What Influences Drug Use By Consumers
Trainer’s notes (for use with Manual)
PURPOSE and content
This session aims at encouraging participants to identify the various factors which influence drug use by consumers. The factors they identify are grouped into layers of influence:
- the family level;
- the community;
- the health-service institutions;
- the national level;
- the international level.
The module thus provides participants with a framework which links individual drug-use behaviour to the multi-layered environment which shapes drug use. The framework presented forms the basis for an analysis of drug-use problems; and the development of interventions which aim at changing drug use behaviour as well as at changing the environment in which drug use takes place, to enable more appropriate use of drugs.
OBJECTIVES
At the end of the session, participants will be able to:
1. Identify factors that determine drug use by consumers in each of the five levels of influence (individual/family/community/health care institutions/the national level/international level).
2. Recognise the relative importance of the factors with respect to efforts to promote rational use of drugs by consumers.
PREPARATION
Participants are expected to:
- Read Chapters 1 and 2 of the Manual “How to investigate the use of medicines by consumers”.
- Reflect on drug-use problems in their country and the factors that influence them at each of the five levels.
- Read the two case-studies in Activity 1.
What influences drug use by consumersTrainer’s Notes
The trainer needs to:
Select three drug-use stories:
The session can start with three very short stories on a specific type of drug use. Examples of short ‘drug-use stories’ are given below. If possible, the stories are presented by participants themselves. Try to identify two participants who have done drug use studies, or who work in communities and thus have good insight into what people do with drugs. Ask them if they are willing to present a drug-use story (duration around 3 minutes). Discuss in detail with the two selected participants what they will present. And prepare a short drug-use story yourself as well. It is best if the stories present different types of drug use practices and can help participants in identifying a wide range of factors. Clarify that the presentation should only describe in detail what people do, not why they do so. The ‘why’ will be discussed in the session.
Make sure there are two flipcharts in the front of the meeting room, with thick markers. These will be used to list factors which influence drug use by consumers raised by participants in response to the drug-use stories.
Get a good overview of the factors by level
By reading Chapter 2 of the Manual, the facilitator can make sure (s)he is familiar with factors which influence drug use by consumers by layer of influence. This will enable him/her to make a good synthesis of the factors which are identified during the session.
Prepare for the activity
Make sure that participants receive a copy of the Activity the evening before the session takes place.
Read the case studies given in Activity 1 carefully, and prepare a brief summary to be presented when introducing the activity.
Make sure core library texts (see listing) are available for distribution
The core readings should be available for distribution. Distribute them at the end of the session when people are filling in their evaluation forms. The trainer should briefly explain why the readings are “core”.
CORE library
WHO (1988) WHO Ethical Criteria for Medicinal Drug Promotion.Geneva, World Health Organization.
Mintzes B (1998) Blurring the boundaries. New trends in drug promotion. HAI-Europe, Amsterdam.
ORGANISATION AND KEY POINTS OF THE SESSION
Structure and timing of the session
1. Introducing the session - 5 minutes
2. Three drug-use stories - 15 minutes
3. Participatory identification of factors which influence drug use by consumers - 25 minutes
4. Family and community level factors - 30 minutes
Break - 15 minutes
5. Short summing up of health institution level factors - 5 minutes
6. National level factors, including drug promotion - 30 minutes
7. Activity - 50 minutes plus 20 minutes feedback
8. Summing-up - 5 minutes
Visual aids
- Title slide
- Objectives
- The session
- Layers of influence
- The family level
- Perceived safety and efficacy
- Gender roles and medicines
- The community level
- Community drug distribution
- The health institution level
- Extent to which health worker advice is sought
- The national level
- Drug promotion
- WHO ethical criteria on drug promotion
- Ethical criteria adoption
- OTC advertising: IOCU study
- Increase in promotion towards consumers
- Top DTCA expenditures
- The international level
- Zyban: Information from the Internet
- Activity tasks
- DTCA discussion questions
- Discussion questions: drugs used as abortifcients
1. Introducing the session
(5 minutes)
Introduce the session by explaining its objective (OH 2)
The main objective is:
Identify factors which influence drug use by consumers, by level of influence
Explain why this objective is important: it helps to link individual drug-use behaviour to the multi-layered environment which shapes drug use. It further forms the basis for an analysis of drug-use problems; and the development of interventions to change drug-use behaviour as well as at changing the environment in which drug use takes place, to enable more appropriate use of drugs.
Ask participants now to listen carefully to three drug-use stories. We are now going down to the real-life situation of medicine-use in communities: day-to-day medicine use. Tell participants that there will be no opportunity in between for responses, but that we will discuss all stories at once. Explain that the stories will be used to identify factors which influence drug-use practices.
Mention the five layers of influence(OH 4):
- family level;
- the community;
- the health-service institutions;
- the national level;
- the international level.
2. Three drug-use stories (15 minutes)
Present the three short drug-use stories (see “Preparation”). The stories should take around 3–5 minutes each. The facilitator makes sure that the story-tellers do not use up too much time. Examples of drug-use stories are:
Drug-use story 1:
The use of antibiotics to treat perceived womb-related inflammations in Thailand
Studies on women’s health in the north-east of Thailand have shown that women commonly suffer from a condition called ‘mot-luuk ak-seep’. ‘Mot-luuk’ means ‘womb’. ‘Ak-seep’ means ‘inflamed’. The symptoms women mention are backache and lower abdominal pain. Mot-luuk ak-seep is a common condition. Women believe it is caused by inflammation of the womb. They usually treat it in self-medication with a few antibiotic capsules. One specific type of antibiotic is especially popular. It is Gano®, a locally produced brand of Tetracycline. The manufacturer of this brand encourages use for womb-related indications by depicting a drawing of the uterus on the package and on billboards promoting Gano®.
Drug-use story 2:
Treatment of malaria with injections and other drugs in Uganda
In Uganda an elaborate community drug use study has been done. People in rural communities often treat fever with chloroquine injections. They go to informal drug sellers in their communities for these injections. AIDS prevention campaigns have warned against unhygienic injections. Perhaps as a consequence, people do not trust the injections provided at health facilities anymore. An injection use study found that 60% of families keep syringes and needles in their homes, and they take these to the drug seller when they need an injection. If the chloroquine injection does not work, and the fever continues, people go to the hospital or they try other medicines such as Fansidar®, or Comaquin® (contaning chloroquine). Children are often given Septrin® (cotrimoxazole), a medicine which is commonly used for respiratory conditions.
Drug-use story 3:
Considering a new medicine to quit smoking, Netherlands
A social worker in the Netherlands is home from work, burnt-out. Because of stress she started smoking again, which she regrets. Now she is at home and feeling depressed and exhausted. She is going to a psychotherapist who is helping her tackle the extreme tiredness and depression. He advises her to take a new drug Zyban®. He says that it will help her quit smoking, which she wants, and that this drug also works as an antidepressant. He suggests she asks her doctor about it. Her doctor tells her that she will have to pay for the drug herself, as it is not yet included in the Dutch reimbursement scheme, so her insurance company will not pay for the drug. Zyban® is a new drug he says and relatively expensive. If she wants an antidepressant he can prescribe another drug. The social worker is not sure what to do and searches the internet. She enters “Zyban” in a search machine and is directed to various sites with information on the drug, including possibilities to purchase it. She discusses the issue with a friend. She tells her friend that she is inclined to take the drug, citing information from the internet: It’s a pill which does not contain nicotine. You can start using the pill, without having to stop smoking, and it is relatively cheap cessation therapy – it is more expensive to continue smoking. Her friend cautions her: It is a new drug. Perhaps it is not safe. The social worker then goes to the pharmacy and buys nicotine chewing gum instead. The pharmacist gives her a leaflet about Zyban, and tells her it is new, and perhaps better for her.
Optional: use OH 20, which gives the key messages that the social worker found on the internet.
3. Participatory identification of factors which influence drug use by consumers (25 minutes)
The facilitator asks the participants: why do these drug-use practices occur? Which factors influence these drug use practices? Which factors cause the women in the north-east to use antibiotics for perceived womb-related inflammations? Why are injections so popular in the treatment of fever in Uganda; why is the social worker inclined to take Zyban® even if it will not be reimbursed by her insurance company.
Ask co-facilitators to write the factors on two flipcharts or whiteboards which you place left and right in the front of the room. Ask one of them to list all the individual and community factors mentioned. Ask the other facilitator to list the health institution and international level factors.
Stop this exercise, when the participation becomes less lively. Do so after around 25 minutes of discussion.
4. Family and community level factors (30 minutes)
Invite the participants to now focus on the individual/community level factors. Give a relative quick overview of the factors mentioned, building on the ones identified in the Chapter 2 of the Manual (pp. 7-11).
The family level (OH 5)
Overhead 5 gives an overview of family level factors. Add on a second overhead additional factors which have been listed on the flipchart.
The community level (OH 8)
Present OH 8, and add additional factors using an overhead marker.
Tell participants that you want to discuss a few of these individual and community factors in more detail – highlighting how these factors constrain or facilitate efforts to encourage rational drug use by consumers.
You can pick up issues that emerged in the earlier participatory identification of factors.
Option one: discuss gender roles and medicines
If the gender roles in provision of medicines have been mentioned in the discussion, discuss these briefly in more detail.
Gender roles and medicines (OH 7)
The main point to highlight is that when developing health communication interventions you need to know who is involved in administering medicines, deciding on what medicines get bought, and in the buying of medicines. If men are involved in the treatment of childhood illnesses, as is the case in Pakistan, then it is important to target information to them as well as to ‘mothers’ (the usual target of child-health campaigns).
Option two: Discuss perceived safety and efficacy and its implications
Discuss in more detail the factor ‘perceived safety and efficacy’ of medicines.
Perceived safety and efficacy (OH 6)
Drug use studies show a number of important trends. Perceived safety and efficacy:
- is related to colour, taste, and shape of medicines
- is related to dosage form
- depends on perceived compatibility between medicine and the person taking the medicine
- depends on the perceived cause of the illness.
Encourage participants to think through the influence of people’s ideas about medicines for programmes which aim to promote the rational use of medicines.
Some medicines, such as cough-cold remedies, only relieve symptoms. They do not cure. Other medicines, such as some tonics, are pharmacologically inert. If people feel better when taking medicines which only relieve symptoms or are pharmacologically inert, is it then justified to develop interventions programmes which discourage the ‘inessential’ use of these medicines? Note that placebos can work. People can feel better after taking medicines which have no pharmaceutical action. In clinical trials, usually around one third of the patients react to placebos. Suggest that perhaps campaigns should focus on discouraging the use of medicines which are harmful and discouraging the use of expensive placebos. There is no harm in using cheap placebos, if they make people feel better? Whole traditions of folk-healing are based on the efficacy of placebos! Doctors want to be able to prescribe placebos, otherwise patients go elsewhere and get drugs which are more dangerous.
If you have time, continue to discuss why it is so important that essential drugs programmes consider perceived safety and efficacy of medicines. For example:
Option three: Discuss people’s preference for cough-cold syrups
In South Africa, provincial public health authorities decided to discontinue the supply of cough-cold syrups used widely in the treatment of childhood coughs and colds, because of their limited therapeutic value and the high expenditures on these drugs. The discontinuation of supply of the cough-cold syrups led to an increase in demand for antibiotic suspensions and analgesic. The public health authorities realised that people think they need to give syrups to children with coughs. They decided to procure one cough syrup and supply it to the health facilities in order to meet the demand for syrups in the treatment of coughs-colds. The syrup has limited therapeutic value, and no adverse effects.
Option four: Discuss the popularity of Yachud in Thailand
Another example is the use of pre-packaged Yachud in Thailand. Yachud are produced locally in Thailand. They contain a number of different medicines for specific health conditions. For example Yachud for muscle pain typically contains dexamethasone or prednisolone tablets, as well as a relatively unsafe analgesic called phenylbutazone. Some Yachud include the tranquillizer diazepam. The distribution of pre-packed Yachud has been banned in Thailand a few years ago. But consumer demand continued. People consider Yachud to be needed in the treatment of muscle-pain. Pharmacies therefore now prepare ‘fresh’ Yachud. When customers ask for it, they put a number of different medicines in little plastic sachets.
These last two examples show that changes in drug supply and regulatory actions will not have much effect if not accompanied by consumer-oriented communication activities which explain why the medicines are banned.
This is a good moment for break. Tell participants that after the break we will discuss the other layers of influence, focusing on the national level.
Break (15 minutes)
The health institution level (OH 10)
The national level (OH 12)
In the break, review the factors on these overheads and add any additional health institution and national level factors that emerged during the earlier discussion.
5. Short summary of health institution level factors
(5 minutes)
Probably you need not spend much time on this level. People are very aware of the factors. Summarise the health institution factors briefly referring to the overhead prepared in the break.
The health institution level (OH 10)
Optional: Use OH 11 to highlight that health worker advice is often not sought when treating illness episodes. The data presented in this overhead are derived from community surveys focusing on common health problems. Point to variations between countries. Refer to the Manual (pp. 11-13) for sources of these data.
6. National level factors, including drug promotion
(30 minutes)
Give an overview of national level factors which influence drug use by consumers. Use the overhead prepared in the break.
The national level (OH 12)
Discuss the factors briefly.
Probably during the earlier discussion the importance of drug promotion emerged; and the difficulty of countering the “you-need-a-pill” message conveyed in drug promotion. You can use 13-18 to give a brief introduction on drug promotion.