The DTC is responsible for educational programmes for the health-care professionals within the hospital or facilities that it oversees. If these programmes are not put in place, there will be a persistent and noticeable decline in the knowledge levels of health professionals and a related decrease in rational medicine use. All professionals, particularly those involved in health care, need constant updating of their skills and knowledge. It is impossible for physicians, pharmacists, nurses, paramedical staff and others to keep up with the constant changes in the drug literature without intensive individual effort and continuing education provided by the health-care system. Educational strategies rely on the availability of standard treatment guidelines or protocols in order to set the standards of care to which prescribers should adhere.
7.2.1 In-service education programmes, workshops, seminars
The information on medicines and drug therapy is constantly changing. The DTC is responsible for ensuring that all staff receive up-to-date information, in-service education and other educational programmes. In addition, educational programmes can be used to address medicine use problems that have been identified by the DTC. The success of such programmes in terms of impact on medicine use will depend on the information presented, how it is presented, and by whom. A problem-based approach as described in the Guide to good prescribing: a practical manual (WHO 1994a) has been found to be particularly effective for educating prescribers at both undergraduate and postgraduate levels.
Large group meetings (more than 15 participants) can be effective if they are well prepared, targeted, use interactive methods and provide a few clear messages as to what behaviour change is expected. For example, a lecture on antimicrobial resistance in which staff sit in rows of chairs and listen to a lecturer talk about bacteriostatic or bactericidal medicines for an hour is likely to have minimal effect. A more successful approach might be for the facilitator to introduce the topic of antimicrobial resistance in terms of an actual patient (or a made-up patient case) and use a problem-based approach to decide what treatment should be given. At the end it is important to summarize the discussions and leave participants with clear messages as to what should be done. Visual aids can help the discussion, but should be carefully prepared since people learn in different ways.
Small group meetings (less than 15 participants) are usually more effective than larger ones and have the advantage that they can be held at the work site for shorter periods of time and can allow more interaction and reinforcement of messages. Wherever possible, the teaching should be problem-based, using real-life examples suggested by the staff. Previously prepared material can be used to illustrate points in the subsequent discussion and/or in the summing up of the discussion. In hospitals it may be possible to group staff for an hour over tea either in the morning or afternoon on a regular basis, for example weekly, to discuss particular drug issues.
Individual teaching can be the most effective, but is also the most time-consuming. Drug representatives are the best at doing this. In 15 minutes a drug representative can persuade a doctor to change his or her prescribing practice. They do this by being charming (good communication skills), having only one or two key messages to convey, and providing visually attractive memory aids (colourful pamphlets or notepads, desk calendars, engraved pens, etc). They also use the names of opinion leaders to support claims, and always follow up a visit with a reinforcement visit. It is perfectly possible for pharmacists or members of the DTC to use the same approach, which is called academic detailing (O’Brien et al. 2000, Ilett et al. 2000).
Influencing opinion leaders has been shown to influence prescribing habits significantly. Health-care opinion leaders are the people that junior staff go to for advice. It may be the professor or the senior consultant, but often it is not. It may be a middle-grade doctor in a large hospital or it may be an experienced nurse in outpatients, an effective pharmacist or a ‘smart’ junior doctor. Identifying the opinion leaders is important and relatively easy. Once the opinion leaders have been identified, it may be a good idea to invite them to join the DTC and to target individual teaching at them. They should be provided with education, guidance and policies. These leaders are likely to be in a position to teach or direct other health-care staff on the appropriate standards of care. Figure 7.2 shows the impact that influencing an opinion leader had on antimicrobial surgical prophylaxis in a hospital in the USA.
Figure 7.2 Effects of opinion leader on antibiotic use. In a US hospital, researchers approached the head of obstetrics to seek permission to replace cefoxitin with cefazolin for prophylaxis in patients undergoing caesarean section. The professor reviewed the papers and then instructed staff to make the change, with dramatic and sustained results (Everitt et al. 1990).
Educational outreach is based on small group or individual face-to-face meetings in the prescribers’ workplace. As described above, it has been fully and successfully exploited by the world’s pharmaceutical industry. Pharmaceutical companies employ thousands of representatives to meet face-to face-with prescribers to provide information and market their drugs. DTCs should provide educational outreach programmes of their own using locally available opinion leaders and trained educators. Principles of this type of education include:
• focusing on specific problems and targeting the prescribers
• addressing the underlying causes of prescribing problems, such as inadequate knowledge
• allowing an interactive discussion that involves the targeted audience
• using concise and authoritative materials to augment presentations
• giving sufficient attention to solving practical problems encountered by prescribers in real settings.
Patient education influences drug prescribing. Provision of regular patient education by health staff will educate patients about appropriate therapy and adherence to drug regimens, so leading to improved health outcomes. An educated patient population will have less demand for inappropriate medicines, especially antibiotics. The importance of patient education cannot be overemphasized. The more education patients receive, the more likely they are to benefit from improved health-care outcomes. Doctors, nurses, pharmacists and paramedical staff should all contribute to this effort on a routine basis.
7.2.2 Drug information resource centre/unit
Neither training nor other educational activities of the DTC can be successful and sustainable without a reliable source of unbiased information. There should be, at least, a small drug information resource centre or a library with at least two or three current authoritative reference books, and, if possible, peer-reviewed journals. Copies of the DTC’s own formulary list, formulary manual and standard treatment guidelines (STGs) should be readily available (i.e. every prescriber should have a personal copy, or there should be a copy in every ward, every consulting room in outpatients and in the pharmacy). Other practical materials such as STGs for other diseases, formulary manuals and the national EML can be secured from other institutions and organizations. Drug information units may produce local bulletins that can give updated and practical drug prescribing information. Many materials can be acquired free of charge, but the DTC should request a small budget from the hospital management to cover the purchase of books, journals and bulletins.
7.2.3 Drug newsletters and bulletins
Drug newsletters can be a valuable component in providing drug information. These newsletters can be published monthly, quarterly or at longer intervals and should provide staff with unbiased and accurate information about drug therapy. Newsletters and bulletins have an advantage over formal group presentations because busy practitioners can read the information at a time that suits them. However, printed materials, including newsletters, are unlikely to be effective in changing irrational prescribing habits unless they are combined with a more interactive teaching method. Many drug newsletters and bulletins are already published by commercial ventures and distributed worldwide (see annex 4.1). However, a local bulletin can be an invaluable asset since it will provide more information concerning medicines and medicine-related problems of specific interest at the local level. Drug newsletters are more likely to be effective in improving rational drug use if certain principles are adhered to, as shown in box 7.1.
BOX 7.1 PRINCIPLES OF EFFECTIVE DRUG NEWSLETTERS
• The reasons for prescribing behaviour are understood and are addressed, for example lack of knowledge, distrust of in-country drugs or generics.
• Concise, up-to-date information of immediate use is offered.
• Information is limited and key points are repeated; lengthy presentations of new information and reviews will lose the interest of most readers.
• Short headings and visually appealing illustrations are used, so catching the attention of readers.
• The text is brief and simple.
• The information presented is derived from reputable journals, and the references are provided.
• The information provided is orientated towards actions and decisions.
• Feedback from professional staff on the value of the newsletter is asked for and changes made as necessary.
• Local experts are asked to write and comment in order to improve acceptability and credibility.
7.2.4 Formulary manual and standard treatment guidelines
The use of a formulary manual has been shown to be a valuable asset to providing information about drugs to health staff (see section 3.3 and annex 3.2). Likewise manuals or pamphlets on STGs can provide information on diagnosis and treatment (see section 3.4). Like all printed materials they will be more effective if they are pocket-sized, regularly updated and easily available, and accompanied by other more interactive educational strategies.