|Public education in rational drug use: A global survey (WHO/DAP, 1997, 97 p.)|
Projects generally reported the existence of planning groups (88%). The most frequent members of these groups were pharmacists/dispensers (75/72%), followed by prescribers (69/54%), communication experts (50/52%) and target group or other community representatives (50/54%). Most planning groups comprised more than one type of member; over half had four or more categories represented.
Reasons for the project
Reported reasons for project development are listed in Figure 2. The majority of projects (90%) mentioned "perceived need" to address a problem as a principal reason for developing the project.
Some one-third of the projects were based on research. Proportionately more developing (43%) than developed (27%) countries based their projects on research, which may be due to the influence of external support and consultants. These studies were either qualitative or quantitative, and included household surveys, consumer surveys, focus-group interviews, surveys of practitioners, and observation of sales patterns. Most research was qualitative; the quantitative research that was carried out was nearly always in conjunction with a qualitative study. There appears to be no correlation between the use of research and the type of projects, nor between the use of research and the country where the project takes place. However, nearly all respondents (88%) reporting to have based their project on research also listed "perceived need" as an important reason. This may indicate that the research was carried out in order to support or justify the perceived need.
The questionnaire did not ask for elaboration on the types or results of research carried out, nor how this research was used in project planning. Nonetheless, there are several examples that can be described here:
· One project to maximize the role of community pharmacists in controlling asthma (Illawarra, Australia) simultaneously surveyed consumers who were buying a particular type of inhaler, and prescription drug sales for asthma. These data together revealed specific management deficiencies on the parts of consumers, pharmacists and doctors, and helped orient the project's messages and activities.
· The Medicine Information Project in Australia used (and continues to use) focus groups with volunteer Medicine Information Persons to determine the general and specific content of future topics to be covered.
· The South Pacific Consumer Protection Programme based the development of their project on a needs analysis.
· The Uganda Red Cross, which supports the IEC component of the national essential drugs management programme, conducted an extensive Knowledge-Attitude-Practice (KAP) study to help plan the third phase of the programme.
· The Kenya Essential Drugs Programme, which aimed to correct misperceptions about drugs and their use, carried out qualitative research to determine the knowledge, attitudes, and practices of the target population.
· The French project "L'Enfant, sa Famille, et les Médicaments" (Child, Family, and Medicines) held a colloquium in 1993 to gather, present and discuss research relevant to the consumption of medicines by children. These research papers have been published, and the results of one survey of childrens views on medicine and health care were produced in popular form (as an illustrated brochure) for the use of pharmacists. Apart from the brochure, it is not clear exactly how or whether the results of these studies - which range from sociology approaches to pharmacology studies to psychoanalytic descriptions - were later applied.
Just under 30% of projects drew inspiration from other projects, or used others as models. These range from the very specific ("previous DES Awareness Week models", "Streetwize comics model") to the general (HAI-Europe networking project "RUD in Baltic countries").a
a These figures may not give a total picture, as demonstrated by two situations within the present study. The questionnaire includes a corresponding question which asks the respondent if there are other projects which have replicated their activities or used them as a model. One project in the Netherlands responded to the question about replication by ticking "yes" and describing the Swiss telephone information line. However, the Swiss project responded that they did not replicate or draw on an existing model. A note from a staff member of HAI, familiar with both projects, was able to clear up the mystery by specifying the Swiss had visited the Dutch project but did not replicate it. A similar situation exists between two African countries: the Kenya EDP project reports that the Uganda Red Cross replicated their project, whereas the latter said they did not replicate another project nor draw on models. These discrepancies may also be a function of the background knowledge of the persons filling out each questionnaire, or a function of the understanding of the words "model after" and "replicate".
Project themes varied widely and are shown in Figure 3. Additional themes included safety (keeping drugs out of the reach of children), traditional medicine, and the exploration of alternatives to medication for certain conditions.
In developing countries, many projects had two themes, whereas in developed countries projects were more likely to have only one. This is interesting in the light of the greater proportion of developing country projects which report that they are based on research. It may be that the research carried out was to determine how to best communicate particular (predetermined) themes, rather than the more basic question of which theme to select.
Of the specific problem drugs that were targeted, developing countries mentioned antidiarrhoeals and antibiotics most frequently (India, Malaysia, Uganda, Peru), whereas developed countries focused more on benzodiazepines and other sedatives (Australia, Germany, Netherlands). The most frequently-mentioned specific illnesses selected as themes in developing countries were diarrhoea and malaria. The only illness mentioned frequently among developed countries was asthma. This finding is compatible with the types of health problems found in developed and developing countries: specific drugs may present more of a problem in industrialized nations, whereas disease conditions (and the drugs often misused towards their control) are more visible in developing countries.
The principal reason for theme selection perceived need matches that reported for initial project development. This need was sometimes perceived by the organizing institution itself, and may even reflect the charter or mandate of the institution. This is exemplified by the Pharmacy Self-Care Programme, conducted by the Pharmaceutical Society of Australia. This professional society recognized that in order for the self-care movement to be successful, pharmacists needed to take a bigger role in primary health care and public health, and that changing the behaviour of pharmacists was part of the Society's charter. Self-care programmes sponsored by national associations of pharmacists, usually in collaboration with national industry associations or individual procurement manufacturers are becoming increasingly wide-spread, in developed countries. Publicity for the movement and consumer education materials on self-care is found in a growing number of pharmacies.
The frequency of "perceived need" may also reflect the interest and concerns of the institution that people's needs are not being met. It should be pointed out that the wording of the free-answers allows a good deal of latitude for interpretation, and some of the answers that were construed as perceived need may actually belong to a different category. For example, "most common illnesses, complaints...by the target group" was interpreted for this study as perceived need, but could reflect the results of research.
The third most common reason for selecting a theme was related to the recommendations of an advisory group, or board, internal or external. These advisory groups may be consumer groups, the planning group of the project, special interest groups, or an editorial staff member. A small number of projects mentioned basing their selection on existing data or on a literature search.
Target groups covered a wide range and are shown in Figure 4. Projects commonly (38/42%) reported five or more target groups. Relatively few (11/24%) had only one specific group in mind. Most projects (89/56%) included "general public" in their list. Prescribers/pharmacists (57/52%) and health workers (59/44%) vied for second place, nearly exclusively as a secondary target, or as a channel for reaching the consumer. Mothers were targeted between 35-47% of the time, and other groups range from 5-39%.
Respondents were requested to identify the specific behaviour changes or outcomes expected as a result of the project. All projects listed at least one expected outcome; over half of the projects listed two; four projects listed up to five . These outcomes fall into six general categories:
· changes in general knowledge or attitudes;
· changes in specific behaviour of the target audience;
· changes in prescribing behaviour;
· improved communication between practitioner and client;
· patient adherence to treatment (compliance);
· government or policy changes.
The distribution of expected outcomes is shown in figure 5.
Changes in general knowledge and attitude account for about one-half of all expected outcomes for both developing and developed countries. Some examples include "create a critical attitude", "change of attitude regarding self-medication", "safe and effective use of non-prescription medicines", and "raise consumer awareness".
Specific behaviour changes were the next most frequently-mentioned, and were slightly more prevalent in developing countries. Some of the specific behaviours listed are: "discourage drug sharing"; "viewers ask for additional information"; "parents follow instructions on labels"; "to obtain written advice"; "keep iron supplements in childproof containers and out of the reach of children"; and "reduce treatment-seeking from quacks".
The remaining categories varied in their order of importance. Some developing countries included an emphasis on changing prescribing behaviour, whereas developed countries focused more on improved communication between practitioners and clients. However, all developing country projects that intended to change prescribing behaviour did so as part of a larger set of objectives that demonstrate the logical association between prescriber behaviour and consumer behaviour. Some examples are: raising the awareness of health professionals in general (Thailand) and pharmacists in particular (South Africa); gaining the voluntary participation of doctors in the prescription of generic drugs (again Thailand); ensuring more rational prescribing that leads to lower drug expenditures (Cameroon); and more appropriate prescription, dispensing and consumption (Brazil).
For developing countries, policy and legislation were mentioned fourth most frequently, whereas for developed countries this category took sixth place. This difference is coherent with the situations in which many countries find themselves today. Developed countries are likely to have strong legislation and strictly controlled policies. However, improvements in the industrialized world have not been matched in developing countries where human and financial resources are scarce for regulatory development, enforcement and monitoring.
The great number and variety of educational materials developed by the responding projects are shown in Figure 6. Materials categorized as other include promotional material for health professionals, audio cassettes, buttons, stickers, and information cards.
Over half of the developing country projects produced five or more types of educational materials, whereas developed countries were more likely to have from one to five types.
Materials were developed by interdisciplinary teams of people, usually made up of project personnel, health professionals, and a specialist in education, health education, or communication. Public affairs staff and journalists are also mentioned. No difference was found between the types of people involved in materials development between developing and developed countries.
Just over half of all projects report having pretested their materials before using them, and of these, nearly all did some revisions. For developing countries, by far the most frequent revisions concern language and images; these were mentioned 11 and eight times respectively, by 13 responding projects. Language was simplified, clarified, or changed to allow better understanding by the target audience. For developed countries, changes include improving technical details, changing the type of material used, and changing the layout to be more attractive or understandable.
78% of developing and 94% of responding developed country projects sent samples of their materials.a Very few posters were received, despite reports that nearly half of the projects had developed them. Most of the materials sent were leaflets, booklets, brochures and videos.
a These have been catalogued by project identification number and are available in the DAP offices.
b The episodes of Streetwize Comics reviewed for this survey included sketches on the use of "recreational" drugs and on the use of medications for chronic conditions such as epilepsy
· a Netherlands brochure on medications for women entitled "Women don't have to swallow everything". This brochure encourages women to take a critical view of the medications they are prescribed or advised to take, and to become an informed partner in therapeutic decisions;
· an attractive booklet, with questions and answers for discussion, to be used as a complement to radio broadcasts on RUD in Peru. The same project produced (among other materials) a booklet on popular medicine and natural cures, or alternatives to medicines. This includes both generic names and brand names where appropriate, for ease of identification;
· cartoon booklets from several projects: Some of these give standard, general messages such as "consult the health centre" and "follow the health worker's advice". Streetwize comics, however, from Australia, is an example of a closely-targeted comic that attempts to combine confrontational and educational approaches. It targets what may be considered a marginal group, and addresses problems of drugs and safe sex using very explicit graphics and language.
· materials for pharmacists: a project in France sent booklets of home-care cards ("fiches info-patients"), to be filled out by a pharmacist when dispensing a medication. The Prescribing Awareness Programme (Australia) developed drug information sheets for pharmacists, to help them to give adequate information to customers.
· innovative sets of materials:
· The Medicine Information Project (Australia) sent a set of materials, many in six languages (see box, page 28). These included pamphlets, stories (to be used as case studies or examples of MIP successful interventions), sample presentations for the volunteer peer counsellors, and checklists of questions that older persons should discuss with their physician about medication use. Another Australian project, Talking Medicines, produced an entire kit to help community leaders organize a RUD campaign, with sections on campaign background, the consumer, the pharmacist, the doctor, the community worker, and suggested seminars to give. A further Australian project, to promote the consumption of folic acid before pregnancy, produced a series of recipe cards for high-folate foods. A project in the USA to limit iron poisoning in children produced visually powerful stickers for pill bottles, to encourage the safekeeping of iron tablets.
· Projects in both Belgium and Latvia developed information "pill-boxes", modeled after the Med-Sense project; these are considered innovations in the light of their use. The Belgian project adapted the pill-boxes to the needs of students, and used them in conjunction with information stands and a quiz. Latvia, a country with little recent history of liberal public education, began with an out-of-the ordinary approach to education on RUD.
· An NGO in Peru made a video of TV interviews focusing on changing attitudes to self-medication and developing preventive care, for use in clubs for the retired and school programmes.
· Another Peru video, shown in community kitchens and group meetings, targeted mothers of children under five and the inappropriate use of drugs in infant diarrhoea.
· US OTC manufacturers produced video consumer information on such subjects as how to administer drugs to children, and warnings about potential poisoning with overuse of iron supplements.
· One Australian eight minutes looped video for use in shopping centres and health fairs targeted better communication between the elderly and health professionals; another aimed at the same audience, dealt with common problems in the use of medicines.
· Both Australia and the US developed videos as part of school education kits.
· Projects in countries, such as Bolivia and Colombia, developed videos intended to raise public awareness of national drug policy activities and aims.
· The street theatre group in Germany used video to record a collection of skits.