Background
On January 30th
, 2020, the World Health Organization (WHO) declared a public health emergency of international concern due to the advent in China of a disease called COVID-19 caused by a novel coronavirus, SARS-CoV-2, and its rapid spread [
1]. Approximately 6 months later, almost 20 million cases and approximately 700,000 deaths have been reported worldwide [
2].
To date, there is still no treatment or vaccine for this pandemic. Several studies have evaluated the efficacy of hydroxychloroquine-based treatment with or without azithromycin [
3‐
5]. However, the efficacy of these medicines has not been proven for curative treatment of the disease. Chloroquine and hydroxychloroquine were also evaluated for prophylaxis against COVID-19 in clinical trials among close contacts of individuals diagnosed with COVID-19 and health care workers. Although the preclinical results are promising, there is currently no evidence of the effectiveness of chloroquine/hydroxychloroquine in the prevention of COVID-19 [
6].
The COVID-19 epidemic created widespread psychosis and anxiety among the population in sub-Saharan Africa [
7]. This could be linked, on the one hand, to the high mortality observed in some countries, such as Italy and Spain, and on the other hand, to the lack of technical resources to combat the disease in sub-Saharan Africa. Regarding the African continent, the WHO indicated that it fears the worst, as the better resourced health-care systems of developed countries have faced enormous difficulties in dealing with the epidemic [
8]. Faced with this situation and the variety of information circulating on social media, many plants and substances without the minimum requirements of efficacy and tolerance have been proposed to treat or prevent COVID-19 [
9]. The use of these substances without medical advice is considered self-medication, which is defined as taking medicines, herbs or home remedies on one’s own initiative or on the advice of another person without consulting a medical doctor [
10]. In the context of the COVID-19 pandemic, cases of poisoning and death have been reported in the USA and Nigeria in persons self-medicating with chloroquine [
11,
12].
Health literacy plays an important role in self-medication behavior [
13]. Concerning the COVID-19 pandemic and other coronaviruses, the level of knowledge is globally low according to a meta-analysis of 70 scientific articles. Indeed, the proportion of people with a low level of knowledge ranged from 4.3 to 57.9% among health professionals and from 4.0 to 82.5% in the rest of the population [
14].
Togo, similar to most West African countries, is experiencing significant population growth (2.8% per year): its population has more than tripled in less than 30 years, rising from 2.7 million inhabitants in 1981 to 8,608,444 inhabitants in 2020 [
15]. The demographic context is characterized by (i) a predominantly young population (60% of Togolese are under 25 years old); (ii) a high population density in the coastal regions; and (iii) rapid and uncontrolled urbanization, especially in
Lomé (capital) [
15]. Economically, the gross domestic product per Togolese was 682 U.S. dollars in 2019, making Togo the 11th poorest country in the world [
16].
In Togo, although the dispensing of psychoactive drugs is regulated by law and requires a prescription, this is not the case for other drugs, including antibiotics, which can be sold without a prescription [
17,
18]. Despite the efforts of the Togolese National Order of Pharmacists to curb the overuse and limit access to antibiotics without a prescription, these drugs are still widely consumed through self-medication [
19].
Togo reported its first case of COVID-19 on March 5th
, 2020, and the number of cases multiplied by ten in 3 months, with 98 cases and 6 deaths on April 26th [
20] compared to 908 cases and 18 deaths on July 31st, 2020 [
2]. On October 27, 2020, the country reported 264 cumulative cases and 6 deaths per million inhabitants [
21]. The absence of a recognized treatment for the disease and its constant progression requires a re-evaluation of self-medication practices in Togo, where 80% of people resort to self-medication [
22] and 60% resort to traditional pharmacopoeia [
23]. Thus, this study was conducted to estimate the prevalence of preventive self-medication and its associated factors in an epidemic context where there is no preventive or curative treatment.
Discussion
The WHO does not recommend self-medication with any medicines, including antibiotics, as a form of prevention or management of COVID-19. Despite the advice of clinicians and governments, 34.2% of the people surveyed in our study used a treatment without a prescription. These treatments included modern treatments as well as traditional medicine. The prevalence of self-medication found in our study is probably related to i) the long delay in finding an appropriate treatment for COVID-19 based on an adequately powered randomized trial [
27]; ii) the influence of social media that proposes any type of product to prevent or treat COVID-19 [
9]; iii) the influence of leaders (political and religious) who have claimed the efficacy of certain products or who claim to have discovered traditional remedies [
28,
29]; and iv) the stigmatization of people infected with SARS-CoV-2, which encourages some people to take care of themselves at home [
30].
Chloroquine/hydroxychloroquine was used by 2.0% of the population, and this proportion varied from 0.8% in people working in the health sector and 7.3% in people working in the informal sector. The use of chloroquine/hydroxychloroquine could be linked to the fact that a study published in March 2020 concluded that hydroxychloroquine was effective for the reduction of viral load and recovery time in Covid-19 patients [
5]. However, there have been many warnings about the improper use of chloroquine/hydroxychloroquine outside of hospital or clinical trial settings for COVID-19. Its use may increase the risk for arrhythmias or death [
31,
32]. Political leaders such as president Trump also claimed to use chloroquine for COVID-19 prevention [
28]. This type of declaration shared with the community could be destructive and nonproductive in regard to public health communication.
In our study, azithromycin was used by 1.2% of the sample. Self-medication with antibiotics such as azithromycin could cause harm to the patient and increase the risk of antimicrobial resistance [
33]. The low prevalence of the use of azithromycin could be explained by its relatively high cost and by the fact that, in recent years, the Togolese pharmacists’ association has insisted that these products be sold only with a prescription, even the necessity of a prescription is not regulated by law.
While chloroquine and hydroxychloroquine are controlled medicines that are sold in pharmacies, this is not the case for vitamin C. In our study, vitamin C was used by approximately one-third (27.6%) of the participants. Several studies have suggested the effectiveness of a high dose of vitamin C in the management of COVID-19 [
34,
35]. However, it is also important to note that high doses of vitamin C may cause side effects, most specifically an increased risk of kidney stones [
36].
In April 2020, a traditional medicine called
Covid-Organics for the prevention and treatment of COVID-19 was promoted in Madagascar [
28]. However, the number of cases of COVID-19 in Madagascar quadrupled from 2214 to 10,748 in July 2020 [
2,
37]. Several reasons could explain the increase in the number of cases of COVID-19, but this increase raises questions on the effectiveness of
Covid-Organics, which has not yet been properly tested in therapeutic trials. Artemisia plant, the main component of
Covid-Organics, has shown some beneficial effects in the treatment of malaria but has not been found to be as beneficial as artemisinin-based combination therapies (ACTs) [
38]. The WHO, fearing the risk of the development of a resistance to ACTs linked to the use of this plant, does not recommend it for the treatment of malaria [
38]. Furthermore, no studies have proven the efficacy for the prevention or treatment of COVID-19. In our study, one out of ten (10.2%) participants declared that they used traditional medicine for COVID-19 prevention. This finding could be explained by the fact that the use of traditional medicine is common in African culture and relatively less expensive than modern medicines [
23], although the composition of these mixtures is usually unknown [
23,
39]. In regard to traditional medicine, the WHO welcomes innovations around the world, including repurposing drugs and traditional medicines and developing new therapies in the search for potential treatments for COVID-19 [
9]. The WHO is working with research institutions to select traditional medicine products that can be investigated for clinical efficacy and safety for COVID-19 treatment [
9].
In this study, self-medication was found to be significantly associated with being female, working in the health sector and having a high school education level or higher. There are conflicting data on the relationship between sex and self-medication [
40,
41]. Some studies conducted on self-medication reported that female sex was significantly associated with self-medication. A study conducted among undergraduate students of a private university in Nigeria showed that 88.2% of females versus 71.1% of males reported using self-medication [
42]. In Spain, the prevalence of self-medication was 16.93% (2715) for women and 14.46% (1469) for men (
p< 0.05) in a study about sex differences in self-medication [
43]. The reason for the association between female sex and self-medication is not clearly known, but in the context of the COVID-19 outbreak, greater anxiety among women, as described in Iran and Italy, cannot be excluded [
44,
45].
A 2018 systematic review and meta-analysis of observational studies conducted in Ethiopia showed that healthcare professionals and students were the main practitioners of self-medication [
46]. In our study, self-medication was associated with working in the health sector. Knowledge and access to prescription-only medicines are potential factors of self-medication among health professionals. A lack of time to consult with a doctor and the desire to keep one’s health status secret were also mentioned as factors that could explain self-medication among health care personnel [
47]. According to the WHO, approximately 10% of all COVID-19 cases globally are among health workers. In Africa, information on health workers’ infections is still limited, but preliminary data show that health worker cases make up more than 5% of cases in 14 countries in sub-Saharan Africa alone, and in four of these countries, infections among health workers constitute more than 10% of all infections [
48]. The higher risk of infection among health care professionals, their knowledge of drugs and their ease of access to drugs may also explain their higher practice of self-medication [
49,
50].
Self-medication has often been associated with a lower education level. A study on knowledge and self-medication with antibiotics conducted in a Lebanese adult sample reported that self-medication was significantly associated with low education level (
p=0.036) [
51]. This was not the case for the present study conducted in the context of the COVID-19 outbreak. Indeed, participants with a high school level or higher were more likely to self-medicate. This finding could be explained by the fact that a good knowledge of diseases is known to be associated with self-medication [
52‐
54]. The greater access of the educated population to the internet and their ability to understand information about treatment (which is often published in official languages) found on social networks may also explain this trend.
Surprisingly, a history of clinical manifestation was not associated with self-medication in our study, which confirmed the finding that self-medication was more likely to be used for the prevention of COVID-19 and not to treat specific clinical manifestations of COVID-19, which are similar to malaria symptoms.
This study has some limitations. We did not collect data on the doses of the drugs used and the length of time they were used. For traditional medicines, the composition of the different traditional products used was not collected. It should also be noted that in the Togolese context, traditional medicines are very often used in combination with modern medicines. Another limitation of this study is that the questionnaire used was developed entirely by our team and had never been used before. Even if the questionnaire had been pretested, biases (primacy effect, order effect, etc.) could not be excluded. Furthermore, the study was based on declarative data, which may have led to an underestimation of the prevalence of self-medication due to social desirability bias. Finally, according to the characteristics of the surveyed population (people with a high risk of SARS-CoV-2 infection), the extrapolation of these results to the general population should be performed with great caution.
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