Self-medication with antimalarials drugs in Lubumbashi city (DR Congo)

Self-medication for malaria is very common in Sub-Saharan Africa where this parasitosis is endemic. In order to determine the extent, characteristics and factors associated with this practice in medical area in the city of Lubumbashi, a cross-sectional descriptive study was carried out by direct interview from January 2018 to June 2018, in the internal medicine departments of 10 General Referral Hospital (GRH) . Five thousand one hundred and thirtyfour patients were consulted among them, 96.6% (average age 38.7 ± 8 years; average income: 100 ± 12 USD; gender male/ female ratio: 0.86) practice self-medication with antimalarials. They used it for the first time at an average age of 13-17 years. Quinine (36.4%) and Carica papaya (0.4%) are the most used remedies in conventional and non-conventional medicine, respectively. Several risks are incurred during this practice when the most cited are worsening side effects (53%), incomplete treatment (37%) and appearance to health sciences (37%). Age (17-35 and > 65 years old), low income (50-150 USD), membership in a health sector and the claim to know antimalarial drugs, predispose patients to self-medication. There is an urgent need to regulate this practice to avoid its harmful consequences.


Introduction
Malaria is the first parasitic disease in the world [1] and constitutes a major public health problem in Sub-Saharan Africa [2,3], particularly in Democratic Republic Congo (DRC) [4,5]. In DRC there is no social security system, [6,7], the majority of the population lives below the poverty line, causing the emerging phenomenon of self-medication.
This practice is very a common in both developing countries [8,9] as well as developed ones [10,11]. Although several negative consequences, including appearance of antimicrobial resistance, drug poisoning, non-beneficial drug interactions, drug dependence or addiction, have been reported during this practice [12]. Reasons allowing this practice to subsist are often mentioned, in particular the cost of treatment, the low purchasing power, the trivialization of some diseases or the complicity of some pharmacy salespeople who do not respect the rules for dispensing drugs and longtime waiting in hospitals [8,[13][14][15].
In DRC, few works have been devoted to self-medication [16,17]. In Lubumbashi, cases of self-medication have been reported in Kasapa university campus [12], and when managing febrile episodes in children under the age of 5 years [18]. These works did not focus mainly on the practice of self-management of malaria by the general population. This study intends to describe the practice of self-medication by the population of Lubumbashi to treat malaria. It presents the frequency of this phenomenon; its characteristics as well as the factors associated.

Experimental setting
The study was carried out from January 2018 to June 2018, in the internal medicine departments of 10 public hospitals in the city of Lubumbashi in the southern part of DRC. Their global hospitalization capacity is approximatively 1000 beds. These hospitals are namely: Hakika, Jason Sendwe, Kamalondo, Kampemba, Katuba, Kenya, Kowe, Mumbunda, SNCC and Vangu.

Patients and methods
This cross-sectional descriptive study was carried out by a direct interview using a guide questionnaire, with all patients, aged over 15 years old, met in the internal medical services of these 10 GRHs in good condition speaking and having provided informed consent. The questionnaire included 20 items related to antimalarials self-medication practices as well as socio-demographic characteristics of respondents. The sample size precalculated with Schwartz's formula: n = z 2 xpx (1-p) / m 2 (where z = confidence level, set at 99%, p = prevalence of self-medication in Lubumbashi set at 50%, m = margin of error fixed at 5%) was 663 patients. However, we have taken all the patients who met the inclusion criteria to improve the accuracy.

Ethical Considerations
Ethical approval was granted from the Department of Pharmacology of the Faculty of Pharmaceutical Sciences of the University of Lubumbashi and all participants were asked for their consent to participate in the study before being given the survey. The responses were anonymous and confidential, and the participants were informed that before start answering the questionnaire.

Statistical data analysis
Graph Pad prism version 6 software was used to analyze the data statistically. The chi-square test and odd ratio established the factors associated with self-medication, a probability level p < 0.05 was considered significant.

Socio-demographic characteristics of respondents
Five thousand one hundred thirty-four patients have been met the internal medicine departments of 10 GRHs in the city of Lubumbashi from January 2018 to June 2018. Their majority, 4,960 (96.6%) admit having already practiced selfmedication against malaria and most of them are women (male-female sex ratio: 0.86), with an average age of 38.7 ± 8 years (extremes: 16 and 65). The respondents were from the 7 municipalities of the city of Lubumbashi and exercise several trades, most represented by traders (23%) and public employees (19.5%). Most respondents of this study were from secondary school education level (47.6%), with less access to health services (86.8%). They have an average monthly income of 100 ± 12 USD (extremes: 50 and 900 USD) and are 50% Catholic (Table 1).

Knowledge of respondents on malaria
The surveyed people associate several signs to diagnose malaria, the first two groups of which consist of fever and dizziness (37%) followed by bitterness and fever (29%). Fever is the most common sign in each of the symptom groups ( Fig. 1).

Figure 1
Signs of malaria identification by respondents (n=4960).

Impact of self-medication according to the GRH
The frequency of self-medication varies considerably from one hospital to another between 84.9% (GRH Kamalondo) and 99.7% (Katuba). It was higher in patients who attended GRH Jason Sendwe (30.5%) followed by GRH Kenya (18.9%) ( Table 2). N: total number of patients encountered in the GRH; Ni: number of patients who practiced self-medication in the GRH; Fr (relative frequency of selfmedication in the medium concerned (= Ni * 100 / N); Fa (absolute frequency of self-medication in the medium concerned (= Ni * 100/5134). NA: Not applicable.

Reasons for patients to practice self-medication and their knowledge of the risks incurred during this practice
Several reasons have pushed interviewed patients to practice self-medication among which, we note search for time saving (32%) and the difficult to confide in a health professional (18%), are the most mentioned alongside a claim knowledge of effective remedies (8.5%), less mentioned. Although they resort to self-medication, the patients nevertheless recognized certain risks incurred, the most and the least cited of which were worsening side effects (22%) and inadequate treatment respectively ( fig.2).

Figure 2
Reasons for self-medication (a) and knowledge of its risks (b) (n=4960).

Cost of malaria treatment in modern health care and traditional medicine in Lubumbashi
The average cost of treating malaria over three days in the health facilities in which this study was carried out is 37.9 ± 9.95 USD/7 days or 12.3 USD per day. The highest cost is observed in two GRHs, Jason Sendwe (56.3 USD) and Mumbunda (57 USD) and the lowest cost is observed in GRHs, Hakika (30 USD) and Kowe (30 USD). In traditional medicine, treatment for malaria is ≤ $ 5 and in most cases (45%), it is free (Fig. 3). Age, instigator of first self-medication, main sources, person of recourse in the event of failure, reasons for changing medication and frequency of self-medication depending on the patients Almost 40% of patients resort to selfmedication whenever the need arises ( fig 4f) and more than a third (40%) started it as a teenager between 13 and 17 years old (Fig. 4a) although a large fraction do not know the exact age. The instigator of the 1st most incriminated selfmedication is the parent (37%) and the main sources of information during this practice are providers in the health services (39%) and the internet (23%). People sometimes change medications for several reasons, the most mentioned of which are the lack of healing (39%) and the appearance of unbearable effects (28%). In the event of failure to selfmedicate, the patients's resort to several people, preferably the doctor (66%) (Figure 3).

Medicinal Plants used in self-medication against malaria in Lubumbashi
Several patients interviewed (3661 or 73.6%) also use medicinal plants, 18 of which have been mentioned. These plants belong to 13 families dominated by Asteraceae (23%). From these plants flow 20 recipes which mainly use (80%) leaves as a decoction (75%) and which are administered orally (100%). Carica papaya (18), Cymbopogon. citratus (15) and Eucalyptus abdita (15) are the three most cited plants (Table 5) and Cissus aralioides is the only one whose anti-malarial use has not been reported in the literature.

Factors associated with self-medication during this study
Six factors are associated with self-medication with antimalarials in this study. These are age (17-35 years and over 60), monthly income (] 50 -150] years), membership in a health science, prior use of traditional medicine and the pretension of knowledge of antimalarials (table 6).

Discussion
This study completes the extent, associated factors, and characteristics of self-medication during the management of malaria in people attending 10 public hospitals in the city of Lubumbashi between January 2018 and June 2018. The results show that the city is experiencing self-medication using both conventional and traditional medicine.
Despite respondents are informed about self-medication risks (Figure 2), many of them resort to it with a much higher frequency (96.6%) than that observed in other regions such as the Middle East: 43% [31], Mbeya in Tanzania : 19 % [32], Antananarivo : 22 % [33] or Addis-Ababa : 75,5 % [34] but close to that of Saudi Arabia [15], Jordan [35] or Bangladesh [36]. In Lubumbashi a study carried out in the university campus of UNILU had reported a frequency of the same amplitude for any pathology concerned [12].
Fever associated to one or more other symptoms ( Fig. 1) was the major sign conducting people to self-diagnosed malaria; as fever is known to be a major symptom of malaria according to WHO and many other accepted guidelines for the management of malaria [37]. Self-medication with antimalarials products would be favored by the low level of education (Table 1) and the easy access to antimalarials drugs, which are supposed to be dispensed only on medical prescription. Furthermore, the various signs of self-diagnosis of malaria mentioned by interviewed ( fig. 1) suggest that, the kind of malaria generally treated in self-medication concerns the simple malaria. In this context, the high use of quinine by self-medicated people (36.4%) would be considered as an irrational use of medication, as is observed in most cases of self-treatment [38][39][40] especially since quinine is normally used in 2nd or 3rd intention or in case of severe malaria [3,41,42].
People resorting to self-medication have given several reasons motivating them such as time saving and the law cost of self-treatment as mentioned in other previous studies [43][44][45]. A possible approximation can be established between the average monthly income of respondents (100 ± 12 USD) and the average cost of malaria care in biomedicine (37.9 ± 9.95 USD) suggesting that very likely, the use of self-medication would be very related to financial reasons which is also one of the factors associated with self-medication during this study (table 6).
The first instigator of self-medication is the parent as in some previous studies [12,15]. In a country where almost, the entire population does not have health insurance, it seems very likely that the practice of self-medication will start within the family. This familiarity is also observed in the transmission of self-medication information (fig 4) where the informants mainly use the knowledge that underpins the health sciences.
In this study, the malaria self-medication is associated with drug misuse (table 4), in particular, the duration of treatment with Arteether, the correct dosage of which is one ampoule once a day for 3 days in the case of simple malaria. P. falciparum chloroquino resistant [37] and for cerebral malaria, 25 mg (J1-3) / kg to 12.5 mg (J3-5) / kg [41]. Another misuse concerned the combination of Artemether-Lumefantrine whose treatment duration is normally 3 days [46,47]. These irrational uses of drugs, which are moreover frequent in self-medication, are responsible for the development of antimalarials resistance [48,49]. On the other hand, they expose to antimalarials toxicity as stated elsewhere [50,51].
The use of medicinal plants as the first line approach is a practice recognized by 80% of the world population for the primary health care [52][53][54]. In this study, we observed a high rate (73,6%) of malaria self-medication with medicinal plants suggesting that the use of medicinal plants in Lubumbashi is a popular knowledge. This situation can be compared to the fact that almost all (94.4%) of the plants were subsequently reported as antimalarials (Table 5) and the only species that antimalarial activity is not reported is Cissus aralioide.
Six factors are associated with antimalarials self-medication in this study: age, monthly income, membership in a health science, previous use of traditional medicine and the claim of knowledge of antimalarials unlike two studies where the associated factor was education [55,56], and in accordance with the works for which the age [57,58] and previous selfmedication [57,59] were associated factors.

Conclusion
Malaria self-treatment is a very common practice in Lubumbashi in both modern and traditional medicine. The selfmedication with antimalarials products involves several notable abuses. It is important to get more implication from health regulatory authorities to significantly reduce the extent of this phenomenon which has a negative impact in the fight against malaria at the national level.