Transcript Determinants and Practices: A Qualitative Study on

Determinants and
Practices: A Study
on the Use of Medicines in
Amman
Qato, Dima PharmD, MPH candidate1
Badriyeh, Daoud, MS2
Ruhi, Randa, MS3
1 University of Jordan, College of Pharmacy, Fulbright Scholar 2002, Johns Hopkins School of Public
Health
2 Research Assistant, Al-Isra University, Amman, Jordan
3 Independent Social Researcher/Interviewer
Abstract
Determinants and Practices: A Study on the Use of Medicines in Amman
Dima Qato, PharmD, MPH candidate1Badriyeh, Daoud, MS2Ruhi, Randa, MS3
1 University of Jordan, College of Pharmacy, Fulbright Scholar 2002,2 Research Assistant, Al-Isra University, Amman,
Jordan, 3 Independent Social Researcher/Interviewer
Problem Statement: Impediments to the rational drug use have never been studied in Jordan, including
Amman. Until the determinants and patterns of drug use are properly understood and examined, will
effective policy recommendations and interventions be implemented and sustained to improve the use of
medicines in the socio-economically diverse communities of Amman. This study attempts to forge an
understanding of the role of pharmaceuticals in the community and how perceptions and knowledge about
health and medicines effects treatment decisions. OBJECTIVES:1) To determine patterns and understand
determinants of actual treatment seeking practices in treatment seeking process (especially selfmedication) in the event of illness) 2) To determine types of medicines found at the household level and
determine knowledge and perceptions regarding common illnesses and treatments. DESIGN: Qualitative
study consisting of household interviews and a survey of pharmacy. Between March-June 2003,
information was gathered from households and private pharmacies throughout the district of Amman
STUDY POPULATION AND SETTING: A sample of volunteers in the peri-urban and urban community of
the district of Amman, comprising 30 households (Households were defined as including, at minimum a
mother and at least one child <15 years of age) and 150 private pharmacy consumers (any age or gender
) who sought to purchase medicines with or without a prescription) in 20 different pharmacies. OUTCOME
MEASURES: 1) Type of treatments, prescriber, source of treatment, and average number of medicines (if
any) per reported illness episode according to SES and educational status; 2) Prevailing perceptions of
medicines in community;Preferences and perceptions related to particular drugs in the treatment-seeking
process RESULTS: Compared with those of higher SES, the lower SES had more drugs at home, tended to
self-medicate, and misuse medicine (e.g. antibiotics and chronic disease drugs were taken only with the
onset of symptoms, and not as prescribed). CONCLUSIONS: Variations in the patterns of treatmentseeking behavior were associated with SES, which is likely linked to maternal educational status and
cultural beliefs, with practices in the use of medicines of the poorer populations having serious health
implications. While understanding the problem of irrational drug use is a multidimensional challenge,
within this challenge is an opportunity to improve the use of drugs through public health and pharmacy
education in the poorer communities of Amman.
Introduction/Significance
The District of Amman in Jordan in which this study was
conducted operates approximately 200 pharmacies which often
serve as the primary resource for health care
Impediments to the rational drug use have not been studied in
Jordan, including Amman and until the determinants and
patterns of medication use are properly understood and
examined, will effective policy recommendations and
interventions be implemented and sustained to improve the use
of medicines in the socio-economically diverse communities of
Amman.
With the variations in SES and residence in Amman in relation to
health, there is a potential variation in the treatment seeking
process.
Significance
An understanding of the different levels and determinants
involved in the health and treatment seeking process is needed
before effective interventions and programs are developed.
The socio-economic determinants, the criteria used in this study,
include poverty (income and employment), residence and
education, all variables that have influenced health in Jordan’s
socio-economically diverse communities.
This study attempts to forge an understanding of the role of
pharmaceuticals in the community and how perceptions and
knowledge about health and medicines effects treatment
decisions.
Background
With over 200 private pharmacies in Amman, often easily accessible to many in
the urban areas but more difficult in the rural areas of Jordan, the pharmacist’s
role in community health and improving the use of medications is crucial in
order to better the overal health status of the Jordanian population. Jordan’s
IMR and U5MR is below the average for the developing world and the Middle
East for 2001, at 27 and 33, respectively
Women in rural and peri-urban localities have a higher birth rate and infant
mortality rate compared to urban residents. Socio-economic disparities (perhaps
due to maternal education) are apparent in the nutritional status of children;
rural children more likely than the urban to be stunted (14% vs. 6%) and To
illustrate variations in disease burden across various districts in Jordan: Amman
had 230 cases of HIV/AIDS, which account for 73% of the HIV/AIDS cases in
Jordan. Whereas, the number of cases of Brucellosis and Amebic Dysentery
were highest in the northern rural district of Mafraq, with 115 and 262 cases,
underweight (9% vs. 4%), respectively.
Setting
Within the District of Amman, there are Refugee camp
populations, peri-urban poor communities (mainly “East
Amman” including Jabal Taj, Marikh, Webdeh, Natheef, Wihdad
and Ashrafiya) and more economically advantaged communities
surrounding the city of Amman (Mainly “West Amman” including
Shemeisani, Abdoun, Khalda and Jubeiha).
For the purposes of this study housholds and pharmacies in East
Amman and West Amman were utilized, with the East Amman
households/pharmacies defined as Lower SES and West Amman
as Higher SES.
Objectives
1) To understand actual treatment-seeking practices in the
treatment seeking process (especially self-medication) in the
event of illness at the pharmacy and household level
2) To determine types of medicines found at the household level
and knowledge and perceptions regarding common illnesses and
treatments
3) Analyze the differences and implications between the
pharmacies and households in East Amman vs. those in West
Amman
Methods
DESIGN: Qualitiative study consisting of structured household interviews
recording medicines at household and treatment decisions made for illness
episodes recalled within previous 2 weeks and a survey of pharmacy clients.
Between March-June 2003, information was gathered from households and
private pharmacies throughout the district of Amman.
STUDY POPULATION AND SETTING: A sample of volunteers in the periurban communities of East Amman and communities in West Amman comprising
30 households (Households were defined as including, at minimum a mother
and at least one child <15 years of age) and 150 private pharmacy consumers
(any age or gender ) who sought to purchase medicines with or without a
prescription) in 20 different pharmacies.
OUTCOME MEASURES: 1) Type of treatments, prescriber, source of
treatment, and average number of medicines (if any) per reported illness
episode according to SES; 2) Prevailing perceptions of medicines in
community;Preferences and perceptions related to particular drugs in the
treatment-seeking process8
Results
Table 1: Differences in East Amman (lower SES) and West Amman (higher
SES) in Average Number of medicines at household level and Average
number of medicnes taken per illness
HIGHER SES
LOWER SES
Average # of
Medicines at Home
23
41
Average # of
medicines taken
before relief of
symptoms (for 2
week illness recall)
per illness episode
1.4
2.25
Results
Table 2:Comparison by Prescriber of Medicine, Treatment category and Average
number of Medicines Bought by Pharmacy clientele in East and West Amman
Category
East Amman
West Amman
Prescriber/Referral to Pharmacy
Self or Family or Friend
30%
5%
Pharmacist
12.5%
10%
Physician (with Prescription)
58%
85%
Antibiotic
20%
15%
Analgesic/Antipyretic
22%
18%
Gastrointestinal
13%
7%
Vitamins/Natural Products
7%
8%
Cough/Cold/Allergy
13%
15%
Chronic disease and
psychiatric
13%
26%
Injections
2%
1%
Other
4%
9%
Average Number of
Medicines per Client
2
1.3
Treatment Category
Results Summary
Stratification by SES (as determined by income, employment, maternal education and residence) into lower
and higher indicated as East and West Amman ,respectively, was done after completion of study. According
to results obtained, compared with those of higher SES, the lower SES had more medicines at home (41
compared to 23) and tended use more medicines to recover from illness episode (2.25 compared to 1.4).
Also, there was insignificant difference between both groups in relation to source of household medications
with most from pharmacy a few from family and friends in both groups. Also, approximately 30% of East
Amman residents who sought to purchase medications from the pharmacy were referred to by self, family
or friends or self-medicated, compared to only 5% of those in West Amman pharmacies. There was a
limited difference ( 12.5% in East Amman vs. 10% in West Amman) in treatment recommendations
provided by pharmacist in both categories. 58% of East Amman pharmacy clients sought to purchase
medication with a physicians prescription, whereas in West Amman that percentage was the highest at
85%.
Also, 20% of East Amman clients bought to pucrhase an antibiotic, compared to 15% of West
Amman resident.s 22% and 13% of all medicines bought were analgesics/antipyretics and GI, respectively
for East Amman, compared to 18% and 7% in West Amman. Therefore, the difference in use of GI
medications seems to be almost double in East Amman, where the use of Analgesics is a high percentage
in both groups. The use of vitamins, Cough/cold/allergy medications were similar across both groups.
Injection medications where higher (2% compared to 1%) in the East Amman group, whereas chronic
disease medications, including psychiatric drugs, were highest in the West Amman Group ( 26% vs. 13%
of all medications bought at pharmacy).
Discussion
To emphasize that households of lower SES (as indicated by East Amman residence)tend to
utilize more medications is apparent in that the average number of medications per client
was higher for the East Amman pharmacies compared to 1.3 at West Amman pharmacies.
While the use of In-depth interviews would more accurately determine consensus in
the perceptions and understandings of households towards medicines, after completed the
household interviews in this pilot study, there is general concensus and a tendency in East
Amman households to believe that medicine is not only an effective, but also necessary in
treating illness, which is reinforced in the higher precentage of self-medication in this
population. It was also determnined that East Amman households preferred folk medicine
as well as pharmaceuticals in the treatment of disease more so than West Amman. While
households in both groups lacked an understanding of the importance of prevention of
illness, it was greater in East Amman. In addition, households in East Amman often
misused antibiotics and chronic disease medications by using the medicine at the onset of
symptoms and not as prescribed. East Amman households used more injections and
suppository medications and preceived injections drugs to work faster and more effectively.
Conclusion/Implications
Variations in the patterns of treatment-seeking practices associated with SES in
this population is likely linked to maternal educational status and cultural beliefs,
with practices medicine use of the poorer populations having serious health
implications with the misuse of medication and inappropriate treatment The fact
that the poor populations in Jordan, whether peri-urban, refugee or rural
populations use a higher percentage of antibiotics reinforces the variation in
disease burden in Amman and in Jordan as a whole: with the poorer populations
having more infectious disease and less on the management of chronic disease .
This is again reinforced with the high percentage of chronic disease medications
sought by pharmacy clientele in West Amman when compared to East Amman.
Hence, socio-economic variability is translated in the distribution of disease as
well as the distribution of medicines in these populations.
Conclusion/Implications
While understanding the problem of irrational drug use is a multidimensional challenge,
within this challenge is an opportunity to improve the use of drugs through public health
and pharmacy education in the poorer communities of Amman,including, but not limited to
East Amman, as SES is not only a determinant of health and disease, but also of treatment
seeking practices and the use of medicines. More is needed in the East Amman
communities in health education (on medicines-especially analgesic and antibiotics- and
chronic health conditions) and public health awareness with a focus on prevention and at
the household and community level.
Quantitative studies as well as more qualitative studies in the various districts in Jordan are
necessary in order to fully understand the drug use situation in the region to be able to
institute a national strategic program in rational drug use and public health.
The inextricable relationship between public health and pharmacy is indicated in this study,
and the promotion of rational drug use at all levels of the health care system in Jordan,
including the household is imperative in order to improve the use of the medicines, especial
in the poor communities that are more vulnerable.