The findings from this study are presented in line with the study objectives. They are further described using related themes supported by quotes from the community members’ and IHCPs’ perspectives.
Socio-demographic characteristics of participants
A total of 157 community members were involved in the FGDs (53 males and 104 females). More participants were captured in Kano (55.4%) as compared to Ibadan (44.6%). The majority were aged 40 years and above and from informal settlements. In Kano, more participants came from formal and informal settlements, while in Ibadan, more slum residents participated (18.4% vs 6.4%). Most of the participants had secondary education (43.6%), while over a tenth had no formal education (12.8%) or only primary education (12.8%). However, Ibadan had more participants with no formal education than those from Kano (12.3% vs 7.5%). Most of the participants were traders (46.4%), artisans (18.6%) or unemployed/housewives (16.4%). In Kano, more unemployed/housewives were reported compared to Ibadan (15.7% vs 0.7%).
Twelve IHCPs (7 males and 5 females) were also interviewed. Their mean (SD) age was 35 ± 4.3 years, and they had practiced for an average of 15.2 years. Half (6) of the IHCPs were from informal settlements, while the rest were evenly distributed between formal (3) and slum (3) settlements.
Burden of malaria
The burden of malaria was consistently emphasized as high in both cities. Participants overwhelmingly identified malaria as a widespread health issue within their communities, irrespective of settlement type. They described malaria as endemic, noting that it is a persistent disease they have lived with due to its year-round occurrence. Some participants estimated that malaria accounts for about half of all childhood illnesses in their area and emphasized its severity, referring to it as deadly. Additionally, children and pregnant women were identified as the groups most vulnerable to malaria.
“Malaria is the most common disease that is affecting everyone, especially this year, both the children and the adults, and it is deadly because we have so many patients that die due to this malaria (KII 16, Traditional Doctor, Informal, Kano)”
Poor environmental hygiene and sanitation that promote the breeding of mosquitoes were some of the major factors identified by both community members and IHCPs as drivers of malaria in all settlement types especially in informal and slum settlements. The participants mentioned open gutters, overfilled dumpsites, and the presence of water bodies as some of the environmental problems.
“… the cause of it is that the whole environment is polluted; many houses have gutters that go through the front and back of the house, and mosquitoes are always in the gutter, and when mosquitoes come inside the house, it will bite the children, and so many of us did not like mosquito nets, I don’t like to hang that mosquito nets…”( FGD 6, Female Participant 2, Slum, Ibadan).
However, some participants, including community members and IHCPs, had differing opinions on the causes of malaria. Notably, some individuals from informal settlements and slums believed that malaria could be caused by food preservatives, stress, and excessive exposure to sunlight.
“…Adults also come down with malaria through diets. A lot of food we consume nowadays has high chemical concentration in them. The use of chemicals in boosting crop production is a cause and all those chemical residues get deposited in our bones, thereby causing body aches leading to malaria. (KII14 Traditional Doctor, Slum, Ibadan)”
“…. It is caused by stress when you are stressed, apart from that when you go out under the sun it also causes malaria. (FGD 5, Female participant, Informal Settlement, Ibadan)
IHCP’s perceived competence and practice
Community members and IHCPs largely view IHCPs as competent, citing personal experiences, cultural values, and positive malaria treatment outcomes. IHCPs, particularly HDS and THs, attribute their competence to spiritual beliefs in their methods. Drug peddlers are also seen as competent for providing immediate symptom relief. In slum areas, trust in PPMVs is reinforced by their dual roles as health facility staff and PPMV store operators. Below are supporting themes and quotes.
Positive experience of community members influences perceived competence
Community members consistently return to IHCPs, including PPMVs, DPs, THs, and HDSs, due to positive treatment outcomes and satisfaction with care. This pattern was observed across both cities, regardless of settlement type.
A community member who visits a PPMV had this to say:
“They prescribed medicine for me. I bought and took it and I felt better…… (FGD 6, Female Participant, Informal Settlement, Kano).”
The IHCPs also recounted their experiences treating these community members, noting that patients typically recovered from the illness, with some reporting improvement in a shorter time than expected. They believed these outcomes enhanced the community’s perception of their competence.
“…. Most people that are coming to me, once I tell them that the herbs should be taken for a week or so, before three days they will have been very okay even before the dates I gave them, so they come back (KII 13, Herbal seller, Informal, Ibadan)”.
Spiritual beliefs and beliefs in the effectiveness of treatment method by HDSs and THs drives perceived competence
All the herbal drug sellers and traditional healers in both cities claimed to be confident in their ability to manage suspected malaria cases. They affirmed that using natural ingredients provided by God, coupled with spiritual support, enhances their ability to treat malaria effectively.
“I am very competent, once I know the child has malaria at tender age and they brought the child to me, I know God will help me to treat such a case (KII 13, Herbal Drug Seller, Informal Settlement, Ibadan)”.
“…I keep saying to you that; if you bring children and pregnant women, with God’s grace, I am sure I have the competence to treat them (KII 16, Traditional Healer, Informal Settlement, Kano).”
Most herbal drug sellers and traditional healers also believed in the superior effectiveness of herbal or traditional medicine compared to orthodox medicine, which they felt provided only temporary relief. This view was also shared by some community members, especially those from informal settlements and slums.
“…I will say that traditional medicine is more helpful than the drugs in hospital because traditional medicine cure the illness completely while the drugs given to you in the hospital will just relieve you from it for some days and you will be sick again (KII 13 Herbal drug seller, Informal Settlement, Kano)”
Inappropriate malaria management practices by IHCPs queries competence
Additionally, most IHCPs often do not follow the recommended treatment guidelines for malaria. The PPMVs usually treat their clients with common monotherapy anti-malarials, while some use artemisinin-based combination therapy (ACT). However, a common practice among them is to combine these anti-malarials with multivitamins and antibiotics if they perceive malaria to be severe or persistent. On the other hand, drug peddlers typically give a combination of drugs such as paracetamol, ibuprofen, and aspirin, known locally as “akapo” in the Yoruba language.
“….We treat complicated malaria infection with antibiotics because nowadays malaria is so resistant to antimalaria. So, if you give some people antimalarial you still need to add Amoxicillin to it… (KII 11, PPMV, Formal, Ibadan)”
“…. We go to Alakapo (drug hawker or seller who sells and give all sorts of combination of drugs) (FGD 3, Male Participant, Slum, Ibadan).”
The HDSs and THs typically use various items, including leaves and tree bark, which are cooked to extract the beneficial medicinal compounds. The resulting water extract is then used for treatment. Clients may be instructed to drink, inhale, or bathe with the extract. The dosage of these herbal medicines is determined based on the perceived severity of the illness by the herbal drug sellers/traditional healers.
“…do you know neem tree? we use it, we also use mango leaves and Zumbur leaves then lemon leaves and pawpaw leaves this are what we use for the steaming while the Zumbur is in powder form these are what we use to cure malaria….”(KII 16, Herbal drug seller, Informal, Kano)
“Whenever they come to me for treatment and I give them a 1.5litre bottle full of herbs, they recover from the malaria by the time they use it within the first three days. (KII 16, Herbal drug seller, Slum, Ibadan)
Furthermore, IHCPs reported that they do not confirm malaria diagnosis before they treat their clients. They rely on the clients’ signs and symptoms, and based on experience, they prescribe medications. This was common to all categories of IHCPs interviewed regardless of the city or type of settlement.
“…….It is from the patient eye that I will know, the eyes will be yellow and the hand will be pale, she will be short of blood, so when I detect such things. I will know that it is severe malaria, and that is how I will know what types of herbs that I will use for that person because there are some herbs that are good to enhance blood. So if we discovered that malaria is severe, we will cook more herbs with the one that will enhance the blood for the patient to drink (KII 14, Herbal Seller, Slum, Ibadan).
Perceived reasons for patronizing IHCP
Participants noted that community members often visit IHCPs, particularly PPMVs/DPs, because of the affordability of medicines and the option for credit or deferred payments. Many also emphasized cultural beliefs in the effectiveness of herbal remedies as a critical motivator for visiting traditional healers or herbal drug sellers. Participants also explained that these providers are often consulted when the illness is perceived as mild, with the hope of quick relief. Another major factor highlighted was the convenience and accessibility of these IHCPs within the community, especially when formal healthcare facilities are closed or hard to reach. These findings are organized according to the themes below.
Affordability of services
Both the community members and IHCPs affirmed that the treatment provided by the IHCPs was reasonably priced, as some participants claimed that hospitals (formal health care providers) charge about 10 times more than IHCPs. Many highlighted that IHCPs provide flexible payment options, often allowing treatment to begin without full payment upfront, further enhancing their utilization. This affordability and payment flexibility were consistently reported across both cities and in all settlement types, though more participants from informal and slum settlements emphasized these points. Participants from these areas particularly appreciated the financial accessibility of IHCPs, noting that deferred payments or installment plans allow them to seek treatment they might otherwise avoid in their communities, where financial capability is low. Some participants stated the following:
“For me, I do rush to chemist because they say” cut your coat according to your size” I do rush to chemists because with your 1,000 naira the chemist vendor will treat you well, with injection and even tablets (drugs), but when you go to hospital there you can spend more than ten thousand naira, before they treat you, they will admit you and so on which cost a lot of charge. So, for me I prefer going to the chemist (FGD 7, Female Participant Formal, Kano).”
“We mostly go to chemist because they can give drug when we don’t have money and can pay later (FGD 5, Female Participant, Informal, Kano).”
“…. if they prescribed to me and I don’t have enough money to buy everything that was prescribed, I have checked and the money is not enough, I will just go and buy the traditional ones (FGD 6, Female Participant, Slum, Kano).
Perceived mildness of illness
Some community members in both cities and all settlement types reported that their decision to visit IHCPs is influenced by their perception of the illness’s severity. They believe that if the symptoms of malaria are mild, there is no need to seek treatment at formal health facilities such as clinics or hospitals. Instead, they feel that such cases can be adequately managed by purchasing medication from PPMVs or seeking remedies from herbal drug sellers.
“…. If the child’s condition is not too bad before going to the hospital, we go to the chemist for treatment (FGD 7, Mother of U5, Formal Settlement, Kano).”
“People go to the herb sellers as a first step at least to look at it, when it gets to two or three days, and there are no changes then they will go to the health center …. (FGD 5 Female Participant, Informal Settlement, Ibadan).”
Accessibility and prompt service
The IHCPs across both cities identified accessibility as one of the significant reasons community members often use their services. The IHCPs, especially PPMVs, reported they are closer to the community members and can be accessed 24 h a day, even on weekends when some primary healthcare facilities are closed. Some IHCPs also mentioned that they are frequented because community members prefer the quick service they offer. The community members can obtain all the drugs they need in a short time, unlike waiting in long queues at health facilities where they might be prescribed similar drugs available at the PPMV stores. This opinion was identical in all settlement types.
“The main reason people seek drugs from us is because we are closer to them. Regardless of the time, they can knock on our door and request medication” (KII 11, PPMV, Informal Settlement, Kano)”
“If there is occurrence of malaria during weekend among those that are not rich enough and public health facilities are not opened, they usually go to chemists (FGD 7, Mother of U5, Formal Settlement, Kano).”
“…For some it is time. The time they will use at a private hospital cannot be compared to a health centre. That discourages them from going. Some think it wise to just go to medicine store to buy drugs since drug will still be prescribed to them at the health centre..” (KII 12, Drug peddler, Slum, Ibadan)”
Belief in efficacy of herbs
Findings indicate that one primary motivator for community members visiting herbal sellers or traditional healers was the solid cultural belief in the efficacy of their treatment methods, a view corroborated by the HDS and TH themselves. Several community members, particularly those in urban slums and informal settlements, strongly affirmed that herbs had been used since the time of their ancestors, and their knowledge of herbal medicine was passed down through generations. They reinforced this belief by demonstrating how to cultivate these herbs and identify useful varieties.
“I believe in herbs. I have malaria herbs and all in one herb at home. I believe in herbs because if you use herbs, you will pass out malaria through urine (FGD 1, Male Participant, Formal Settlement, Ibadan).”
“…Some have a stronger belief in the efficacy of herbal mixtures. They do have it at home and even use it as a preventative measure. (KII 14. Traditional Doctor, Slum, Ibadan)
Contingency treatment option
This study also found that community members often seek care from formal healthcare providers and some IHCPs, such as PPMVs, for conventional treatments. Still, they frequently turn to herbal or traditional medicine when these treatments fail to meet their expectations. They noted that when conventional treatments do not provide the desired relief or are perceived as ineffective, people often shift to using herbs, believing them to offer a more lasting or holistic solution. Community members and IHCPs affirmed this practice in both cities and all settlement types.
“I also want to say that if after taking the normal white man medicine and it did not work, it requires other native ways like herbs (FGD 7, Mother of U5, Formal, Ibadan).”
Community members in informal and slum settlements in one of the cities also described vividly the circumstances under which they sought treatment from these categories of IHCP. As some participants said.
“… If I took a hospital medicine, if I take it and it didn’t work for me, I have another way, and that way is I will go to a traditional doctor, our local medicines of before I will do the needful and if Allah permits, I will be fine and will recover (FGD 6, Female Participant, Informal, Kano)
“…We have traditional healing home like Baba Na Kabara if our children’s are sick, we try hospital first, if the drugs didn’t work for them then we go to him and buy traditional drug which is N200 to 250 naira and his drug is very effective to our children (FGD 9, Mother of U5, Slum, Kano)”
Perceived side effects of orthodox medicine
A few participants cited concerns about the side effects of orthodox medication as a critical reason for seeking treatment from HDS and TH. They expressed apprehension that conventional medicine often carries undesirable side effects that impact long-term health. One of the IHCPs specifically mentioned fears regarding the effects of orthodox medicine on fertility and male sexual potency, with some believing that regular use of these medications can lead to reduced fertility or diminished sexual performance in men.
“Some of this orthodox medicine used to weaken manhood or kill cells in the body, it is the chemicals that are used to prepare those orthodox medicine that cause it, but herbs do not have such things because there are no chemicals in them (KII 14, Herbal drug seller, Slum, Ibadan).”
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