In all, 30 participants were interviewed. We contacted a total of 93 persons: 56 could not be reached via the phone numbers they provided, five declined participation without giving reasons, and two began the interviews but withdrew. Most of the final participants (24 out of the 30) were recruited from one community. There was community unrest and subsequent movement of people from the other community, and many potential participants could not be reached or could not participate in the interviews. Our final sample had equal numbers of participants representing the five categories based on network sizes and use of online sources for seeking lay health advice. However, within categories 1 to 4, few samples in the age/sex groups were missing and replaced with the alternatives with characteristics closest to the missing sample. For instance, in cat. 1 we replaced female 18–29 with a sample from female 30–49 group aged around 30 years.
We identified six main themes from our analysis of people's experiences of lay consultation: (1) Intentions and motivations for speaking to lay consultants (2) Use of bounded networks (3) deciding on how to act on advice from lay consultants (4) choosing not to engage lay consultation (5) Giving lay advice/support (6) Use of digital communication for seeking lay advice
Intentions and motivations for speaking to lay consultants
We found three broad intentions for which people discussed a health concern/illness with a lay consultant: for casual reasons, direct and indirect seeking of support. Most participants described their conversations as casual discussions where they mentioned an illness/health concern without intending to seek any particular support. In such cases, participants said they spoke to a lay consultant that was accessible or proximate at the time, or because it was normal to express as explained by a participant:
I just told mummy landlord because we both sleep and wake up in the same house. For my family, I had to tell them. Not that the issue was something I could not handle myself (Cat 5 Female 18–29).
Some of the conversations happened between neighbours who noticed a change in their neighbours appearance or behaviour.
My neighbours checked on me when they notice that I am at home because they do not usually see me at home. They came and knocked on the door to ask "hope all is well, we see you at home?". I told them that I am a little ill, and they asked me and ask if I have taken drugs or injections. (Cat 5 Male 30–49)
About half of the participants consulted or thought they would consult their lay network members for different forms of support. People who engaged in these forms of conversations mainly sought different advice, including suggestions about what might be the cause of their symptom/illness, advice about medications from people who have experienced similar symptoms in the past, and advice about alternative medications or home remedies. Some people sought financial support to care for themselves during an illness. A few persons wanted their network members to empathise with them and provide hands-on assistance:
Ah, I told her so I can be assisted with what I cannot do, maybe I want to sweep a place, and I cannot sweep it, I will say oya sweep here for me, I have backache, I cannot sweep it". (Cat 4/F/ 50–64).
Some participants did not directly ask for advice, reassurance or suggestions but thought that by mentioning their health concerns to a network member, they would obtain some form of informational or practical resource. This pattern was more common among the male participants. For instance, a male participant was asked why he talked to his wife when he was feeling unwell, and they responded that:
I just wanted her to know, because once she does, she would definitely have something to say. (Cat 4 Male 30–49).
Participants reported that regardless of their intention speaking to lay network members, the network members offered some form of advice or suggestion in their responses. For instance, a female participant explained the lay suggestions and therapies she received from her parents when they noticed something was wrong with her:
When I discovered a twitch in my feet…and I was staggering while walking, my parents noticed and said it was due shortage of blood. They said I should buy Ugwu (spinach), malt and milk. That I should mix it and drink it. (Cat 4/F/30–49).
Participants had mixed reviews about the advice from their lay consultants. About one-third of the participants thought they were useful as they felt better after following the advice. One participant said they received useful and non-useful advice from the same network members. A few participants reported negative experiences using lay advice about medicines from lay consultants. For instance, one participant said a neighbour advised them to use a prescription -tramadol 60 g when they complained about feeling weak. After using the medication, they experienced adverse effects for which they needed emergency care. They were later informed by healthcare professionals that tramadol was a 'hard drug' and was considered illegal in Nigeria.
Use of closely-knit and immediate network members
We found that participants spoke to close-knit network members, including family, friends, and neighbours. In most cases, family members were the first or only persons with whom people discussed an illness or health concern. Proximity to and emotional connection with the family members contributed to why they dominated the lay consultation networks. The specific family members consulted depended on the participant's status- for instance, married people tended to speak to their spouses, younger persons spoke to their parents, especially their mothers, and older participants spoke to their adult children.
Participants reported that household members tended to notice or detect changes in their health and play significant roles in supporting them:
I told my wife because you know she is my defence minister…If something happens to me, she would be the first to know, she knows what usually happens to me and what she uses for me that makes my symptom resolve, she knows who to call, the kind of drug to use that would make my body okay. (Cat/5/M/ 30–49)
A small number of participants mentioned health concerns/illnesses to a few friends and neighbours. In some cases, this was because their family members were not proximate. Generally, people preferred neighbours and friends with whom they shared a strong bond and close contact. Participants said they looked out for critical qualities, including knowledge, mutual respect, experience with a similar health concern, intimate connection, reciprocity, and trust that the person would not divulge private information they share with them.
Use of digital communication devices and online sources for seeking lay advice
Most lay consultation took place face-to-face however we found a small number of participants used digital devices to speak to a network member living in a distance or check online sources for information. Some participants did not originally plan to discuss a health concern when they phoned their network members, but casually mentioned it when catching up. Others called to ask for advice or financial assitance to help them obtain care for a health concern.
Only one-fifth of the participants used online platforms, including Google, Facebook or Whatsapp groups to obtain health advice for a health concern and confirm advice from lay consultants or healthcare providers. Two of the participants reported passing information they retrieved online to others.
The main barrier to using online lay sources for advice seeking for most participants was the lack of access to smart devices. Most participants could not afford the phones. One person said their smart device was stolen in the community, and they now use a small phone (referring to a basic phone). Another participant highlighted that they prioritised meeting other needs to owning a smart device:
When we give our children proper training and education, it is better than the touch screen phones (Cat 4/M/30–49).
One-third of the participants said they did not know how to use the internet generally or did not know how to search for health advice. The older participants (50–64) did not know how to use internet and operate smart devices or thought those were meant for younger persons. The younger participants knew how to operate the devices and used the internet for other purposes, but did not know how to check for targeted health advice-seeking:
If not for the way you mentioned it now, I did not know they check for health issues online. I use it for checking stories, joining groups, and commenting. So, I have not even come across health groups not to talk of joining (Cat 5/F/18–29).
Besides socioeconomic reasons, several participants noted other reasons for not using online sources for lay advice-seeking, including proximity and access to other sources of advice network members, PMVs, herbs sellers and formal healthcare facilities; scepticism about online health information, and prioritising getting immediate care for health concerns over seeking advice from online lay sources.
If I am not feeling fine now, you cannot expect me to carry phone and search on the phone about anything; when I am sound and healthy, I can check for what is wrong (Cat 1/M/30–49)
Deciding on how to act on advice from lay consultants
Participants actively chose how to engage with advice and suggestions offered by others. They decided on whether the opinions of others were useful or not. For instance, a male participant said they classified advice from others as good, bad or non-substantial and then proceeded to apply the good ones. Many participants said they had their personal approaches and strategies to address health concerns/illnesses and used those to filter advice and suggestions from other people.
In any advice they give me, my opinion matters a lot. When somebody gives me advice, I feel that is their own opinion. If I feel that the advice is okay, then I may follow up, but if the advice is not okay by me, then I will not do it, and that is it. (Cat/1/M/ 30–49)
Some participants were critical of advice or information from lay people because they were not experts. They recognised that the opinions are likely subjective and not credible. They questioned the source and credibility of lay people's advice and suggestions.
If someone who is not a doctor or nurse says something about health, I may not do it because I will be wondering how they got the information. Like "how do you know what you are saying?" (Cat 4/F/18–29).
In line with being critical, some participants consulted multiple persons or perceived experts to determine the credibility of an advice. Getting similar advice from multiple lay network members gave people some confidence. Some confirmed with the Chemists, particularly regarding advice about medicines. Only a few persons confirmed with formal medical care providers such as medical doctors, as this required some form of payment for consultation. Those seeking care from the health practitioners utilised the opportunity to ask them about lay advice they received.
However, there were two instances where participants said they had no choice but to utilise advice from network members. In one instance, a middle-aged female respondent said she was too ill, and her husband sought advice and made the decisions on her behalf. In another instance, a young female respondent said she followed her husband's advice to seek care from a particular provider because he had 'authority' in their household as he paid for healthcare.
Choosing not to disclose illness/health concerns or seek advice from lay consultants
People exercised agency by deciding not to disclose their illness/health concerns or seek advice from others. The decision was linked to how people perceived their health needs or relationship with others. Several persons said they usually had familiar symptoms that they dealt with independently, took herbal concoctions to prevent serious illness or accessed medicines from PMVs to promptly treat an illness and prevent it from becoming something big, all of which contributed to not requesting or needing advice from lay others.
Few participants did not seek advice from lay others because they preferred and had access to formal health care providers. For instance, one participant that accessed formal health care insurance through their organisation explained their preference for formal health advice thus:
I cannot have a health issue now and then consult a farmer to explain to him… I cannot have a headache and meet with a market woman... The Hospital is the best place to get advice concerning that. You may now have to test to know what exactly happened. (Cat 1/M/30–49)
A few participants did not discuss a health concern they were experiencing with others because they did not want to bother them or create a sense that they required attention. In one case, a respondent said they did not appreciate being called and checked upon frequently by network members because they were unwell and were more interested in getting solutions to the problem as soon as possible.
However, about half of the participants highlighted mistrust towards some neighbours as a reason for non-disclosure. A common notion amongst the participants was that neighbours would gossip, mock, or deliberately offer them negative advice:
I do not seek advice because I realised that once I discuss things like that with neighbours, it is like I am doing more harm to myself. Because it is not every frog that lies on their stomach that has a stomach ache (meaning not everyone has good intentions for you)…I might ask a question about stomach ache, and in their minds, they would say, 'oh he is just having stomachache, I hope he will soon have head ache'. Cat/2/M/18–29)
People who distrusted their neighbours avoided speaking to them about their experience, minimised their condition when discussing it with them or anonymised themselves when asking neighbours for advice about their experience.
Giving lay advice or support
In one-third of the interviews, people talked about giving advice and assistance to other network members. Some said that network members approached them for health-related advice because they possessed physical health attributes and social qualities that others admired. For instance, one person said network members admired and asked them for advice because they were rarely sick:
They usually wonder why, despite how much I labour-because I do not like being idle, I do not usually fall sick. They ask me, "What is the secret to your wellbeing?" So I tell them: "You, go do this, go do this", and if they do it, God makes it successful. (Cat 5 Male 50–64).
Some thought others approached them because they had knowledge or experience of health issues, empathy, and compassion. People tended to particularly to persons with fewer resources: "If I have someone whose situation is not as good as mine, I do help in my way" (Cat 5/F/50–64).
However, it was important to participants that their advice or support was appreciated, as this would determine whether they provided continued support:
If I advise someone today and the person does not heed, if the person comes back at another time, I will not respond because they didn't turn up on the previous advice I gave... For instance, you have stomach pain and I ask you to use Buscopan (a medication), but you used paracetamol; please can the pain resolve? (Cat 5 Female 18–29)
Giving support to others was a strategic way of investing in networks with the hope to receive their support if needed in the future. For example, one participant said they were open to helping despite not having enough resources because:
If I help someone today, I do not know who will help me tomorrow nor who will help my children. (Cat/5/F/18–29).
However, a few participants did not give advice to others because they were busy with work or thought that people would not trust their advice. People who cited the later reason were referring to their neighbours that they had a complex relationship with. They avoid telling them about lay therapies or referring them to particular health providers because the neighbours might suspect them to providing misleading advice.