Responding projects are categorized into seven main categories, based primarily on their principal activities, with supporting information from the project title, description, and additional information provided. These categories represent the principal approach of the project, although most projects had several activities. Categorization is based on a composite of responses to several questions and is therefore subjective. The categories are: pharmacist training; mass media; school programmes; consumer publications; mixed approaches; innovations; telephone service.
A small number of projects fell into more than one category; these were counted twice. For example, a project may have a strong focus on mass-media, but also carry out several other important types of activities thus qualifying it to be counted a second time under "mix". The distribution of projects across these categories may be seen in Figure 7.
Figure 7 - "Types" of programmes
Training of pharmacists was a principal theme in a small number of projects. Examples include the Netherlands, where a broad-based project to improve the quality of prescribing and dispensing encouraged dialogue between pharmacists and physicians, and trained them to better communicate with their patients. The Illawara Pharmacy Association (Australia), trained pharmacists in communication skills with the specific objective of helping patients to better manage their asthma.
Mass-media was a principal focus in both developing and developed country projects (approximately 27%/20%). The Lady Pharmacist's Association of Ghana used mass-media (radio, television, and newspaper) in conjunction with health centre talks and some school health education. A consumer organization in El Salvador published press articles, broadcast radio programmes and television spots, in addition to participating in a televised debate and holding community meetings. A non-governmental organization in Mexico used mass-media to promote community meetings and a medical school conference, while HAI Mexico and the National Institute of Consumers conducted a similar set of activities focused on Michoacan State (see box overleaf).
DES Action, a private non-profit organization in the USA, produced a public service announcement for television and eight for radio to raise awareness about in-utero exposure to DES (a synthetic oestrogen). DES Action Canada used radio spots and newspaper articles as part of a larger effort that included posters and fact sheets for professionals. The National Corporation of Swedish Pharmacies used both printed materials and mass-media in their annual campaigns (Dementia, Diabetes, Skin diseases). The Pills and Older Persons' Project (POPP) in Australia used radio spots and newspaper articles, complemented by a relaxation video, to raise the awareness of older persons about drug use and other options. Another Australian project, Tranquilizer Recovery and New Existence (TRANX), targeted the decreased use of benzodiazepines and increased access to counselling via newspaper articles, radio and television programmes.
The National Asthma Campaign in Australia used, among other approaches, a well-known cricket player as a central character in a mass-media effort.
Michoacan, Mexico holds a campaign:
Towards the Rational Use of Drugs
Given evidence of an overabundant use of medications by the general population, of an over-prescription of medications by medical doctors, and of unethical drug promotion, a non-governmental organization in one state of Mexico embarked on a short but intense educational campaign. Participants in the planning were prescribers, government officials, community members, students, the media, and communication experts.
The campaign targeted the general public, but also prescribers and medical students. Materials developed included posters, leaflets, press articles, slides, radio and television programmes, and posters for doctors. Many of the printed materials were displayed at points of prescription; others were used during 3-day seminars held at the local medical school. The mass-media broadcasts lasted for three months, with increasing intensity just prior to the medical school conferences.
Feedback after the campaign was very positive. Medical professionals and students expressed increased awareness of the problems. The pharmacology curriculum of the local university was revised. Articles published in the local and national press suggested a significant change in general knowledge about rational drug use
School education programmes are mainly found in developed countries. The Medi-Studt project in Belgium focused on secondary school students, with an "info-pill-box", information stands, and a quiz about topics of particular interest to that age group (see box overleaf). The Michigan Model of Comprehensive School Health Education targeted primary school children and adolescents. It aimed to raise awareness of health problems and reduce risk behaviours related to alcohol and tobacco use, STDs, and AIDS. Teachers were trained to add these issues to their ongoing health education components, and parallel manuals were designed for teachers and parents.
The Good Use of Medicines (Le Bon Usage des Médicaments) project in France produced a widely disseminated teaching kit for 9-11 year olds, containing cartoon and exercise booklets, a poster and teaching notes.
Two additional projects in the USA targeted younger school children. "Tex's Team" in Texas used pharmacy students to teach groups of 8-9 year-olds about drug safety and compliance. "Katy's Kids" in Iowa took a similar approach, where members of the Young Pharmacists Committee worked with children 5-7 years of age to encourage them to take responsibility for their health and ask questions of the pharmacist. Their talks to classes were complemented by the showing of a video and by newspaper articles.
"Far-Well" and "Medi-Studt"
The best medicine for students - Belgium
Students are "open" to new information; learning is their job. Students are also prone to using medications, especially in order to study well during examination time.
Knowing this, the higher-educational institutions (non-university) in Belgium requested Projekt Farmaka, a non-profit independent organization, to assist. The result, designed and developed by a planning group consisting of a pharmacist, prescribers and students, was an innovative "pill-box" of information destined for distribution in schools and student clubs. The choice of subject matter in these "pill-boxes" was based on the most common illnesses and complaints, and on the most commonly-used medicines by students. The main message? "Use a medicine ONLY WHEN IT IS NEEDED."
But activities went far beyond the simple distribution of the "pill-boxes". Information stands were set up during school breaks and at lunch time, with displays and posters. In order to get a "pill-box", a student had to complete a quiz form with five pertinent questions. Workshops were held with the students to discuss the information. Mass-media also participated, with radio interviews and television announcements.
The campaign was well-timed. It was held during the examination period, when students are prone to taking vitamins and "pep pills", and to having sleep-related problems. The students were particularly open to discussions about medications, and wanted to learn more. Some schools have established a "medicines panel" to disseminate additional information about problem drugs, and to discuss issues like sports and diet. Other schools are organizing question-answer sessions focusing on medications.
The "pill-box" concept was innovative and sparked people's curiosity. The materials could be improved, to be sure, and future campaigns will take into consideration more of the students' views on content, in addition to design.
Publications to consumers
Publications to consumers were by far the most commonly-mentioned types of interventions by developed countries. These include a wide range of materials and a variety of projects. For example, a university-based project on pharmaceutical care in the elderly in the Netherlands provided leaflets on self-management of asthma to be distributed by pharmacists (along with counselling). A non-prescription drug manufacturers' association in Germany produced patient brochures on the care of minor illnesses and indications to be distributed at points of prescribing and points of dispensing. Despite their source, these brochures included no product information. A similar type of association in the US produced leaflets to educate parents about child dosing; these leaflets were distributed in conjunction with a television news release. The same association produced an eight-page insert in Readers' Digest to promote the correct, safe, and responsible use of over-the-counter medications. This was followed by a secondary distribution to the public via pharmacies, consumer groups, and ethnic organizations.
A consumer group in the United Kingdom distributed leaflets about general RUD issues in adult day schools, and another in the USA regularly mails out a health newsletter called "Worst Pills Best Pills News". Projects in two developed countries, Australia and Japan, and several developing countries, produced comic booklets for their consumer audiences.
Although many developing country projects developed good printed materials for consumers, very few used publications to consumers as a principal approach; this is likely due to lower literacy levels and to greater difficulties in distribution.
Projects were categorized as "mixed" when several approaches were used with equal importance, none of them seeming to dominate a set of activities. An equal proportion of developing and developed country projects fall into this category. For example, the Health Financing for Primary Health Care project in Viet Nam used posters, radio programmes, television spots, television programmes, and health worker training to promote the rational use of antibiotics and the use of pills over injections. The Uganda Red Cross Society used a combination of workshops, training courses, street theatre, printed materials, school health education, and various mass-media channels to promote general education about RUD. The Pharmaceutical Society of Australia's self-care programme used a similar mix, with health centre talks and place-of-dispenser information instead of street theatre. Hello IPSS, in Peru, is partly a telephone service, but it also promotes RUD information through mass-media, slide shows, and posters. Similarly, Med-Smart, a multi-focused approach to the quality use of medicines in Western Australia, established a telephone service to be used in support of a community development approach with home visits, village meetings, and health worker training.
Raising public awareness and calling for public action via street theatre in Germany
"I've seen your theatre bus; it is wonderful!" "Let me tell you what happened to ME..." "BRAVO! Please let me sign your petition to send to drug company X." Such are the comments that follow the BUKO Pharma-Kampagne street theatre performances across Germany. This grassroots NGO, funded by the Lutheran Church and the European Community, recruits actors from all over the country to perform in principal shopping areas during peak hours, and in local assembly halls or schools in the evenings. Flyers and information booklets about a selected topic are also distributed, and members of the audience may have the opportunity to sign protest cards or a petition. During the day, a pertinent slide-show may be shown in the theatre bus; evening ("inside") performances are often followed by a slide show and lecture/discussion.
The themes of the street theatre performances vary from general education about rational drug use, to the very specific issue of decreasing the use of benzodiazepines (sedatives), to raising the public's awareness of certain actions of pharmaceutical companies in developing countries. Themes are developed according to the priorities of the BUKO Pharma-Kampagne, and are discussed by a multi-disciplinary planning group consisting of pharmacists, medical doctors, community members and street theatre performers (often social/political activists).
The medium of street theatre was selected in order to reach the "common people", whom the group feels may be difficult to reach via printed materials only. The success of this activity depends largely on the commitment and motivation of the actors. BUKO Pharma-Kampagne puts on 1-2 tours per year, with 30 performances per tour; each performance reaches between 10-50 people. They judge their success by the reaction of the audiences, and claim that besides funding, their only real constraint is bad weather.
A few projects stood out as innovations. For example, the Buko Pharma-Kampagne street theatre in Germany used (and still uses) activist actors in street theatre presentations (see box above). Although street theatre is traditional in many developing countries, it is unusual in developed societies.
You and Your Medicines, public education on over-the-counter medicines in the United Kingdom, developed materials for low-literate consumers in collaboration with an adult literacy programme. This is an example of an innovative means of sharing scarce resources: the public education programme wanted a vehicle to reach a particular population, and the literacy programme benefited by having a subject of interest to their participants. Finally, the Medicine Information Project trained elderly volunteers as peer educators in Australia (see box). Peer education has been used by other public education programmes such as family planning and AIDS control; however, it is an unusual approach to use for the elderly.
Medicine Information Persons: Elderly Australians help one another
Older persons have very particular health problems, and are often inclined to taking an unusual number of medications to combat them. This population may also be easily influenced by mass-media, and accurate, unbiased information is not always available.
The Combined Pensioners and Superannuants Association, a consumer organization for older persons, was aware of these problems and carried out focus group research to see what could be done about them. The result was the development of a peer education programme using ordinary community members selected from senior's groups (age 55 years and over). These volunteers receive five days of participatory training by project staff in such topics as: consumer rights and responsibilities (re doctors, the health system, hospital discharge); specific medications (e.g. those that contribute to incontinence; tranquilizers); problem-solving skills; assertiveness; presentation skills; and active listening. The training is ongoing, with one "update" day each quarter.
After the initial training, the peer educators (called Medicine Information Persons, or MIPs) are provided leaflets on subjects of particular interest, such as getting a good night's sleep, using cheaper brands of medicines, and questions to ask the doctor or pharmacist. The MIPs then give community talks, and discuss with their peers over a cup of tea or in other informal settings.
The MIPs are selected from a range of populations, including different ethnic and language groups (Greek, Spanish, Turkish, Italian, Australian Aborigine), people of low literacy level, and disabled persons. These MIPs are credible. They can both provide information in a culturally- and age-sensitive manner, and model desired behaviours. A proper impact evaluation has not been carried out for lack of funds, however monthly reports of activities and published MIP reports (which make excellent reading) indicate that the MIPs are well-accepted and that the project is moving towards success.
Seven responding projects have developed telephone services as a main part of their activities. Only two of these were in developing countries, most likely due to obvious issues of development and availability of telephones. Hello, IPSS takes care of your health, in Peru, publicized their telephone line through television spots, radio interviews, and workshops for health professionals. The project was overwhelmed by the telephone responses and had to expand to handle the calls effectively. The Sierra Leone Medical and Dental Association held a weekly one-hour radio phone-in programme called What the doctor says.
Tele-info Medicines in the Netherlands provided health information to individuals outside of a pharmaceutical setting; what began as an experiment organized by a consumer organization was finally taken over by a pharmacist association in order to meet the great demand. DES Action Canada publicized their telephone line over the mass-media during DES-Awareness Week and got an excellent response. Med-Smart, in Australia, established a telephone advisory service for medication inquiries, and a telephone reminder service for "at risk" consumers. Finally, Switzerland established a phone service to provide the public with independent information about medicines. This project has found a secondary benefit in that consumers educate themselves before calling in order to ask appropriate and intelligent questions.
Distribution of activities and channels used
Activities and channels of communication listed are shown in figure 8.
Figure 8 - Activities and channels of communication used
*Mass-media includes (% of mass-media); Radio (89%), TV (64%), Newspaper (68%), Other (32%).
NOTE: Percents are not mutually exclusive.
Mass-media responses included radio, television, newspaper and cinema. Of these, radio was the most widely used in developing countries, and newspapers in developed countries. This may be because television is an expensive medium (in all countries) and in many developing countries has a limited reach. No response included cinema.
Just under half of developing country projects mentioned using training courses, community meetings, and/or health centre talks. This may be a reflection of available channels in the developing world, or of the seeming emphasis on prescriber behaviour. Developed countries, on the other hand, had an even distribution across these activities, and had a much bigger "other" category. This included such activities as a slide show in a mobile bus, direct mail, peer educators, "open house" activities at hospitals and pharmacies, and audio tapes. Most projects (70/53%) conducted five or more activities. No developing country project had only one activity, and the distribution was fairly even across a low range (8-16%) for two to four activities.
Reasons for choice of activities
The reasons for choosing to conduct certain activities were clear. "Reach" (the proportion of the target population who are accessible through a certain activity or channel) was by far the most frequently-cited reason, with “cost” (affordability) and “available expertise” following closely. This holds for both developing and developed country projects. "Opportunity for cooperation" played an important role for both types of country; however ”credibility” and “tradition” were much stronger reasons for developed countries than for developing. Consistent with other questions having the possibility of selecting more than one response, about half of the projects cited two, three, or four reasons for having chosen their particular activities; over 40% gave five or more reasons for doing so.
Persons carrying out the work
Implementing personnel are shown in Figure 9.
Figure 9 - Implementing personnel
The greatest proportion of projects had only one (14/39%) or two (30/23%) groups of people involved in actually implementing the activities.
Sources of funding were diverse, and are shown in Figure 10. Developing country projects were most commonly funded by international organizations or international NGOs; together these provided nearly two-thirds of the funding sources. This was the most likely source of funding if activities were implemented by the same organization or NGO. Less than 10% reported receiving funding from the ministry of health. Contrary to these figures, about one-third of developed countries reported receiving at least partial funding from the ministry of health, one quarter from a professional association, and another 15% from private nonprofit bodies related to the pharmaceutical industry. Most (65/53%) projects reported only one funding source.
Figure 10 - Source of funding
Reported project costs had an enormous range, from a few thousand US dollars (Ghana, India, Mexico) to over a million dollars (Australia, Netherlands). Given the differences in types and numbers of activities, in coverage (see below), and in project duration, it is not possible to make a useful cost comparison. Moreover, many reported costs may reflect only partial reality. For example, a three-month mass-media campaign on RUD in Mexico is reported to have cost only US$ 2,000; this most certainly does not include costs of personnel, nor the costs of producing printed materials and radio and television broadcasts. To effectively evaluate costing, a follow-up survey would need to be carried out. A list of project costs and duration may be found in Annex I.