Rational use depends on the knowledge, attitudes and practices of health care practitioners and consumers. Educational strategies for both groups are essential but frequently neglected or inappropriate. In the case of health care practitioners there is often a focus on the transfer of narrow, time-limited pharmacological knowledge, rather than on the development of lifetime prescribing skills and the ability to assess drug information critically.
The education of consumers is a particularly neglected area in all parts of the world. This is of especial concern in developing countries, where prescription products are widely available without prescription from numerous sources, such as pharmacies, grocery stores and market vendors, and where drug promotion is ill-regulated and frequently inappropriate. In some countries up to 80% of medicines are purchased directly by consumers without passing through formal health care channels. Thus an educational strategy that concentrates solely on health care practitioners will have limited impact on the rational use of medicines in the population.
Adequate knowledge does not always lead to appropriate behaviour. For example, when economic incentives exist to prescribe more expensive drugs, education alone will not change the prescribing pattern. Other interventions, such as a change in remuneration structure, will be needed. Moreover, if the local health centre has no drugs, long queues, and unpaid staff while the friendly market vendor is near at hand, more than education is needed to change consumer behaviour. For this reason it is critical to consider and to understand the environment in which drug use takes place when planning educational strategies.
Basic training of health professionals
Improving the basic training of health professionals is an important strategy for achieving rational drug use. The essential drugs concept and its practical application should be included in the curriculum of all health workers. Emphasis needs to be placed on problem-solving techniques, critical appraisal skills and good communication with patients. The WHO Guide to good prescribing,62 available in over 20 languages, is a very successful student manual on the principles of rational prescribing, which has been adopted by developed and developing countries. It is also being used for in-service training of doctors and has been adapted for the training of paramedical prescribers. A teacher’s guide is also available.63
Those involved in dispensing drugs (pharmacists, pharmacy assistants) also need to be taught the essential drugs concept and the principles of rational use, and these concepts should be included in their curricula. In addition, they should be trained to communicate effectively with patients, to explain the appropriate use of drugs and to answer questions as part of pharmaceutical care. The role of nurses in prescribing and dispensing and in communicating with patients should also be recognized, and nurses should therefore be included in training programmes.
In-service training of health workers
Continuing education, supervisory visits and focused lectures and workshops can be effective in increasing knowledge and changing behaviour. Experience has shown that the impact on behaviour is likely to be maximized if specific prescribing and dispensing behaviour is targeted, if the groups are small, if known experts are involved in the teaching, and if the training is followed up with specific feedback on their actual prescribing. Face-to-face contact between prescribers and dispensers with trained educators is effective but requires considerable human and financial resources.
Training of drug sellers
In countries where there is a shortage of trained pharmacists and pharmacy assistants, prescription drugs are sold by drug sellers with no formal qualifications or training. Basic in-service training could be provided to them. Practical training based on checklists and simple written information can help them to do their job well and to communicate effectively with patients. Some promising results have been reported.64
Drug information centres
An underlying factor in many aspects of irrational drug use is the lack of access to independent drug information. Information supplied by the pharmaceutical industry through mailings, visits by drug representatives and industry-sponsored drug formularies is very often the only type of drug information available to prescribers. Drug information centres are an important tool in responding to the need for independent drug information.
Drug information centres can be established and maintained by the government, or linked to a teaching hospital. The latter is the better option when their functions include a 24-hour poison information service. They can also be very effectively run by NGOs, particularly those targeting information to consumers. Some drug information centres have started with one person and a small set of core books, and then expanded as resources and needs permit. Centres often fail when they try to do too much too soon, without clear prioritization and plans for long-term sustainability. More information on drug information centres is available.65
Drug bulletins are a useful means to disseminate unbiased and updated drug information to prescribers and consumers. When they are prepared and issued by the regulatory body they tend to be drug-oriented. Drug bulletins issued by teaching institutions or NGOs tend to be more disease-oriented and comparative in nature.
Consumer information and education
Consumer education is an important area, often neglected in developing and implementing national drug policy. Most medicine programmes tend to place greater emphasis on the supply of essential drugs to health centres and the training of health care practitioners to prescribe properly than on promoting rational use of medicines by consumers. However, drug use studies show that people commonly use medicines without health practitioners’ advice, that their drug use pattern is shaped by their own experiences with medicines, and that they obtain their medicines from various sources, including the informal sector. Given this situation, more attention should be paid to educating consumers on the appropriate use of drugs.
Patients should be given information about the drugs that they are taking. This is important to promote adherence to treatment and achieve the maximum benefit from the treatment. On a wider scale, public education is needed so that people have the skills and knowledge to make informed decisions about how to use drugs (and about when not to use them) and to understand the role of drugs in health care, with their potential benefits and risks. Recent experience in consumer education on drug use can be found in a WHO report.66
Interventions directed towards consumers are most relevant if they focus on patterns of irrational drug use that are common, and cover problems that consumers themselves consider to be important. Useful criteria for prioritising problems include: the scale of the problem, the seriousness of health consequences, the costs, and the appropriateness and feasibility of a community intervention.
Principles to guide public education should include the following:
• public education should be included in national drug policies.
• public education should address important drug use issues that consumers should be appropriately informed about.
• public education should encourage informed decision-making and cover basic concepts related to drug action; how to choose when to self-medicate and when to seek medical advice; which conditions do not require medication; how to read a drug label or patient information.
• public education on drugs should recognize and take account of cultural diversity and the influence of social factors.
• NGOs, teachers, professional associations and community groups have an important role to play in public education programmes and should be involved in planning, development and implementation.
• education programmes should have clear and measurable objectives. It should be recognised that to change deep-rooted beliefs and practices requires a sustained effort and a stepwise process which moves from creating awareness, to acquiring knowledge and finally changing behaviour.
Ideally, education programmes should have long-term sustainability. Although short campaigns, especially using the media, may be used to raise awareness they are most unlikely to change behaviour in the long-term or contribute to sustained community empowerment and knowledge. One important and sustainable approach is to incorporate drug use education in school curricula as part of health education at an early age. Another approach is to include modules in adult education classes, such as literacy courses.
Inappropriate self-medication using prescription drugs, which is widely practised in developing countries, can be dangerous to people’s health. It also has economic consequences. Self-medication using antibiotics is an example. The public must be educated about this problem.
Medicines approved as being safe for self-medication (non-prescription drugs) are normally used for the prevention or treatment of minor ailments or symptoms that do not justify a medical consultation. Drugs approved for over-the-counter (OTC) sales should be provided with labels and instructions that are accurate, legible and clearly understandable by laypersons. These should include complete information on the contents of the drug, indications for use and for discontinuing use, recommended dosages, warnings about unsafe use or storage, and warnings about drug interactions. This subject is closely linked to effective drug regulation.