The outcome of this study suggests that the PPMVs are the first and often the only point of call for healthcare services among nursing mothers in the rural areas and that they are easily accessed by those that live in rural areas. In Nigeria, owner-operated drug retail outlets or PPMVs are the main source of medicine for acute conditions [19]. In particular, drug shops comprise a sizeable portion (nearly 40%) of the private healthcare sector in Nigeria and provide between 80 and 90% of all child health services in rural areas [10, 11]. Durowade and associates [23] in their study showed that majority of the clients could access PPMV shops within 2–30 min’ walk and that clients could go to the PPMVs houses or call them on phone after closing hours. This study further corroborated the findings in the study conducted by Iheoma and co-workers [24] where they noted that PPMVs are accessible, affordable and are valuable sources of healthcare services, products and information.
The results also clearly suggest that the PPMVs remain the most popular source of medicine and health services among young people. The reasons for their choice of the PPMVs include geographical proximity, cheap drugs, good response to care (i.e. symptoms resolved), no delay in accessing care, good rapport with the people and access to credit facility are consistent with previous studies from Nigeria [7, 11, 25]. In addition to these enablers, Okonkwo and Okonkwo [11] added that Nigerian youths prefer PPMVs because they are more accessible to young patrons than public sector health service providers; display non-judgemental attitudes towards young people’s sexual healthcare needs; they are diplomatic, confidential and offer a wide array of sexual health services to youth, despite policy regulations that constrain this.
PPMVs have played vital roles in the health care system in different parts of Nigeria. In assessing the enablers and barriers to the use of PPMVs, we found that the geographical proximity of PPMVs was a major enabler to their patronage by the young people in the study area. This finding has been corroborated by earlier studies which reported that PPMVs located in an area close to the community was a strength for their operation [11, 26, 27]. This has also been noted by PPMVs themselves as reported by Sieverding and Beyeler [26]. This finding is important as it reflects that geographical barriers present a challenge to accessing healthcare, which is critical to address when progressing towards achieving universal health coverage. In most rural communities where there are access challenges, PPMVs fill the gaps. They are perceived as the frontline health workers in these communities, playing an important primary health care function [28]. Since the PPMVs already have some trust and rapport with the community and can provide some basic services, they can play an important role in healthcare delivery and should be considered as an integral part of Nigeria’s strategy towards universal health care. They could be made more functional through proper training and regulation.
Majority of the young people in this study, affirmed that drugs sold by PPMVs were cheaper and more affordable than those in hospitals and pharmacies. This is in agreement with the study by Iheoma and co-workers [24] they acceded to the fact that drugs purchased from PPMVs are cheaper. A significant proportion of the respondents reported that the affordable cost of products and services encouraged their use of services provided by PPMVs. Similar observations have been reported earlier [27]. Financial barriers to accessing the formal health system have also been reported as reason for patronage of PPMVs, as they cannot afford services of private hospitals and clinics [19]. In this study, other enablers found, regarding the patronage of PPMVs by young people, just as the nursing mothers, were their good response to given care (resolution of symptoms) by the PPMVs, short waiting time and friendly nature of PPMVs.
The resolution of symptoms, short waiting time and friendly nature of PPMVs were reported to encourage patronage of PPMVs in previous studies [29,30,31]. These findings draw attention to some gaps to in the formal health system that need urgent attention. The importance of patient satisfaction to encourage accessing health services and the negative effects of prolonged waiting time on service uptake have been reported [32,33,34]. Similarly, the absence of health insurance coverage and the subsequent financial impact of out-of-pocket spending should be considered for their implications in achieving universal health coverage (UHC). In a bid to avoid catastrophic health spending that may result from accessing health care in the formal setting, these young people are attracted to the cheaper alternatives provided by the PPMVs.
This study showed that the nursing mothers agreed that PPMVs sell low quality medicines. This is in consonance with earlier studies which showed that nearly half of antimalarial drugs stocked in PPMV shops were sub-standard or expired [35, 36]. PPMVs generally have low health knowledge and poor treatment practices, stock poor quality medicines (e.g. partial or repackaged doses) [37] and substandard formulations [38] as well as commodities they are prohibited to sell [39]. Sale of substandard and expired drugs by the PPMVs was also one of the barriers reported by the young people in our study. This may be related to weak enforcement of the set down guidelines and regulations by the regulatory authority [34]. The implication of this finding is that if the PPMVs are not strictly regulated and supervised, they may likely contribute to increased morbidities and mortalities attributable to use of substandard and expired drugs.
A fairly significant population of the nursing mothers felt that PPMVs in their locality do not have the prerequisite training to operate PPMV shops. They also agreed that operators generally have low health knowledge about proper treatment for common illnesses. This is so because conventionally, the minimum educational attainment stipulated by PCN for registration of PPMVs has been primary schooling [24] and Egbohin his work [40] stated that formal medical or pharmacy training is not required for PPMV licensure. Our study showed that perceived lack of training of PPMV staff was one of the main barriers to seeking health care from them among youth. Despite this, youth still accessed their services, potentially due to limited availability of alternatives or financial barriers to accessing the formal health sector. This perceived lack of training of PPMV staff is supported by Oyeyemi et al. [41] who reported that only a third of PPMVs had previous health related training. Additionally, Chiaka and colleagues [29], showed that PPMVs are not knowledgeable in diagnosis and treatment of diseases.
A systematic survey carried out by Beyeler and associates [25] noted that most PPMVs have low health knowledge and poor health treatment practices. For the PPMVs to give appropriate and timely advice to caregivers who tend to the sick children, it is necessary that they have basic knowledge of the presentation, cause, treatment and prevention of childhood diarrhoea [43]. However, Liu and his workers noted that majority of shop owners they assessed in their study in parts of Nigeria, have completed secondary or post-secondary education [10]. With a significant association demonstrated between knowledge and education level, an opportunity is presented for policies and interventions that emphasize education and training of PPMVs to improve their knowledge on childhood diarrhoea (and perhaps other childhood illnesses?) and to function optimally in primary care delivery in the community [42, 43].
The respondents fully agreed that sale of medicines without prescription in their locality was rampant. This study validates the result of the study by Akinyandenu and colleagues [43] where they noted that the sale of antibiotics without medical prescription has been observed in many countries [39]. A study conducted in Nairobi showed that about 64% of chemists sold antibiotics without prescription [36]. Antimalarials, analgesics, antibiotics and antiseptics were the most purchased drugs from PPMVs in our study. This outcome is related to the commonly endemic illness and injuries in rural setting and has been corroborated in earlier studies [27]. It is also instructive to note that some prescription-only medications are sold by these PPMVs. This clearly points to weak regulation of these drugs.
Most nursing mothers in this study agreed that they treat their children’s cough and cold with antibiotics in self-care without consulting a health worker. This is in tandem with the study which noted that 80% of illness episodes are self-treated with medicines obtained from community pharmacies [44]. This study further revealed that more than half of the respondents obtained these antibiotics used in the treatment of childhood cough and cold from PPMVs. Indalo [45] in his study showed that most chemist shops in peri-urban areas sold antibiotics without prescription.
A considerable proportion of the nursing mothers, noted that they sought for treatment of their children’s cough within 1 h of noticing the sickness. This must have been made possible because the respondents are nursing mothers, who given their close contact with children were frequently the first to identify illness symptoms [46]. Most of these mothers had a minimum of secondary schooling qualification. This agrees with a study conducted in Cross River and Bauchi States of Nigeria where they noted that mothers who have not attended school have lower rates of appropriate care seeking when compared to those that have attended school [47]. Appropriate care seeking involves identifying the need to take the child for treatment outside the home, ensuring that the care is not delayed and that the child is taken to appropriate health facility or provider [48].
Drug advice on the treatment of coughs and colds and on antibiotic use were obtained from patent medicine vendors and from health workers. This work agrees with the study by Prach and co-workers [36] where they noted that in addition to selling drugs patent medicine vendors can be a source of advice about illness and drug therapy [49]). The work done by Abdu-Aguye [50] showed that patent medicine vendors knowledge about antibiotics is moderate and needs to be enhanced by further training to ensure that they do not transfer wrong knowledge to their clients [50].
The respondents self-reported perceived efficacy of antibiotics was very high, with up to 90.8% reporting that their children got well after antibiotic treatment. The awareness of antibiotics could have been made possible by the information provided to them during counselling by PPMVs and health workers. This gives credence to the findings of Ibeneme and colleagues [29] where they noted that fewer than half of the mothers who resorted to PPMVs for treatment of childhood febrile conditions perceived that their child had fully recovered. However, in this study a few of the mothers noted that the sickness persisted after treatment. Okeke and his colleagues [39] noted that this persistence could be due to misdiagnosis and/or mismanagement of the health condition.
Interestingly, among the young people, our finding showed that only 25.5% of the respondents have ever purchased family planning products. Furthermore, the MNR for the questions related to the frequency of buying and using family planning products like condoms, oral contraceptives and contraceptives injections was very low, ranging from 1.4 to 1.7 out of 5-point Likert scale. The low rate of use of family planning commodities by youths is also reported in previous studies [51,52,53]. Nigeria, is among the countries globally with highest rates of adolescent fertility at 109 births per 1000 girls aged 15–19 per year, and yet also has one of the lowest rates of use of modern contraception in adolescents [54]. In Nigeria, 98.8% of married adolescent girls and 50.3% of unmarried sexually active adolescent girls do not use a modern contraceptive method [55]. Among the reported barriers to adolescent contraceptive use are lack of knowledge of services, cost, shyness and community stigma about sexual activity and disapproving attitudes from providers [56,57,58]. In Nigeria, adolescent sexual and reproductive health is affected by cultural, religious, legal, political and economic contexts [59].
A number of Nigeria health policies and other initiatives aimed at reducing disease burden in the country incorporate PPMVs as primary health care service providers [60]. As shown in this study, the PPMVs sell both antibiotics and contraceptives they are legally unauthorized to sell. Given their geographic spread, market share, and accessibility, PPMVs represent an important and often the only opportunity for access to primary health care services in most rural communities in Nigeria [7]. Consequently, despite regulations, it is common for PPMVs in Nigeria to provide services they are legally prohibited from offering, for which they have not received any training, including injectable contraceptives and dispensing antibiotics [7]. One of the main factors responsible for this is the high client patronage for these types of medicines, of which the PPMVs may be the only available source. Available report indicated that 11% of women who use injectable contraceptives noted getting their injectables from PPMVs [51]. While the majority of PPMV shops stock family planning commodities, few have received training on family planning methods, and therefore provide inadequate or often misleading counsel to their customers on family planning options or usage, and are less likely than other family planning providers to inform customers about method options or side effects [10, 51,52,53].
It has been argued that given the growing importance of family planning in Nigeria, contraceptives, including injectable contraceptives, should be added to the list of drugs that PPMVs are expected to stock in their shops [51]. There are calls for studies with training components for PMPVs on how to counsel clients about injectables, screen clients for eligibility, sell the method and administer injections with close supervision and monitoring by the NAPPMED and the FMOH [51,52,53]. Incorporating PPMVs into the health system may lead to increased use of family planning services among the target population of rural adolescents and the role of this towards UHC. This would require policy change and collaboration at the national level.
