Characterization of pharmaceutical medication without a medical prescription in children before hospitalization in a resource-limited setting, Cameroon

Introduction The use of different therapeutic approaches is common among sick children in Cameroon. The main objective of this study was to characterize the use of non-prescription drugs and describe the therapeutic itineraries of sick children before admission to the hospital. Methods A cross-sectional and prospective study was conducted from January to May 2017. A closed-ended questionnaire (CEQ) consisting of one or several response options was administered to the parents/guardians of the children on admission to the hospital in the pediatric ward of the Laquintinie Hospital in Douala (LHD) and the Cité des Palmiers District Hospital (CPDH) of the city of Douala. Inclusion of participants was made consecutively for adolescents who gave their consent and parents or guardians who signed the informed consent for all children. The confidentiality of the data was ensured by the replacement of the names by codes. Results Overall, 295 hospitalized children were included with an average age of 3.1 (SD: 3.3) years in the study. More than half of these children (58.6%) came from LHD. More than 90% of parents had at least one therapeutic recourse (TR). The ratio of boys to girls 3/1. Self-medication (74.1%) and medical consultation (16.9%) were the main therapeutic paths in 1st recourse. The medical consultation (80.2%) and the pharmaceutical advice (16.9%) were used frequently in 2nd recourse. The mean lapse time to see a medical professional was 2.7 days (min-max: 0-14 days). The main symptoms associated with TR were fever (76.6%), vomiting (24.7%) and diarrhea (22.7%). The most frequently used drugs were Analgesics/antipyretics (47.6%), antimalarials (15.0%) and antibiotics (10.2%) and the family medicine box was the highest source of drugs. Conclusion Self medication remains the first therapeutic path, followed by medical consultation as second therapeutic path taken when the disease is perceived as serious.


Introduction
Therapeutic itineraries (TI) have become considerably diversified with the transition from traditional medicine to modern medicine under the influence of various religions in Africa. The supply of healthcare systems has expanded but with limited and unequal access to care [1][2][3]. TIs refer to the pathways that patients and their families follow and the therapeutic options or remedies they choose depending on the context in which they evolve. TI can be in a public or private health facility, formal or non-formal, modern or traditional medicine, and the use of healthcare services as first or second level according to the health pyramid [4][5][6][7][8][9]. The combined use of modern medicine and alternative medicines are frequent.
Previous studies conducted on the nature and determinants of these treatment options have identified several factors (environmental, socio-cultural and economic, demographic issues, diversity of supply and accessibility to different health centers) influencing the use of services [10][11][12][13][14][15][16][17][18]. In Africa, self-medication (SM) is the first therapeutic remedy. It is defined as the use of drugs to treat a pathological situation, real or imagined without prior medical consultation on the indication, dosage and duration of treatment [19]. SM involves the use of medication by the consumer to treat self-recognized disorders or symptoms, or the intermittent or continuous use of a medication prescribed by a physician for chronic or recurring illnesses or symptoms by family members, especially in children or the elderly [20]. Barbieri reported that "behavioral codes for a disease would be directly determined by the recognition and classification of symptoms" [21].
On the contrary, the use of healthcare services is seen as a constraint imposed by the severity of the disease in children [22], moreover the perception of the severity of the disease contributed in 71% of the cases in the use of the self-medication [10]. The interest of consulting a doctor is perceived as essential by the patient or their guardian only in case of presumed gravity of the disease, or after a failure of a drug (pharmacy, road side or even traditional medication) often badly used. In the case of children, TI and the risks related to pediatric self-medication have been the subject of few studies [23][24][25][26]. Several studies in Europe, India and Africa on self-medication have identified the transient nature of the disease [10,27,28], limited financial resources [22] and high cost of care, as being the main reasons for justifying SM [29]. Other factors, such as education, sex, socio-economic status, availability of drugs and socio-cultural perception of the disease, also influenced the population's response to the disease [10,19]. Only two studies of care seeking behavior and household medications, conducted in 2006 and 2011 based on data from the 2011 DHS-MICS [30], indicated that self-medication appears as a first-line therapeutic itinerary. In first intention, 60% of children aged 5 to 14 and 54% of children under 5 had self-medication in Cameroon [10,31]. The continuous diversity of care supply and ongoing epidemiological transition in Cameroon are calling for more recent data. The aim of the study was to characterize the use of non-prescription drugs through the analysis of therapeutic itineraries taken by sick children before admission to a hospital. we used four key variables as follows: "Recourse to self-medication" based on modern or traditional medicines available at home, bought in pharmacies or on the street or provided by a traditional healer.

Methods
"Medical recourse" as any use of a health service (public or private such as a hospital, health center, and clinic). "Pharmaceutical advice" as advice given by a health professional (pharmacist or clerk) on a health problem to a patient before the purchase or not of a drug with or without a doctor's prescription "Traditional medicine as any medication based on traditional treatments or the use of a traditional healer (recognized person using knowledge, skills and practices based on theories, beliefs and empirical experiences to keep humans healthy).
Definition of operational terms: Therapeutic recourse was defined as the various requests for care which a person can make to a specific group of people or an institution during a morbid condition. These recourses include self-medication, traditional medicine and modern medicine. This same definition was proposed in 1978 by Kleiman in the classification of health care systems and was updated by Akoto et al [33,34]. Medical prescription is an act of prescribing treatment on a prescription, after having made a diagnosis. The prescription may concern drugs, medical devices, biological or radiological examinations. The right prescription recommended in Cameroon is done by doctors, midwives, dentists and nurses as part of the delegation of tasks. We administered a questionnaire to collect information on socio-demographic characteristics of children/adolescents (age, sex, place and year of birth) and of parents/guardians (age, sex, level of education, occupation and family economy context, perception of the disease and place of residence to identify accessibility to a healthcare facility, the health related cost and the reasons for the choice of TO and TI). We also collected information that could justify the choice of TO and TI to identify accessibility to a healthcare facility and health related cost. Starting from simple cross tabulation of the generated variables, we analyzed the TI of sick children/adolescents (self-medication, formal care, traditional medicine) during a given episode of illness before ad-mission to pediatric ward. From simple tabulation and cross-matching of variables, we were able to picture the TI of sick children/adolescents as the sequence (traditional medicine, self-medication, formal care) within a given disease episode before admission to pediatric ward. The interviewer also

Therapeutic itinerary of hospitalized patients
Time-to-medical intervention: the time to see a health professional was 2.7 days (inter-quartile range ((IQR) =1-3) and was lower in girls (2.5 with min-max: 0-14 days) compared to boys (2.9 days with min-max: 0-20) but this difference was not statistically significant (p=0.577). According to age groups and health facility, no statistically significant difference was found.
Therapeutic options and therapeutic itineraries of patients: Table   2  Parents/guardians who admitted using traditional medicine accounted for less than 5% of patients' itineraries in the 2 nd TO.
Traditional medicine was not used as an initial TO Figure   3 represents the 10 different therapeutic itineraries described by parents/guardians before their child's admission. Of the 295 patients  another health facility and discharged against medical advice.

Administered drugs
Origin, classification and reading of drug information leaflets: the Table 6   interactions and contraindications were also found in the "family pharmacy box" and «pharmacy».

Discussion
After parents/guardians' interview, 295 hospitalized children were   [25,38,39]. The four mean reasons reported by parent/guardians for the use of SM as first therapeutic itinerary in 1 st therapeutic recourse was that they considered the disease as mild in 63.4%, they reported knowledge of treatment in 11.7% and the financial problem in 6.9%. A study conducted in Congo Lubumbashi has found that 31.5% of mothers practiced self-medication because of limited resources [40].
In India, minor illness (30.6%) and financial problems (12%) were the main reasons for the use of SM [41]. in India [25,36,42]. The drugs according to legal classification accounted for one-third of all drugs administrated to children and pharmaceutical medications without medical advice for this did not conform to the WHO recommendations on responsible selfmedication [43]. A significant difference in misuse was observed between parents/guardians who reported reading the medications instructions and those who said they did not read it. These results are comparable to those reported by Kassabi-Borowiec et al, the reading of the leaflet was mentioned in 30% of respondents as the guiding element in taking drugs [27]. More than 60% of drugs consumed before admission to the hospital came from the family pharmacy box. Previous study has shown that non-prescription use was positively associated with keeping antibiotics at home and selfmedication with antibiotics [42,44]. The drugs stored in the family medicine boxes can be explained by excessive prescription and/or non-compliance by the patient. It is therefore essential that doctors prescribe medications appropriately (quantity the patient needs) and encourage them to get rid of the remaining medications.
Limitations: First hospital study that gives us interesting results on the behavior of the parents, the therapeutic itineraries taken, and the specific drugs used and their origin in case of illness of their sick child. But this study was carried out in only 2 hospitals in Douala in urban areas and hence is not representative in pediatrics general population even through these are major hospitals at two different pyramidal levels in Cameroon. The results may underestimate the demand for traditional care. Also, it would have been relevant to extend the field of study to rural areas. In addition, the ab-sence of the variable socialization medium prevented the control results related to ethnicity.

Conclusion
The response of many families to the use of medications without medical prescription/advice for their children's disease was self-

Competing interests
The authors declare no competing interests.

Acknowledgments
We are particularly grateful to parents who accepted their children to be included in this study. Our appreciations are also extended to the pediatric staff of LHD and CPDH for their support and cooperation during the survey. Thanks to Dr. Mandeng and Dr.
Alexis Awung who reviewed and revised the manuscript for language editing.