Improving use of medicines by consumers

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Improving use of medicines by consumers
World Health Organization University
of Mahidol University of Amsterdam
Royal Tropical Institute
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Point of departure layers of influence

• Individual
• Family and community
• Health institution and drug facility
• State
• Global

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Individual views

• Color, shape and taste of the drug
• Past experience
• Perceived cause of the illness
• New medicines perceived to be better

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Explaining efficacy

• Pharmacological
• Meaning-response
• Social efficacy

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Efficacy branding
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Community Factors

• Pill for every ill culture
• Community drug supply channels
• Community information channels
• Community disease management
• Community pharmacies

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Many descriptive community studies
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Community medicine supply
Town
Drugstores (35)
Neighbourhood
Clinics (2)
stores (40)
Medications (1324)
Hospital (1)
Neighbours and
Doctors (7)
relatives (5)
Household stocks and
free-clinics (8)
Neighbourhood
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Informal channels the main source of drugs
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Advertising the main source of information
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Promoting generics?
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The health institution level

• Irrational prescribing
• Low quality of counseling
• Lack of appropriate dispensing
• Irregular supply of medicines
• Over and under the counter payments for medicines

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Health worker often NOT consulted

• Thailand 7 of episodes (rural)
• Philippines 8 of episodes (urban) 20 of
  episodes (rural infants)
• Pakistan 56 in NGO-PHC area, 48 in controls
  (rural)
• Ghana 42 in urban, 43 in rural

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National level factors

• Implementation of essential drugs policy
• Regulation of drug promotion, and enforcement
• Drug costs, financing and reimbursement policies
• Advocacy by consumer and patient organizations
• Medicine information in school curricula, TV and
  radio programmes, and the internet

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(ill)health communication on TV
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(ill)health communication on the internet
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Action intervention cycle
Step 1 Describe
drug use and identify
problems
Step 2 Prioritise
problems
Step 3 Analyse
problems and identify
solutions
Improve analysis
Step 7
Step 4
Improve intervention
Monitor and
Select and
evaluate
develop
intervention
intervention
Improve intervention
Step 5
Step 6

Pretest
Implement
intervention
intervention
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Principles investigating drug use

• Efficient
• Flexible
• Participatory
• Interactive
• Triangulated

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Step 1. Describe and identify problems

• (Un)published studies
• Key informant interviews
• FGDs
• Observations
• Community drug use surveys

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Step 2. Prioritize RDU problems

• Scale of the problem
• Health risks involved
• Costs
• Feasibility of interventions

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Commonly reported RDU problems

• Non adherence
• Self-medication with prescription drugs
• Overuse of drugs (antibiotics, injections,
  analgesics, and tranquillizers)
• Use of needlessly expensive drugs

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Step 3. Analyze problems
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  Problem analysis
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Step 4. Select appropriate interventions

• Educational
• Managerial
• Regulatory
• Depends on problem analysis
• Mix of methods usually best!

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Worlds apart

• Activists learn by doing, without rigorous
  evaluation
• Researchers conduct community interventions
  trials without planning for wider application

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Lack of evidence

• Existing intervention studies focus on diarrhea,
  ARI, Malaria, AIDS
• Many descriptive studies pointing to problems in
  consumer drug use
• No studies on effects of regulatory measures on
  drug use by consumers
• Lack of data on cost-effectiveness

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What we do know

• Educational intervention studies on diarrhea, and
  malaria show knowledge and appropriate use
  increases
• Studies on the community management of ARI show
  health outcomes improve
• ARV adherence and FP acceptability studies show
  quality of counseling and social support matter

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Step 7. Monitoring and Evaluation

• Preparation
• Planning
• Implementation
• Effect

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Evaluating implementation the process

• Which of planned activities were carried out?
• What messages were disseminated?
• How many people did the message reach?
• Did the target audience pay attention?
• Did the target audience understand?
• What problems were encounter

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Measuring effects

• Change in knowledge?
• Change in behavior?
• Improvements in health?
• Negative or unexpected effects?
• Define clear outcome measures!

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will depend on the complexity of behaviour, its
reinforcement in culture,the presence/absence of
opposing forces and the resources at your disposal
Short term knowledge,skills, awareness
What can be achieved?
Medium term 1-3 yrs behaviour change
Longer term lt5 yrs Change in health
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Four evaluation designs
Type of design Action Measuring change
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Four evaluation designs
Type of design Action Measuring change
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Problems in proving effects

• Contamination
• Intervention changes over time
• Difficult to measure mix of methods
• Unplanned interventions by others
• Confounding factors

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Training shopkeepers on malaria treatment
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Evaluating a mix of methods

• OF TRANSACTIONS DRUG SELLER GIVES ADVICE
• DS only 49 before -gt 84 after
• DS CI 70 before -gt 99 after
• OF TRANSACTIONS CLIENT REPEATS INSTRUCTIONS
• DS only 3 before -gt 61 after
• DS CI 3 before -gt 60 after
• FEVER CASES IN WHICH CHOROQUINE USE GOOD
• DS only 10 before -gt 69 after
• DS CI 10 before -gt 83 after

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Effects of advocacy