It was identified that household heads aged 35 years and older, longer distance of the household to the nearest health facility ≥ 5 Kms and presence of antimalarial drugs stored at home were significantly associated with self-medication for malaria while experiencing ≥ 6 malaria episodes in the household was protective against self-medication for malaria in Kakumiro District. Self-medication was common among male adults and despite the fact that majority used the recommended drug for the management of malaria in Uganda, the dose used was inappropriate for most patients but nevertheless, a majority of the patients recovered without hospitalization. In addition to antimalarials, patient used other drugs like antimicrobials purchased from mainly drug shops and clinics and the main reasons for self-medication included antimalarial stockouts at the health facilities, lack of transport to health facilities and uncomplicated malaria.
The study revealed an association between older age of the household head (35 years and above) and self-medication for malaria. This could be because of the increased responsibilities, the presumed lack of complexity in malaria treatment, known antimalarial treatment and the proximity of drug shops driving older household heads into self-medication for malaria rather than visiting a health facility. Similar findings have been revealed by other scholars where age (31–46) and > 61 years old were associated with self-medication [15]. Strengthening social and behavioural change measures that enforce healthcare seeking in accredited health facilities and highlighting dangers of self-medication would ensure that all patients, regardless of age, seek care at health facilities for appropriate treatment.
Longer distances of > 5 Kms were also associated with self-medication for malaria. This coupled with the frequent drug stock outs explains the reluctance to invest in transport to travel to a distant health facility without assurance of drug availability and a possibility of purchasing drugs from a private entity after consultation. This uncertainty coupled with long distanced drives patients into practicing self-medication. This finding is similar to others scholars stating the association of long distances to health facilities and the cost of seeking care to self-medication [16, 17]. Uganda has a policy to improve access to healthcare which is to have a health facility within 5 km radius from every home. From the 2018 WHO report, only 75% of Ugandans had improved access to healthcare as per this policy. This implies that 25% of the population still struggles [18]. Ensuring that every household is within 5 km radius through construction of additional health facilities could improve access to health care, potentially reducing the risk of self-medication for malaria.
The study further revealed presence of antimalarial drugs stored at home as an associated factor to self-medication for malaria. This could be because of the presumed lack of complexity of malaria and the frequent drug stock outs at the health facilities requiring patients to store their drugs at home to prepare for events when they get a patient. However, some of drugs were not adequately stored compromising their potency. Interesting to note is that even participants that had not practiced self-medication for malaria also had drugs stored in their homes suggesting intent to self-medicate. This finding is similar to findings from other studies were communities have stored their drugs in special containers for future illness and the main reasons were long distances to health facilities and only 42% of these drugs were stored appropriately [16, 19, 20]. Strengthening social and behavioural change measures that highlight dangers of self-medication and discourage storage of drugs at home would ensure communities refrain from drug storage in home and the eventual self-medication.
The reported high prevalence of self-medication with inadequate doses and inappropriately stored antimalarials underscores the need for extra efforts to monitor and institute measures to control the emerging artemisinin resistance. Various scholars have documented an increasing prevalence and spread of partial resistance of P. falciparum to the artemisinin component of artemisinin-based combination therapy. Common mutations include: pfk13 C469Y, pfk13 A675V, pfk13 S522C, 469 F, 561H, 441L whose prevalence ranges from 10 to 50% for various locations in Uganda and the genetic analysis indicates local emergence of mutant parasites independent of those in Southeast Asia [21,22,23]. Besides genomic surveillance, there is need for strengthening efforts to identify and address drivers for this increasing prevalence of partial resistance given the heavy burden of malaria on the continent and the high dependence on artemisinin-based combinations for malaria management.
Furthermore, having a high number of malaria episodes ≥ 6 in 6 months was found to be protective for self-medication for malaria. This could be because of the cost attached and the low income of the communities since majority had a monthly income below Ushs 300,000/= (USD. 81). The drugs used for self-medication are mainly purchased from drug shops and clinics requiring substantial amount of money which might be available in case of frequent malaria infections in a home. Families with more frequent malaria episodes are more likely to visit a health facility for free drugs as opposed to families with fewer malaria episodes. This is contrary to other scholars that have revealed financial constraints as an associated factor to self-medication; however, both studies agree to the source of the drugs being private drug shops and clinics regarded to be cheaper drug sources [24, 25].
There was no association between education level and self-medication for malaria. This is contrary to other studies that have reported an increasing risk for self-medication for malaria with increasing education level [4, 14, 25,26,27]. This could be because the highest percentage of respondents had a generally low education status below primary level.
Study limitations
The study used self-reported data and as such, there was possibility of information bias. This was controlled by ensuring participants understood the rationale for the study which is the identification of existing healthcare gaps in the management of malaria for improved malaria management and control. The fear of reporting self-medication knowing that it is discouraged by the health officials could have underestimated the prevalence for self-medication in this study. Informed written consent was sought after a detailed explanation of the study purpose and objectives.