The use and misuse of non-steroidal anti-inflammatory drugs (Ibuprofen) and paracetamol among mothers who presented with their children in health facilities in Enugu, South‒East Nigeria

Abstract

Background

The availability of NSAIDs (ibuprofen) and paracetamol as over-the-counter drugs and the widespread use of these drugs in the management of fever in children have led to several forms of misuse.

Objectives

This study aimed to document the pattern of misuse of NSAIDs and paracetamol among mothers who presented with their children in the outpatient clinics of 20 hospitals in the Enugu metropolis.

Methods

This cross-sectional study was conducted in twenty health centres among mothers who brought their children for follow-up, immunization, or other minor pediatric illnesses. One thousand mothers who attended both rural and urban health centers in Enugu metropolis were consecutively enrolled in the study. A validated interviewer-administered questionnaire was used for the study.

Results

The majority of the respondents (86.3%) gave either ibuprofen or paracetamol three to four times daily. NSAIDs (ibuprofen) were purchased mainly from patent medicine vendors (44.5%) and government hospitals (31.3%). The majority of the mothers (884, 88.4%) gave their febrile children ibuprofen, while 65 (6.5%) gave both ibuprofen and paracetamol, and a minor proportion (39, 3.9%) gave paracetamol. The majority of the respondents (87.0%) misused ibuprofen, whereas 84.6% misused paracetamol. A total of 16.5% of the respondents were aware that a child could die from fever. A total of 13.1% of the respondents did not see fever as always linked with teething. A total of 39.6% of the respondents had a good perception of fever. The respondents who had a good perception of fever were approximately nine times more likely to misuse either ibuprofen or paracetamol than those who had a poor perception (AOR = 8.5, 95% CI: 2.0–36.1). The respondents who were less than 30 years old were ten times less likely to misuse ibuprofen than those who were 50 years and above (AOR = 0.1; 95% CI: 0.04–0.3). Similarly, respondents who were between 30 and 39 years old were ten times less likely to misuse ibuprofen than those who were 50 years and above (AOR = 0.1; 95% CI: 0.05–0.3).

Conclusion

The use of ibuprofen is more widespread than the use of paracetamol by mothers in febrile children, with the majority of mothers reporting side effects as deterrents. However, the misuse of both ibuprofen and paracetamol was noted to be high among these mothers. There was no marked difference in the use/misuse of ibuprofen or paracetamol among mothers who attended urban and rural hospitals.

Introduction

The use and misuse of drugs is an emerging and re-emerging global public health issue [1, 2]. Approximately 5.5% of the world’s population, especially those aged between 15 and 64 years, had used drugs in the preceding year [3, 4]. Similarly, approximately 585,000 deaths due to drug use and misuse were reported in 2017, and mortality has since increased. In Nigeria, the commonly misused drugs are nonsteroidal anti-inflammatory drugs (NSAIDs), of which ibuprofen is paramount [3].

Nonsteroidal anti-inflammatory drugs (NSAIDs) are medications used in the management of inflammatory illnesses [1]. They help relieve symptoms of acute and chronic inflammation without improving clinical sequelae. These compounds inhibit prostaglandin synthesis by inhibiting cyclo-oxygenase (COX). This group of drugs includes ibuprofen, aspirin, diclofenac, indomethacin, naproxen, and piroxicam [1]. These drugs are not without adverse effects following prolonged use or misuse [1]. The use of ibuprofen at high doses is associated with an increased risk of cardiovascular events [1]. The misuse of ibuprofen is defined as the use of the drug outside the physician’s prescription (either as an underdose or overdose) [1, 2].

The availability of ibuprofen as an over-the-counter drug and the widespread use of these drugs in the management of fever in children have led to several forms of misuse. There is documented evidence of untoward effects in some studies [4, 5]. In addition, suicides and para-suicides involving these drugs have been reported among adolescents, and they are often associated with accidental poisoning in children [6–8].

Ibuprofen causes gastrointestinal ulceration, which is increasing in prevalence worldwide [10–16]. These untoward effects are commonly reported in children taking ibuprofen for more than 6 weeks [9, 10]. However, this may also occur with the ingestion of low doses. Other complications that may arise from the use and misuse of ibuprofen include chronic kidney disease, specifically from prolonged use [11]. Congestive cardiac failure, anaphylaxis, and blood dyscrasias have also been reported with prolonged consumption of ibuprofen [11].

Paracetamol, also known as acetaminophen, was first synthesized in 1878 but was first marketed in 1950 because of early reports of methemoglobinemia. Paracetamol is the most commonly used antipyretic [12]. Despite its misuse, paracetamol continues to be recommended as a first-line treatment in the UK guidelines. At therapeutic doses, it is not associated with many side effects, but misuse may cause renal and hepatic injury [12]. It is the most commonly misused drug among children less than 6 years old [12, 13]. Paracetamol is a weak inhibitor of prostaglandin synthesis. Unlike ibuprofen, paracetamol interferes with the peroxidase activity of COX isoenzymes, especially COX‐2 [13].

This study aimed to document the pattern of misuse of ibuprofen and paracetamol among mothers who presented with their children in the outpatient clinics of 20 hospitals in the Enugu metropolis. This work also harnesses the difference between use and misuse patterns in rural and urban hospitals and makes recommendations for abating this menace.

This study has also provided new insights, which include significant knowledge gaps, “fever phobia,” [14] and reliance on personal experience rather than professional guidance. Drug dosing based on severity of symptoms, as caregivers frequently determine dosage based on the child’s age or the perceived severity of the illness instead of relying on the child’s body weight, which often leads to this often leads to under-or over-dosing. Furthermore, a low level of education of the caregiver is significantly associated with understanding the appropriate dosage and duration of treatment [14].

It is important to note the rationale linking the misuse of common medications for fever and the general drug misuse culture. This can be resolved based on context, societal perception and intent. For instance, based on intent, the misuse of drugs for febrile illness is borne out of the quest to relieve symptoms, reduce perceived severity of illness [15]. It could also be due to fever phobia, i.e. anxiety or misconception of dangers arising from febrile episodes in children, such as perceived fear of brain damage [15]. On the other hand, general drug misuse could stem from stimulation, the need to feel high, sedation or even the intent of committing suicide [15].

Furthermore, the misuse of drugs for febrile illness could involve the use of over-the-counter (OTC) medications such as acetaminophen and ibuprofen, or antibiotics, while the general drug misuse could involve the use of Illicit drugs (heroin, cocaine) or diverted prescription medications (opioids, stimulants, sedatives) [16]. Lastly, the misuse of drugs for febrile illness has a low tendency for developing addiction, while the general drug misuse has a high propensity for psychological and physical dependence, which may lead to life-threatening consequences [16].

Methods

Study area

The study was conducted at 20 outpatient clinics at both public and private hospitals located in Enugu State. These included 13 urban hospitals and 7 rural hospitals. These hospitals provide services for maternal and child health.

Study design

This is a cross-sectional study conducted in twenty health centers among mothers who brought their children for follow-up, immunization, or other minor pediatric illnesses.

Study population

One thousand mothers who attended both rural and urban health centres in Enugu State were enrolled consecutively in the study. The study was conducted between July and October 2024. All the mothers attending the health centres during the period of study and who fulfilled the inclusion criteria were enrolled in the study. Mothers of childbearing age, children between the ages of 1 month and 240 months, and those from whom verbal informed consent was obtained were included in the study. Children who were admitted for severe illnesses were excluded from the study. Mothers or caregivers who were not willing to participate in the study were also excluded from the study.

Definition of misuse

Misuse is defined as the use of a drug outside label directions or in a way other than being prescribed or directed by a healthcare practitioner [17]. This definition includes patients taking more drugs than prescribed or at different dosing intervals (either under dose or overdose) [17, 18].

Ibuprofen misuse

Misuse of ibuprofen is defined as doses more than 10 mg/kg given at intervals shorter than 6 h” and/or “more than 4 doses in 24 h [19].

Paracetamol misuse

Misuse of Paracetamol is defined as doses more than 15 mg/kg given at intervals shorter than 6 h” and/or “more than 4 doses in 24 h [17–20].

Sample size determination

A minimum sample size of 1000 was obtained via the method of sample size estimation by Glen et al. [21] after 10% attrition was considered with a 95% confidence level and 5% precision for a population > 300,000.

Study instrument

A validated interviewer-administered questionnaire was used for the study. This questionnaire was adapted by Chinawa et al. [22] and uses a group of children aged six weeks to 16 years and their caregivers attending the paediatric outpatient clinics of the hospitals included in the study. The questionnaire covers questions in Part A and Part B. Part A covers the sociodemographic variables of the caregivers, whereas Part B is divided into 17 major subheadings that cover areas such as perception and practice in the management of fever in children. The types of ibuprofen used to treat fever at home by mothers, the use of paracetamol in the treatment of fever, the dose and frequency of administration of ibuprofen and paracetamol at home, and where ibuprofen and paracetamol are procured by mothers. The outcome measure of the study was the misuse of ibuprofen and paracetamol. Good use of ibuprofen and paracetamol was determined by the respondents who correctly administered ibuprofen and paracetamol in the right doses on the basis of age and the correct number of times in a day, which was four. Five variables were used to assess the perception of fever among the respondents. For each of the variables, a correct response was assigned a score of one, whereas an incorrect response attracted a score of zero. Respondents who scored ≥ 50% of the total score were regarded as having a good perception of fever, whereas those who scored < 50% of the total score were designated as having a poor perception of fever. In determining the factors that are associated with misuse of ibuprofen and paracetamol, some independent variables were cross-tabulated with the outcome measure, misuse of ibuprofen. The variables that had a p-value of < 0.2 in the bivariate analysis were entered into the logistic regression model to determine the predictors of misuse of ibuprofen and paracetamol. The results of the logistic regression analysis are presented as adjusted odds ratios and 95% confidence intervals, and the level of statistical significance was set at a p-value of < 0.05.

Cronbach’s α was used to evaluate the internal validity of the questionnaire.

Using the formula: α = N *C/v+(N-1) * C.

where N = the number of items and C = the mean covariance between items. V= item variance. A score of 0.8 was obtained, indicating a satisfactory level of validity. Pearson’s correlation coefficient was used to calculate the test–retest reliability. A score of 0.5 indicated high reliability.

Sampling technique

A multistage sampling technique was used for the selection of respondents for the study. Enugu State has a total of 17 local government areas (LGAs), five of which are designated urban LGAs and 12 of which are regarded as rural LGAs. Using a simple random sampling technique of balloting, three LGAs were selected out of the five in urban areas, and another three LGAs were also selected out of the 12 LGAs in rural areas. This serves as the first stage. In the second stage, the list of health facilities in the selected LGAs was made. Using a simple random sampling technique of balloting, two health facilities were selected from the first five health facilities in each LGA on the basis of attendance at the OPD. This served as the second stage. Proportionate allocation was used in allocating the number of respondents who were included in the study from health facilities in urban and rural areas. In terms of numerical strength, 60% of the respondents were allocated to health facilities in urban areas, whereas 40% were allocated to those in rural areas. A systematic random sampling technique was used to select respondents for inclusion in the study. The average six-month attendance in the OPD of each health facility served as the sampling frame, and dividing this number by that derived by the proportionate allocation (sample size), a sampling interval was obtained for each health facility. On each day of data collection, the index client was selected via a simple random sampling method through balloting, after which the sampling interval was applied for each health facility.

Data analysis

Data entry and analysis were performed via the International Business Machine, Statistical Product and Service Solutions (IBM-SPSS) statistical software, version 25. Categorical variables are presented as frequencies and proportions, whereas continuous variables are summarized as means and standard deviations. When data are skewed, medians and interquartile ranges are reported. Chi-square tests of statistical significance and multivariate analysis via binary logistic regression were used in the analysis, and the level of statistical significance was determined by a p-value of < 0.05.

In determining the factors associated with the outcome measure of the study, ‘Misuse of NSAIDS’, the socio-demographic characteristics of the respondents and other variables that follow a logical sequence were cross-tabulated with the outcome measure of the study. Variables that had a p-value of < 0.2 on bivariate analysis were included in the binary regression model to determine the predictors of the outcome measure [23]. The results of the binary regression analysis were presented using adjusted odds ratios and a 95% confidence interval. The level of statistical significance was determined by a p-value of < 0.05.

Results

Table 1 shows the sociodemographic characteristics of the respondents. The mean age of the respondents was 39.3 ± 10.3 years. The highest proportion of the respondents, 38.7%, was in the 30–39 years’ age group, while the lowest proportion, 0.4%, was less than 20 years old. The median age of the children was 36 months. Among the respondents, 77.0% had attained tertiary education, whereas 1.6% had no formal education. A greater proportion of the respondents (61.0%) were in health facilities in urban areas.

Table 1.

Sociodemographic characteristics of the respondents

Variable	Frequency (n = 1000)	Percent (%)
Age of respondents
Mean ± SD	39.3 ± 10.3
Age of respondents in groups
< 20 years	4	0.4
20–29 years	166	16.6
30–39 years	397	39.7
40–49 years	222	22.2
≥ 50 years	211	21.1
Age of last child in months
Minimum	0
Maximum	240
Median (Interquartile range)	36 (90)
Mean ± SD	56.0 ± 61.5
Age of the child in groups
< 1 year	364	36.4
1–5 years	291	29.1
5–9 years	139	13.9
> 9 years	206	20.6
Educational attainment of the respondent
No formal education	16	1.6
Primary education	35	3.5
Secondary education	179	17.9
Tertiary education	770	77.0
Location of health facility
Urban	610	61.0
Rural	390	39.0

Table 2 shows the medications frequently given for fever. The main problems associated with fever included vomiting, 38.0%; vomiting/poor appetite/cough, 18.5%; and poor appetite, 13.2%. The medications frequently given for fever included ibuprofen, 88.4%; ibuprofen and paracetamol, 6.5%; and paracetamol, 3.9%.

Table 2.

Factors associated with fever in children

Variable	Frequency (n = 1000)	Percent (%)
Your child has experienced a fever before
Yes	951	95.1
No	30	3.0
Sometimes	19	1.9
The age when children usually have a fever
Before 3 months	630	63.0
4 months	20	2.0
5 months	14	1.4
6 months	13	1.3
7 months	8	0.8
8 months	11	1.1
Before 1 year	304	30.4
Worry about time for fever
Yes	905	90.5
No	80	8.0
Not bothered	15	1.5
Problems associated with fever
Vomiting	380	38.0
Vomiting/poor appetite/cough	185	18.5
Poor appetite	132	13.2
Undue crying	121	12.1
Cough	42	4.2
Vomiting/undue crying	42	4.2
Loose stools	32	3.2
Greenish stool	19	1.9
Poor appetite/cough	11	1.1
Abdominal discomfort	5	0.5
Any other	31	3.1
Medications frequently given for fever.
NSAIDs
Ibuprofen	884	88.4
Diclofenac	4	0.4
Aspirin	3	0.3
Combination of NSAIDs and Paracetamol
Ibuprofen and paracetamol	65	6.5
Non NSAIDs
Paracetamol	39	3.9
Any other	5	0.5

Table 3 shows the misuse of ibuprofen and paracetamol among the respondents. The majority of the respondents (86.3%) gave Ibuprofen or paracetamol three to four times daily. Ibuprofen and paracetamol were purchased mainly from patent medicine vendors (44.5%) and government hospitals (31.3%). The majority of the respondents (87.0%) misused ibuprofen, whereas 84.6% misused paracetamol.

Table 3.

Use and misuse of ibuprofen and Paracetamol among the respondents

Variable	Frequency (n = 1000)	Percent (%)
Dose of paracetamol or ibuprofen 100 mg/5 mls
1 ml (20 mg)	399	39.9
2.5 mls (50 mg)	540	54.0
5 mls (100 mg)	26	2.6
7 mls (140 mg)	2	0.2
10 mls (200 mg)	2	0.2
Any other	31	3.1
Number of times Paracetamol and Ibuprofen could be given in a day.
Once	34	3.4
Twice	85	8.5
Three times	830	83.0
Four times	33	3.3
Five to six times	3	0.3
Any other	15	1.5
Misuse of Ibuprofen
Yes	769	87.0
No	115	13.0
Misuse of paracetamol	(n = 39)
Yes	33	84.6
No	6	15.4
Misuse both Ibuprofen and Paracetamol
Yes	60	92.3
No	5	7.7

Table 4 shows the perceptions of fever among the respondents. Fewer than one-fifth of the respondents (16.5%) were aware that the cause of fever could lead to the death of the child. A minor proportion of the respondents, 13.1%, did not see fever as always linked with teething. Fewer than half of the respondents (39.6%) had a good perception of fever.

Table 4.

Perception of fever among the respondents

Variable	Frequency (n = 1000)	Percent (%)
The cause of fever could lead to the death of the child
Yes (correct)	165	16.5
No	835	83.5
Apply medications to children in times of fever
Yes (correct)	377	37.7
No	623	62.3
Medicines for fever could have side effects on children
Yes (correct)	810	81.0
No	190	19.0
First point of call in case of a fever
Healthcare worker (correct)	687	68.7
Nonhealth worker	313	31.3
Fever is associated with teething
Yes	869	86.9
No (Correct)	131	13.1
Perception of fever
Good	396	39.6
Poor	604	60.4

Table 5 shows the factors associated with misuse of NSAIDs among the respondents. The respondents who were less than 30 years old were ten times less likely to misuse ibuprofen than those who were 50 years and above (AOR = 0.1; 95% CI: 0.04–0.3). Similarly, respondents who were between 30 and 39 years old were ten times less likely to misuse ibuprofen than those who were 50 years and above (AOR = 0.1; 95% CI: 0.05–0.3).

Table 5.

Factors associated with misuse of NSAIDs (ibuprofen) among the respondents

Variable	Misuse of NSAIDs (n = 884)		P value on bivariate analysis	AOR (95%CI)***
	Yes N (%)	No N (%)
Age of respondents in groups
< 30 years	108 (76.1)	34 (23.9)	< 0.001	0.1 (0.04–0.3)
30–39 years	261 (79.3)	68 (20.7)		0.1 (0.05–0.3)
40–49 years	202 (96.7)	7 (3.3)		0.9 (0.3–0.6)
≥ 50 years	198 (97.1)	6 (2.9)		1
Educational attainment of respondents
Tertiary education	594 (87.5)	85 (12.5)	0.430	NA
Secondary education and below	175 (85.4)	30 (14.6)
Location of health facility
Urban	484 (87.7)	68 (12.3)	0.432	NA
Rural	285 (85.9)	47 (12.2)
Perception of fever
Good	312 (90.7)	32 (9.3)	0.009	1.2 (0.7–1.9)
Poor	457 (84.6)	83 (15.4)

Discussion

The aim of this study was to determine the prevalence and pattern of use and misuse of ibuprofen and paracetamol and to document associated factors. This study revealed that for the majority of the mothers, they gave their children ibuprofen when they had a fever. Owing to its wide safety margin, ibuprofen is commonly used in the management of children with febrile illnesses [23–26]. Another reason mothers administer ibuprofen to their wards could also be from widespread advertisement of the drug, as highlighted in the current study. The increased use of ibuprofen despite warnings from the Federal Ministry of Health (FMOH) is commonplace [26, 27]. For example, a study showed that 11% of children exceeded the maximum dose of ibuprofen in 24 h, which was worsened by the low cost of the commodity [26–29].

The prevalence of misuse of ibuprofen in the current study was higher than that reported by Wonodi et al. [30]. , who noted that 13% of mothers gave an overdose of ibuprofen to their children. The lower prevalence reported by Wonodi et al. [30]. may be due to the smaller sample size used. In addition, they considered only an overdose of ibuprofen while neglecting the prevalence of under-dosing [30].

Similarly, Li et al. noted that although 51% of patients received inaccurate doses of both paracetamol and ibuprofen, they obtained a much lower prevalence of 26% among mothers who gave their children ibuprofen. In addition, the prevalence of paracetamol overdose was also noted to be lower (62%) in their study. The lower prevalence reported by Li et al. [31] could be because the author did not consider the possibility of under-dosing in their subjects. In addition, the maximum age of their study participants was 10 years.

Furthermore, the prevalence rate of misuse was also higher than that reported in the study of Kaliba et al. [32] in Zambia, who reported high rates of 27.2% and 32.9% for ibuprofen and paracetamol, respectively. They noted that despite laws on the regulation of drugs in the country, it is not enforced. The differences in prevalence rates obtained from this study and others cited in the literature above could be due to differences in methodology, lack of uniform criteria in the definition of misuse and misuse of NSAIDs, and the profile of study populations. These differences have also been corroborated by Richard et al. [33]. in their study on over-the-counter drug misuse [33]. The misuse of OTC drugs has been corroborated in several other studies [35–40]. Studies have shown that doses higher than the recommended doses are used by the subjects who bought drugs over the counter [38–40].

The study revealed that most caregivers noted side effects as a possible sequela of taking either ibuprofen or paracetamol. Ibuprofen and paracetamol are associated with dose-dependent gastrointestinal adverse effects and hepatic effects, respectively [40]. Kaliba et al. [32] noted that 27.1% of the subjects who misused drugs had varying degrees of side effects. This finding was also corroborated by Rainsford et al. [40]. , who reported the adverse effects of paracetamol and ibuprofen in their clinical trials. They noted minor adverse effects of approximately 10% with paracetamol and 8% with ibuprofen when they were given up to 30 days. Renal and hepatic toxicity are adverse effects associated with the misuse of ibuprofen [41, 42]. Furthermore, an idiosyncratic reaction has been reported in children who misuse ibuprofen [43].

Surprisingly, although the majority of the caregivers’ first points of call for their febrile children were healthcare workers, they misuse these drugs. This may be caused by advertisements for these drugs on all social media [44]. The irrational use of drugs in the management of children with fever despite physicians’ advice has been widely documented. For example, Uzochukwu et al. [35] noted that the irrational use of drugs for fever and other diseases, such as diarrhoea, could be due to inadequate assessment of the patient, poor communication between the physician and the caregivers, lack of thorough history and proper examination, and extravagant and incorrect prescribing by physicians [36].

The majority of the caregivers (in the current study) who misuse these drugs are between 30 and 39 years old. Possible explanations for the findings above could be due to greater exposure to social media and health education by this age group [46–48].

The study revealed no association between mothers’/caregivers’ level of education and misuse of ibuprofen. The clustering of caregivers/mothers in the secondary school category may also explain the findings above. In contrast, Amaha [48], Lawan [40], and Babatunde et al. [50] reported positive correlations between education and the use of OTC drugs. They noted that respondents with low levels of education tended to use non-prescribed OTC drugs than those with higher levels of education.

This study revealed no difference in the misuse of either ibuprofen or paracetamol between rural and urban caregivers. The high number of caregivers from the urban health centers in the study may also explain the rural‒urban ambivalence in the misuse of ibuprofen and paracetamol, as observed in the present study. In contrast, Dineshkumar et al. [51] noted a higher prevalence of misuse in urban areas (37%) than in rural areas (17%) in India. They also noted that following a doctor’s prescription, a greater proportion of subjects from rural areas purchased all the prescribed drugs than did those from urban areas.

Over 90% of caregivers who presented to the hospitals of study worried about fever. The causes of worry range from fever, which can cause vomiting, poor appetite, cough, excessive crying, diarrhea, the passage of greenish stool, and abdominal discomfort. Furthermore, most caregivers who misuse ibuprofen and paracetamol had a very poor perception of fever (39.6%), a phenomenon called fever phobia; they also believed that fever is dangerous and is often associated with teething. These findings are consistent with those of Adimorah et al. [52], who noted associated teething in febrile children. Although mothers generally have a poor perception of fever, as described above, most caregivers who have a good perception of fever are approximately nine times more likely to misuse NSAIDs than those who have a poor perception of fever. Fever is not necessarily an ominous sign, as it has a beneficial effect on fighting infection [38, 53]. Nevertheless, it can be a source of worry for caregivers [53].

Limitations

This study is limited by recall bias, self-reported dosing, hospital-based sampling, and the absence of triangulation (e.g., verifying prescriptions or observing medication containers).

Conclusion

The use of ibuprofen is more widespread than the use of paracetamol by mothers in febrile children, with the majority of mothers reporting side effects as deterrents. However, the misuse of both ibuprofen and paracetamol was noted to be high among these mothers. There was no marked difference in the use/misuse of ibuprofen or paracetamol among mothers who attended urban and rural hospitals.

Authors’ contributions

CJM conceived and designed this study, whereas OJT, CAT, OEN, CPU, NCD, MNC, OBA and CJM helped in the critical revision of the article. OEN and CJM also performed the data analysis/interpretation.

Funding

This study was not funded by any organization. We bore all the expenses that accrued from the study.

Data availability

Data are provided within the manuscript or supplementary information files.

Declarations

Ethical approval and consent to participate

Ethical approval was obtained from the research and ethics committee of Enugu State University Teaching Hospital (Parklane) Enugu, Nigeria, and verbal informed consent was obtained from the mothers who brought their children to the health centers.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.