In this blog, user-centered care outcomes and other pertinent Consumer Satisfaction (CS)-based issues are assessed as potential undercurrent for changes in contemporary urban usage of HM. A plurality of survey respondent in future CS-based studies will strongly agree with the notion that formulation options available for treatment are diverse and are adequate and offer satisfactory levels of safety. General perception of therapeutic efficacy of formulations will also be high as users will approve, as satisfactory, the scope and intensity of symptom attenuation after formulation use. Despite significantly low awareness of side effects and labeling information on contraindications (see blog ¾), a large majority of users will strongly view formulation package presentations as satisfactory and will consider its graphic designs effective in generating high levels of user awareness of formulations’ therapeutic value. Contrary to expert opinions, users will also affirm that formulations labels disclose adequate information on dose and on frequency of usage. Users’ affirmation that HM-based treatment regimen is highly relevant in today’s urban Ghana will confirm earlier literature reports across Africa about its complementary role in the provision of healthcare in urban communities with impaired access to formal Allopathic Medicine (AM) health services. Users’ declared intentions to re-use HM and to recommend HM to others will support a high overall satisfaction level with prevalent state and norms about the composition, formulation, presentation and marketing of HM.

This specific blog adds to the repertoire of accumulating diversity of narratives that are needed for the presentation of a comprehensive and an enduring description of Ghana’s existing and rapidly evolving HM industry. This blog also bridges the knowledge gap between contemporary HM practice and its extant literature and fills a significant knowledge gap in HM’s continuous drive towards mainstreaming its tenets as a commodity-driven health care industry with enduring clinical and significant policy impacts. For ease of accessibility, the information contained in this blog is itemized.

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Whatever the case may be and whichever way current HM is evaluated, there seems no denying that HM has undergone a transformative awakening and a cultural renaissance in Ghana and has consequently assumed a broader healthcare role. High urban use prevalence signifies a groundswell of public responsiveness to HM. But what role has consumers played in the development of the chemistry of current trends in presentation and usage? Are HM Providers influenced solely by user perceptions and by user needs when they develop new formulations? Did providers utilize user patronage or solicited user feedback as incentives to perfect old formulations? These subheadings attempt to provide some clarity on these and other related unanswered issues.

Awareness of the availability of formulations

An array of unorthodox persuasive strategies (that differs in content and in frequency from brand to brand) have promoted HM use in ways that signify a growing urban openness to the variety of treatment modalities offered by it and gives new insights into  clinical herbalism offered by its providers.

As a health communication tool, ads stimulate HM conversations among novices, provide therapeutic knowledge of herbs to the uninformed, alter public perceptions and attitudes to its use, and cement use behaviors among enthusiast. In fact without adequate publicity, consumers may neither know of all the available formulations on offer for the same conditions nor be aware of the many treatment options available for different diseases. Perhaps the escalating use prevalence is the product of unconventional advertising within an enabling culture that benefits from the historical attestation of safety and efficacy.

TV and radio advertising has specifically provided a robust HM user awareness culture within urban communities and its use of conventional and unorthodox advertising content with diverse persuasive strategies has appealed to most adult demographic groups. The awareness culture created by the ads have altered demand among targeted patient populations, advanced our understanding of consumer choice that governs contemporary HM-based healthcare; enhanced the diagnostic and therapeutic specificity of specific formulation thereby expanding the therapeutic and preventive approaches for diseases. Users, at least, are aware of medications developed through an alternative health system that can be leveraged when needed to improve health. Future studies can assess the main and interactive effects of nationally disseminated TV and radio ads on HM purchases as a means to elucidate the role that ad content and ad environment plays on HM choices by urban users. Additional future studies can examine how providers modify their marketing and promotional strategies to increase consumers’ demands for the wide array of formulations.

Providers spurred by continuing demand formulate new recipes of aphrodisiacs and advertise them widely on national TV often with lurid display of sexuality. Arguably marketing, not clinical need is driving the use of such HM-based aphrodisiacs whose catchy names and slogans that leave little thoughts to the imagination. Future studies can explore viable advertising models that provides a nuanced view of HM and that has the highest probability of improving HM formulation awareness in a balanced health literacy environment within AM underserved urban communities where recalcitrant disease rates are high.

On a practical level, TV commercials aired at primetime on the top TV networks, product placements in neighborhood store outlets, and point-of-purchase promotions at HM centers and large markets in urban areas ensures that the clinical marketplace is saturated with barrage of health promoting and health protecting information on HM therapy and that users only have to extract useful information from this barrage to make purchasing decisions. Future studies can examine how users’ awareness of HM availability and the perceptions of their own health status affect their purchasing intentions, formulation choices, and eventual health outcomes.

While awareness of the multiplicity of formulations improves health literacy and health outcomes, their impact on contemporary use culture remains unknown. Has the relatively higher level of awareness created by TV and radio ads increased HM use intentions among consumers? What is the degree to which variability in actual usage diverge with use intentions created by awareness campaigns?

Strategic changes in the advertising focus of providers may exert strong independent effects on users’ formulation choice and by extension on formulation availability. Future studies can examine the impact of HM product advertising on purchase decisions and on use behaviors through a national survey that list users experiences about the model brand use. It can also assess the perception, attitudes and beliefs about HM use behavior at the intersection of product marketing and product promotion. Such studies may ultimately offer likely explanations through which marketing ads exposure has effects on HM use trajectories. Other related studies can examine the persuasive impact (by measuring advertisement comprehension, liking, credibility, influence, and overall appraisal) of HM advertisements on a nationally representative urban panel of HM users. The goal of such studies is to determine if ads about HM impacted perceptions of the HM quality, effectiveness and safety.

Study results may then elucidate processes and targets for health messaging that impacts HM use and attitudes among urban adults. Ultimately such findings will have significant clinical and policy impacts on current and future HM use in Ghana, as the study will inform providers and regulatory agencies on perceptions of safety and effectiveness of HM in the marketplace.

Alcohol-infused aphrodisiacs are now commonly used for recreational drinking by many young adults. Such links between exposure to HM marketing and HM alcoholic bitters use among the youth is yet to be uncovered. A related study may also provide evidence of how ads increase youth access to alcoholic bitters. When does alcoholic HM-bitters use experimentation escalate into life-long habits of an alcoholic?  The study may assist in providing better understanding and offering prevention of the significant public health problem that self-medication of healthy and sick urban populations affords.

What are the strategic steps that providers utilize to create their marketing strategies designed to attract consumers and to increase user purchases? What are the individual use culture-related factors that impact the user's receipt of ads on optimal HM-based pharmacological treatment? How do purchasing patterns of formulation by brands (for ready-to-use) or specificity of herbs (for-in-house preparation) predict the diseases that are most treated with HM formulation? Study results directly emanating from study questions have the potential of informing national policies on improving user awareness of and user access to HM formulations.

Provider initiatives that increases use prevalence is enhanced through increasing the awareness level of potential users to the therapeutic and prophylactic efficacy of formulations. But awareness must also be raised about the possibility of adverse health among users. The medical literature is replete with reports of nephrotoxicity, hepatotoxicity and hepatic failure that are associated with the ingestion of some herbal medicinal products. The concluding question here is: are users aware of the potential for developing nephrotoxicity, hepatotoxicity and hepatic failure?

Options available for symptoms treatment

Survey respondents will express that multiple user options are possible with the available range of formulations. In fact, there is no lack of patient options given the current evolution of HM from hygienically substandard crude extract preparations by obscure herbalist to treat few diseases into industrial scale preparations that caters to a broad range of conditions. The menu of options includes formulations that are alternatives to AM drugs and formulations that highlights the increasing inter-connection between of AM and HM use cultures.

Users now draw from comprehensively rich and varied options that include formulations that target minor ailments such as headache and malaria to those that target putatively major sicknesses such as STDs (HIV, syphilis and gonorrhea) and diabetes and high blood pressure. Large available options give users a sense of greater control over formulation choices, improve the quality of provided care, promote safer clinical practice and foster the achievement of better patient outcomes. But users have few options for cardiovascular health and mental health. This observation calls for widespread translational efforts to improve HM-based therapeutic options for certain diseases. Additionally, accessible and acceptable ready-to-use HM formulations are very limited for children and for pregnant women. As a consequence, many desirous pregnant women and parents resort to the use of “in-house remedies” to treat their symptoms and that of their children.

But for users who choose not to taste bitter formulations, the menu of other formulation options is rather sparse. User unperturbed by bitter formulations seems to have advantageous options-disproportionately large number of formulations have bitter principles. Bitterness of formulations may reduce choice in a way that may stimulate the purchase of less bitter alternatives for the same condition. Future studies can examine whether brand-specific differences in tastes of formulations leads preferentially to the patronage of less bitter formulations as therapeutic substitutes. Preclinical trials can provide formulations with improved tolerability and better safety profiles than current therapeutic options with high levels of “bitter principles.” For formulations that are unusually bitter, other routes of administration (rectal) besides oral may be considered.

Consumer feedbacks will assist Providers in formulating new products that will alleviate symptoms and improve health-related quality of life. Formulations developed with user input will have a large market opportunity and significant clinical importance. Critical questions that remain unanswered are: Is it CS and consumer demand that is responsible for these large varieties of formulation types? Alternatively, are currently available formulations attributable solely to the work of providers? Do providers work in tandem with users to develop new formulation that can be used alone or in combination to treat/manage diverse symptoms? A trend towards customer-driven marketplace means that HM products can be customized to the preferences of individual consumers. This scenario occurs in most HM care centers scattered in urban communities throughout Ghana.

It needs to be re-stated that HM formulations can be compared using a variety of measures including costs, tolerability and acceptability. User acceptability of accessible options hinges on satisfaction indices that encompass cost, taste, relative efficacy and safety and health-related quality of life measures. Even with formulations that utilize same herbal plants, each brand remains unique as different relative amounts of herbal plants form the composition. To optimize currently available treatment options, providers can systematically vary the dose of each herbal plant and the number of herbal plants to identify the most efficacious formulation. Differing methodological strategies available for formulation improvement can be tailored to address different symptoms and answer different questions that include user receptivity and co-use with AM anti-malaria drugs and adverse health effects.

Future studies can examine how population health needs influence the formulation types and HM-based treatment regimen availability for use by needy patients. It is anticipated that the number of clinical cases with successful therapeutic outcome will rise as patient exposure to diverse HM formulations broadens and as newer formulations enter the market. Future studies can assess how the availability of different formulations affect health outcomes including disease prevalence and disease treated by patients who rely solely on the use of HM to treat their symptoms. Included in this assessment is the evaluation of the effectiveness and cost-effectiveness of HM-based treatment in Ghana and an exploration of the ways in which the generated data can provide useful inputs to the policy making process on the ongoing integration of HM into the current AM health care system.

How well therapeutic effects are known

Therapeutic efficacy of HM formulations is usually known or anticipated in advance of purchase of formulation. This observation supports the view that market forces that are reshaping HM are putting unprecedented premium on efficacy, more so than, on safety.

It is not considered rare that HM enthusiasts have “herbal plant name-disease symptom association” in memory and can easily predict conditions most formulations are intended to cure or manage from the listed plant name. Also, therapeutic knowledge of most brand named formulations are high among their unique clientele. But for the uninitiated, initial knowledge of the therapeutic effects of formulations might be obtained from TV or radio ads or might be culled from the label or from the print media or gleaned from discussions with trusted peers. Historical knowledge of herbal plants and its specific therapeutic effects acquired through generations are key to the sustainment of age-old “in-house” HM preparation.

Package presentation

With cost limitation as a major drawback, HM formulation packages are presented with only modest graphic and with little or no glossy features.

Helped narrow the search for medication to specific samples

Available formulation types are driven by clinical need of users. Cognizant that the needs of different patient populations vary depending on the type of sickness and on the severity of the symptoms, Providers have on offer a wide assortment of formulations.

Consistency of health improvement from symptom to symptom

Users will assert that most of current formulations provide symptom relieve and/or reduce symptom distress after use. And that symptoms as varied as headache, malaria and diabetes will eventually peter out with adherence to the HM formulation of choice. As consequence, HM adherents see HM as a means of reducing symptom distress and creating less AM healthcare utilization.

How quickly symptoms disappeared

Most patients want their symptoms to disappear as quickly as possible and will consequently use time taken for symptoms to disappear as an indirect estimate of the formulation’s efficacy. And while the perception remains that severe symptoms required high dosages for efficacy, most users will be ambivalent that it took shorter/longer for their symptoms to disappear with HM than with AM drug.

How well herbal medicine meets health expectations

Satisfactory user response on health optimization will indicate that users perceive their health needs and expectations are met by HM. Wide availability of different formulations for the management of an equally large scope of disease conditions suggests that available HM formulations indeed represent the range varied symptoms.

How likely to return to use herbal medicine for same symptoms

Users re-use intentions are key direct correlates of user satisfaction and this observation is an indispensable component to future profitability and growth of HM. Re-use intentions signify that the formulation adequately treated/managed the symptom of interest and its efficacy has led to its acceptability as part of users’ routine healthcare.

Many users will express willingness to return to HM for their symptoms and this scenario shows that the level of confidence in the benefits offered by the formulation’s therapeutic ability far outweighs the levels of inherent risks posed by safety concerns.

How likely to recommend herbal medicine to someone

Recommendation of formulations to others is probably the end-stage manifestation of user approval of formulation attributes and often connotes uninhibited user satisfaction that is un-tempered by possibility of adverse side effects. A relatively high level of loyal users, in survey studies, will state that they are willing to provide potential referrals to others. Such observations suggest that individual formulations that are available encapsulates in their collective entirety user high perception of good therapeutic value. Is users loyalty predicated on product quality, price or on therapeutic value? How widespread is the willingness of existing users to recommend formulation to others?

How likely will users purchase same or similar medication for treatment of same or other symptoms

Re-purchase intentions are inextricable tied to satisfactory results from prior use. That a high number of respondents expressed re-purchase intentions will suggest high user acceptability of formulation therapeutic values along with the offered price. Future studies can examine objective measures of purchases such as store-purchase receipts to infer user enthusiasm for re-purchase intentions. Are users open to purchase new and different formulations as they are offered? And are Providers educated on the need to track the tendency of users to purchase same or related products after prior use? Study results will have the potential of informing local and national policies on improving retail access to affordable HM.

Overall user satisfaction

Substantial numbers of users will have their overall perception on HM as good. Users overall perceptions that HM-based health care benefits and its health-related quality of life improvements is good in spite of its limited scientific evidence base for efficacy and safety seems a contradiction. Future studies can develop a nuanced understanding of the underlying complexity that triggered the good overall perception of HM health-related processes.

Concluding remarks

There are currently no existing mechanism to assess how Ghanaian HM users provide feedbacks on the efficacy, tolerability and safety of formulations they use. This "feedback" process is vital and its broader application in routine HM care is desirable for consistent improvement in formulation efficacy. The long-term application of this “feedback” mechanism will certainly change the face of practice of clinical HM for the better.