A global survey of public education in rational drug use1 has revealed that efforts in both developing and developed countries are being severely hampered by under-funding, lack of support and a shortage of expertise. The outcome, says the report, is a vicious circle in which projects are poorly planned, weakly implemented, and not evaluated rigorously enough.
1 WHO/DAP. Public education in rational drug use: a global survey. DAP Research Series No.24. Geneva: World Health Organization; 1997. WHO/DAP/97.5.
The report by the Action Programme on Essential Drugs is based on the first ever global survey of public education in rational drug use. The study set out to establish who and what is being targeted by rational use programmes; who is doing the work, how and why; what are the needs and lessons learned; and what future action needs to be taken. The survey included data from about 100 questionnaires and educational material gathered from 38 countries (25 developing and 13 developed countries).
Critical need for public education
The report points out that in many parts of the world up to 80% of illness episodes are self-treated with modern pharmaceuticals. And even where formal health care channels are used, it is the consumer - not the prescriber - who determines whether and how the drugs are used. These decisions are based on the shared beliefs of family, friends or the wider community; information from prescribers and dispensers; and promotional material. As a result, consumers need access to accurate and understandable information about the potential benefits and risks of medicines in general, including possible side effects; how they act within the body; and the limitations of pharmacotherapy and other treatment options.
“With the exception of Australia, no country - developed or developing - has undertaken a structured public educational programme, targeting all members of the community and developed by a coalition of stakeholders,” says the report. The authors point out that in developing countries it is not surprising that, in view of the wide range of other competing areas of drug policy, public education in rational drug use is often given low priority. But its neglect by developed countries is more difficult to understand.
“It is more difficult to explain the lack of commitment by developed countries to systematic and structured public education in rational drug use, given the potential economic and public health benefits,” the report states.
Until now few public education in rational drug use interventions have been documented or evaluated. As a result, experience cannot be shared or built on. The DAP survey was intended to help close this gap.
A surprise finding was that there were fewer differences than expected between the types of programmes in developing and developed countries. The most significant was the different media used. While education programmes in developed countries relied more on the printed word to get their message across, programmes in developing countries reported more frequent use of the mass media, especially radio. In developing countries, the most popular channel of communication was the mass media (76% of projects) followed by workshops (70%) and the distribution or display of printed materials (26%). Developed countries focused mainly on printed materials (61% of projects) and the mass media (56%).
Reaching out to schoolchildren and the elderly
School projects accounted for a large number of education programmes, especially in developed countries, but only Sweden had launched a nationwide programme targeting all schools. Projects ranged from a novel “pill-box” information campaign in secondary schools in Belgium (see Box 1), to projects for younger children in the United States, involving the use of pharmacy students to teach drug safety and compliance, and encourage children to take responsibility for their own health.
Many of the sample school kits submitted had been developed in collaboration with the pharmaceutical industry or pharmacy organizations. Most failed to highlight the risk/benefit equation of drug use, or even that the same active substance may be marketed under different brand names and at different prices. In addition, little effort was made to encourage children to develop a more objective view of the commercial promotion of drugs.
A variety of innovative approaches are being used by groups in both developed and developing countries to get the message across. In Germany, the BUKO Pharma-Kampagne uses street theatre presentations to raise public awareness about rational drug use, while in Australia, the Medicine Information Project makes use of trained elderly volunteers as peer educators to promote rational drug use among the elderly population. Volunteers receive an initial five days’ training, updated four times a year. The topics covered include consumer rights and responsibilities, use of specific medications, assertiveness, problem-solving, as well as presentational and listening skills. Elsewhere, telephone services in Peru and the Netherlands have been forced to expand the service after being swamped with calls on medicine-related health issues.
“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 lunchtime, 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.
No words are necessary to convey this message on the dangers of becoming dependent on tranquilisers
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 nongovernmental 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.
Disseminating the survey results is essential to promote effective public education. Here the global survey is publicised at a pharmacists’ association meeting in the Netherlands
Photo: WHO/D.A. Fresle
The authors warn that the use of a wide range of different materials in some developing country projects - inadvertently promoted by funding and supporting agencies - may lower their effectiveness by diluting the message. The report highlights the difficult balance needed between having a few, well-developed and well-used complementary materials and a large number of relatively unconnected ones.
The report reveals that almost half the projects used educational material that had never been pre-tested. Of those that did pre-test materials, most reported that the materials needed subsequent revision. Although the survey did not extend to the quality of pre-testing, the authors warn that the methodology for this is often lax. Common weaknesses in the material submitted included a proliferation of messages and the overuse of scare tactics, while some required considerable training before they could be used effectively. The report recommends the development of relatively simple methodologies to ensure that all materials can be thoroughly pre-tested and, where necessary, revised before use.
Another weak spot identified in the report is the lack of structured planning. Most projects selected fairly general themes on the basis of “perceived need” and their target groups and expected outcomes were also very broad. However, significantly more developing countries (43%) than developed countries (27%) had based their projects on research findings (including consumer and practitioner surveys, focus-group discussions, and patterns of drug sales).
Of the specific drug problems targeted, developing countries most frequently cited antidiarrhoeals and antibiotics, while developed countries focused more often on benzodiazepines and other sedatives. The illnesses most often targeted were diarrhoea and malaria in developing countries and asthma in the developed countries.
The report highlights the failure of most projects to evaluate the impact of their activities. As a result, cost/benefit analysis is impossible - deterring many potential donors. Very few projects were able to provide evaluation reports. And, with the exception of rational use of drugs projects in Australia and Viet Nam, most focused on activity monitoring rather than impact assessment.
“This is unfortunate,” the authors point out, “for public education programmes are often accused of a lack of rigour in their work, leading to a questioning of their value and consequent difficulties in obtaining support for such programmes.”
However, the report also warns that the impact of public education strategies is often incremental - moving gradually from initial awareness raising, to knowledge creation, community empowerment and behavioural change. “This may be difficult to evaluate in the short-term - particularly using classical methodologies,” say the authors,” and care is needed that we do not ‘throw out the baby with the bath water’ in an attempt to evaluate impact with scientific rigour.”
In the absence of systematic evaluation studies, many projects gave estimates of the impact of their activities. In developing countries, 40% of projects judged that their project had met its objectives, compared to 66% in developed countries. Meanwhile, 60% of developing countries and 30% of developed countries said the project objectives had been partially met. No developing country and only 4% of developed countries deemed their project to have been a failure.
Both health professionals and the general public need better information and education about when and how to use drugs
National Council on Patient Information and Education, USA
The main problems faced by projects included:
shortage of funds;
inadequate external collaboration and support;
shortage of time and personnel;
opposition from vested interests (both commercial and professional);
This Kenyan health education poster warns against one of the most common dangers in many developing countries - untrained drug vendors whose products are often substandard or counterfeit
Ministry of Health, Kenya
Of these, the lack of funds was the major problem for developing countries, while for developed countries, the principal constraint was a shortage of time and personnel. On sources of funding, the survey found that developing country projects were most likely to be funded by international organizations or international NGOs, while ministries of health and professional associations were the major source for developed countries.
Tackling the problems
The report notes that if public education is to be properly researched, backed by the necessary tools and knowledge, and be effective and sustainable, it must be adequately resourced - ideally from a variety of funding sources. It says new, more creative and sustainable sources of funding are needed, possibly including:
a tax on commercial drug information budgets to provide independent information to consumers and to support community projects;
incentives to dispensers to develop community education projects or extend individual counselling - particularly in countries where dispensing is covered by social insurance schemes;
independent consumer information for sale at a price that covers recurrent costs.
The report also highlights the need for greater advocacy at international, national and regional levels to promote the importance and rationale of public education in rational drug use. It says there is a need for greater understanding of its potential contribution to public health and savings in health expenditure. Better advocacy, say the authors, would help “avoid simplistic, unsustainable, and token approaches that contribute little to real community empowerment and understanding, but simply pay lip service to the very real information and educational needs of the community in this important area.”
Also needed are opportunities for short-term training and access to simple, practical tools essential for research and development activities, especially for small-scale community-based programmes. The authors point out that no courses exist in the area of public education in rational drug use, and call for the development of an international training course through which educators could strengthen their communication skills and, in turn, train national colleagues through in-country training programmes.
“Organizations or people who intend to carry out public education projects need clear, usable guidelines to help them better plan and structure their activities, including better definitions of the theme(s), the desired outcomes of the project, and the target audience.”
The report also calls for the development of supportive coalitions and partnerships which could help strengthen the work and long-term sustainability of many organizations, especially those working in relative isolation. But it also warns that organizations need to ensure they are not hijacked by powerful interests “less interested in the community’s own perception of needs and empowerment, and more concerned with ‘marketing’ behaviour considered desirable by the dominant group.”
The most encouraging finding of the survey was, despite its current failings, at its best, public education on rational drug use can and does work. Among developing countries this was the second most important lesson learned and for developed countries the third most important. In Bolivia, a primary health care project declared that it was possible to get the community to take responsibility for their health, while rational use of drugs campaigners in Bangladesh reported that effective lobbying had shown that “continuous, logical insistence to producers on rational/ethical production works.” Elsewhere, in Australia, the Medicine Information Project noted that, “empowering consumers can drive change at all levels of the health system.”