(2004; 98 pages)
2.2 The household level
The way medicines are used is influenced by individual beliefs about them, which in turn may have been shaped by members of the immediate family and those in extended family networks. Important factors at this level are outlined below.
Perceived need for medicines
Evidence suggests that people have lost their trust in the body’s ability to fight disorders without the ‘help’ of medicines, even for self-limiting disorders, such as colds and diarrhoea. Studies on drug use by consumers show that people think that they should take medicines immediately at the onset of illness to prevent it from becoming worse.
People take medicines not only to treat symptoms of ill health but because they believe that medicines are also needed to stay healthy. Preventive use of drugs is a topic often neglected in discussions on appropriate medicines use. However, drug sales increasingly tend to involve products such as vitamins, which are commonly taken because people think they will prevent illness.
BOX 1. MEDICINE BELIEFS AMONG RURAL VILLAGERS IN PAKISTAN
“Medicine is needed for every illness. If medicine is not used, the illness will become serious.”
Rasmussen ZA et al. (1996). Enhancing appropriate medicine use in the Karakoram Mountains. Community drug use studies. Amsterdam, Het Spinhuis.
Ideas about efficacy and safety
People use medicines according to their own ideas about drug safety and efficacy. Anthropological studies reveal that people believe that the safety and efficacy of medicines are determined by a number of factors including:
• the colour and shape of medicines. In Sierra Leone, for example, red medicines are thought to be good for the blood (Bledoe and Goubaud, 1985)
• the method of administration. In Uganda, for instance, people believe that medicine injected into the bloodstream does not leave the body as quickly as that administered orally. Oral medicine is compared to food, which enters the digestive system and eventually leaves the body through defecation (Birungi, 1994)
• compatibility between the medicine and the person taking it. A medicine that is effective for one person may not be effective for another. In the Philippines, people use the concept hiyang to explain why a medicine did not work for a particular patient. In Indonesia and Thailand similar concepts exist
• whether a medicine was effective in the past. If so, they are likely to use it again
• the “newness” of a medicine (new medicines are believed to be more effective).
People’s choice of medicine usually also depends on the cause that they attribute to the illness and its perceived severity. In Ghana, for example, people consider heat to be the main cause of measles. Heat also causes constipation and stomach sores in children. To treat measles people use Septrin (cotrimoxazole) syrup, multivitamin syrup, calamine lotion, akpeteshie (local gin) and a herbal concoction given as an enema to ‘flush out’ the heat (Senah, 1997). If illnesses are thought to be caused by witchcraft, it is likely that a traditional healer will be used rather than medicines bought at a local shop. However, if the illness is believed to be caused by bodily imbalance related, for example, to hot-cold notions, it is likely to be treated with medicines. More severe disorders may be brought to the attention of health workers or traditional healers, depending on what the cause of illness is believed to be.
Finally, people’s ideas about a medicine can actually affect its efficacy. This has been documented in numerous studies on the psychological and physiological effects of placebos (harmless substances that look like the actual medicine but contain no active ingredient). In double-blind trials on new drugs, for example, approximately one-third of the participants respond to a placebo.
Uncertainty resulting in poly-therapy
People are often uncertain about the cause of disorders as well as the most effective treatment. As a result, they tend to use several therapies at the same time, often combining modern and traditional remedies. If the condition is serious they may consult a variety of modern and traditional health providers.
Drug consumption roles
Drug use is not only defined by people’s ideas about medicines but is also determined by the role people play within families in the process of buying, administering and deciding about medicine use (see box below).
BOX 2. CULTURAL INFLUENCES ON THE SELECTION AND USE OF MEDICINES
In the Philippines, (Hardon, 1991) mothers decide whether or not they should buy and give medicines to their children. Men are usually not involved in decision-making on the treatment of common childhood illnesses. Instead, women consult with neighbours and relatives on treatment options. Married women in this country manage household expenses and the family’s income, and do not have to consult their husbands about the cost of medicines. Husbands take a more active role only when a health problem becomes severe.
In contrast, in Pakistan, (Rasmussen et al., 1996) women are constrained in their efforts to treat children’s health problems. They cannot go to the bazaar or hospital in town to obtain drugs, as cultural norms forbid such mobility for women. Because male family members must buy medicines, men are more closely involved in decisions about children’s treatment. They often receive information on a medicine’s use at the bazaar or health facility and pass this on to their wives who actually administer the drugs.
The cost of medicines
Cost is a major factor shaping drug use at the family level in developing countries and among those patients in industrialized countries who are not covered by insurance schemes. When presenting a prescription for several different medications at a pharmacy, consumers have to decide which medicines they can afford to buy. In developing countries, 50%-90% of medicines are paid for ‘out-of-pocket’. In parts of Africa, Asia and Eastern Europe, drugs account for up to 80% of household health expenditures.
People frequently waste money on drugs. Often they are unaware that cheaper, generic alternatives exist or they do not realize that many medicines are ineffective. Public health workers are sometimes surprised that people pay for medicines in the private sector when they could obtain them free of charge at public health centres. Studies show that people are willing to pay for what they consider to be good and effective remedies. Moreover, people often believe that more expensive medicines (usually brand name products) are more effective than cheaper ones. Interventions which enable people to find cheaper alternatives for medicines, by teaching them how to identify the active component of a drug, and how to compare prices, can draw on strong community interest. This is because such interventions help to deal with the high cost of medicines, an important day-to-day concern for people who are poor.1
1 WHO and HAI (2003) have developed a new approach to measuring medicine prices, see references.
Literacy levels of consumers
Literacy determines the extent to which people have access to written information on medicines, such as package inserts or educational posters with a written message. However, people who cannot read sometimes ask others, including their children, to explain what is written on or inside medicine packages.
The “power” of medicines
At the family level, medicines use is also influenced by the pharmaceutical efficacy of medicines. Analgesics are popular because they relieve pain; cough syrups because they stop the cough; antibiotics because they cure infections. Some medicines, such as tranquillizers, are even more “powerful” and may cause dependencies.