Not using the medicine in the way intended by the prescriber
This is the problem which health workers tend to stress and which has been the focus of many drug use studies (Homedes and Ugalde, 1993). These studies, though suffering from methodological limitations, give a general view of low levels of adherence to medical regimes.1 People tend to forget the details of the advice given, or fail to purchase all the drugs that are prescribed, because they lack the financial means to do so. Patients sometimes stop taking the prescribed drugs or take the wrong dosage.
1 NB: Compliance and adherence are words used to describe whether a consumer takes a medicine in the way intended by the health professional who prescribed it or according to the instructions on the packaging. Some people prefer not to use the word compliance because it implies a normative view that the consumer should obey/comply with instructions. The word concordance may also be encountered in this context. It refers to a consultation process between the health professional and the consumer, who reach agreement about the best course of treatment in a way which values the perceptions and opinion of both parties.
Homedes and Ugalde identify four types of patients who request medical advice but do not follow it:
• those who are motivated to comply but do not know, or have forgotten, all or part of the recommendations
• those who are knowledgeable but insufficiently motivated to follow them
• those who may not be able to adhere because of poverty, inaccessibility to medication or other external constraints
• those who change their minds and for a variety of reasons decide not to follow the recommendations.
Homedes and Ugalde argue that poor consumer adherence to medical regimes is problematic but they also argue that adherence should be viewed in the light of the quality of health workers’ prescribing practices. Interventions to improve adherence only make sense if health workers’ prescribing practices are appropriate and rational.
Self-medication with prescription drugs
Another problem is that in many countries people can purchase drugs over-the counter that legally should only be sold on prescription. In the Philippines, Hardon (1991) found that people keep copies of prescriptions to re-use. Doctors’ consultations are expensive and repeated use of prescriptions is a way to economize.
Self-medication with prescription drugs is especially a problem in developing countries where pharmacies freely supply medicines over-the-counter, as do informal drug shops and small groceries. Sometimes people even self-medicate with prescription drugs on the advice of traditional healers. People keep stocks of leftover medicines in their homes, and re-use them or give them to neighbours or relatives who request them. These practices also occur in countries where dispensing of medicines is regulated more strictly. The possibility of buying medicines through the Internet means that drugs available only on prescription in one country can be obtained by post from a country where regulation is less strict. Immigration and people’s increased mobility mean that more people buy medicines where it is easy to obtain them - or obtain them through family and friends. For example, immigrants, used to the free availability of “prescription drugs” in their countries of origin, may still obtain these medicines from visiting friends and family members.
Misuse of antibiotics
Antibiotics are important drugs, but they are over-prescribed and overused in self-medication for the treatment of minor disorders such as simple diarrhoea, coughs and colds. When antibiotics are used too often in sub-optimal dosages, bacteria become resistant to them. This is a serious concern to public health policy-makers. The result is treatment failure when patients suffering from serious infections take antibiotics. People buy sub-optimal dosages because they cannot afford the full course prescribed, or because they are not aware of the need to complete antibiotic courses. Even in industrialized countries where antibiotic dispensing is better regulated, non-compliance with the prescribed regime is a common problem. People who have not understood the need to complete the course stop using antibiotics when the symptoms disappear, while others take an overdose as they think that this will lead to faster recovery.
Studies by Lansang et al. (1990, 1991) and others highlight some of the problems with antibiotic use in the Philippines. Surveying 59 drug stores in Makati, Metro Manila, the authors found that two-thirds of 1608 antibiotic transactions were made without prescriptions. They also found that for each antibiotic prescribed the customers purchased only 10 units (tablets or capsules) or less. In a rural setting in the Philippines, the authors found that 57% of 6404 antibiotic transactions were without a prescription. The median number of antibiotics dispensed in a single visit was six tablets or capsules. These findings indicate widespread sub-optimal use of antibiotics in self-medication in the Philippines.
Another interesting study by Boomongkon and colleagues (1999), reveals how concerned women are about chronic and recurrent uterus-related problems in Northeast Thailand. Women refer to symptoms, ranging from abdominal and lower back pain to vaginal discharge, itching, odour and rash, using the term pen mot luuk (literally “it’s the uterus”). They fear that these problems will turn into cervical cancer if not treated, a perception inadvertently perpetuated by the cervical cancer education and screening programmes. Eighty percent of women surveyed (n = 1028) reported self-medicating the last time they experienced symptoms. Two-thirds of them bought antibiotics, specifically under-dosages of two brands of tetracycline, Gaano and Hero. Tetracycline is medically inappropriate for many of the problems that women classify as mot luuk, but the manufacturer of Gaano appears to endorse its use by having a picture of a uterus on the package.
Overuse of injections
Health workers and patients in many countries believe that injections are more effective than tablets. This not only leads to unnecessary expenditure (in many cases tablets are a cheaper form of therapy), it also leads to unnecessary health risks when the injections are administered in unhygienic conditions or syringes and needles are re-used without being sterilized.
A WHO study on injection practices in developing countries found that in Uganda around 60% of patients bring along their own syringe and needle when they visit health facilities for treatment. The instruments have generally not been sterilized properly. People keep the injections at home because they do not trust the injections provided in the health facilities (Van Staa and Hardon, 1996).
Overuse of relatively safe medicines
In many countries people believe that they need a “pill for every ill”. At the onset of all kinds of minor disorders they immediately take drugs. Vitamins and analgesics such as multivitamins, acetylsalicylic acid and paracetamol, though relatively safe, are the most commonly used drugs in many countries. This practice is not without risks. Aspirin can cause stomach bleeding and paracetamol, if taken in excess, can cause death.
In a community study in Thailand, Sringernyuang (2000) describes the overuse of analgesics in rural Thai communities. People are addicted to analgesics for pain relief, related to hard agricultural labour. For the agricultural labourers a painkiller a day is essential. It allows them to continue work and have a regular income. Health workers recognize that the practice is unsafe, as it can lead to stomach bleeding, a commonly reported health problem in Thailand.
Unsafe use of herbal medicines
In developing countries people use herbal medicines routinely in self-care. In many countries programmes exist that test the safety and efficacy of these medicines, and some of them are selected for inclusion in national health programmes. The production of herbal medicines is commercialized in countries, such as China, India and Thailand, and marketing is similar to that for modern pharmaceuticals. In industrialized countries the use of herbal medicines is also increasing. People believe that they are more natural than modern pharmaceuticals. Some herbal medicines are potent, and their safety is not as evident as people think. Also they can be dangerous when taken in combination with modern pharmaceuticals. For example, the antidepressant herb St John’s Wort cannot be used in combination with Selective Serotonin Re-uptake Inhibitors (SSRIs).
Use of non-essential combination drugs
When suffering from coughs and colds, people tend to take all kinds of cough and cold remedies that contain more than one active ingredient. Sometimes these drugs even contain substances that counteract each other: one substance to suppress a cough and another to encourage it. Hardon (1991) notes that the most popular cough and cold remedies in the communities where she conducted her study combine substances that counteract each other. Such remedies do not contribute to a cure and are a waste of money. People should take the active ingredient that they need, and if they need two drugs then they can take two different preparations.
Use of needlessly expensive medicines
In many countries people rely on brand name drugs when choosing therapies. Branded products are often more expensive than the same products under generic name. Also people do not realise that two different brand name drugs may contain exactly the same substance. The price of medicines is an important concern for consumers.