Trainer's Guide
Framework for Changing Drug Use Practices

1.Identify particular drug use problems, and place them in the perspective of the factors underlying problems in drug use.

2.Identify eight to ten different approaches to improve problems in drug use which have been tried in developing and developed countries

3.Understand some of the strengths and weaknesses of different approaches in terms of demonstrated effectiveness, cost, and suitability for specific country contexts and drug therapy problems.

PREPARATION

1.Read the Session Notes.

2.Review the Case Study, Correcting Antibiotic Misuse In a South American City.

3.Review the ICIUM conference summary (http://www.who.ch/programmes/dap/icium/summary.html)

FURTHER READINGS

1. Soumerai SB. Keynote address: Conference on Factors affecting Drug Prescribing (sponsored by the Victorian Drug Usage Advisory Committee). Melbourne, Australia, 1987. Published in Australian Journal of Hospital Pharmacy 1988; 18(3)(suppl): 9-16. (See Annex)

2. Avorn J, Harvey K, Soumerai SB, et al. Information and education as determinants of antibiotic use. Reviews of Infectious Diseases 1987; 9(S3):S286-S296.

3. Plumridge RJ. A review of factors influencing drug prescribing. Vol 1. Australian Journal of Hospital Pharmacy 1983; 13:16-9.

VISUAL AIDS LISTING

1. Title Slide
2. Objectives
3. Components of the Drug Use Program
4. Some Factors Influencing Drug Use
5. Learning about Factors Underlying Drug Use
6. Changing a Drug Use Problem
7. Strategies to Improve Drug Use
8. Educational Interventions
9. Prescriber Training
10. Printed Educational Materials
11. Face to Face Education
12. Yogyakarta Diarrhea Study: A Comparison of Two Educational Interventions
13. Yogyakarta Diarrhea Study: A Comparison of Two Educational Interventions
14. Yogyakarta Diarrhea Study: Impact of Targeted Training on Health Workers Knowledge
15. Yogyakarta Diarrhea Study: Impact of Targeted Training on Prescribing ORS
16. Yogyakarta Diarrhea Study: Impact of Targeted Training on Prescribing Antibiotics
17. Yogyakarta Diarrhea Study: Impact of Targeted Training on Prescribing Antidiarrheals
18. Impact of Small Group Training on ORS Sales in Kenyan Retail Pharmacies
19. Impact of Patient-Provider Discussion Groups on Injection Use in Indonesian PHC Facilities
20. Effects of Opinion Leader on Choice Antibiotic for Prophylaxis in a Teaching Hospital
21. Managerial Strategies 1:
22. Managerial Strategies 2
23. Standard Treatment Guidelines
24. Prescribing Audits plus "Feedback" to Prescriber
25. Regulatory Options
26. Combined Intervention Strategies
27. Impact of Training on Use of Diarrhea Treatment in Three Mexico Settings
28. Conclusion: Interventions to Change Drug Use (1)
29. Conclusion: Interventions to Change Drug Use (2)
30. Conclusion: Interventions to Change Drug Use (3)
31. Activity One
32. Activity Two

 ORGANIZATION AND KEY COMPONENTS OF SESSION

First Component

· (20-30 minutes) 2 VA 's 1-6

Overview of Framework for Changing Drug Use Practice

• Brief outline of the session objectives and its organization.
• Describe relevant components of drug use system, i.e. Illness pattern, pharmaceutical supplies and the behavior of prescribers and consumers.
• Factors influencing drug use practices, deriving from personal setting, interpersonal setting between provider and patient, socio-cultural setting, work environment, and the situation of drug information and marketing.
• Underline the importance of identifying the underlying reasons for drug use behavior, utilizing qualitative method, before making decision of any intervention.
• Overview of the process of changing drug use problem from examination, diagnosis, treatment and follow-up. Remind participants about its analogy to the treatment of illness.
• Overview of three different strategies, educational, managerial and regulatory approaches. Briefly describe the differences, strength and weaknesses of these strategies with some examples.

Second Component

· (25-30 minutes) 2 VA 's 7-19

Educational Interventions

• Briefly describe the basic principle of educational intervention, i.e. providing information, knowledge and motivation for changing drug use behavior. Explain various forms of educational interventions, i.e. training, dissemination of printed materials and media based approaches.
• Describe the goals of pre-service prescriber training, i.e. to equip the students with appropriate knowledge, required skills and critical attitude for rational prescribing (a kind of immunization against influencing behavior for irrational practices). Critically appraise the weaknesses of the existing curricula of medical, paramedical and pharmacy education in achieving these goals. Invite comments and experiences from participants. Describe the initiative for innovative approach of pre-service prescriber training undertaken by WHO in collaboration with the University of Groningen (Guide to Good Prescribing), with problem based pharmacotherapy training approach. Explore other innovative initiatives that participants know about.
• Outline different forms of printed educational materials. Describe briefly the strengths and weaknesses of printed materials as well as the requirements for effective printed materials.
• Describe the principles of effective face to face education. Strengths and weaknesses of conventional large group seminar versus small group interactive approaches.
• Describe the Yogyakarta diarrhoea study investigating the impacts of large group seminar approach as compared to a small group approach in improving the use of drugs for acute diarrhoea in children.
• Describe other examples of small group approaches undertaken in Kenya for improving ORS sales as well in Indonesia for reducing the misuse of injectibles.
• Describe another approach in changing drug use by influencing the opinion leaders, i.e. the choice of prophylactic antibiotics in sectio-cesarian surgery.
• Summarize the strengths and weaknesses of educational interventions.

Third Component

• Remind participants about the goal of managerial strategies.
• Describe various forms of managerial strategies, i.e. those through changes the selection, procurement and distribution of drugs, through changes aimed at prescribers, through changes aimed at dispensers, and changes in economic incentives.
• Describe the importance of standard treatment guidelines and how to effectively utilize it. Share some good examples with participants.
• Explain about the principles of prescribing audits and feedback. Underline the strength of providing feedback to prescribers in changing prescribing.
• Describe the basic principle of regulatory strategies, i.e. to restrict and to enforce. Explain various available forms of regulatory approaches.
• Discuss the example of combined intervention in Mexico for acute diarrhoea and share with participants about the finding. Explore the feasibility of such strategy in different setting.

Fourth Component

· (40 minutes) 2 VA 's 30

Activity one: Correcting antibiotic misuse in a South American City

• Explain the objective of the exercise and the task that should be accomplished by participants. Clearly explain the instruction to participants.
• Participants are required to learn the case study and discuss the issues within the group (25 minutes)..
• Reports summaries from each group in a plenary discussion (15 minutes).
• Summarize the discussion on the case study.

Activity two: Effectiveness of different interventions in addressing factors underlying drug use

• Explain the objective of the exercise. Clearly describe the instruction and the task that should be undertaken by participants.
• Participants are required to work in a group on the assigned work, i.e. assessing the likely impacts of 10 selected strategies in addressing the underlying causes drug use. Which interventions likely to produce the biggest impact?
• Each group reports the finding of the discussion, sequentially from each different intervention strategy. Discussions are to be pursued between groups for each intervention.
• Summarize the results of the discussion.

Sixth Component

Conclusion

• Overall summary of the session by facilitator.

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