition of self-medication even though many attempts have been made to define it. Self-medication has been defined variously in literature. Osemene and Lamikanra (2012) define self-medication as “the use of drugs with therapeutic intent but without professional advice or prescription” or “the use of nonprescription medicines by people on their own initiative”. It is worthy to note that these definitions of self-medication seem too simplistic and limits the scope of the term. It is the World Health Organisation’s (WHO) definition of self- medication that adequately defines the very essence of self-medication. Broadly speaking, self- medication as defined by WHO (2000) is “the use of drugs to treat self- diagnosed disorders or symptoms, or the intermittent or continued use of a prescribed drug for chronic or recurrent disease or symptoms and involves obtaining medicines without a prescription, resubmitting old prescriptions to purchase medicines, sharing medicines with relatives or members of one’s social circle, or using leftover medicines stored at home”. This working definition casts a wider net in identifying and classifying self-medication practices. Pfaffenbach, Tourinho and Bucaretchi (2010) further broaden self-medication practices to include “disrespecting the medical prescription either by prolonging or interrupting the dosage and the administration period prescribed”. However, care provided to children by caregivers, family and parents through self-medication is usually improper and not the most efficient way to treat URTIs. This very often leads to complications and other additional problems such as adverse drug reactions leading to hospital 10 University of Ghana http://ugspace.ug.edu.gh admissions of these children (Olivier et al, 2009; Lewinski, 2010), excessive and improper use of antibiotics (overuse/underuse), which is one of the causes of child mortality and bacterial resistance to drugs (Montasser, Helal & Rezq, 2012). Furthermore, caregivers use drugs without prescriptions in treating their children under five years with URTIs due to the misconceptions and misunderstandings about the appropriate applications and effectiveness of antibiotics. Hughes, McElnay & Fleming (2001) pointed out that previous symptom of disease, sociocultural and socioeconomic features, attitude towards a disease, how healthcare is funded and the availability of medical products as some factors that influence self-medication among caregivers of children under five years with URTIs. Another study conducted by Lukovic et al (2014) revealed that age, educational levels, previous experience with the symptoms or disease, economic condition of individuals, home kept prescription drugs, significance attributed to the disease and family attitudes influence self-medication (WHO, 2000; Klemenc-Ketis & Kersnik (2010). The mass media has also been identified as a major factor influencing self-medication for URTIs among children under five years. Constant advertisement of drugs on social media, print media, television and radio contribute to the increase in demand for non-prescribed drugs, OTC drugs and locally prepared drugs such as herbal medicines and other concoctions believed to guarantee the wellbeing of children under five years with URTIs. According to the WHO (2000), the increase in competitive promotion of self-medication products has contributed greatly enhanced consumer awareness of the availability of the products and eventually boosts demand. The safety and quality of these products being promoted and sold via the internet could therefore not be guaranteed, putting individuals, particularly children at risk of morbidity and mortality. 11 University of Ghana http://ugspace.ug.edu.gh 2.2 Types of self-medication Two forms of self-medication have been generally identified in literature which are responsible and irresponsible self-medication. 2.2.1 Responsible self-medication According to Hughes, McElnay and Fleming (2001), responsible self-medication refers to “the healthcare assumed by the patient where he or she has a greater degree of responsibility in the management of a symptom or illness, using a pharmaceutical product available OTC”. Shehnaz, Agarwal and Khan (2014) show that responsible self-medication involves “treatment of self- recognized disorders or symptoms, through the use of medicines that are approved, available without prescriptions OTC drugs, and are considered relatively safe and effective when used as directed”. Responsible self-medication is also synonymous with rational use of drugs. According to the World Health Organization (WHO), “the rational use of drugs occurs when the patients receive adequate medications for their clinical diagnosis, in doses corresponding to their individual requirements, at the lowest possible cost for the individual and society” (Pfaffenbach et al., 2010). This suggests that prescribing professionals have a role to play in fostering responsible self-medication by ensuring that medications are prescribed appropriately to leave no room for left over medications. Responsible self-medication among children is solely ensured by the parents or individual responsible for the healthcare needs of the child since decisions regarding treatment of any condition of the child is taken by them. In developing countries with limited resources and healthcare access, some governments encourage citizens to engage in responsible self-medication of minor illnesses as such a practice is seen as “an opportunity to take responsibility and to manage their own health” (Gualano et al., 2015). 12 University of Ghana http://ugspace.ug.edu.gh 2.2.2 Irresponsible, Non-rational or Inappropriate self-medication Irresponsible self-medication has also been identified as “taking inadequate doses, sharing medicines, a short duration of treatment, and stopping treatment upon the improvement of disease symptoms” (Skliros et al., 2010). Gualano et al (2015) highlighted that practice takes place in varying ways and includes all such instances where “medicines are provided by other people, generally relatives, friends or colleagues, who share both the drugs and the knowledge about their use, and who always lend old prescription to buy new medicine without consulting a doctor in order to know if the active principle is appropriate”. A systematic review and meta- analysis of household antimicrobial self-medication in developing countries revealed that the most common inappropriate practice in nonprescription use of antimicrobial agents include: short duration of treatment mostly less than five days, insufficient dose of medication, wrong indication (use of antibacterial drugs in treating viral infections), and exchange/sharing of medicines (Ocan et al., 2015). Generally, in using non-prescription drugs, the patient is responsible for drug usage or seeking medical advice, especially when the illness does not improve (Ocan et al., 2014). But in irresponsible self-medication, this responsibility is sometimes not observed. It is believed that inappropriate drug use correlates with high illiteracy levels in developing countries. In addition, inadequate information for drug usage as well as challenges in regulation of drug supply and dispensing in developing countries contribute to irresponsible self-medication which predisposes patients to drug interactions, masking symptoms of underlying disease and development of resistance especially with the antimicrobial drugs (Mehta et al., 2007; Okeke, Klugman & Bhutta, 2005). 13 University of Ghana http://ugspace.ug.edu.gh 2.3 Prevalence of self-medication among children Self-medication is a “common practice” in many health care systems worldwide (Ocan et al., 2014). Lilja et al (2008) indicates that self-care as a form of self-medication is basically used to treat minor self-limited conditions. In an estimated 90% of cases, “people treat their symptoms with self-medication” (Ahonen 2008). Across all settings, as revealed by WHO (2000), healthcare systems realise that more than 50% of all medicines prescribed, dispensed, or sold are being used irresponsibly. The widespread nature of self-medication extends to children who are often self-medicated by their parents, family members and other caretakers. Compared to adults, self-medication is likely to be high in children due to their vulnerability to sickness owing to their underdeveloped immune system. For instance, Bham, Saeed and Shah (2016) highlight that the average Acute Respiratory Infections (ARI) experience of child is 6-8 spells in a year worldwide and “OTC drugs are frequently administered by parents to their children as ARI causes discomfort and distress to the parents”. Research has shown that the pattern of illness of children, who tend to be the primary users of healthcare services in developing countries, is reflected in medication use which may induced by the media and performed without indication and medical prescription (Santos, Barreto, & Coelho, 2009). In Brazil, “approximately 80 million people practice self-medication, and the risk of this practice is correlated with the level of education and information about drugs, as well as the accessibility of medications in the health system” (Cruz et al, 2014). In Australia, “common cold contributes to a high burden of disease in the general population despite its minor and temporary effect” (Chen & Kirk, 2014) and “its high prevalence and notable impact on quality of life of people generates an economic burden greater than any other clinical condition” (Fendrick, Monto, Nightengale, & Sarnes, 2003). Further studies revealed that 14 University of Ghana http://ugspace.ug.edu.gh “the common cold is typically managed through self-care, comprising use of antihistamines, antitussives, mucolytics/expectorants and decongestants and more than 40% of parents in Australia purchase OTC cough and cold medicines for their children” in Australia (Kloosterboer et al., 2015). However, rare evidence exists to confirm that “the efficacy of these medicines and OTC symptomatic medications for cough and cold raise particular concerns as a result of their potential undesirable effects (Smith, Schroeder, & Fahey, 2012). Furthermore, in a study to assess self-medication among children and adolescents, 403 population-based study articles were reviewed. The findings suggest that self-medication among children was highly prevalent with the frequencies of self-medication ranging from seven to 7- 67% (Pfaffenbach et al., 2010). Moreover, Vernacchio, Kelly, Kaufman, and Mitchell, (2008) investigated cough and cold medication use by US Children from 1999–2006. The response rate to the survey during the period 1999– 2006 was 61.9%, and 4267 individuals who were aged 0- 17 years were enrolled with a median age of 9 years. Of the 4267 children surveyed, 439 had used a CCM in the previous week, for a weighted prevalence of use of 10.1% (95% confidence interval [CI]: 9.2–11.0). Among all ages combined, the 1-week prevalence of use of any cold and cough medication declined significantly throughout the course of the study, from a high of 12.3% in 1999–2000 to a low of 8.4% in 2005–2006. A systematic review of self-medication among adolescents in different countries revealed that the overall prevalence of self-medication ranged from 2 - 92%. A high prevalence was reported from Germany, the United States, India, Malta, Kuwait, United Arab Emirates, Sweden and Spain (Shehnaz, Agarwal, & Khan, 2014). Studies of self-medication among children under-five years of age in African countries including Ghana are limited. 15 University of Ghana http://ugspace.ug.edu.gh 2.4 Benefit and risks of self-medication Ocan et al (2014) reports WHO’s initiative to encourage community treatment of common diseases using self-medication to help reduce the burden on health care services with developing countries as the most to benefit from this practice since developing countries face limited healthcare infrastructure and human resource constraints as well as a regulatory and legal framework to ensure responsible self-medication. Regarding the benefits of responsible self- medication, Esparanza (2010) highlights “increased access to medication and relief for the patient, the active role of the patient in his or her own health care, better use of physicians and pharmacists skills and reduced (or at least optimized) burden of governments due to health expenditure linked to the treatment of minor health conditions”. Self-medication is beneficial to individuals and the society as a whole. For individuals, as pointed out by WHO (2000), self-medication is a rapid and easy way to treat self-limiting conditions at a reduced cost than prescribed medication and puts individuals in charge of managing their own health. For society, practicing self-medication reduces the health care costs, the use of self-medication is beneficial since it decreases health care costs for many countries. Employers even benefit from responsible self-medication practices as “it enables employees to continue their work instead of contacting health care services and taking sick leave” (WHO, 2000). However, self-medication has inherent downside risks. For instance, failing to follow dosage instructions and wrong indication may pose drug reactions, make sickness more serious and even cause death (WHO, 2000; Reinstein, 2005). Esperanza (2010) highlights some potential risks of self-medication practices including “incorrect self-diagnosis, delays in seeking medical advice when needed, infrequent but severe adverse reactions, dangerous drug interactions, incorrect 16 University of Ghana http://ugspace.ug.edu.gh manner of administration, incorrect dosage, incorrect choice of therapy, masking of a severe disease and risk of dependence and abuse”. 2.5 Factors influencing with self-medication among children Several factors could influence self-medication practices among children. These factors could range from individual and personal, health system to socio-economic and societal norms, belief systems and cultural. 2.5.1 Parental socioeconomic background Background characteristics of parents have been associated with self-medication among children. Emerson et al (2006) indicates that the education, wealth and status of a parent significantly influences self-medication among children. Ecklund and Ross (2001) found out that psychosomatic symptoms, chronic illnesses, and/or poorer self-rated health were reported by their parent or themselves as compared to children with high parental socioeconomic background. In addition, Bauman, Silver and Stein (2006) and Larson et al (2008) also found out that the presence of multiple social risk factors such as poor education, poverty, family structure, and family conflict have a cumulative effect on children’s poor health and that parental low socioeconomic background in childhood may also predict poor health in adulthood (Melchior et al., 2007). However, Currie et al (2007) posited that family income is not a major determinant of predicting child’s health. Little empirical evidence exists that explores the relationship between parental socio-economic background and drug usage among children. On the other hand, Tobi et al (2003) and Ishida, Ohde and Takahashil (2012) show that high socioeconomic background of at least one parent is positively associated with OTC medicine use among children and adolescents. This suggests that parents or caregivers who have more education are well-informed and confident about drug usage to cure their children (Aoyama, Koyama and Hibino, 2012). 17 University of Ghana http://ugspace.ug.edu.gh However, Holstein, Hansen and Due (2004) reports that “low social class of adolescents, according to parents’ occupation, is associated with increased use of medicines for specific symptoms compared to adolescents from higher social class”. 2.5.2 Individual and personal/ Household / Societal norms and Cultural factors influencing self-medication At the level of the individual, several personal factors are identified to influence self-medication practices and these includes sex, income, self-care orientation, and medication knowledge (Sawalha, 2008). For instance, some individuals tend to undertake activities aimed at promoting their health without any assistance from professionals and are described as self-care-oriented people. Thus, self-care orientation coupled with medication knowledge are regarded as crucial factors that shape and determine attitudes of individuals toward self-medication (Sawalha, 2008). Parental views, experiences, and attitudes toward medicines motivate self-medication among children (Kankkunen et al., 2008, and Jensen et al., 2010). For example, a positive-oriented parent can take initiative to curb pain of child than a parent with a negative attitude about medicines (Rony et al (2010). A parent’s disposition towards medication becomes a predictor of self-medication and drug misuse (Shehnaz, Agarwal, & Khan, 2014). In addition, there are existing practices within households in communities that tend to facilitate inappropriate use of drugs and promote self-medication. Studies have shown that in developing countries where there are deficiencies in healthcare delivery systems such as frequent drug stock outs, communities are influenced to store drugs in homes (Yousif, 2002), and the presence of medicines at home ensures easy access to drugs and sharing of drugs which promote self- medication and inappropriate drug use (Wasserfallen et al., 2003). Shehnaz, Agarwal and Khan (2014) also identified that household practices such as the use of old prescriptions, sharing of 18 University of Ghana http://ugspace.ug.edu.gh medicines with friends/relatives, and use of leftover medicines from previous prescriptions/stocks at home are major drivers of self-medication among different communities globally (Shehnaz et al., 2014). Furthermore, the societal norms, belief systems and culture of people play “an important role in how different symptoms are detected and regarded as a medical problem” (Lilja et al. 2008). For instance, parental perceptions about symptoms and cultural variations may influence self- medication among children. Jensen et al (2010) reports that over 90% of parents took their child o to see physician if body temperature was high (39 C). This behavior may be influenced by cost and access considerations. The reasons for this were that parents felt they should not make their own judgements, and also because the medical treatment of children is free of charge (Aoyama et al., 2012). 2.5.3 Provider factors There are several factors influencing self-medication which emanate from the level of the existing health system of countries. According to Ocan et al., (2015), healthcare delivery systems with inadequacies have problems with self-medication. For instance, Pereira et al, (2007) found that self-medication in children includes several practices through which the individuals responsible for the healthcare needs of the child decide which drug they will use (and or in which way) for the symptomatic relief or “cure” of a condition. The problems of access, frequency of drug stock outs and lack of medical personnel are common in developing countries may influence communities to store drugs in homes and this has been found to be associated with sharing of drugs which further increase the risk of inappropriate drug and self-medication (Ocan et al., 2014). Self-medication can also be influenced by the high cost of health care and lack of enforcement of legislations regarding over-the-counter sale of medicines (Yousef et al., 2008) 19 University of Ghana http://ugspace.ug.edu.gh while in a developing country self-medication could also be a consequence of the difficult access to health services and of the problem of lack control of pharmaceutical production and selling (Gualano et al., 2015). Pfaffenbach, Tourinho, and Bucaretchi, (2010) also indentified that healthcare systems in many countries fail to allow access to essential drugs and others have weak drug regulation systems which provide almost no barriers for purchasing medicines without a prescription and these greatly influence self-medication. 2.5.4 Mass media The proliferation of various media channels in both print and electronic forms have led to easy access to information on medicines as different kinds of medicines are advertised to the general public on these media platforms. This influences individuals to resort to use of medicines without medical consultation. For instance, Gualano et al., (2015) observed in their study that promotional advertising of OTC drugs through mass media has contributed in changing people’s attitude to use medications/ drugs and this potentially can lead to increase of drugs consumption as an easy way to take care of personal health problems without recourse to medical consultation. 2.6 Conclusion The literature reviewed showed that several studies have examined self-medication in different settings among different groups across the globe. While some studies have focused on self- medication of specific medications such as malarial drugs and antibiotics, others have looked at self-medication among various age groups. Most of these studies are predominantly limited to examining practices of self-medication among adolescent and adult populations. Studies on self- medication among children especially factors of self-medication among children under five years with upper respiratory tract infections are limited in Ghana. Thus, the primary aim of this study 20 University of Ghana http://ugspace.ug.edu.gh is to assess self-medication for URTI among children under five years with upper respiratory tract infection, a disease that is common among children. 21 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE METHODOLOGY 3.1 STUDY DESIGN This study employed a descriptive cross-sectional design using quantitative method to assess self-medication among children with upper respiratory tract infections (URTIs) in the Tema East sub-metro of the Greater Accra Region. 3.2 STUDY AREA The study was conducted at the Tema Metropolitan Assembly. Tema metropolis is one of the 16 districts in Greater Accra Region. The new Tema Metropolis is bounded in the North-East by Ashaiman Municipality, in the North-West by Adentan Municipality, on the West by Ledzokuku-Krowor Municipality, in the South by the Gulf of Guinea and in the East by the Kpone-Katamanso District. Generally, the metropolis stretches between latitude 5037’N in the southern coastline and latitude 5041’N at its northern most limits. The Tema Metropolis has a population of about 403,934 (Ghana Statistical Service, 2010), making it the second largest populated district in the Greater Accra Region. The Tema East Sub-metro, where the study was conducted, is one of the sub-metros of the Tema Metropolitan Assembly. The Tema East Sub-metro is a fishing community with low income levels. It has one health centre and a private hospital to serve the healthcare needs of the people. There are also several pharmacy and chemical shops from which residents can easily obtain over-the-counter drugs. The study was conducted in Oninku Electoral area, which is one of the communities in the Tema East sub-metro. This community randomly selected using balloting. 22 University of Ghana http://ugspace.ug.edu.gh Figure: 3.1: Map of Tema Metropolitan Assembly (Source: Google Maps). 3.3 VARIABLES 3.3.1 Dependent variable The dependent variable of the study was self-medication among parents/caregivers with children under five years with URTI within the past two weeks. Self-medication was further sub-divided into responsible self-medication and irresponsible self-medication. 3.3.1.1 Responsible Self-Medication For the purposes of this study, responsible self-medication refers to using approved medication for URTI treatment as directed by parents/caregivers to treat children under five years suffering URTI within the past two weeks at the time of the study. Approved medication includes cough mixture, Procold, Amoxacilin and Paracetamol. Using approved drugs as directed ranges between three to seven days. 23 University of Ghana http://ugspace.ug.edu.gh 3.3.1.2 Irresponsible Self-Medication For the purposes of this study, irresponsible self-medication refers to using either unapproved medication for URTI treatment or using approved medication not as directed by parents/caregivers to treat children under five years suffering URTI within the past two weeks at the time of the study. Approved medication includes cough mixture, Procold, Amoxacilin and Paracetamol. Irresponsible self-medication results when drugs are used less than three or five days. 3.3.1.3 Overall Self-Medication For the purposes of this study, overall self-medication is a composite variable derived from combining the indices for responsible self-medication and irresponsible self-medication. 3.3.2 Independent Variables The independent variables of the study include socio-demographic characteristics, individual/household/societal factors, mass media factors and provider factors. 3.3.2.1 Socio-demographic characteristics Socio-demographic characteristics of parents/caregivers in this study include the age, sex, number of children under five years, education level, marital status, occupation and income as well as spouse’s educational level and occupation. 3.3.2.2 Individual/Household/Societal factors Individual / household / societal factors include self-care orientation and attitude towards medicine, storage and use of left-over medicine at home, provision of medicine by family/friends, social norms, beliefs and habits of self-medicine. 24 University of Ghana http://ugspace.ug.edu.gh 3.3.2.3 Mass Media Factors Mass media factors include advertisement and ownership of phone/radio/TV. 3.3.2.4 Provider Factors Provider factors include availability of OTCs in locality and cost of URTI treatment. 3.4 STUDY POPULATION The study population included parents/caregivers with children under five years suffering Upper Tract Respiratory Infections (URTIs) during the past two weeks at the time of data collection in the Tema East Metropolis. 3.4.1 Inclusion criteria Parents/caregivers with children under five years who experience Upper Tract Respiratory Infections (URTIs) in the past two weeks prior to the study were included in the study. URTI was described and identified by its disease symptoms such as cough, cold, running nose, pneumonia, etc. To recruit a parent/caregiver for the study, the researcher and her assistants toured and visited households in the community and after disclosing purpose of study, verbally asked parents/caregivers whether they had children under five years old. Where parents/caregivers had children under five years, the research team enquired whether within the past two weeks, any of their children under five years had suffered any of the disease symptoms of Upper Respiratory Tract Infections (URTIs) such as cough, cold, running nose, pneumonia and bronchitis. If their children suffered any of these symptoms of URTIs or had been diagnosed by a medical practitioner within the past two weeks, voluntary consent was sought from the parent/caregiver to participate in the study. 25 University of Ghana http://ugspace.ug.edu.gh 3.4.2 Exclusion criteria Parents/caregivers with children under five years with URTIs who refuse to give consent were excluded from the study. Parents/caregivers with children who are seriously sick with URTIs were also excluded from the study. 3.5 SAMPLING 3.5.1 Sample size determination A sample size of 151 was derived using Cochran’s sample size formula shown below (Cochran, 1972) 2 2 n = Z P (1-P)/ (d) Where, n = sample size required. Z = confidence level (95% level of confidence - 1.96). P = Least prevalence of outcome variable (self-medication among children) = 10% obtained from literature (Vernacchio, Kelly, Kaufman, & Mitchell, 2008). d = Margin of error (5% =0.05). Substituting, 2 2 n = (1.96) (0.1) x (1- 0.1)/ (0.05) = 138. Adding 10% to make up for non-response and wrongly filled questionnaire will give a total sample size of 151. 26 University of Ghana http://ugspace.ug.edu.gh 3.5.2 Sampling Method A non-probability sampling technique, however similar in practice with systematic random sampling procedure, was used. A key landmark in the area was identified and together with the two research assistants the study team moved in one direction either left or right. Every second house in the direction taken by each of the study team members was sampled for the study. If a selected household did not have any child under five years who had a recent episode of URTI, it was replaced by the next nearest household. With selected households that had more than one child under five years with URTI, data was collected for only one randomly selected child. 3.6 DATA COLLECTION METHODS AND TOOLS 3.6.1 Data collection A structured questionnaire was developed and administered to study respondents to collect data on self-medication. Items on the questionnaire were read and explained to individual respondents to choose the options as they deemed fit. At times, some of the questionnaires were left to the respondents to be completed through self-administration. This was appropriate and convenient where the respondent was willing to participate in the study but could complete the questionnaire at his or her convenience. The questionnaire for the study collected data on socio-demographic characteristics of participants, provider factors; mass media factors individual/household/societal norms and cultural factors influencing self-medication. 3.6.2 Data processing and analysis Microsoft Excel was used to create a data file which contained the raw scores of the survey data collected. This was further cleaned and exported to STATA 15 for coding and statistical data analyses. Descriptive statistics were computed to thoroughly describe the respondents and 27 University of Ghana http://ugspace.ug.edu.gh logistic regression analysis, an inferential statistics procedure was used to assess the extent to which the predictors influenced the dependent variables. 3.7 Background characteristics of parents/caregivers and children Descriptive analysis was used to describe the background characteristics of parents/caregivers and the children. The results were presented in tables with frequencies and percentages. 3.8 Determination of prevalence of self-medication 3.8.1 Determination of responsible self-medication The prevalence of responsible self-medication was determined by quantifying the number of participants who practiced responsible self-medication and the number divided by the total number of children who have received treatment expressed as a percentage. This was expressed as; 𝑷𝒓𝒆𝒗𝒂𝒍𝒆𝒏𝒄𝒆 𝒐𝒇 𝒓𝒆𝒔𝒑𝒐𝒏𝒔𝒊𝒃𝒍𝒆 𝒔𝒆𝒍𝒇 𝒎𝒆𝒅𝒊𝒄𝒂𝒕𝒊𝒐𝒏 𝑵𝒖𝒎𝒃𝒆𝒓 𝒐𝒇 𝒓𝒆𝒔𝒑𝒐𝒏𝒅𝒆𝒏𝒕𝒔 𝒘𝒉𝒐 𝒑𝒓𝒂𝒄𝒕𝒊𝒄𝒆 𝒓𝒆𝒔𝒑𝒐𝒏𝒔𝒊𝒃𝒍𝒆 𝒔𝒆𝒍𝒇 𝒎𝒆𝒅𝒊𝒄𝒂𝒕𝒊𝒐𝒏 = × 𝟏𝟎𝟎 𝑻𝒐𝒕𝒂𝒍 𝒏𝒖𝒎𝒃𝒆𝒓 𝒐𝒇 𝒄𝒉𝒊𝒍𝒅𝒓𝒆𝒏 𝒘𝒉𝒐 𝒓𝒆𝒄𝒆𝒊𝒗𝒆𝒅 𝒕𝒓𝒆𝒂𝒕𝒎𝒆𝒏𝒕 3.8.2 Determination of irresponsible self-medication Irresponsible self-medication was determined by quantifying the number of respondents practicing irresponsible self-medication and the number divided by the total number children who have received treatment expressed as a percentage. This would be expressed as: 𝑷𝒓𝒆𝒗𝒂𝒍𝒆𝒏𝒄𝒆 𝒐𝒇 𝒊𝒓𝒓𝒆𝒔𝒑𝒐𝒏𝒔𝒊𝒃𝒍𝒆 𝒔𝒆𝒍𝒇 𝒎𝒆𝒅𝒊𝒄𝒂𝒕𝒊𝒐𝒏 𝐍𝐮𝐦𝐛𝐞𝐫 𝐨𝐟 𝐫𝐞𝐬𝐩𝐨𝐧𝐝𝐞𝐧𝐭𝐬 𝐰𝐡𝐨 𝐩𝐫𝐚𝐜𝐭𝐢𝐜𝐞 𝐢𝐫𝐫𝐞𝐬𝐩𝐨𝐧𝐬𝐢𝐛𝐥𝐞 𝐬𝐞𝐥𝐟 𝐦𝐞𝐝𝐢𝐜𝐚𝐭𝐢𝐨𝐧 = × 𝟏𝟎𝟎 𝐓𝐨𝐭𝐚𝐥 𝐧𝐮𝐦𝐛𝐞𝐫 𝐨𝐟 𝐜𝐡𝐢𝐥𝐝𝐫𝐞𝐧 𝐰𝐡𝐨 𝐫𝐞𝐜𝐞𝐢𝐯𝐞𝐝 𝐭𝐫𝐞𝐚𝐭𝐦𝐞𝐧𝐭 3.8.3 Determination of overall prevalence of self-medication 28 University of Ghana http://ugspace.ug.edu.gh The overall prevalence of self-medication was then determined by summing up the indices for the prevalence of responsible self-medication and irresponsible self-medication. = (𝑹𝒆𝒔𝒑𝒐𝒏𝒔𝒊𝒃𝒍𝒆 𝑺𝒆𝒍𝒇 𝑴𝒆𝒅𝒊𝒄𝒂𝒕𝒊𝒐𝒏 𝑰𝒏𝒅𝒆𝒙 + 𝑰𝒓𝒓𝒆𝒔𝒑𝒐𝒏𝒔𝒊𝒃𝒍𝒆 𝑺𝒆𝒍𝒇 𝑴𝒆𝒅𝒊𝒄𝒂𝒕𝒊𝒐𝒏 𝑰𝒏𝒅𝒆𝒙) 3.9 Determination of factors influencing self-medication Chi-square statistical analysis was also used to test for significant associations between socio- demographic characteristics of participants and the outcome measure (self-medication). Each of the factors was individually regressed with the main outcome measure (self-medication) in bivariate analysis to determine crude estimates. Factors with a level of significance of 0.05 in the bivariate analysis were then selected and included in a multivariate regression analysis to determine predictors of self-medication. These tests were performed at 95% confidence interval and results were presented in tables, graphs and charts using a logistic regression model. 3.10 Quality control The following measures were taken to ensure quality of data for the study: 3.10.1 Training of research assistance Prior to the start of field work, a day training session for the two research assistants was organized by the researcher with the prime aim of equipping them with the required skills needed to assist in the study. The training helped to clearly spell out their tasks, including a discussion of the purpose of the study, ethical issues and administration of questionnaires.3.10.2 Pre-test/ Pilot study A pilot study was conducted to pretest the research instrument, in this case a questionnaire, in the Tema West sub-metro. This was necessary to ensure the validity and reliability of the 29 University of Ghana http://ugspace.ug.edu.gh questionnaire which was meant to be used to collect primary data from the parents/caregivers of children under 5 years. 3.10.3 Supervision and checking The two research assistants were supervised during data collection. A concerted effort was made to ensure that data collected was accurate and complete, especially free from response sets. In addition, the contact details of the respondents were obtained so that clarification of answers on the questionnaire could be easily obtained from the respondents. 3.11 Ethical clearance Ethical clearance was sought from Ghana Health Service Ethics Review Committee, Research and Development Division, Accra. Informed consent of respondent was also sought before they participated in the study. 3.11.1 Community entry The District Health Directorate as well as the District Assembly and the leadership of the community was contacted and notified of the intention to conduct the study. Subsequently, an introductory letter was obtained from the Head of Department, Health Policy, Planning and management, School of Public Health, College of Health Sciences, University of Ghana and sent to them. A copy of the ethical clearance letter from the Ghana Health Service Ethics Review Committee was also sent to the authorities. 3.11.2 Privacy, confidentiality and anonymity To ensure the anonymity of the participants of the study, the questionnaires did not require the names of the participants. Though the contact details were obtained, it was meant to clarify responses when the need be during data processing and analysis. The interview was conducted in private with individual respondents so as to guarantee their privacy. 30 University of Ghana http://ugspace.ug.edu.gh 3.11.3 Compensation There was no compensation for participating in the study and there was no cost associated with participating in the study. All participants were duly informed about this before they chose to take part in the study or not. 3.11.4 Risk and Benefits This study posed minimal risk to participants since this is a non-invasive study. Study respondents used a minimum of 30 minutes of their time in answering the questionnaires. There were no direct benefits associated with taking part in the study. However, it is expected that the results of the study would contribute towards policy decisions making on self-medication in order to improve upon health services delivery. 3.11.5 Voluntary withdrawal Participants were informed that participation in the study was voluntary and that they could communicate their intention to withdraw from the study at any point in time. Where a participant withdrew from the study, data obtained on that participant was deleted. Also, participants were made to believe that they could choose to answer questions. Despite the risk of high non- response rate, participants were informed that they could make a decision to answer a question or not. However, participants were encouraged to provided adequate, accurate and complete information to make the findings of the study more meaningful. 3.11.6 Consenting process The purpose of the study was explained to each participant and consent to participate was sought verbally and in writing using a written consent form which could be signed by each participant. 31 University of Ghana http://ugspace.ug.edu.gh 3.11.7 Data storage and usage Questionnaires used for collecting the data were stored in a large paper envelope and stored in a safe free from risk of fire and damage. Also, the data files created during the data collection and processing phase of the study was stored on external drive for safe keeping. 3.11.8 Declaration of conflict of interest The researcher as the Principal Investigator declared no conflict of interest in this study. 32 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR RESULTS 4.0 Introduction This chapter presents the findings of the current study on the assessment of the type of self- medication and the factors influencing URTIs among children under 5 years in the Tema East Sub-Metro in the Tema Metropolitan Assembly. 4.1 Background characteristics of parent/caregivers and children The response rate of the study was 126 (83.4%). Majority of the parents/caregivers were female 88 (69.8%)). Most of them were aged between 20 – 29 years 48 (38.1%)), of which 18 (14.3%) were male parents/caregivers and 30 (23.8%) were female parents/caregivers. Most of the parent/caregivers had had Middle/JSS education (51 (39.8%)). Furthermore, majority of the parents/caregivers were privately employed, with 68 (54%) of them married. Most of the parents/caregivers were low income earners 76 (60.5%). Moreover, the spouses of these parents/caregivers were SHS/Vocational level graduates 54 (42.9%) and most were also private employees 104 (82.5%)). Majority of the parents/caregivers had one child under 5 years 66 (52.3%) of which 70 (55.6%) were males and 56 (44.4%) were females and most of them aged one year 53 (42%). Only 50 (39.7%) of these children were insured. 33 University of Ghana http://ugspace.ug.edu.gh Table 4.1: Background characteristics of parent/caregivers and children Distribution of Parent/ Caregivers Items Number (%) Male (%) Female (%) Total (%) Sex 38 (30.2) 88 (69.8) 126 (100) Age ˂ 19 9 (7.1) 35 (27.8) 44 (34.9) 20-29 18 (14.3) 30 (23.8) 48 (38.1) 30-39 9 (7.1) 18 (14.3) 27 (21,4) 40+ 1 (0.8) 5 (4.0) 7 (4,8) Non-Response 1(0.8) 0 (0.0) 1 (0.8) Educational Level No Education 4 (3.2) 4 (3.2) 8 (6.4) Primary 9 (7.1) 24 (19.1) 33 (26.2) Middle/JHS 16 (12.7) 35 (27.8) 51 (39.8) SHS/Vocational 9 (7.1) 21 (16.7) 30 (23.8) Tertiary 0 (0.0) 3 (2.4) 3 (2.4) Occupation Government Employee 2 (1.6) 8 (6.4) 10 (8.0) Private Employee 34 (27.0) 68 (54.0) 102 (81.0) Unemployed 2 (1.6) 12 (9.5) 14 (11.1) Marital Status Not Married 18 (14.3) 40 (31.8) 58 (46.1) Married 20 (15.9) 48 (38.1) 68 (54.0) Income (GHS) Low (< GHC 399) 25 (20.0) 51 (40.5) 76 (60.5) Middle (GHC 400 – 799) 5 (4.0) 15 (12.0) 20 (16.0) High (GHC 800 +) 1 (0.8) 2 (0.8) 3 (1.6) Non-Response 7 (5.6) 20 (15.7) 27(21.3) 34 University of Ghana http://ugspace.ug.edu.gh Educational Level (Spouse) No Education 4 (3.2) 5 (4.0) 9 (7.2) Primary 3 (2.4) 2 (1.6) 5 (4.0) Middle/JHS 9 (7.1) 30 (23.8) 39 (30.9) SHS/Vocational 18 (14.3) 36 (28.6) 54 (42.9) Tertiary 4 (3.2) 15 (11.9) 19 (15.1) Occupation (Spouse) Government Employee 8 (6.4) 11 (8.7) 19 (15.1) Private Employee 29 (23.0) 75 (59.5) 104 (82.5) Unemployed 1 (0.8) 2 (1.6) 3 (2.4) No. of children < 5 years 1 22 (17.4) 44 (34.9) 66 (52.3) 2 16 (12.7) 23 (18.3) 39 (31.0) 3 3 (2.4) 12 (9.5) 15 (11.9) 4 1 (0.8) 5 (4.0) 6 (4.8) Sex of children < 5 years with 70 (55.6) 56 (44.4) 126 (100) URTI Age (Years) < 5 years 1 29 (23.0) 24 (19.0) 53 (42.0) 2 14 (11.1) 22 (17.4%) 36 (28.5) 3 17 (13.5) 7 (5.6) 24 (19.1) 4 7 (5.6) 2 (1.6) 9 (7.2) Non-Response 3 (2.4) 1 (0.8) 4 (3.2) NHIS for < 5 years with URTI Insured 30 (23.8) 20 (15.9) 50 (39.7) Uninsured 40 (31.7) 36 (28.6) 76 (60.3) Total 70 (55.6) 56 (44.4) 12600) 35 University of Ghana http://ugspace.ug.edu.gh 4.2 URTIs status of children under 5 years About 41 (32.5%) of children under 5 years were still suffering from URTIs at the time of the study. On average, male children and female children had suffered URTIs for 6 days and 5 days respectively. About 99 (78.6%) of children suffering URTI had received treatment and 27 (21.4%) had not received treatment. Of those who had not received some treatment, 7 (25.9%) of parents/caregivers attributed that to child not being registered on NHIS, 8 (29.6%) to cultural and social norms; 5 (18.5%) to inadequate income; 5 (18.5%) to religious beliefs and self-care orientation 1 (3.7%). For those who had received treatment, 26 (26.3%) of parents/caregivers sought treatment from a health facility, 33 (33.3%) from home remedy and 40 (40.4%) from chemical shop a shown in figure 4.1. The general symptoms observed by parents/caregivers, where cough and running nose was 107 (84.9%)). Figure 4.3: Place of URTI Treatment Health Facility ([VALUE]) Chemcial Shop ([VALUE]) Home Remedy ([VALUE]) 4.3 Prevalence of self-medication The prevalence of responsible self-medication was 41 (41.4%) and that of irresponsible self- medication was 58 (58.6%) as shown in figure 4.2. The overall prevalence of self-medication was 99 (78.6%). 36 University of Ghana http://ugspace.ug.edu.gh Figure 4.4: Prevalence of responsible and irresponsible self-medication Irresponsible self- medication ([VALUE]) Responsible self- medication ([VALUE]) 4.4 Factors influencing self-medication This section describes the factors that influence self-medication among children under 5 years suffering URTIs. Factors include parental socio-demographic, personal/household/social, providers and media factors. 4.4.1 Socio-demographic factors Table 4.2 shows that none of the socioeconomic factors had significant associations with self- medication (p>0.05). 37 University of Ghana http://ugspace.ug.edu.gh Table 4.2: Socio-demographic factors influencing self-medication Background n (%) OR 95% CI p-value Characteristics of Parents/Caregivers Sex Male (Ref) 32 (32.3) 1 Female 67 (67.7) 0.87 (0.37, 2.03) 0.744 Age ˂ 19 (Ref) 37 (37.4) 1 20-29 40 (40.4) 1.20 (0.49, 2.97) 0.693 30-39 16 (16.2) 0.88 (0.26, 2.94) 0.835 40+ 6 (4.0) 1.47 (0.19, 11.59) 0.716 Educational Level No Education (Ref) 0 (0.0) 1 Primary 0 (0.0) 2.47 (0.23, 26.46) 0.455 Middle/JHS 41 (41.8) 1.39 (0.13, 14.70) 0.783 SHS/Vocational 21 (21.4) 4.00 (0.35, 45.10) 0.262 Tertiary 1 (1.0) 1 Occupation Government Employee 6 (6.1) 1 (Ref) 81 (82.7) 0.69 (0.13, 3.62) 0.658 Private Employee 11 (11.2) 0.57 (0.75, 4.30) 0.587 Unemployed Marital Status Not Married (Ref) 49 (49.5) 1 Married 20 (50.5) 1.24 (0.56, 2.76) 0.598 Income (GHS) Low (< GHC 399) [Ref] 66 (75.0) 1 Middle (GHC 400 – 799) 19 (21.6) 1.60 (0.58, 4.48) 0.366 High (GHC 800 +) 3 (3.4) 0.72 (0.06, 8.37) 0.795 Educational Level 38 University of Ghana http://ugspace.ug.edu.gh (Spouse) 4 (4.2) 1 No Education (Ref) 2 (2.1) 0.86 (0.04, 16.85) 0.919 Primary 34 (35.4) 0.53 (0.15, 1.93) 0.336 Middle/JHS 43 (44.8) 0.68 (0.20, 2.36) 0.542 SHS/Vocational 13 (13.5) 1 Tertiary Occupation (Spouse) Government Employee 17 (17.4) 1 (Ref) 81 (82.7) 1.39 (0.47, 4.14) 0.549 Private Employee 1 Unemployed No. of children < 5 years 1 (Ref) 50 (52.6) 1 2 31 (32.6) 0.80 (0.32, 2.00) 0.639 3 12 (12.6) 1.27 (0.36, 4.50) 0.708 4 2 (2.1) 1.27 (0.08, 21.51) 0.867 Sex of children < 5 years with URTI Male (Ref) 56 (56.6) 1 Female 43 (43.4) 10.3 (0.46, 2.31) 0.937 Age (Years) < 5 years 1 (Ref) 46 (47.4) 1 2 27 (27.8) 1.74 (0.66, 1.59) 0.262 3 17 (17.5) 1.67 (054, 5.16) 0.375 4 7 (7.2) 1.41 (0.28, 7.07) 0.679 NHIS for < 5 years with URTI Uninsured (Ref) 61 (61.6) 1 Insured 38 (34.4) 1.77 (0.78, 4.04) 0.173 39 University of Ghana http://ugspace.ug.edu.gh 4.4.2 Provider factors, personal/household/social and media factors Table 4.3 provides results from logistic regression analysis. It shows the extent to which provider factors, personal/household/social factors influence self-medication by reporting adjusted odd ratios (AOR), 95% confidence intervals and p-values. The most important insight from the logistic regression procedure as shown in table 4.3 relates to the extent to which provider factors influence self-medication. Parents/caregivers with children under five years who practiced self- medication were 0.01 times at with availability of OTCs in locality (0.1 (CI [0.00,0.04]; p<0.05). While all other factors lacked statistical significance, the availability of OTCs in the locality significantly predicted self-medication among parents/caregivers of children under five years suffering URTI. On the other hand, personal, social and media factors were insignificantly related to self-medication. Table 4. 3 - Predictors of self-medication Factor Factors influencing self- n (%) AOR 95% p-value medication CI Provider Availability of OTCs in 99 0.01 (0.00, 0.000 my locality (100%) 0.04) Cost of URTI Treatment 99 0.46 (0.08, 0.397 (100%) 2.77) Personal/Household/Social Self-care Orientation and 99 0.16 (0.02, 0.074 attitude towards medicine (100%) 1.19) Storage and use of left- 99 0.71 (0.12, 0.704 over medicine at home (100%) 4.27) Provision of medicine by 99 1.88 (0.27, 0.523 family and friendships (100%) 13.14) Social norms 99 1.27 (0.21, 0.794 (100%) 7.80) 40 University of Ghana http://ugspace.ug.edu.gh Belief and habits of self- 99 1.04 (0.13, 0.971 medicine (100%) 8.00) Media Advertisement 99 0.25 (0.04, 0.163 (100%) 1.75) Ownership of 99 0.45 (0.07, 0.399 Phone/Radio/TV (100%) 2.88) 41 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE DISCUSSIONS 5.0 Introduction This chapter discusses the findings of the study in the context of empirical findings in the literature. 5. 1 The prevalence of self-medication for URTI among children below 5 years The study found out that the overall prevalence of self-medication for treating URTIs among children under 5 years in the Tema East Sub-metro in the Tema Metropolitan Assembly was high. This high prevalence of self-medication can be explained by the fact that Tema is a fishing community with low income and educational levels among parents/caregivers coupled with lack of health facilities but a proliferation of pharmacy and chemical shops. The study revealed that about 76 (60.5%) of parents/caregivers earned below four hundred Ghana cedis (GHC 400), only about 3 (2.4%) had tertiary education and 76 (60.3%) of children under 5 years were uninsured on the National Health Insurance Scheme (NHIS). From the above findings, a prevalence of self-medication of 99 (78.6%) generally confirms the assertions of Shehnaz, Agarwal and Khan (2014) that the overall prevalence of self-medication in different countries range between 2% – 92%. Also, the prevalence of self-medication as revealed in this study is generally higher than prevalence scores obtained by Pfaffenbach et al. (2010) and Vernacchio et al (2008) who obtained prevalence scores of about 67% and 10.1% respectively. With the overall prevalence of self-medication of 99 (78.6%), the study found out a prevalence of responsible self-medication of about 41 (41.4%) as compared to a 58 (58.6%) for irresponsible 42 University of Ghana http://ugspace.ug.edu.gh self-medication. This finding indicates that irresponsible self-medication is more prevalent than responsible self-medication. Yet this finding is not surprising given the socio-economic and cultural makeup of the Tema community as indicated earlier. The researcher also observes that the Tema community has one health center and a private hospital and this further explains why only 26 (26.3%) of parents/caregivers may have visited a health facility for URTI treatment for their children under 5 years as revealed in the study. Moreover, it is noteworthy that about 73 (73.7%) of parents/caregivers claimed that their children had received URTI treatment from chemical shops and home remedies instead of from health facilities. These practices seem to explain the high irresponsible self-medication in the Tema East Sub-metro community. This study confirms the observations of Skliros et al. (2010) and Gualano et al. (2015) on irresponsible self-medication. This phenomenon is however alarming in view of the risks and dangers inherent in irresponsible self-medication. For instance, Mehta et al (2007) and Okeke, Klugman and Bhutta (2005) have opined that irresponsible self-medication predisposes patients to drug interactions, masking symptoms of underlying disease and development of resistance especially with the antimicrobial drugs. 5.2 The factors influencing self-medication 5.2.1 Socio-demographic factors The study sought to find out whether socio-economic factors influenced self-medication among children under 5 years for URTI treatment. However, the adjusted odd ratios obtained for the following socio-economic factors such as sex, age, educational level, occupation, marital status and income of parents/caregivers as well as the sex and age of child under 5 years and whether or not a child was insured under NHIS, found no statistically significant associations with self- medication. 43 University of Ghana http://ugspace.ug.edu.gh Though Ecklund and Ross (2001), Tobi et al (2003) and Ishida et al (2012) explored the association between parental socioeconomic background and children’s use of OTC medicines and found out that high socioeconomic background of at least one parent was positively associated with OTC medicine use among children and adolescents. However, this study failed to confirm these empirical findings and the issue of whether or not socio-economic factors significantly influence self-medication among children remains unresolved. 5.5.2 Provider factors, personal/household/social and media factors The study sought to find out the extent to which provider factors, personal/household/social and media factors influence the prevalence of self-medication for treating URTIs among children below 5 years. Of the three main factors, only provider factors had a significant association with self-medication. It appears that parents/caregivers typically perceive provider factors such as the availability of Over-The-Counter (OTC) drugs as the predominant factor in influencing self- medication. The study indicates that parents/caregivers were about 0.01 times more at odds to be influenced by provider factors than personal/household/social and media factors. Therefore, provider factors such as availability of OTCs are highly related with practice of self-medication among parents/caregivers. This finding confirms the assertion that the prevalence of OTC drugs influences self-medication. Dabney (2001) found out that 60% of self-treatment of ailments without professional help involved OTC drugs and this phenomenon as observed by Nichol, D’Heilly and Ehlinger (2006) occurs mostly in developing countries such as Ghana. Moreover, Yousef et al (2008) argued that self-medication can also be influenced by the high cost of health care and lack of enforcement of legislations regarding over-the-counter sale of medicines. Whilst Gualano et al (2015) also posited that self-medication could be attributable to difficulty in getting access to health services 44 University of Ghana http://ugspace.ug.edu.gh and control lapses in pharmaceutical production and marketing in a developing country like Ghana. This study is very insightful in the context of empirical findings that pinpoint provider factors as the predominant factor in self-medication. 45 University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX CONCLUSION AND RECOMMENDATIONS 6.1 Conclusion This study concludes self-medication was high in the Tema East Sub-Metro especially irresponsible self-medication. This was mainly influenced by provider factor and not socio- economic factors. 6.2 Recommendations The following recommendations are made to control the prevalence of self-medication for URTIs among children: 1. In view of the high prevalence of irresponsible self-medication, the Tema East Sub-Metro Health Administration should organize health talks in media and at OPDs to educate the general public on risks and costs of self-medication. 2. 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Guidelines for the regulatory assessment of medicinal products for use in self-medication (Report No. WHO/EDM/OSM/00.1). Geneva, Switzerland: World Health Organisation. Yousef, A.M., Al-Bakri, A.G., Bustajani, Y., & Wazaify, M. (2008). Self-medication patterns in Amman, Jordan. Pharmacy World & Science, 30(1), 24–30. Yousif, M.A (2002). In-home storage and utilization habits: a Sudanese study. East Mediterranean Health Journal, 8(23), 422–431. 51 University of Ghana http://ugspace.ug.edu.gh APPENDICES Appendix A: Participant’s Consent Form School of Public Health College of Health Sciences University of Ghana Research Topic: Assessment of self-medication among children in the Tema East Sub-metro of the Tema Metropolitan Assembly. Introduction I am ACHEAMPOMAA ANGELA, a student pursuing Masters in Public Health in the School of Public Health, University of Ghana. I am the principal investigator in this study and together with my research assistants we are conducting a study on the above subject. You are warmly invited to take part in the study. But before you make a decision to take part in the study or not, we would like you to read this consent or let someone read it to you to guide you in making your decision. There will be no costs for participating in this research and there will be no payments awarded for participating in this research. The only cost you will incur will be the time taken to answer the questionnaire. Apart from the time that will be lost in answering the questionnaire, the invasion of your privacy and the discomfort that may be caused in answering some questions, there are no risk associated with participating in the study. There are also no direct benefits for taking part in the study but the study. The purpose of the study is to determine the factors I University of Ghana http://ugspace.ug.edu.gh influencing self-medication and the findings will help suggest solutions to address self- medication among children under five years. Confidentiality Every single information you provide will be held in absolute confidence and data collected in this study are strictly for research purposes and will be stored with passwords on electronic media and in safely locked boxes. Access to the data will be limited strictly to the researcher and supervisor. Anonymity will be ensured in dissemination of findings from this study since participants will not be identified by their names. The data collected will be stored with passwords on electronic media and in safely locked boxes and used strictly for the purpose of research. Ethical Approval The study has been reviewed and approved by the Ghana Health Service Ethical Review Committee (GHERC). This committee is there to ensure that participants in researches are protected from harm and their rights are respected. Participant’s Consent Form I have read the foregoing information/ the foregoing information has been read to me or translated to me in a language that I understand and I have fully understood it. I consent voluntarily to participate in this study. II University of Ghana http://ugspace.ug.edu.gh (Name and signature of a witness should be provided in a case where the participant cannot speak or read English) Signature/thumbprint: ____________________________________ Name of witness: __________________________________________________ Signature/thumbprint of witness: ____________________________________ Interviewer's Statement I, the undersigned (your name), have explained this consent form to the participant in simple language that she/he understands, clarified the purpose of the study, procedures to be followed as well as the risks and benefits involved. The participant has freely agreed to participate in the study. Signature of interviewer ………………………………………….. Date …………. / ………….. / ……………. Address: Telephone number: Email address: In case of any concern you can contact the GHSERC Administrator, Miss Hannah Frimpong on: 0243235225 / 0507041223. III University of Ghana http://ugspace.ug.edu.gh Appendix B: Questionnaire Self-medication among children under five years in the Tema East sub-metro, Greater Accra Region. Dear respondent, This is a research carried out on self-medication among children less than five years in the Tema East sub-metro of the Tema metropolitan assembly. I will therefore like to take a few minutes of your precious time to answer these questions. You are assured that the answers you give will be strictly confidential and your name will not be mentioned in my research reports. Thank you. Qn. No. Questions Responses Section 1 Demographic Information A. Child 1. In the last 2 weeks, has any of your children under 5 |___| years contracted URTI? (symptoms like running nose and cough) 1. Yes 2. No (Stop interview, move to next selected household) 2. Sex: |___| 1. Male 2. Female 3. Age in years (0-4 years) |___| 4. Does your child possess a valid NHIS card? |___| 1. Yes 2. No B. Mother / Caregiver 5. Age in years |___|___| 6. Number of children ˃ 5 years |___| 7. What is your current level of education? |___| 1. No education 2. Primary 3. Middle/JHS 4. Secondary/ Vocational IV University of Ghana http://ugspace.ug.edu.gh 5. Tertiary 8. What is your marital status |___| 1. Not married 2. Married 9. What is your spouse’s educational level |___| 1. Not educated 2. Primary 3. Middle/JHS 4. Secondary/Vocational 5. Tertiary 10. What is your occupation |___| 1. Government Employee 2. Private Employee 11. What is your spouse’s occupation |___| 1. Government Employee 2. Private Employee 12. What is your monthly income (salary plus monies GHS______________ from other sources) Section 2 URTI 13. Is your child still suffering from URTI? |___| 1. Yes (Skip Question 15) 2. No 14. If No, how long did he/she had the URTI? (number of |___|___| days) 15. Has your child received treatment? |___| 1. Yes 2. No 16. If No, why not? |___| 1. Cultural/ social norms 2. Inadequate income 3. Child not registered on NHIS 4. Self-care orientation (personal) 5. Religious beliefs 6. Not applicable 16. Where did the child receive treatment? |___| 1. Health facility (End interview) 2. Home remedy 3. Not applicable 17. Was the child showing symptoms of URTI such as |___| V University of Ghana http://ugspace.ug.edu.gh cough and running nose? 1. Yes 2. No Section 3 Prevalence of Self-medication 18 What medication did you give you child? Responsible Self-Medication Irresponsible Self-Medication Approved Used as directed Not used as directed medication used: Cough Mixture 3 - 7 days |___| Less than 3 days |___| Procold 3 – 5 days |___| Less than 3 days |___| Amoxacillin 5 – 7 days |___| Less than 5 days |___| Paracetamol 3 – 5 days |___| Less than 3 days |___| Other medication specify:_________________________________________ 1. Approved medication |___| used as directed 2. Approved medication not used as directed 3. Not approval/other medication 19. Where did you obtain the medicine to treat your child? Source: Bought OTC |___| |___| Bought OTC using |___| |___| lend old prescription Left over |___| |___| medication Provided by other |___| |___| people (relatives, friends, colleagues) 20. Deduce from questions 18 and |___| 19: 1. Responsible 2. Irresponsible Section 4 Factors of Self-medication 21. What influenced you to give this medication to your child? VI University of Ghana http://ugspace.ug.edu.gh Provider Factors Tick Personal/Household/Social Tick Media Factors Tick [] Factors [] [] Availability of |___| Self-care orientation and |___| Advertisement |___| OTCs in my attitude towards medicine locality Cost of URT |___| Storage and use of left-over |___| Ownership of |___| treatment medicine at home phone/radio/TV Provision of medicine by |___| family/friends Social norms |___| Beliefs and habits of self- |___| medicine Deduce from question 21: |___| 1. Provider Factors 2. Personal/Household/Social 3. Media Factors THANK YOU VII