(2004; 98 pages)
2.3 The community level
The community is the immediate context in which individuals and families deal with their health problems. People talk to each other about therapies, creating and reinforcing existing drug use cultures, and they rely on local sources of drugs. Factors that influence medicines use at the community level include:
Medicines use cultures
Drug use studies often find a clear, local drug use culture in communities. A set of medicines is used routinely to treat the most common health problems. People know what medicines are needed for these problems and they obtain them at local drug stores, general shops or the market. For example, in Uganda, most people use chloroquine as first-line treatment for malaria and buy it at general stores.
Medicines supply systems
The community drug supply system plays an important role in drug use by consumers. Public health managers often assume that people get medicines at public health facilities, such as local primary health centres, which stock essential medicines. However, this is usually not the case.
Most studies on community drug use show that people tend to rely on informal and private channels for their drug needs, using these outlets to buy medicines without a prescription. An additional advantage is that purchases can also be made at convenient times, as these private and informal channels have long hours and open at the weekend. Consumers’ decisions on where to obtain their medicines, or whether to obtain any at all may be influenced by previous experience, distance and transportation costs, the stigma attached to visiting formal health outlets, work or family demands or similar considerations. Figure 2 shows the drug supply channels used by consumers in a poor urban community in the Philippines. It reveals that 75% of medicines are obtained from the private sector, either directly from town pharmacies or through sari-sari (neighbourhood) stores.
Information on medicines is a valued commodity which also shapes drug use. Drugs bought at the pharmacy rarely include package inserts and the brand name is often the only information available to consumers. Other possible information sources include:
• radio and television programmes
• educational sessions organized as part of primary health care programmes
• community health workers
• drug sellers in small shops or markets
• traditional healers who have incorporated pharmaceuticals into their therapeutic regimes
• magazines, newspapers and comics, re-used prescriptions and popular health books
Primary health care programmes that aim to enhance appropriate use of medicines often ignore the messages relayed to consumers through mass media drug promotion by manufacturers. In the Philippines, Hardon (1991) found that the most commonly used medicines in self-care were those promoted most frequently on the local radio station during times when women listened while performing household chores. The station aired three to four of these advertisements per hour.
Figure 2. Community drug distribution channels: an example from the Philippines
Source: Hardon, AP. (1991). Confronting ill health: medicines, self-care and the poor in Manila. Quezon City, Health Action Information Network.