Improving the use of pharmaceuticals through patient and community level interventions

Evaluation of Nasal Decongestants by Literature Review

Over-the-counter drugs are medicines that are available to consumers without a prescription. The most common оver - the-counter preparations in self - medication are nasal decongestants that can be used systemically or locally in the form of drops or nasal sprays. The most common indications for nasal decongest-ants are viral infections and allergic conditions in order to alleviate the symptoms so it is necessary to inform the users about the type of drug, the active substance it contains and the correct dosage regimen. Given their availability and the prevailing safety precaution, these preparations can lead to numerous prolonged conditions and complications. The mechanism of action of nasal decongestants is based on the reduction of blood vessels’ swelling in the nose, which helps the opening of the airway. As a result, most nasal decongestants cause vasoconstriction (narrowing of blood vessels). There are nasal decongestants that block histamine and have a good effect on people who suffer from seasonal allergies.

Availability (free sale) and prolonged use of the decongestant lead to a decrease in the sensitivity of the alpha receptor, which leads to the need to increase the dose at shorter time intervals to achieve the same effect. As a consequence, patients use excessive, uncontrolled doses of nasal decongestants, which is a public problem and warns of the necessity of identification and the taking of measures to prevent their uncontrolled procurement and use.

Components Affecting Pharmaceutical Strategic Purchasing: A Scoping Review

Pharmaceutical strategic purchasing is considered as a key to improve access to medicines especially for developing countries. The aim of this scoping review is to determine the most important components affecting pharmaceutical strategic purchasing. Here, we employed a comprehensive search strategy across PubMed, ProQuest, EBSCO, ISI Web of Science, Scopus, ScienceDirect, and Google Scholar for the terms related to medicines strategic purchasing. Among 13 included studies, 7 (53.85%) and 6 (46.15%) studies belonged to the developing and developed countries, respectively. Six main variables were emphasized as the effective variables on medicines strategic purchasing, including purchasing interventions, target group and service users, providers and suppliers of interventions, methods and motivations, price, and finally structure and organization. It seems that the insurance organizations of developing countries can achieve strategic purchasing only through the modification of the pharmaceutical pricing system and payment systems. Furthermore, they should pay attention to the real needs of target groups (demand) and modify the structure and organization as well as purchasing the most effective medicines from the best pharmaceutical providers.

Factors associated with the inappropriate use of antimicrobials

Antimicrobial resistance continues to grow and antimicrobial use in food animal production and to a lesser extent in human patients is under fire. Much of the criticism has to do with the misapplication of these drugs in both settings. Research indicates that patients, food animal producers, physicians and veterinarians have all played a part in misusing antimicrobials, often because of mistaken beliefs. This paper reviews this research and introduces a theoretical perspective, the Theory of Planned Behavior (TPB), which broadens our understanding of the motivations for misuse. In particular this approach shows that individuals making decisions about antimicrobial use take into account social pressures from and a sense of obligation to significant others in their social networks. Our own work summarized in this paper indicates that both feedlot veterinarians and feedlot managers' antimicrobial decisions are influenced by both expectations from and obligations to a variety of actors in the feedlot network (other veterinarians, feedlot clients, consumers, pharmaceutical companies, and regulatory bodies). Generally across 4 circumstances of antimicrobial use (for acutely sick cattle, chronically-sick cattle, at-risk cattle, high-risk cattle), it is largely the perception that peers and clients expect feedlot veterinarians to use antimicrobials and feedlot veterinarians sense of obligation to these groups that have the most influence on their decisions to recommend antimicrobials. Based on these findings, the question of engaging in changing the choices made by those working with food animals must start with those who influence the decision to proscribe or use antimicrobials. As our data come from the United States and may be unique relative to other countries, these efforts should begin by ascertaining who influences these decisions. The next step is to then change the beliefs of these significant others.

What determines the duration of patient medication compliance in patients with chronic disease: are we looking in the wrong place?

Objectives: The objective of this study was to do a pilot inquiry, to determine whether physicians with similar practices in the same neighborhood demonstrated any difference in the duration of compliance among their patients.

Methods: Through a cooperating urban community pharmacy, patients with prescriptions for hypertension and type II diabetes were identified for this pilot study. Patients refill medication records were searched to determine the average number of months of drug regimen compliance. The patient data of the four local physicians were separated and compared.

Results: One physician was able to generate refill durations nearly double that of the average duration of medication refills seen in the patients consulting the several other nearby physicians.

Conclusion: In this pilot study, it was determined that there are differences in the compliance behavior of patients attending different physicians. We can conclude that some communication or personality characteristics of some physicians appear to be more successful in achieving higher compliance. Subsequent studies should identify those which may be at least partially responsible for this finding.

Drug dispensing and information giving in Belo Horizonte, Brazil

PURPOSE

The purpose of this paper is to examine drug dispensing and associated activity in Belo Horizonte, Brazil. The paper aims to describe factors associated with patient information giving and dispensing time.

DESIGN/METHODOLOGY/APPROACH

A specific protocol for recording data gathered from observations included: number of dispensing sessions; medical specialties active at the time; medication number and type; dispensing outcome; if information giving was observed and dispensing time. Information giving and time were considered response variables. The chi-square test and odds-ratios were used to verify associations between response and explanatory variables.

FINDINGS

In 43 percent (45) consultations, information giving accompanied dispensing and was associated with number of dispensing sessions and medical specialty offered on a particular day. Assistance time was associated with drug type and number, which increased as dispensing sessions decreased.

RESEARCH LIMITATIONS/IMPLICATIONS

Seasonal variations in the demand for pharmacy assistance were not investigated and sample size precluded multivariate analyses. Consequently, new studies may deepen understanding about communication between physicians, pharmacy assistants and users.

PRACTICAL IMPLICATIONS

Pharmacy staff could improve quality and efficiency if two aspects were taken into account: fluctuating workload, and external conditions within which tasks are undertaken.

ORIGINALITY/VALUE

The paper identifies external conditions that interfere with drug dispensing.

Delayed care seeking for fatal pneumonia in children aged under five years in Uganda: a case-series study

OBJECTIVE

To review individual case histories of children who had died of pneumonia in rural Uganda and to investigate why these children did not survive.

METHODS

This case-series study was done in the Iganga/Mayuge demographic surveillance site, Uganda, where 67 000 people were visited once every 3 months for population-based data and vital events. Children aged 1-59 months from November 2005 to August 2007 were included. Verbal and social autopsies were done to determine likely cause of death and care-seeking actions.

FINDINGS

Cause of death was assigned for 164 children, 27% with pneumonia. Of the pneumonia deaths, half occurred in hospital and one-third at home. Median duration of pneumonia illness was 7 days, and median time taken to seek care outside the home was 2 days. Most first received drugs at home: 52% antimalarials and 27% antibiotics. Most were taken for care outside the home, 36% of whom first went to public hospitals. One-third of those reaching the district hospital were referred to the regional hospital, and 19% reportedly improved after hospital treatment. The median treatment cost for a child with fatal pneumonia was US$ 5.8.

CONCLUSION

There was mistreatment with antimalarials, delays in seeking care and likely low quality of care for children with fatal pneumonia. To improve access to and quality of care, the feasibility and effect on mortality of training community health workers and drug vendors in pneumonia and malaria management with prepacked drugs should be tested.

The role of the pharmacist-voices from nine African countries

OBJECTIVE

To explore views on pharmacy practice in Africa as perceived by pharmacists from several African countries. METHOD AND SETTING: Data was collected using pre-tested semi-structured interview guides. A total of 15 pharmacists from nine African countries were interviewed. The analysis used a phenomenographic approach where categorisation with regard to differences in expressed perceptions of the pharmacist's role was made.

MAIN OUTCOME

Perceptions on pharmacy practice in Africa as expressed by pharmacists from nine African countries.

RESULTS

Four qualitatively different ways of perceiving the pharmacist's role were identified and sorted into subcategories under the two main categories A and B as follows A. Pharmaceutical information provider with the sub-categories: A1. The satisfied dispenser, and A2. The dissatisfied dispenser; and B. Health care provider, with the sub-categories: B1. The health care team member, and B2. The lifesaver. In category A, the pharmacist is described foremost as a provider of pharmaceuticals and information with a distinction being made with regard to whether the interviewees expressed dissatisfaction with their situation or not. In category B, the pharmacist was described as a provider of health care and two different approaches to this were found.

CONCLUSION

The study describes different ways of perceiving the role of the pharmacist in nine African countries. It offers an insight into the situation of the African pharmacist that can be used as a starting point for further discussion and research on the development of pharmacy practice and for the creation and implementation of national Good Pharmacy Practice (GPP) guidelines.

The World Bank, pharmaceutical policies, and health reforms in Latin America

Health care systems spend a relatively high percentage of their resources on the purchase of medicines, and the poor spend a disproportionate amount of their income on pharmaceuticals. There is ample evidence in the literature that drugs are very poorly used. World Bank-led health reforms aim at improving equity, efficiency, quality, and users' satisfaction, and it will be difficult to achieve these goals without making medicines accessible and affordable. The purpose of this article is to examine the adequacy of World Bank pharmaceutical policies, as recommended in various Bank documents, for Latin America and to examine the implementation of the policy recommendations. The authors found that the World Bank identified and recommended a set of pharmaceutical policies that matched the needs of the region. But, as revealed through fieldwork and a review of the literature, the recommended pharmaceutical interventions were left out of the health reforms, and most of the loans that included pharmaceutical interventions allocated funds only to the purchase of drugs. The authors formulate four hypotheses that may explain the lack of congruence between the recommended policies and the strategies financed by World Bank health reform loans to the Latin American region.

Improving access to pharmaceuticals in Brazil and Argentina

The population of many Latin American countries is having increasing difficulty in accessing needed medicines due to the rise in their unitary cost and the growing number of poor in most countries of the region. A number of countries have taken steps to increase access to pharmaceuticals and have had different levels of success. This article reports on two country-wide programmes: the AIDS programme in Brazil, which has been judged as being highly successful, and the Remediar programme that has been implemented recently in Argentina. Both programmes have significantly increased access to needed pharmaceuticals, and Argentina has done it in a record time. In the discussion, we suggest that pharmaceutical interventions are successful when there is a firm political commitment, they are comprehensive, include the participation of civil society, and use a combination of methods to control the rising cost of medicines, including centralized international competitive bidding processes for drug procurement and reliance on multi-source drugs.

How do patients use antimalarial drugs? A review of the evidence

Patient adherence is a major determinant of the therapeutic response to antimalarial drugs, as most treatments are taken at home without medical supervision. With the introduction of new, effective, but more expensive antimalarials, there is concern that the high levels of efficacy observed in clinical trials may not be translated into effectiveness in the normal context of use. We reviewed available published evidence on adherence to antimalarial drugs and community drug usage; 24 studies were identified of which nine were 'intervention' studies, seven were classified as 'outcome studies', and the remainder were purely descriptive studies of antimalarial adherence. Definitions, methods, and results varied widely. Adherence was generally better when treatments were effective, and was improved by interventions focusing on provider knowledge and behaviour, packaging, and provision of correct dosages. There is insufficient information on this important subject, and current data certainly do not justify extrapolation from results with ineffective drugs to new effective treatments. Research in this area would benefit from of standardization of methodologies and the application of pharmacokinetic modelling.

Development of the choices and acquisition of antibiotics model from a descriptive study of a lay Honduran population

Antibiotic resistance is a global public health problem that is accelerated by overuse and misuse of antibiotics. In today's world of increasing international travel and exchange of goods, the spread of antibiotic resistant organisms is a growing threat. Despite significant antibiotic use in developing nations, research to describe and curtail inappropriate use is limited. In this study, the investigators developed a model of antibiotic use, choices and acquisition of antibiotics model, from a study of a lay population in Honduras. A representative sample of 939 rural and urban Hondurans completed the Preguntas Para El Uso de Antibiotics questionnaire to determine how the participant made choices about antibiotic use. The study indicated that the rural participants used significantly fewer antibiotics than the urban participants and that the demographic indicators did not show a significant difference in antibiotic use in those of lower socioeconomic status. In addition, the participants reported that they seek out professional advice and care rather than self-prescribing. Implications for educational and empowerment programs based on the model are discussed.

Chlamydia and gonorrhoea in pregnancy: effectiveness of diagnosis and treatment in Botswana

BACKGROUND

Millions of patients are prescribed drugs for sexually transmitted infections (STIs) in developing countries each year, yet the treatment effect of these prescriptions is largely unknown.

OBJECTIVES

To determine if the prescribing of erythromycin and ceftriaxone to pregnant women with STI symptoms leads to a reduction in the prevalence among these women of chlamydia and gonorrhoea, respectively.

METHODS

We compared the prevalence of chlamydia among 116 pregnant women who had been prescribed erythromycin for a history of STI symptoms in their current pregnancy with the prevalence in a control group of 557 pregnant women who had not been prescribed this drug. Similarly we compared the prevalence of gonorrhoea among 110 pregnant women who had and 561 women who had not been prescribed ceftriaxone.

RESULTS

There was no significant difference in the prevalence of chlamydia among the women who had and the women who had not been prescribed erythromycin four times daily for 10 days (7% v 8%). Contrarily, none of the women who had been prescribed a single dose of ceftriaxone had gonorrhoea, whereas 4% of the women who had not had this drug prescribed did have gonorrhoea.

CONCLUSIONS

The prescribing of erythromycin seems to have had a limited effect on chlamydia in this population, whereas the prescribing of ceftriaxone led to the curing of gonorrhoea. Ceftriaxone is provided as a single dose injection at the point of care, and the differential effectiveness between the two drugs may reflect low compliance with the complex erythromycin regimen. Interventions to increase compliance could improve cure rates. The use of a simpler drug regimen should be considered when low compliance is likely.

Meta-Analysis of Interventions for Medication Adherence to Antihypertensives

OBJECTIVE

To identify methods targeted at improving adherence to antihypertensives and determine their effect on adherence using meta-analytic techniques.

METHODS

A literature search from 1970 to December 2000 using MEDLINE, International Pharmaceutical Abstracts, PsychLit, ERIC, and EMBASE was performed using the terms compliance, adherence, and medication. Randomized articles with an intervention directed at a patient/caregiver, a comparator group, and a minimum of 10 subjects in each intervention group were identified by 3 independent reviewers. Articles that did not report sample size data or adequate results of the intervention were excluded. Sixteen citations focusing on antihypertensive adherence were identified. Of the 16 citations, 6 studied either more than one intervention in the same population or different interventions in different patient populations, yielding 24 cohorts with 2446 patients.

RESULTS

Fifty-eight percent of the methods focused on behavioral interventions (BIs), 29% studied the effect of a combination of behavioral and educational interventions (BEIs), and 13% utilized educational interventions (EIs) alone. Overall, the study groups were nonhomogenous (Q = 183.92; p < 0.001). However, when the groups were separated by the intervention type, the BIs were homogenous (Q = 1.19; p = 1.00) with an overall effect size (ES) of 0.04 (95% CI −0.01 to −0.09), indicating a trend toward improved adherence. Fifty percent of the BIs were performed in the physician's office; however, setting did not influence the intervention's impact (p = 0.13). Within the BIs, no single intervention improved adherence over others.

CONCLUSIONS

Based on the interventions included in this meta-analysis, there is no single intervention that improves adherence to antihypertensives over others; therefore, a patient-specific approach should be modeled.

Child health: reaching the poor

In most countries, rates of mortality and malnutrition among children continue to decline, but large inequalities between poor and better-off children exist, both between and within countries. These inequalities, which appear to be widening, call into question the strategies for child mortality reduction relied upon to date. We review (1) what is known about the causes of socioeconomic inequalities in child health and where programs aimed at reducing inequalities may be most effectively focused and (2) what is known about the success of actual programs in narrowing these inequalities. We end with lessons learned: the need for better evidence, but most of all for a new approach to improving the health of all children that is evidence based, broad, and multifaceted.

Strategies to improve adherence to recommended chloroquine treatment regimes: a quasi-experiment in the context of integrated primary health care delivery in Ghana

This paper presents the results of an intervention study carried out as part of the activities of a District Health Management Team responsible for integrated primary health care delivery in a rural district in Ghana. The aim was to test the impact of a combination of improved information provision to patients and drug labeling on adherence to recommended anti-malarial treatment regimens focusing on oral chloroquine, for the outpatient management of acute uncomplicated malaria. The study had a quasi-experimental pre-test post-test control group design with partly random allocation by clinic. The results show that the intervention resulted in an improved flow of information to clients prescribed chloroquine, and better labeling of drugs for the home treatment of acute clinical episodes of malaria in the intervention area. Improvements in adherence occurred in all clinics. However, improvements in adherence were most marked in the clinic that was worst performing at the start of the intervention. Implications of the results for improving adherence to chloroquine therapy on an outpatient basis are discussed.