| PURPOSE AND CONTENT While prescribers play an essential role in the choice of medicines, the role of the consumer (the patient) is equally important. Public knowledge, attitudes and perceptions regarding the use of medicines influence the decision to seek health care, from whom and whether the proposed treatment is followed. In some countries more than 50% of medicines consumed (including prescription drugs) are bought over the counter, often from unauthorized sources, and often in response to aggressive commercial marketing. This session will focus on the need for public education on the use of medicines, how to develop and implement a relevant strategy, and discuss possible constraints. It will also review some of the initiatives currently taking place in different parts of the world and discuss principles of effective public education. To develop your ability to:
1. Study the module Principles of Face to Face Education. 2. Read Chapter 33 of Managing Drug Supply 2nd edition A substantial list of further readings and resource materials can be found in Annex One In emphasizing the prescriber's role in promoting rational drug use, it is easy to lose track of the importance of the patient. To do so is a serious mistake. The knowledge, attitudes, and education of the general public are crucial determinants in the decision to seek health care, the choice of provider, the use of medicines, and the success of treatment. THE PATIENT'S ROLE Patients are actively involved in the therapeutic encounter and in treatment. In the final analysis, it is the patient who will decide whether to go ahead with a treatment or not. Patients go through a series of decisions before a treatment is self-chosen or prescribed. First: People who are ill have to believe that there is "something wrong" with their health. This perception is to some extent culturally defined. Second: People have to decide whether this problem is significant enough to make them seek help, or if the symptoms will go away without treatment.
Third: Once they have decided that help is needed, people choose where to seek help: this may be at a hospital, a primary health care center, a private physician, a pharmacist, a market vendor, a traditional healer, a relative or other member of the community. They may decide -- although this assessment may not be accurate -- that the symptoms are sufficiently minor or that they are familiar enough with the required treatment to directly self-medicate either with a modern pharmaceutical or a traditional remedy.
(Figure1). Community drug distribution channels: an example from the Philippines. Source: Hardon A. Confronting ill health: medicines, self-care the and poor in Manila, HAIN, Quezon City 1991.
This figure is based on weekly interviews on health problems and treatment practices during a five month period with 126 families in two urban slums in Metro Manila. The arrows illustrate the relative importance of the various routes that pharmaceuticals follow before reaching users. In this example the health centers only account for a fraction of drug supply. The majority of drugs are purchased in neighborhood stores and/or in pharmacies, together accounting for around 80% of total drug purchases. The study further revealed that around 50% of the medications were obtained in the community. Think about the situation in your own country:
Fourth: Once they have a prescription, patients decide whether to buy the drugs or not; whether they are going to buy all the items recommended in the prescription, or only some of them; and which drugs to buy. In doing so they may need to decide what items are important and worth buying. Fifth: Patients decide whether and when to take the medicines; whether to continue taking them, if side effects occur or if their symptoms disappear, and what to do with any medicines that remain unused. B. CONCEPTS OF DISEASE ETIOLOGY If we ask a physician what causes a certain disease -- diarrhea for example -- the answer could be "eating food contaminated with bacteria or virus which produces toxins that lead to a disturbance in the electrolyte absorption at the small intestine." Yet, if we ask an illiterate villager the same question, the answer could be: "Evil eye leads to weakening resistance and enables spirits to hurt the patient." Before any attempts are made to design a health education program, it is important to understand the popular concepts of disease etiology in the community. For example, a study in Jamaica revealed that most illnesses are believed to be caused by (1) "cold," (2) "gas" or "wind," (3) "heat," (4) "bile," (5) "blood imbalances," and (6) "germs." Etiological explanations involving heat, cold, bile, and gas/wind are applied mainly to symptoms in which there is a feeling of pain, heat, or chill, or where there is discharge. Those involving imbalances of blood are applied to internal conditions and changes in the skin; those involving germs are applied primarily, but not exclusively, to venereal diseases. In Java, as another example, many mothers perceive diarrhea as a normal consequence of physiological growth of the child. This often lead them to underestimate the condition before it becomes more serious. What are some popular concepts of disease etiology in your country? C. CONCEPTS OF CURE A commonly held belief is that "symptoms" are equal to "disease." Therefore, if there are no symptoms it is assumed that a person is well. When symptoms are present, they are the diseases itself. For example, a skin lesion, caused by diabetes, is considered the disease itself. By this reasoning diabetes is considered cured if the lesion goes away. This may explain why it is sometimes difficult to convince diabetic or hypertensive patients to continue taking their medicine even after the symptoms have disappeared. D. CONCEPTS ABOUT THE THERAPEUTIC VALUE OF DRUGS Some patients may value drugs according to:
Generally, a medicine that quells a symptom is considered "good," and one which does not, is considered ineffective. This may explain why some patients, and even physicians, are reluctant to use ORS for childhood diarrhea; the symptoms do not immediately disappear after its use. Often, patients demand or prescribers prescribe more drugs for acute diarrhea, since ORS is not considered as a drug (not stopping the diarrhea). E. EFFECT OF PROMOTION AND MARKETING ON THE USE OF DRUGS Drug promotion is playing an increasingly important role in shaping utilization patterns. With over 50% of all medicines bought directly by the consumer, direct promotion of OTC drugs to the consumer is common in almost all countries of world. In areas where legislative and regulatory control of pharmaceutical promotion is weak - the case in most developing countries - prescription drugs are sometimes also advertised. Even in the U.S. direct advertising is now allowed. Uncontrolled advertising may be misleading and can contribute to inappropriate drug use with major financial and public health implications for the individual and the community. One study in Yogyakarta, Indonesia, showed that most consumers do not know the active ingredient of the most commonly used commercial products. They often relate the indication only with trade-names, due to misleading advertisements. This may lead to the use of different commercial products with the same active compounds at the same time. Or, certain products may be used for the wrong indication, e.g.: paracetamol for symptom of weakness. Think about the methods of drug promotion that exist in your country:
See Annex Two for some examples. F. SOCIAL MARKETING Traditionally, health education has been of low priority in national public health strategies. One reason for this lack of support is that it has been seen as a soft subject, lacking the intellectual rigor of other more quantifiable scientific disciplines. Another reason is probably the traditional medical model, which holds the patient to be a passive recipient, rather than an equal partner a health care interaction. Until recently, also health education (as traditionally practiced) has often suffered from a lack of comprehensive planning. Health educators have too often pushed down messages, in inappropriate language through weak communication channels, and failed to reach or impact on the target audience. Health education materials often failed to take into account that all human behavior is integrated into a cohesive cultural context. What may seem irrational in terms of Western scientific understanding may often be perfectly rational in terms of an individual's culture and framework of reality. Starting in the 1970s, a number of developments broadened our view of how health education could and should be practiced. In 1978 in Alma Ata, WHO initiated a fundamental change in public health thinking, moving from an emphasis on disease eradication to one stressing prevention and the needs of the rural poor and social equity. This strategy centered on the core empowerment of the community through education and participation in decision-making. Health educators and communicators began to look for workable and proven strategies that would enable public health communication to take place within a comprehensive and viable framework. One area was commercial marketing practice, since it was obvious that such marketing must be successful in influencing behavior. Companies would not spend billions of dollars a year in advertising and promotion if it were not worthwhile. In the field of drugs, for example, promotional budgets can be as much as 20% of the turnover. This led to using the techniques of commercial marketing to promote social ideals. Social marketing models, first articulated by Philip Kotler and based on commercial marketing practices, show that the consumer (target audience) should be the central focus for planning and conducting a program. The program's components focus on what is known as the 4 Ps.
The formulation of price, product, promotion and place, have to be determined on the basis of research with the consumer to decide what benefits and "costs" they would consider acceptable, and how they might be reached. Lessons learned from social marketing stress the importance of understanding the target audience and designing strategies based on their perceptions, wants, and needs. Another psychosocial model which has been developed to identify what people believe and why they believe it is the Health Belief Model, which explains health behavior through expectancies. Used as a tool for analyzing health-related behavior, its key variables are:
Reviews of this model in the last 10 years found that it is valid for explaining many health behaviors. Perceived barriers were found to be the most powerful single predictor of behavior, and perceived severity the least powerful predictor. These and other behavioral theories are very helpful when developing communication strategies. They have at their core the fact that behavior modification is based on a complex web and analysis of personal and societal factors which must be investigated and taken into account in the communication strategy. This process is very far removed from the classical health educator's job, deciding on a slogan, and commissioning a graphic to be reproduced in 10,000 posters. It focuses on where the consumer is coming from; not the educator. G. GLOBAL PUBLIC EDUCATION INITIATIVES RELATED TO DRUG USE Until recently, national health education focussing on the proper use of medicines was rare in both developed and developing countries, although some consumer organizations have conducted campaigns, usually against unethical marketing of individual drugs. However, escalating cost of medicines, the wasted resources resulting from their misuse, the increasing amount of self-medication, and the influence of advertising, has led to a new focus on the role of and the need for an informed consumer. This is particularly true in countries with a diminishing budget for public sector drug supply. This led to the development of national public education strategies. Another factor has been the growing awareness that a patient/prescriber encounter is an interactive process in which each can influence the other. Some prescribers excuse bad prescribing practice by claiming that patients insist on receiving a certain drug (e.g., an antibiotic) or mode of delivery (e.g., an injection) and will go elsewhere if do not get it. Nationally coordinated public education campaigns on the use of medicines are being implemented in Australia, Bolivia, France, Kenya, Malawi, Myanmar, Sudan, the Philippines, and USA. Campaigns are planned in Laos, Syria, Tunisia and Yemen. Annex Three provides a brief summary of some campaign approaches and activities. There are a number of ways or channels in the community to convey education to the general public, for instance through women's organizations, social activities, religious leaders/groups, at the outpatient unit, art performances like drama, song, etc. In Indonesia, a training module on over-the-counter (OTC) drugs has been field tested and disseminated through community women's organizations with a self-active learning process utilizing drug package inserts. The activity is carried out in small groups and has proved to be effective in improving the appropriate use of OTC-medications (see Annex Four). H. DEVELOPING A PUBLIC EDUCATION STRATEGY Public education cannot compensate for poor products or inadequate health services or staff. However, it can provide the consumer with a better understanding of the benefits and the potential dangers of drug use, and safe sources of drug information and supply. An informed and empowered consumer is able to act in his or her own and in the community's best interests. Changing people's behavior or habits is not an easy task and generally requires a long term strategy based on the behavioral principles outlined under. A behavioral modification intervention has to be undertaken with knowledge of the social and cultural context in which it is based. FIGURE 2
The process Effective Communication involves a number of steps (see Figure 2). It is essentially a process; one that continually evolves and is modified as monitoring takes place. STEP ONE: INVESTIGATE The investigatory stage is essential and at the core of the communication process. It should address the following issues:
3. How should these data be generated? A combination of qualitative and quantitative research methods can be used.
Quantitative methods, such as household surveys, provide useful information on levels of knowledge and on the practice and beliefs prevalent in a given population. They measure what is happening. These methods are most useful as pre- and post-intervention evaluation tools.
Qualitative methods, such as focus group discussions, and in depth individual interviews, yield substantial information about specific behaviors, as well as the reasons and motivations underlying them. They measure how and why things are happening. The focus group is a research method borrowed from commercial marketing. Focus groups are very useful in opening people up to talk more freely, particularly about sensitive subjects. They generate a lot of ideas, and provide language to use in communication materials. STEP TWO: PLAN COMMUNICATION ACTIVITIES The communication plan provides the road map for communication activities. When it is first written it is quite broad. Its primary purpose is to establish clear and feasible objectives and to outline how they are to be reached. However, the communication plan should be adjusted or revised over time as more information on the audience is obtained through research, pre-testing of communication materials and monitoring. A communication plan should include:
The communication plan should include a timetable and a budget, plus the source of financing. It can be very difficult to stick to both. So, overestimate rather than underestimate. Approval of the plan will be needed, and this may entail government ministries, such as health, education or information; broadcasting authorities, and a formal commitment from participating NGOs. Getting the plan formally approved by key authorities helps elicit their commitment and minimizes any possible confusion about objectives and implementation once, implementation has begun. STEP THREE: DEVELOP COMMUNICATION MATERIALS Formative research should provide the data needed to decide on approaches, communication channels, and the messages to be conveyed. It should also provide indications of the language and expressions be used. STEP FOUR: TEST AND REVISE MATERIALS The materials and products are tested on representatives of the target audience to ensure that they are understandable, appropriate and attractive. Testing should answer the following questions:
Pre-testing the materials is essential and will often produce surprising results. A picture may be completely misunderstood, particularly if it uses a stylized design convention in a society relatively inexperienced in graphic images. For example, an ORS poster in Honduras initially showed a sequence of four boxes showing the correct sequence for mixing. The sequential numbers included in each box were interpreted by the target audience to mean that one cup of water was to be added to the packet, two corners torn off, three packets emptied into the bottle and the bottle shaken four times. See module on Printed materials STEP FIVE: IMPLEMENTATION When implementing a public education campaign, it is important that all the resources both human and material are fully prepared. This may mean stockpiling posters, pamphlets video materials, booking venues and arranging for staff to be available well in advance. STEP SIX: MONITOR EVALUATE AND REVISE Stages five and six are closely related. Implementation includes monitoring of activities: Monitoring:
As the program progresses it may be necessary to modify the original plan on the basis of monitoring indicators. Evaluation:
Feedback:
It is important to fully document communication activities not only to facilitate proper monitoring and evaluation, but also to ensure that people planning future communication program can learn from your experience. It is often very difficult in developing countries to find reports of even large the scale communication activities. This leads to unnecessary "reinventing the wheel" and waste of experience and resources. Designing a Public Education Program Rationale
Instructions
WORKSHEET #1.1 Designing a Public Education Program Problem
Audience
Intervention
Financing
Monitoring and evaluation
Further Readings and Resource Materials Planning information, education, and communication programs US Department of Health and Human Services. Making Health Communication Programs Work: A Planner's Guide, NH Publication No. 89-1493, Washington, 1989. World Health Organization, Diarrhoeal Diseases Control Programme. Communication: a Guide for Managers of National Diarrhoeal Disease Control Programs, Geneva, 1987. World Health Organization. Guide to Planning Health Promotion for Aids Prevention and Control, WHO Aids Series No.5, Geneva, 1989. Zimmerman M., Newton N., Rumin L. and Wittet S. Developing Health and Family Planning Print Materials for Low-Literate Audiences: a Guide. Program for Appropriate Technology in Health, Washington, 1989. Elkamel F. Developing Communication Strategies and Programs: a Systematic Approach, UNICEF Mena Regional Office, 1986. Rasmuson, M.R., Seidel, R.E., Smith, W.A., and Booth, E.KM. Communication for Child Survival. HEALTHCOM. Project conducted by the Academy for Educational Development for USAID, Washington, D.C, 1988. Seidel R. Results and Realities: a Decade of Experience in Communication for Child Survival. HEALTHCOM. Washington, D.C., 1992. Molvaer, R.K. Education for Better Health: a Manual for Senior Health Educators. Ministry of Health, Addis Ababa, 1989. World Health Organization, Action Programme on Essential Drugs. Report of an Informal Working Group on Educational Material for Patients. WHO/DAP, 1985. Pan American Health Organization/WHO Regional Office for the Americas. Making Health Communication Programs work in Latin America and the Caribbean: a Manual for Action, Washington D.C.m 1991. Hodgkin C and Hardon A. Towards Rational Drug Use in Southern and Eastern Africa: Proceedings of Harare Seminar 1991. Health Action International, Amsterdam, 1992. World Health Organization. Education for Health: a Manual on Health Education in Primary Health Care. Green, L.W., Kreutscer M.W., Deeds S.G. et al. Health Education Planning: A Diagnostic Approach. Mayfield Publishing Co., Palo Alto, 1980. Kotler, P. and Andreason A.R. Strategic Marketing for Nonprofit Organizations: 3 ed. Prentice-Hall, Englewood Cliffs, 1987. Rogers E.M. Diffusion of Innovations, Free Press, New York, 1983. Suryawati S. Practical Guideline: Improving the Knowledge and Skills in Selecting Medicine Using CBIA Method. An intervention educational module for improving the quality of self-medication. Department of Clinical Pharmacology, Faculty of Medicine Gadjah Mada University, Yogyakarta, 1993. IEC Research methodology World Health Organization, Action Programme on Essential Drugs. How to investigate Drug Use in Communities, WHO/DAP/92.3, 1992. Debus M. Handbook for Excellence in Focus Group Research. Academy for Educational Development, Washington D.C., 1990. Krueger, R.A. Focus Groups: A Practical Guide for Applied Research. Sage Publications, Newbury Park, 1988. Drug promotion and marketing World Health Organization. Ethical Criteria for Drug Marketing and Promotion, Geneva, 1988. Health Action International. Promoting Health or Pushing Drugs? HAI, Amsterdam, 1992. Chetley, A. and Gilbert D. Problem Drugs. Health Action International, Amsterdam, 1986. Silverman M., Lee P.R. and Lydecker M. Prescriptions for Death: the Drugging of the Third World. University of California Press, Berkeley, 1982. Silverman KM., Lydecker M., and Lee P.R. Bad Medicine: The Prescription Drug Industry in the Third World, Stanford University Press, Stanford, 1992. Gupta A.S. (ed.). Drug Industry and the Indian People. Delhi Science Forum and Federation of Medical Representatives Association of India, 1986. Studies of community knowledge, attitude and practice regarding the use of medicine Hardon A. Confronting Ill-health: Medicines, Self-care and the Poor in Manila, HAIN, Quezon City, 1991. Tamang, A.K., and Dixit, S.B. Knowledge Attitude and Practice towards Health and Essential Drugs in Rural Nepal, Bamako Initiative Technical Report Series No. 10, UNICEF, New York, 1992. van der Geest S. Self-care and the informal Sale of Drugs in South Cameroon. Soc.Sci.Med. Vol.25, No.3, pp.293-305, 1987. van der Geest S., Hardon A., Whyte, S.R. Planning for essential drugs: are we missing the cultural dimension? Health Policy and Planning: 5(2): 182-185. Abosede, O.A. Self-medication: an important Aspect of Primary Health Care, Soc.Sci.Med.Vol.19, No.7, pp.699-703, 1984. Robert C.F., Bouvier S. and Rougemont A. Epidemiology, Anthropology and Health Education. World Health Forum, Vol.10, pp.355-64, 1989. Donovan J. L. and Blake D.R. Patient Non-compliance: Deviance or Reasoned Decision-making? Soc.Sci.Med. Vol.34, No.5, pp.507-513, 1992. Sachs L. and Tomson G. Medicines and Culture - a double Perspective on Drug Utilization in a Developing Country. Soc.Sci.Med.Vol.34 no.3, pp.307-315, 1992. Wolf-Gould C.S., Taylor N., McCue Horwotz S. and Barry M. Misinformation about Medications in Rural Ghana. Soc.Sci.Med.Vol.33 No.l, pp.83-89 1991. Newsletters reporting on development communication activities Development Communication Report, a quarterly newsletter available free of charge to readers in developing countries: Clearinghouse on Development Communication, 1815 North Fort Myer Drive, Suite 600, Arlington, VA 220 : reports on IEC activities in all fields of development communication Essential Drugs Monitor, newsletter of the World Health Organization Action Programme on Essential Drugs, published three times per year in English, French and Spanish, free of charge to readers. The Monitor regularly includes reports on research activities and public education campaigns related to the use of medicines. National publication education campaigns on rational drug use Australia: Campaigns on Drug Use and the Elderly; the Wise Use of Medicines; and a school education kit, using videos, TV spots, brochures and posters. For further information contact: Ms L. Coper, National Director, Australian Pharmacy Self Care Programme, National Secretariat, P.O. Box 2l, Curtin ACT 2605, Australia France: Campaign for wise drug use : don't take drugs lightly (Campagne bon usage du médicament : un médicament ca ne prend pas à la legere); posters, leaflets and TV spots (in French). For further information contact: Ministère des Affaires Sociales et de la Solidarité, 100 avenue Raymond Poincaré, 75116, Paris, France USA: Medicine: before you take it talk about it campaign. Posters, leaflets, radio spots, information folders, activity sheets. Annual newsletter for "Talk about Prescriptions month". For further information contact: Mr R. Bachman, Executive Director, National Council on Patient Information and Education, 666 Eleventh Street, N.W., Suite 810, Washington, D.C. 20001, USA Bolivia: Posters, leaflets and radio programs (in Spanish). For further information contact either the WHO Action Programme on Essential Drugs, Geneva, Switzerland or the Bolivian Essential Drugs Programme c/o WHO Representative, La Paz. Philippines: Posters, leaflets and TV spots. For further information contact Dr Quintin L. Kintanar, Head, National Drug Policy Office, Director, Bureau of Food and Drugs, Alabang, Muntinglupa, Metro Manila, Philippines Copies of National IEC strategy plans that can be used as examples in developing programme activities are available from the WHO Action Programme on Essential Drugs. Internet resources: View locally or access on the web at http://www.who.int/dap-icium/posters/3B2_TXTF.html View locally or access on the web at http://www.who.int/dap-icium/posters/3B1_TXTF.html View locally or access on the web at http://www.who.int/dap-icium/posters/3B3_TXTF.html View locally or access on the web at http://www.who.int/dap-icium/posters/3C4_TXTF.html View locally or access on the web at http://www.who.int/dap-icium/posters/3F3_TXTF.html View locally or access on the web at http://www.who.int/dap-icium/posters/3A2_TEXT.html
Public Education Campaigns on Drug Use Australia: public education work has centered around the role of the community pharmacist as a reliable source of information about medicines; on the need for adequate communication between the health professional and the client about prescribed medicines; about polypharmacy of the elderly and actions that older citizens can take to monitor drug use. A school education pack has also been developed and widely disseminated. Materials include videos, TV spots, and educational leaflets and posters. Philippines an active public information campaign has explained the rationale of the National Drugs Policy through a widely distributed booklet, t-shirts, TV spots and posters. The campaign has also highlighted consumer rights, showing what should appear on a properly written prescription, explaining the difference between a generic and a brand name drug, and promoting the individual's right to purchase a cheaper equivalent product.
Malawi: after initial community research, the Government has adopted a comprehensive strategy of public education on the rational use of drugs within the context of the national drugs policy and essential drugs programme. This encompasses education for primary school children in medicine use, and the use of a variety of media such as traditional theater, the literacy programme, the mass media, and graphic materials to disseminate rational use messages. The campaign will also use interpersonal communication through educational sessions on drug use in health centers, and training in communication techniques between prescriber/dispense and patient, explaining both responsibilities and rights to information.
Myanmar: after conducting formative research, the Myanmar Essential Drugs Programme is implementing a public information campaign on the programme and the proper use of medicines using the mass media and printed materials.
Bolivia: education activities have included an illustrated brochure explaining the essential drugs concept and its contribution to health, safety and saving costs for the community, backed up by posters on the same theme, and the broadcasting of more than 50 short radio programs discussing various aspects of drug use and treatment of common ailments.
USA: a campaign which has been conducted over more than a decade by the National Council on Patient Education includes radio spots, resource packs for health professionals, companies, community groups and individuals. Each year activities are intensified in a monthly campaign for which additional materials are produced on various problems/solutions related to the use of medicines. The leitmotif of the campaign has been the need for good communication between prescriber and patient with materials targeted to both groups. In 1989 the campaign focused on the special drug use problems of the elderly.
France: an ongoing campaign urges French consumers not to "take drugs lightly" and includes TV spots, posters, leaflets for pharmacies and press articles. |
