Family traditions, accessibility and cost shape the continued reliance on Cajanus cajan and Azadirachta indica for malaria and typhoid despite prescription medicines in urban and rural Nsukka, Nigeria.

Despite the availability of conventional drugs, the use of medicinal plants for typhoid and malaria remains widespread in Nigeria. This study investigated the indigenous use of Cajanus cajan (pigeon pea) and Azadirachta indica (neem) in rural and urban Nsukka. We assessed: (i) socio-demographic factors influencing knowledge and use; (ii) the association between treatment practices and perceived efficacy; and (iii) socio-economic drivers of continued reliance on these herbal remedies. A cross-sectional survey of 400 respondents selected via stratified random sampling (200 urban, 200 rural) was conducted using structured questionnaires, where the primary outcome of this study was current herbal use, while knowledge was treated as a secondary outcome. Data were analyzed using generalized linear models (GLMs) and multinomial logistic regression (MLR) in R Statistical Software (version 4.3.0). Results indicated that rural residents relied more on herbal remedies due to accessibility, affordability, and family traditions, while urban respondents, despite higher education levels, also used herbal extracts and often alternated them with prescription drugs. Residence, occupation, and age were significant predictors of knowledge and use (P < 0.05), whereas education was not. Nonetheless, perceived efficacy and high prescription costs further sustained herbal use. While these findings highlight socio-cultural and economic factors sustaining herbal medicine use, they also support the need for public health education and integration of evidence-based traditional practices into primary healthcare to ensure safer use. However, the cross-sectional design limits causal inference. Future studies should combine questionnaire-based surveys with laboratory-based assessments.