Original Research

Factors influencing irresponsible self-medication in rural Ethiopia: Insights from Gimbichu district

Seifu Ambissa, Sibusiso Zuma

Received: 03 July 2025; Accepted: 19 Sept. 2025; Published: 11 Dec. 2025

Copyright: © 2025. The Author(s). Licensee: AOSIS.
This work is licensed under the Creative Commons Attribution 4.0 International (CC BY 4.0) license (https://creativecommons.org/licenses/by/4.0/).

Abstract

Background: Irresponsible self-medication practice (ISMP) defined as the use of modern or traditional medicines without professional consultation, guidance or prescription, which poses health risks, is a major challenge in rural Ethiopia, where access to formal healthcare is limited and traditional remedies are widely used.

Aim: To determine the prevalence and factors influencing ISMP among community-based health insurance (CBHI) member and non-member households (HHs) in Gimbichu district, Ethiopia.

Setting: The study was conducted in the rural Gimbichu district of Ethiopia, characterised by limited healthcare access, predominantly agrarian communities, and active CBHI schemes, impacting healthcare-seeking behaviors.

Methods: A cross-sectional analytic survey was conducted among 541 rural adults using multistage sampling. Data were collected via structured interviews and analysed using descriptive statistics and multilevel regression.

Results: The prevalence of ISMP was 66.2%, higher among uninsured HHs (78.6%) than insured HHs (54.9%). Both groups practised self-medication using traditional and modern medicines without professional advice. Key predictors included low educational attainment, HH role (housewives, dependents), medicine hoarding, dissatisfaction with healthcare services, increased travel time to facilities, and perceived minor illness severity. Uninsured respondents were five times more likely to engage in ISMP. Social influences, notably recommendations from family and friends, were strong predictors, especially among the uninsured.

Conclusion: Irresponsible self-medication practice is highly prevalent and shaped by sociodemographic, structural and perceptual factors. Community-based health insurance membership plays a crucial protective role in mitigating ISMP by enhancing access to formal healthcare and reducing reliance on self-treatment.

Contribution: Targeted strategies to expand CBHI enrolment and retention, alongside improving health literacy and healthcare access, are vital to effectively reduce ISMP in rural Ethiopian communities.

Keywords: community-based health insurance; determinants; rural Ethiopia; healthcare access; irresponsible self-medication practice; self-medication; traditional medicine.

Introduction

Irresponsible self-medication practice (ISMP) refers to the use of modern or traditional medicines without authorised professional consultation, prescription or guidance, potentially leading to incorrect dosage, inappropriate medicine choice, adverse drug reactions, delayed diagnosis and other health risks.^1,2,3 This contrasts with responsible self-medication practice (RSMP), which involves safe and informed use of over-the-counter (OTC) medications under clear guidance. Irresponsible self-medication practice, therefore, denotes unsafe or improper self-medication behaviours that compromise individual and public health.^3,4

Irresponsible self-medication practice poses substantial risks to individual and community health, especially in low- and middle-income countries, where limited healthcare access, knowledge and regulatory enforcement compel the population to rely on such practices.^5,6 In Ethiopia, ISMP prevalence varies widely, ranging from 19% to 96%.^7,8 The practice typically involves the use of unverified traditional remedies⁹ and modern medicines used without professional advice, exacerbating risks like antimicrobial resistance, adverse drug reactions⁶ and delayed diagnosis of serious conditions.¹⁰ These challenges are amplified by sociocultural, economic and structural barriers such as travel time, dissatisfaction with healthcare and low health literacy, particularly among women and less-educated population groups.^9,10,11

Rural and farming communities in Ethiopia, constituting about 80% of the population,¹² face a triple burden: limited access to formal healthcare services, widespread reliance on ISMP including inappropriate use of antibiotics, poorly regulated medication sharing and a relatively high prevalence of infectious diseases.¹³ Economically, these communities can be severely impacted by out-of-pocket (OOP) healthcare expenditures for ineffective or harmful care.¹⁴ Recent studies in Ethiopian rural zones, such as South Wollo, report that nearly 30% of households (HHs) experience catastrophic health expenditure (CHE), where healthcare costs exceed critical thresholds of HH income or capacity to pay, pushing families into financial hardship and deepening poverty.¹⁵ Catastrophic health expenditure forces HHs to reduce spending on essential needs or sell assets, increasing long-term vulnerability. Without adequate financial protection, including low health insurance coverage, with only about 28% enrolled in schemes like community-based health insurance (CBHI), many rural HHs rely on OOP or direct payment for health services, exacerbating the economic burden of healthcare costs. Community-based health insurance, a voluntary community-driven pooling mechanism, has shown promise in mitigating these costs by improving access to local health services without immediate payments, thus potentially reducing CHE and its impoverishing effects, especially for vulnerable groups such as women and low-income families.¹¹ However, despite CBHI’s expansion, many rural HHs remain exposed to catastrophic health expenses, which can also worsen ISMP because of cost barriers to formal care.^16,17

While ISMP is widely studied, existing research in Ethiopia lacks granularity on rural contexts, CBHI’s protective role, and the interplay between modern and traditional medicine use. Prior studies focus disproportionately on urban settings or specific demographics (e.g. pregnant women), using inconsistent definitions that obscure the full spectrum of ISMPs.¹

This study addresses three critical gaps. By focusing on Gimbichu’s rural kebeles, it captures the unique sociogeographic context characterised by agricultural livelihoods and mountainous terrain that shape healthcare decision-making. Although CBHI has been shown to increase formal healthcare utilisation by 26% compared to non-CBHI,¹⁶ its association with ISMP remains unexplored. This research examines how insurance status interacts with sociodemographic and enabling factors such as travel time, as well as perceptual drivers like trust in providers and illness characteristics to influence ISMP. Distinct from previous studies, ISMP here is defined as any use of modern or traditional remedies without authorised professional consultation.¹ Findings aim to inform targeted interventions to reduce ISMP and improve healthcare outcomes in rural Ethiopian settings.

Conceptual framework

Anderson’s Behavioural Model of Health Service Utilisation (ABM) guided this study, conceptualising ISMP as influenced by:

• Predisposing factors: Sociodemographic (education, marital status, HH role) and beliefs (trust in traditional medicine).
• Enabling factors: Access to healthcare, insurance status, transportation and availability of hoarded medicines.
• Need and health outcome factors: Perceived illness severity and health literacy.¹⁸

This framework facilitated the identification of determinants, literature review, questionnaire design, data analysis and interpretation. It clarified how structural inequities (e.g. 52% CBHI enrolment in Gimbichu) intersect with individual behaviours to perpetuate ISMP (Figure 1).¹⁹

FIGURE 1: Conceptual framework diagram for irresponsible self-medication practice determinants based on Anderson’s behavioural model.

Study aim and objectives

This study aimed to investigate factors influencing ISMP among CBHI member and non-member HHs in rural Gimbichu district, Ethiopia, by:

• Determining the magnitude of ISMP among CBHI insured and uninsured HHs in rural Gimbichu district.
• Identifying key factors influencing ISMP.
• Comparing ISMP between CBHI insured and uninsured HHs.
• Providing evidence-based recommendations for relevant authorities to mitigate ISMPs.

Research methods and design

Study design and setting

This study utilised a quantitative, descriptive cross-sectional survey with analytic components, conducted in Gimbichu district, Oromia Regional State, Ethiopia. The district is predominantly rural, with about 117 595 residents living in approximately 24 499 HHs, the majority engaged in agriculture. Healthcare infrastructure comprises 5 government health centres (HCs), 33 rural health posts, 7 private clinics and 1 privately owned rural drug vendor. Accessibility is limited because of challenging terrain and lengthy travel distances; primary hospital access is absent, and the health workforce density (doctors and pharmacists per capita) is among the lowest nationally and regionally. Gimbichu became one of Ethiopia’s initial CBHI pilot districts in 2010. By 2018, 21 434 HHs were CBHI-eligible, with 11 945 (52%) registered as members and the remainder non-members.²⁰ This contextual foundation highlights the study’s focus on a resource-limited, insurance-pilot rural setting with significant physical and financial barriers to healthcare.

Study population

The study targeted adults aged 18 years and above residing in rural HHs within selected kebeles, specifically those who reported at least one episode of any illness within the month prior to data collection. Inclusion criteria required self-report of any illness within the 4 weeks preceding data collection, capturing both acute illnesses (less than 15 days duration) and chronic conditions (lasting 15 days or more), availability during the study period, and provision of informed consent. Exclusion criteria comprised individuals under 18 years, permanent formal sector employees or HH members reliant on formal income (since CBHI typically does not cover such HHs in rural areas), temporary residents of less than 6 months, HH members without recent illness, currently hospitalised individuals, those unreachable during the study period, and non-consenting participants. This approach ensured that the study population accurately reflected community members at risk for or engaging in ISMP in a rural Ethiopian context.

Sampling

A multistage probability sampling strategy was adopted to maximise representativeness and minimise selection bias. Firstly, cluster sampling identified 10 rural kebeles from the district’s 33, using systematic random sampling with a sampling interval of three. Secondly, within each selected kebele, all HHs were stratified by CBHI membership status to account for heterogeneity in insurance enrolment rates. Proportional allocation determined the number of HHs in each stratum, yielding a total sample of 557 HHs. Thirdly, systematic random sampling was employed to select HHs from each stratum. If multiple eligible (recently ill) adults lived in a chosen HH, one was randomly selected for the interview.

Sample size

The sample size of n respondents was determined using a 5% level of uncertainty, a 95% confidence interval (CI) and the single population proportion formula for cross-sectional studies:

where n denotes the required sample size, p the estimated proportion of individuals’ Self-Medication Practices (SMPs), z score the cutoff value of the normal distribution and degree of freedom (1.96). E presents the precision required on either side of the proportion (0.05). For this particular calculation, p = 78.1%, representing the prevalence of SMP in Limmu Kossa town, Southwest Ethiopia.²¹ Like Gimbichu, Limmu Kossa is one of the first CBHI pilot districts in Oromia Regional State. The initial sample size was 265 respondents. Considering the cluster sampling design, a design effect of 2 was applied, increasing the sample size to 530. A 10% contingency was added to account for non-response, resulting in a final sample size of 557 eligible HHs. Using population proportion to sampling ratio (PPS), 52% of HHs were CBHI members and 48% were non-members, leading to 291 CBHI member HHs and 266 non-member HHs in the sample (Figure 2).

FIGURE 2: Participant flow diagram showing sampling and selection process for this study.

Data collection

Data were collected via face-to-face interviews using a structured, pre-tested questionnaire. The instrument, initially drafted in English, was translated to Afan Oromo and back-translated to ensure semantic equivalence. The questionnaire covered eight domains: sociodemographics, geography and transport, medicines hoarded at home, recent illness characteristics, CBHI status and ISMP. Knowledge, attitudes and perceptions about ISMP and healthcare quality were measured by 3-point Likert scales. The tool was pre-tested on 5% of the sample in a comparable rural kebele and iteratively refined for clarity and relevance based on pre-test feedback. Trained data collectors with pharmacy backgrounds and Afan Oromo fluency conducted the interviews over a 15-day period (15 January 2019 – 28 February 2019), typically in HH settings and at times conducive for participant availability.

Data quality and supervision

Six trained data collectors worked under the close daily supervision of the principal investigator, who performed spot-checks and reviewed completed questionnaires for completeness, accuracy and internal consistency. All completed questionnaires were collected daily until the predetermined sample was achieved.

Data analysis

Completed questionnaires were manually checked for completeness, errors and inconsistencies before coding. Likert scale responses were coded from +1 (agree) to –1 (disagree), with 0 indicating neutrality. Data were entered into Microsoft Excel and imported into Statistical Package for the Social Sciences (SPSS) version 24.0 for analysis. Descriptive statistics (frequencies, percentages, means, standard deviations [s.d.]) summarised ISMPs and related variables. Data cleaning included checking for outliers and implausible values.

Factor analysis was conducted on scale variables measuring knowledge, attitudes and perceptions using principal component analysis with varimax rotation. The Kaiser–Meyer–Olkin measure and Bartlett’s test of sphericity confirmed sampling adequacy and suitability for factor analysis. Three factors for knowledge, four for attitude and one for perception were initially extracted; however, only one factor each for attitude (‘cues to action’) and perception (‘perceived satisfaction with healthcare quality’) was retained because of multicollinearity. These factors demonstrated strong internal consistency (Cronbach’s alpha ranging from 0.82 to 0.92).

Bivariate analyses identified variables associated with ISMP. Multilevel multivariate binary logistic regression using backward likelihood ratio was performed to determine independent predictors, entering predisposing factors first, followed by enabling, need factors and finally CBHI status. Model fit was assessed using -2 log likelihood, omnibus tests, Nagelkerke R², and Hosmer–Lemeshow goodness-of-fit tests. Final models demonstrated good fit and explained significant variance in SMPs. Prediction accuracy was high, correctly classifying over 86% of cases across models for overall, insured and uninsured HHs.

Ethical considerations

Ethical clearance to conduct this study was obtained from the University of South Africa Department of Health Studies Research Ethics Committee (No. HSHDC/664/2017) and the Oromia Regional Health Bureau (ORHB). These bodies are responsible for ensuring the protection of human subjects, overseeing ethical conduct of research, and safeguarding participant rights and confidentiality. Written informed consent was obtained from all participants in private settings, ensuring voluntary participation and data confidentiality. The study adhered to ethical principles, including avoidance of data fabrication, falsification or plagiarism.

Results

Sociodemographic characteristics

Of the 557 selected respondents, 541 (284 insured vs. 257 uninsured) participated in the study, resulting in a 97.1% (97.6% insured vs. 96.6% uninsured groups) response rate.

The study included 541 respondents aged between 18 years and 80 years, with a mean age of 38.0 years (39.7 years for insured and 36.0 years for uninsured) and an s.d. of 12.4 years. Gender distribution differed notably between groups: 68.1% of uninsured respondents were female, whereas the insured group had an equal gender distribution. Most respondents were married (72.9% insured vs. 77.8% uninsured). Regarding HH roles, 42.9% of respondents were housewives (30.3% insured and 56.8% uninsured), followed by heads of HHs (38.4% overall; 47.9% insured and 28.0% uninsured). Educational attainment varied, with 40.8% of respondents having no formal education (42.6% insured and 41.2% uninsured). Farming was the predominant occupation, reported by 82.3% of respondents (76.7% insured and 88.3% uninsured). The vast majority identified as Orthodox Christians (over 90%) and belonged to the Oromo ethnic group (93.5%) (Table 1).

Enabling and need characteristics

A higher proportion of insured respondents (70.4%) reported visiting formal healthcare facilities, public or private, at least once in the year preceding the study, compared to 58.8% of uninsured respondents. Regarding accessibility, 42.3% of all respondents indicated that the one-way walking distance to the nearest HC was 60 min or less, with a similar distribution among insured (44.4%) and uninsured (40.1%) groups. However, a notable proportion faced longer travel times, with 27.0% reporting 60 min – 120 min and 30.7% over 120 min; among these, slightly fewer insured respondents reported longer distances compared to uninsured counterparts.

In terms of transportation, over half of both insured (58.1%) and uninsured (56.0%) respondents primarily travelled on foot to reach HCs, followed by animal transport (horses or mules) used by approximately 27% in both groups, and public vehicles utilised by 14.8% of insured and 17.1% of uninsured respondents. Additionally, medicine storage at home was common, with 61.4% of respondents – 65.5% insured and 56.8% uninsured – reporting hoarding at least one modern or traditional medication, reflecting prevalent self-care practices within the community.

Among the 541 respondents, the most commonly reported complaints were pain including headaches by 59.3% (47.2% insured and 72.8% uninsured), followed by respiratory tract infection (RTI) (37.7%), fever (20.7%), gastrointestinal (GI) or parasitic diseases (20.3%), dyspepsia (18.5%), diarrhoea (11.5%) and urinary tract infection (UTI) (9.2%). Nearly two-thirds reported a single illness episode during this period, while about one-third experienced two or more illnesses. Around 47% – 48% perceived their current illness as a recurrence of a previous condition within the past year. Most illnesses were acute (less than 15 days) in duration (79.9%), with the remainder chronic. Approximately half of the respondents considered their illnesses minor, while 26.8% and 22.9% rated them as moderate or severe, respectively; notably, a higher proportion of insured individuals perceived their illnesses as severe compared to uninsured respondents. Overall, over two-third of respondents rated their general health as fair or good, though 31.6%, including more insured than uninsured respondents, perceived their health as poor (Table 2).

Prevalence and patterns of irresponsible self-medication practice

Overall, ISMP was practised by 66.2% of respondents during the 4 weeks preceding the study, with a notably higher prevalence among the uninsured (78.6%) compared to the insured (54.9%). Formal healthcare was primarily sought from public HCs by 44.4% of respondents, with insured respondents more likely to use these services (55.3%) than uninsured respondents (32.3%). Meanwhile, 11.6% of respondents – more uninsured than insured – forewent any form of care, including self-medication.

Respondents engaged in ISMP using a variety of products ranging from traditional remedies to modern pharmaceuticals without consulting accredited healthcare providers. Herbal and home remedies were the most commonly used products (approximately 50% in both groups), followed by analgesics or antipyretics and antibiotics. Notably, uninsured respondents reported higher use of antibiotics, analgesics and parasitic drugs, whereas insured individuals used antacids and herbal remedies more frequently. Irresponsible self-medication practice was predominantly practised for pain (including headaches), RTI, fever, GI illnesses and dyspepsia, with variations in prevalence between insured and uninsured groups.

Sources of information were mainly prior experience (42.1%) and advice from family, friends or neighbours (35.3%), with pharmacy personnel playing a smaller role, particularly among insured respondents. Traditional medicines were primarily obtained from open markets, especially by uninsured respondents, whereas orthodox medicines were often sourced from medicines hoarded at home or rural drug vendors, with uninsured respondents more likely to use these informal sources. The main reasons for self-medication included perceiving the illness as minor, prior experience, remoteness of health facilities, advice from social contacts, saving time and money, and emergency needs (Table 3).

Regarding outcomes, nearly 60% of ISMP respondents reported symptom relief, although about 40% experienced partial or no improvement, or worsening of symptoms. Adverse effects were reported by 7.5%, including gastric irritation, nausea, vomiting, diarrhoea and skin reactions. Importantly, a majority of respondents (61.9%), nearly half of the insured and three-quarters of the uninsured, expressed an intention to continue self-medication in the future, highlighting the entrenched nature of this practice within the community (Table 4).

Factors influencing irresponsible self-medication practice

Bivariate analysis of factors associated with irresponsible self-medication practice

Table 5, Table 6 and Table 7 present bivariate analyses of factors associated with ISMP among overall, insured and uninsured HHs.

In the overall HH sample (Table 5), lower education levels were significantly associated with increased ISMP: HHs with no formal education had nearly threefold higher odds (crude odds ratio [COR] = 2.99, 95% CI: 1.86–4.84, p < 0.01), and those with 1st–9th grade education also had elevated odds (COR = 1.79, 95% CI: 1.12–2.86, p < 0.05) compared to HHs with education beyond the 9th grade. Dependents or housewives showed significantly higher odds of ISMP (COR = 3.67 and 2.76, respectively; p < 0.01). Unmarried status was strongly linked to ISMP (COR = 5.13, p < 0.01). Positive belief in family or neighbour recommendations and medicines hoarded at home substantially increased the likelihood of ISMP (COR = 4.49 and 4.75, respectively; p < 0.001). Longer travel time to the nearest public HCs (1–2 h and > 2 h) was also positively associated with ISMP (CORs ~2.1 and 1.9; p < 0.001). Animal transportation reduced the odds (COR = 0.41, p < 0.01). Households reporting two or more illnesses, poor health status, prior illness episodes, longer illness duration and uninsured CBHI status were all significantly associated with increased ISMP.

Among insured HHs (Table 6), no formal education, dependent HH role, unmarried status, positive family/neighbourhood recommendation, medicines hoarded at home, dissatisfaction with public health services, increased distance to public HCs, multiple illnesses (≥ 2) and use of animals for transportation showed significant associations with ISMP. Notably, positive belief in family/neighbour recommendation was associated with a markedly high odds ratio (COR = 35.71, p < 0.001).

In uninsured HHs (Table 7), similar patterns emerged: no formal education, dependent HH role, unmarried marital status, positive belief in community recommendations, medicines hoarded at home, and longer travel time to health facilities (> 2 h) were significantly linked to higher ISMP. Poor health status and minor severity of illness were also significant predictors. However, the number of illnesses did not show a significant association in this group.

Multilevel regression analysis of factors influencing irresponsible self-medication practice among overall households

Multilevel regression identified key predictors of ISMP among all respondents. Lower educational attainment significantly increased the likelihood, with respondents lacking formal education being six times more likely to self-medicate than those with secondary education or higher. Household roles played a role: housewives and dependent members (e.g. children, extended family) were 2.9 and 4.96 times more likely to self-medicate than HH heads. Beliefs about healthcare engagement further influenced behaviour, as respondents who did not prioritise informing physicians of their self-medication history were 18 times more likely to practise it.

Structural barriers also drove self-medication. Travel time exceeding 2 h to the nearest HC increased the odds sevenfold compared to those living within 1 h. Reliance on walking as transportation raised the likelihood nearly threefold versus public vehicle use, while using animal transport reduced odds by 87%. Medicine hoarded at home amplified self-medication rates 17-fold. Dissatisfaction with healthcare doubled the likelihood, and perceived poor or fair health status increased odds by 3.49 and 2.56 times, respectively. Acute illnesses (< 15 days) and prior experience with similar conditions raised likelihood by 6.32 and 2.64 times, respectively. Notably, the uninsured were five times more likely to self-medicate than insured respondents, underscoring insurance status as a critical determinant of healthcare-seeking behaviour (Table 8).

Multilevel regression analysis of factors influencing irresponsible self-medication practice among insured households

Multilevel regression analysis identified several key factors independently associated with ISMP among insured respondents. Unmarried were nearly six times more likely to self-medicate compared to married counterparts, while housewives had a 10-fold higher likelihood than HH heads. A favourable attitude towards family or friends’ recommendations increased the odds of ISMP by seven times. The presence of medicine hoarded at home was a strong enabling factor, increasing the odds of ISMP by 9.71 times. Dissatisfaction with the healthcare at the nearest public HC dramatically increased the likelihood of self-medication by 16.83 times. Those perceiving their health as fair or good were significantly less likely to self-medicate compared to those with poor health status. Additionally, respondents reporting ≥ 2 illnesses were 14.23 times more likely to self-medicate, and prior experience with similar illnesses increased the odds by 3.74 times. Finally, perceived minor illness was associated with a ninefold increase in ISMP (Table 9).

Multilevel regression analysis of factors influencing irresponsible self-medication practice among uninsured households

Multilevel regression analysis identified key predictors of ISMP among uninsured respondents: those with a positive attitude towards family or friends’ recommendations for self-medication were 11 times more likely to self-medicate. The presence of medicine hoarded at home was a strong enabling factor, increasing the likelihood of ISMP by over 25 times. Perceived illnesses significantly influenced behaviour: respondents who perceived their illnesses as moderate and minor were 15.3 and 4.3 times more likely to self-medicate, respectively (Table 9).

Comparison of irresponsible self-medication practice between insured and uninsured households

Multilevel regression analyses revealed significant differences in ISMP based on CBHI status. Uninsured respondents were substantially more likely to self-medicate than insured, with an adjusted odds ratio (AOR) of 5.06. Notably, variations related to belief in unfavourable self-efficacy, medicine hoarding and perceived illness were highly pronounced among the uninsured group, whereas marital status, HH role, perceived healthcare quality and illnesses had stronger associations with ISMP in the insured group. Overall, uninsured respondents exhibited fewer but more potent factors driving ISMP compared to their insured counterparts (Table 8 and Table 9).

Discussion

This study provides a robust investigation into the sociodemographic characteristics, enabling and need factors, and predictors of ISMP among insured and uninsured HHs in the rural Gimbichu district, Ethiopia. The high response rate (97.1%) and representative sample (N = 541) support the validity and generalisability of the findings. This research highlights a high prevalence of ISMP in rural Ethiopia, particularly among uninsured HHs, and underscores the protective role of CBHI in promoting formal healthcare utilisation and reducing ISMPs. Predisposing, enabling and need factors, as conceptualised by the ABM, significantly influence ISMPs.

Sociodemographic profile

The sociodemographic profile aligns with the predominantly agrarian nature of Ethiopian rural communities, with over 82% of respondents engaged in farming.¹² A disproportionately high proportion of females (68.1%) was observed among uninsured HHs compared to insured ones, indicating significant gender disparities in insurance coverage and health-seeking behaviour. This finding echoes prior Ethiopian studies that highlight women’s increased vulnerability to healthcare access inequities.^16,22 The persistently high proportion of respondents lacking formal education (~40%) aligns with national rural literacy data, indicating ongoing challenges related to health literacy and informed health decisions within these communities.¹⁶

Enabling and need factors

Nearly 58% of respondents primarily travelled on foot, and over half reported travel times exceeding 1 h to the nearest HC, reflecting well-documented geographic barriers to healthcare access in Ethiopian rural settings.^16,23 The high prevalence of medicine hoarding at home (61.4%) corroborates previous findings linking easy medicine availability to increased ISMP.⁸ Insured HHs reported higher formal healthcare utilisation (70.4% vs. 58.8% among uninsured), consistent with recognised benefits of CBHI in improving healthcare access.^17,24

Illness profiles revealed a predominance of acute conditions (~80%) alongside chronic illnesses, reflecting a realistic disease burden. Detailed symptom distribution and severity perceptions align with recent large-scale Ethiopian surveys, showing common complaints such as pain, respiratory infections and GI illnesses among rural populations.^16,25

Prevalence and patterns of irresponsible self-medication practice

The overall ISMP prevalence was 66.2% among rural HHs in Gimbichu district within a 4-week recall period. This rate exceeds findings from other Ethiopian regions such as Jigjiga town (37.5%) and Gondar town (50.2%),^10,26 yet is lower than the 73.6% and 71.0% prevalence reported in West Hararghe and Addis Ababa, respectively.^27,28 Variations likely reflect differences in study populations, recall periods, methodologies and operational definitions of ISMP.

Importantly, ISMP prevalence was significantly lower among insured HHs (54.9%) compared to uninsured HHs (78.9%), consistent with findings from Addis Ababa city and Hosanna town.^28,29 This suggests that CBHI membership may reduce reliance on ISMP, possibly because of better access to formal healthcare services. In this study, 58.0% of insured versus 38.9% of uninsured respondents sought formal healthcare within the recall period, with public HCs being the main source (55.3% insured, 32.3% uninsured). National surveys report higher utilisation rates (72.3% insured, 69.3% uninsured), possibly because of broader inclusion criteria and different populations.¹⁶

Both insured and uninsured respondents used a combination of traditional (herbal, home remedies) and modern medicines (analgesics, antibiotics) without professional consultation (insured 92.9%, uninsured 85.6%). Over half used both types concurrently or sequentially, consistent with the study from southwest Ethiopia,³⁰ which may reflect uncertainty regarding illness causes and treatments but poses risks of harmful drug interactions.

Herbal and home remedies were more commonly used by insured respondents (71.2% herbal, 90.4% home remedies) than uninsured respondents (41.6% herbal, 66.3% home remedies), aligning with findings by Hailu et al.³¹ Sociocultural acceptance, accessibility and affordability drive this preference. Many respondents trusted traditional medicines as safe and effective, corroborating research from Eastern Ethiopia.³² However, public health authorities caution against irresponsible traditional medicine use because of risks of adverse interactions, untested efficacy and delays in accessing formal care.³³

Analgesics and antipyretics were widely used (insured 46.8%, uninsured 48.6%), drugs legally classified as OTC but ideally dispensed with pharmacist consultation.³⁴ Antibiotic self-medication was more prevalent among uninsured respondents (51.5%) than insured respondents (20.5%). It was primarily used for diarrhoea, RTIs, fever and pain, raising concerns about inappropriate use and increasing antimicrobial resistance, consistent with reports from Ethiopia.^1,28,35 Use of GI drugs, antacids and ORS was also reported, suggesting a need for regulatory oversight.³⁴

Irresponsible self-medication practice addressed common ailments such as fever (90.3% insured, 97.8% uninsured), pain/headache (73.9%, 76.5%), RTIs (52.2%, 85.7%), GI and parasitic diseases (46.2%, 100%) and dyspepsia (60.3%, 66.3%). These findings align with other studies in Ethiopia.^5,8,35 Nonetheless, use should be medically rationalised to avoid associated risks.

Previous personal experience was the principal source of information on medicines used for ISMP (64.1% insured, 63.4% uninsured), consistent with findings from Gurage zone, southern Ethiopia.³⁶ Additional advice often came from family, friends or neighbours (49.4% insured, 56.4% uninsured), reflecting strong social influences on treatment choices.^36,37 Reliance on lay advice increases risks of misdiagnosis and inappropriate treatment, emphasising the need to improve health literacy.³⁷

Medicines used for ISMP were often hoarded at home (66.0% insured, 57.0% uninsured), with public health facilities cited as the main source.³⁸ This suggests inadequate adherence to prescribed regimens and counselling during medication dispensing.^38,39 Uninsured respondents more frequently obtained medicines from rural drug vendors (19.8% vs. 0.6%), an often less regulated source.⁴⁰ Regulatory enforcement is necessary to restrict medicine access to authorised providers and curb misuse.³⁴

Symptom relief following ISMP was reported by 56.4% of insured and 61.4% of uninsured respondents, comparable to other Ethiopian studies.²⁶ Adverse effects, including gastric irritation and skin rash, were reported by 7.7% of insured and 5.5% of uninsured respondents, aligning with previous national findings.⁴¹ Those who experienced poor outcomes often sought formal care (62.8% insured, 51.3% uninsured) or alternative treatments, although some took no further action. Intentions to engage in ISMP in the future were high, particularly among uninsured respondents, consistent with findings from Hosanna town.²⁹

Common reasons for ISMP included perceiving illness as minor (63.5% insured, 82.7% uninsured), prior personal experience, recommendations from family or friends, and cost concerns, consistent with studies in Hosanna and southwest Ethiopia.^29,30 Remoteness of health facilities (51.3% insured, 54.3% uninsured), a lack of time and emergencies also motivated ISMP, echoing regional literature.^8,26

Factors influencing irresponsible self-medication practice

Community-based health insurance membership was significantly associated with a reduced likelihood of ISMP. Uninsured HHs were 5.06 times more likely to practise ISMP, supported by similar findings in Ethiopia.^30,42 While a lack of insurance restricts access to formal healthcare, prompting reliance on ISMP with traditional remedies or antibiotics, several other factors independently influence these practices.

Predisposing factors such as low educational attainment, gender roles (e.g. women primarily engaged in HH caregiving) and social beliefs persist even among insured HHs, limiting behavioural change. As Table 5 to Table 7 illustrates, respondents without formal education remain at elevated risk of ISMP despite insurance, aligning with studies from Gondar town²⁶ and reflecting persistent limitations in health literacy and trust in formal healthcare providers.¹¹ Low self-efficacy strongly predicted ISMP, with an 18.2-fold increase in odds, consistent with findings in Ethiopia.^36,43 Household roles significantly influenced behaviour: women with caregiving responsibilities remained at higher ISMP risk despite insurance, indicating gender-based decision-making constraints, limited control over resources and greater dependence on informal networks.⁴⁴ Enhancing health literacy among husbands and empowering women remain critical intervention points.¹⁶

Structural barriers such as geographic accessibility persisted regardless of insurance status, with long travel times and reliance on inefficient transportation modes limiting healthcare utilisation, findings consistent with studies across rural Ethiopia.^44,45 Medicine hoarding at home increased ISMP odds by more than 17-fold, emphasising the need for interventions targeting safe medicine storage and disposal to reduce associated risks.^7,38 Additionally, dissatisfaction with healthcare quality and the perception of illness severity limited service utilisation among insured individuals, sustaining ISMPs. These issues highlight gaps in service delivery, perceived value and health literacy that CBHI alone cannot resolve.^11,26

Regarding need factors, acute illness episodes, repeated illnesses, and poor or fair health perceptions increased ISMP, indicating that even insured individuals often practise ISMP for symptoms perceived as minor or recurring without formal consultation, in line with findings from Addis Ababa and Bahir Dar cities.^28,41 The interplay of these factors reveals that CBHI membership reduces financial barriers but does not fully address nonfinancial determinants like education, health beliefs, cultural practices or health system deficiencies, critical drivers shown to influence ISMP.

Contributions of the study

This study advances understanding of ISMP in rural Ethiopia by:

• Providing the first evidence that CBHI significantly reduces ISMP prevalence (54.9% insured vs. 78.6% uninsured), with uninsured HHs five times more likely to self-medicate irrationally.
• Quantifying CBHI’s role in increasing formal healthcare utilisation, contrasting with prior studies that lacked insurance status stratification.
• Demonstrating that CBHI reduces reliance on informal medicine sources (e.g. rural drug vendors) and medicine hoarding, key drivers of ISMP among uninsured groups.
• Quantifying concurrent use of traditional (herbal/home remedies: 50.8%) and modern medicines (analgesics: 31.6%, antibiotics: 25.1%) without professional consultation in rural areas, an unreported synergy in prior reviews.
• Highlighting traditional medicine predominance in remote areas (open markets: 67.3% among uninsured) and its association with prolonged travel time (> 2 h; AOR = 7.03), addressing gaps in rural-specific ISMP research.
• Using multilevel regression stratified by insurance status to identify ISMP determinants for insured (e.g. marital status: AOR = 5.99) and uninsured (e.g. social influence: AOR = 11.03) groups, adding detail absent in broader national reviews.
• Reporting a 66.2% ISMP rate in rural Gimbichu, notably higher than the national average (44%), underscoring overlooked rural–urban disparities.
• Supporting insurance expansion to reduce ISMP, with empirical evidence of CBHI’s effectiveness in remote settings, and calling for integrated policies addressing traditional and modern medicine use.

Limitations of the study

The study acknowledges several methodological limitations that should be considered when interpreting its findings. Its cross-sectional design restricts causal inferences between ISMPs and factors such as predisposing characteristics or healthcare accessibility, despite controlling for confounders. The 4-week recall period, although consistent with global studies,¹² may lead to underreporting of minor illnesses or overemphasising recent events, and recall bias could have been better addressed by using symptom diaries for a subsample. Reliance on self-reported data for knowledge, attitudes and practices introduces potential information bias, as responses were not objectively verified. Comparability with other studies is limited because of variations in definitions of ISMP, populations studied and regional healthcare contexts. Geographically, the results are confined to the rural Gimbichu district, Ethiopia’s first CBHI pilot site, limiting generalisability to urban or socioeconomically different regions. The study period (December 2018 – January 2019) does not capture seasonal disease fluctuations, such as malaria outbreaks, which may affect ISMP patterns.

Conclusion and recommendations

By applying the ABM, ISMP in rural Ethiopia is driven by intersecting sociodemographic (low education, HH roles), structural (long travel times, medicine hoarding) and perceptual factors (minor illness perception). Community-based health insurance membership significantly mitigates these risks by promoting formal healthcare utilisation. The model’s strong predictive power underscores its utility for understanding and addressing ISMPs in rural Ethiopian contexts.

This study offers an evidence-based framework for reducing ISMP in rural Ethiopia through CBHI expansion and culturally adapted medicine regulation. Expanding insurance coverage, enhancing health literacy, regulating drug distribution and improving healthcare access are vital to reducing preventable ISMP in rural Ethiopia. Key recommendations include the following:

• Expanding CBHI coverage to improve healthcare access and decrease ISMP reliance.
• Implementing targeted health education campaigns to improve knowledge about RSMP, risks of ISMP, and the importance of consulting healthcare professionals, focusing on vulnerable groups such as individuals with low educational attainment and women with HH caregiving roles. Health messaging should account for the prevalent use of traditional remedies.
• Addressing structural barriers by expanding rural health infrastructure, improving service quality and partnering with non-governmental organisation (NGOs) to extend outreach in remote, mountainous areas. Improving patient satisfaction will help reduce ISMP driven by negative perceptions of healthcare services.
• Enforcing stricter regulations on medicine sales, particularly antibiotics and traditional remedies from informal sources, and training pharmacy personnel to provide clear dispensing guidance.
• Raising community awareness about safe medicine storage, proper disposal of unused drugs, and avoidance of expired medicines, given the strong link between medicine hoarding and ISMP.
• Engaging community and religious leaders as health ambassadors to influence social networks and promote RSMP.
• Promoting integration of scientifically validated traditional medicine with modern healthcare to ensure safety, reduce harmful interactions and prevent delays in seeking appropriate care.
• Encouraging ongoing research to monitor ISMP trends and evaluate intervention effectiveness using methods such as Global Positioning System (GPS) mapping to target communities facing greater access challenges.
• Future research priorities include nationwide longitudinal studies capturing regional variations, qualitative investigations of contextual factors, experimental studies assessing education and CBHI adjustments, development of validated ISMP assessment tools, and time-series analyses incorporating seasonal disease patterns.

Acknowledgements

The authors acknowledge all the respondents who participated in the study.

The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.

Seifu Ambissa: Conceptualisation, Methodology, Formal analysis, Investigation, Writing - original draft, Visualisation, Project administration. Subusiso Zuma: Review - review & editing. All authors reviewed the article, contributed to the discussion of results, approved the final version for submission and publication, and take responsibility for the integrity of its findings.

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Data are available from the corresponding author, Sibusiso Zuma, on request.

The views and opinions expressed in this article are those of the authors and are the product of professional research. They do not necessarily reflect the official policy or position of any affiliated institution, funder, agency or that of the publisher. The authors are responsible for this article’s results, findings and content.

References