3.1. Selection of questions
All 41 adult respondents (≥18 years) provided responses to the survey's thirteen (13) questions. We chose for this article to examine five (5) questions as they revolved around topics that most of the respondents wanted to comment on. These five questions are:
Q1. Do you know if there is a difference between prescribed and non-prescribed medicine?
Q2. Do you think it is safe to purchase prescribed medicines (without seeing a doctor before) from a local market, shops, neighbours, the Internet, etc.?
Q3. Where do you normally receive/buy prescribed medicines?
Q4: What factors do you consider when you purchase prescribed medicines? (Multiple mentions possible, total responses exceed
Q5. Have you ever questioned the quality and efficacy of the medicines you have purchased?
Regarding the first selected question we found that little more than half of respondents (55.3%, n=21) claimed to be aware of the difference between prescribed medicines and non-prescribed medicines. On a follow-up question, the second question, again just more than half (52.5%, n=21) said it was not safe to purchase prescribed medicines (without seeing a doctor) at local market shops, from neighbours, the internet or other sources. In the third question, the majority (71.8%, n=28) of respondents stated that they normally bought their medicines from pharmacies, while 12.8% (n=5) said they obtained medicines from the clinic. No respondents indicated that they bought medicines from the internet. The fourth question showed that the factor that respondents most frequently considered when buying prescribed medicines was price (43.9% or n=18), with the second biggest factor being packaging (24.4% or n=10). Some respondents (19.5% or n=8) did not know what factors influenced their medicine purchasing decisions. The fifth question revealed that less than third of respondents (30% or n=12) indicated that they had questioned the quality and efficacy of the medicines they had purchased.
3.2. Results from the bricolage toolbox
A comparison of the quantitative and qualitative data revealed that respondents often gave different answers to the same question depending on whether it was asked as part of the survey (asked in a direct way with categorical answer options) or in the recorded conversation. The fact that oral conversations provide more complex responses than the closed-ended questions is not surprising and a well-documented phenomenon (36). However, in a number of cases, the recorded data from the same respondent was not only more nuanced but also contradictory to their responses documented in the survey. This called for a deeper comparison of how the two response categories interact, such a cross-border and bricolage approach which was intended to provide knowledge of respondents' actual opportunities to obtain medicine and their attitude towards it. In this section, we present findings on two major themes that emerged from respondents’ more elaborate answers to the survey questions.
- Trust, risk and self-medication
The majority of respondents stated they used clinics and pharmacies as healthcare providers. Purchasing medicines via the internet or at local marketplaces was deemed by many as risky, or not done at all. Consequently, these respondents pointed to the importance of seeing a doctor when asked Q2.Do you think it is safe to purchase prescribed medicines (without seeing a doctor before) from a local market, shops, neighbours, the Internet, etc.?. However, we found evidence in the fieldworkers’ handwritten notes on the survey that respondents, who had just emphasised the importance of a doctor's visit, "bought prescription drugs elsewhere" without receiving a prescription.
Statements in the survey, as illustrated in the conversation with 25-year-old Nonhlanhla, do not always correspond to the recorded conversation. During the survey Nonhlanhla said, her first option “should be to ask the nurse”, but during the conversation she admitted that she always first self-diagnosed and self-medicated. She then explained what hindered her from approaching formal medical care was because “it is crowded and stressful and there is only one doctor some day during the week”. There are thus high opportunity costs associated with accessing free public clinics and getting a prescription. Consequently, Nonhlanhla only visited the clinics when “it’s really necessary”. Otherwise she would purchase medication such as Medlemon, a well-known all-round cold and flu drug used by many in the respondent’s neighbourhood, from local stores. These stores, as Nonhlanhla and other informants claimed, were often run by Somali owners “who have a reputation for selling low-quality goods”.
Another respondent, the 30-year-old Luzuko who moved to Khaymandi in 2009 from a community outside of Cape Town, acts similarly. He said: “No, no, not to the clinic …well, it will depend on if the budget permits it”. In the conversation he also admitted to avoiding going to the clinic “because of the long time it takes waiting for help”. The concern about long waiting time and all the stress around visiting doctors, as expressed by Luzuko and Nonhlanhla, turned out to be not uncommon among the respondents. From the conversation transcripts, we also noticed that many respondents spoke about their personal situations including their economic status and family relations, which might also contribute to the high opportunity cost.
Another respondent, Onako, the mother of a nine-month baby, stated in the survey that she trusted the expertise of the clinic and the pharmacy. Nevertheless, when the fieldworker wrote her answer on the form, she emphasised the importance of being alert regarding the condition of the drug packaging purchased at the pharmacy. She made sure that “it is similar to the one I got before” as well as ensured “it is properly sealed compared to others I had before [that were not sealed, authors’ explanation]”.
- Bonds that matter
Although most respondents claimed that they only sought care from medical providers at the clinic (mostly nurses) or in some cases a private doctor, the actual circumstances seemed different. Besides the fact that some purchased medicines from a place like "the Somalis’ stores" as shown in the first theme, there existed other important actors that influenced people in the local community. Two such authorities that had an impact on respondents' lives and use of medicines were the Christian Church and traditional healers.
For some of the surveys, where respondents said they received their medicines from the doctor, we found in fieldworkers’ handwritten comments alongside the survey answers a different picture. Sometimes, the medicines were obtained not only through the formal healthcare system, but through the church. In the recorded conversations, there were remarks on the fact that the church now and then shared medicines with people in the community. "It's for free," a respondent said, "and then you take it ... though it's not completely 'free' so to speak". The person continued implying that the church expected gratefulness and loyalty in return.
Besides churches, there also existed completely different bonds that mattered to the local people when it came to health and medicine: culturally-rooted and historically-embedded African traditional medicine (1, 37). Even if traditional medicine is a culturally well-researched field, our study was designed to not ask questions about the topic. We wanted to focus on the grey areas that could arise in connection with biomedical products and not to discuss any falsified traditional medicines. We assumed that specific questions on traditional healers would give too much focus to the use of folk medicine instead of the consumption of biomedical products, which might lead respondents’ attention away from questions on trust in medical expertise and their awareness of SF medical products. Therefore, no quantitative data on traditional healers were captured. However, it turned out that it was not possible to keep the various medical fields separate: traces of the role of traditional healers could be found in the recorded conversations. An illustrative example comes from the conversation with Luzuko and the reaction of the fieldworker. “I go to the doctor or the clinic”, Luzuko declared, “what other options do I have?” He then continued with a laugh, as if he wanted to provoke the fieldworker in terms of there existing alternatives besides the clinic. The laughter was followed by him asking a question, almost making a statement, in a teasing way: “Sangoma, maybe?” Sangoma refers to a traditional healer, commented by the fieldworker on the conversation. “The Sangoma is a central figure in South Africa. Everyone consults a Sangoma”. Further reading of the fieldworkers’ notes showed that consultations with traditional healers were something that neither doctors nor the churches were happy about.