|Year : 2014 | Volume
| Issue : 4 | Page : 420-424
Impact of medicine-related information on medicine purchase and use by literate consumers
Vijay R Thawani, Kunda J Gharpure, Smita D Sontakke
Department of Pharmacology, Shri Guru Ram Rai Institute of Medical and Health Sciences, Patel Nagar, Dehradun, Uttarakhand, India
|Date of Submission||29-Jul-2013|
|Date of Decision||03-Aug-2013|
|Date of Acceptance||16-May-2014|
|Date of Web Publication||4-Jul-2014|
Vijay R Thawani
Department of Pharmacology, Shri Guru Ram Rai Institute of Medical and Health Sciences, Patel Nagar, Dehradun, Uttarakhand
Source of Support: None, Conflict of Interest: None
Aims: To measure impact of information, education, and communication intervention (IEC) on rational medicine use, purchase, and stocking behavior.
Materials and Methods: This was a pre- and post-design, interventional study. Base data were collected in first visit, using pre tested questionnaire from 500 respondents, who were of either gender, English speaking, at least graduates, permanent residents, and willing to participate. IEC was framed based on problems identified from this data. First intervention was handouts distributed in the second visit, containing information on cost saving in medicine purchase. Second intervention was a lecture session on medicine prices, rational use of medicines, and tips on saving on medicine purchase. Five articles about medicine use and price differences were published in the local newspaper, over 10 days, formed third intervention. After 1 month, post-intervention data was collected using same instrument with some additional questions. Results were analyzed by Chi-square test using Graph Pad prism Version 3.0.
Results: Awareness about price variation, self-medication, expiry period, generic and brand quality increased post-intervention. Attitudes toward new, costly, brands, injections, sharing and reusing old prescriptions changed post-intervention. Behavioral changes in stocking habits, adherence to doctors' advice, getting cash memo, comparing prices, reading labels, were seen post-intervention.
Conclusion: People carry false notions about medicines which influence their use and habits. This intervention successfully changed behavior and could bring awareness on many aspects of medicine use.
Keywords: Compliance, cost comparison, generic verses brand, media influence, medicine storage
|How to cite this article:|
Thawani VR, Gharpure KJ, Sontakke SD. Impact of medicine-related information on medicine purchase and use by literate consumers. Indian J Pharmacol 2014;46:420-4
|How to cite this URL:|
Thawani VR, Gharpure KJ, Sontakke SD. Impact of medicine-related information on medicine purchase and use by literate consumers. Indian J Pharmacol [serial online] 2014 [cited 2021 Sep 22];46:420-4. Available from: https://www.ijp-online.com/text.asp?2014/46/4/420/135956
| » Introduction|| |
Medicine use in community has a multifactorial influence.  People often have rational reasons for using medicines irrationally. To correct such irrational use of medicines, health planners need information on irrationality being practiced so that appropriate, effective and feasible strategies can be chosen.  The Ottawa charter has recognized community as an essential voice in matters related to health.  There is an urgent need for public education regarding the appropriate use of medicines, which offers potential benefits to the individual, community as well as policy makers.  Desired changes in the use of medicines through an intervention can be brought about when it is based on evidence of its use in the community and the factors influencing it.
While interventional studies have been attempted to introduce and measure the change in behavior of various stakeholders responsible for irrational use of medicines like clinicians and pharmacists, few interventions have been specifically aimed toward the end users - the consumers. This study was planned because of increasing consciousness and accessibility to medicine related information in the urban population. A household survey was used as they help assess whether and how people access the medicines, how they use them, how much they pay and the manner in which out of pocket payments for medicines affect household finances.  The aim of the study was to inform, educate, and communicate with literate medicine consumers about differential medicine pricing, and measure the impact of this intervention on awareness about proper medicine use, their medicine purchase and stocking behavior.
| » Materials and Methods|| |
This survey-based interventional pre-post design study was undertaken from October 2006 to May 2007 in five geographical divisions of Nagpur city viz., central, east, west, north, and south legislative constituencies.
Preparation of Data Collection Instrument
The planning group comprised a physician, pharmacist, survey methodology expert, language expert, and communication expert who agreed upon the design of the study and what indicators would be used for measurement. The group jointly constructed the survey instrument. Following the guidelines suggested by others,  the survey instrument was prepared, pre-tested, and shortcomings that arose during pre-testing of the instrument were evaluated, discussed, and accordingly the instrument amended.
This was followed by the selection and training of 12 data collectors (DC) of whom six were medical doctors and the remaining six were students of Master of Business Administration (MBA). The DCs were trained in two groups. They were given hands-on training in field survey methodology, while the MBA students were additionally trained in medicine-related terminologies. During data collection, investigators accompanied each DC to two households, to provide hands-on training.
For baseline data collection, DCs contacted 100 households from each area, including the respondents of either gender, English speaking, graduates (at the minimum) and permanent residents of the city who were willing to participate. Medical doctors, pharmacists, and those in the pharmaceutical business were excluded. After data management and analysis, it was realized that additional baseline information was required. Hence an additional questionnaire was prepared which was filled during the second contact with respondents, prior to the intervention. The DCs covered the same respondents throughout the study.
IEC Intervention Instruments
The interventional triad comprised printed handouts, interactive lecture session, and press releases, which were framed on the basis of the problems identified from baseline data.
The first intervention used was a printed handout, information in which was based on the pre-intervention data. The handouts were reviewed by a WHO expert. The DCs went to each respondent and distributed the handout, emphasizing and convincing them about the contained information being vital for considerable savings in their medicine purchase.
Interactive Lecture Session
The second intervention was an interactive lecture session wherein face-to-face communication with the respondents could be achieved. All respondents were telephonically informed about the session and requested to attend. The interactive session aimed at appraising the respondents with medicine pricing information. The presentations included "Medicine price overdose-who should take the blame?", "Rational use of medicines - Patients' perspective", "Facts you must know about medicines" and "How to save on medicine prices".
As part of advocacy, liaison was established with local press of Nagpur who were given a series of articles for publication, about medicine use in general, the variations in prices of generic and branded medicines and how this can affect the monthly expenditure on medicines.
One month after completing the triad of interventions, a post-intervention interview was undertaken, using the same instrument with some additional questions to find the impact of the intervention.
All statistical tests have been applied with two-tailed alternatives and 5% significance level. Pair-wise comparison of proportions for pre and post-intervention groups has been performed by using a normal test. The Chi-Square test for independence of attributes has been applied.
| » Results|| |
A total of 500 respondents were enrolled, of which 323 (64.6%) were men and 177 (35.4%) were women. The average age was 38.83 years (range 18-86, SD 17.3). Monthly income of the family ranged from Rs. 2,000 to Rs. 2,00,000 per month. Average out-of-pocket expenditure on purchase of medicines was Rs. 663 per family per month. Seven respondents were lost to follow-up during the study.
The respondents kept medicines at home for common ailments like pain, inflammation, fever, general weakness, allergy, acidity, apart from the medicines used for their specific disease on regular basis. The main reasons cited for stocking the medicines which were not currently in use was leftovers and excess from previous treatment and habitual stocking. Other responses included purchase due to media recommendation, given by family doctor or friend. This practice changed after intervention with respect to the leftover medicine stock (pre-intervention 46%, post-intervention 39%) and habitual stocking of medicines (pre-intervention 48% and post-intervention 31%) [Figure 1].
With respect to storage of medicines, there were multiple responses as some medicines are stored in refrigerators while some are kept in shelves. Around 86% kept medicines at room temperature while 11% kept some medicines in refrigerator. Seventy-eight percent of the respondents stored the medicines out of the reach of children. Of them, 9.8% kept the medicines in a locked cabinet.
It was found that 66.8% of respondents followed the treatment suggested by a single doctor while 41.6% resorted to mixing of home/traditional remedies along with modern medicines.
Majority of the respondents were aware that medicines have an expiry period (80.4%). Others were not sure about its relevance. The fact that they were not having any access to accurate, understandable information about the medicines they were using was accepted and rued by 76.8%. Around three-fourths of the respondents (77.8%) were willing to attend a free lecture session to gain more information on rational use of medicines.
Medicine use was influenced by certain fixed ideas about new, costly, brands, injections, quality of medicines at public hospitals, multinational company brands, and self-medication. Through intervention it was seen that these false notions were changed to some extent [Table 1] and [Table 2].
|Table 1: Comparison of the pre and post-intervention knowledge, attitude, and practices about medicines|
Click here to view
|Table 2: Behavior of respondents regarding medicines pre (n=500) and post-intervention (n=493|
Click here to view
Around 90% (454) respondents bought their medicines based on doctor's advice while 42 (8.4%) also used their self-perception in addition to the doctor's advice. Purchase decision on pharmacist's advice decreased post-intervention. Price consideration as a deciding factor for purchase also decreased.
Behavioral changes with respect to adherence to doctors' advice, getting cash memo, comparing prices, buying all medicines pre and post-intervention are shown in [Table 2].
The following findings are statistically significant. The proportion of individuals who followed doctors' advice and instructions to the letter showed an increase of 13.4% with a significant decrease in all other followed frequencies. Around 9% more respondents started consulting the doctor before stopping medicine. All the individuals who rarely used to buy all medicines written in the prescription started doing so. Proportions of individuals sometimes or always comparing prices of medicines show significant increase.
When asked about the factors influencing medicine purchase in general, influence of pharmacist's advice increased from 3% to 9% (P = 1.45 × 10 -7 ) while media influence decreased from 25% to 4% which was significant (P < 0.0001). Alarmingly the prescriber factor showed reduction in the percentage though not statistically significant. The knowledge regarding local taxes charged extra on maximum retail price (MRP) was very dismal before intervention as 64.4% either thought it was payable over and above the medicine cost or did not know about it. After intervention 55.98% were sure that MRP is inclusive of all taxes.
| » Discussion|| |
The WHO in its policy document for 2004-07, on the challenges in expanding access to essential medicines, has stated that unaffordable medicine prices limit access to medicines in resource poor settings. In developing countries because of high prices, medicines account for 25-70% of overall health care expenditure compared to less than 15% in most high income countries. Further it has reiterated that irrational use of medicines is a major problem worldwide.  The Management Sciences for Health (MSH) in collaboration with WHO, make the medicine price information widely available in International Drug Price Indicator Guide in order to improve procurement of medicines of assured quality for the lowest possible price.  It has been proved that comparative price information is important for getting the best price.
Quality in-depth and detailed research on medicine price scenario in India has been jointly published by Low Cost Standard Therapeutics (LOCOST) and Jan Swasthya Sahyog (JSS) who are members of All India Drug Action Network (AIDAN).  Many others have given critical commentary of medicine price information.  All these publications have been brought out in the best interest of the end users - the consumers, but it is unfortunate that such good work is not put to use wisely and widely.
It has been suggested that an IEC intervention if meticulously implemented, brings about a positive change in the attitude and knowledge of end users.  However, researchers have shown that information may not always lead to rationality. None of the studied professional sources of information seemed to have a great impact on prescribing rationality. 
We had planned our intervention based on community need assessed through first contact. It was observed that people usually kept medicines at home for common ailments like pain, inflammation, fever, general weakness, allergy, acidity, apart from the medicines used for the specific disease on regular basis. Through IEC intervention the study observed an improvement in the awareness, attitude, and behavior of the respondents. There were less people post-intervention stocking medicines which were not in use. Attitudinal positive change is evident from this finding. Respondent awareness about expiry period of medicines, maximum retail price and patients' rights was abysmal in the pre intervention stage, which improved after our intervention.
False notion about all self-medication being safe decreased considerably thus showing improved knowledge. Respondents tended to buy medicines from any pharmacy before the intervention. Respondents buying always from the same pharmacy increased after intervention thus developing a rapport and trust with the pharmacy thus showing an improvement in behavior. Patients generally respond positively to increased information as a precursor to decision-making.  Our findings are in agreement with the studies which used simple behavioral control interventions on a range of patient outcomes. 
Strengths of the Study
Methods chosen for data collection were structured questionnaire, monthly illness calendar and medicines inventory. This triangulation method was used to allow for validation of data. Sample size was chosen depending upon the feasibility of our reach, funds and quantum of data that we could handle. Sampling strategy chosen was cluster sampling, based on physical nearness of the respondents. The data collectors belonged to varied economic and religious background which made it possible to collect data from the respective levels of economic and different ethnic respondents, giving us a good mix of respondents.
The time course of the project went slightly astray due to several unforeseen reasons. The data collection schedule could not be adhered to because the data collectors were doctors and MBA students who could work only during their free time. It would have been prudent to involve full time data collectors to achieve the set target. The respondents were cooperative and willingly gave information necessary to fill in the questionnaire in the first contact. The second contact was for distribution of handouts and health calendar but we collected some additional information as well. In the third contact however there was some resistance from the respondents to cooperate and disclose information.
As far as change in level of knowledge is concerned, it was achieved through IEC intervention in this study. All round improvement was seen in respondents' behavior in medicine purchase, stocking, and use. Improvement in health spending was achieved. Many of the respondents had started saving considerable amounts in medicine purchases. The study showed some negative/unexpected impact in that while promoting generic use, discussing variation in medicine prices, the concerned pharmacists became apprehensive.
| » Conclusions|| |
People use medicines as per their knowledge, perceptions, and habits. Various factors influence medicine use. This study tried to assess the impact of IEC intervention about medicine prices. Rapid appraisal of the problem showed that people were unaware of the medicine pricing mechanics, did not consider purchase price and were not aware of the difference between generic and branded medicines. They carried false notions about branded medicines, medicines manufactured by foreign multinationals, and big companies.
We feel that such interventions can be tried on mass scale to bring in the change in medicine purchase, stocking, and use in the community. The IEC measures do bring the desired change, as was seen in this study. Social change is a slow and tedious process but once change is brought about, the impact is usually long-lasting. Community IEC interventions about medicine prices can empower the people and enable them to fend for themselves.
| » References|| |
|1.||Session notes of WHO course on Promoting Rational Drug Use in the Community. Available from: http://mednet3.who.int/PRDUC/Materials/Materials.htm#Session%20Notes [Last accessed on 2014 Jun 7]. |
|2.||Hardon A, Hodgkin C, Fresle D. How to investigate the use of medicines by consumers. WHO and University of Amsterdam; 2004. |
|3.||Health Promotion, the Ottawa Charter. Geneva: World Health Organization; 1986. |
|4.||Fresle D, Wolfheim CC. Public education in rational drug use - a global survey. Geneva: World Health Organization;1997. |
|5.||World Health Organization. Using indicators to measure country pharmaceutical situations. Fact book on WHO level I and level II monitoring indicators. World Health Organization; 2006. p. 1 , 52. |
|6.||Kaliyaperumal K. Guideline for conducting a knowledge, attitude and practice study. Available from: www.birds.cornell.edu/.../Guideline%20for%20Conducting%20a%20KA [Last accessed on 2013 Jun 16]. |
|7.||WHO Medicines strategy: Countries at the core 2004-2007. Geneva: WHO; 20 04. |
|8.||International Drug Price Indicator Guide. In: McFadyen JE, editor. Management Sciences for Health (MSH) and World Health Organization. Boston: MSH; 2003. |
|9.||Locost, JSS. Impoverishing the poor: Pharmaceuticals and drug pricing in India. Vadodara: Locost; 2004. |
|10.||Manipal Teaching Hospital Drug Information Bulletin. Drug Information Center. Manipal Teaching Hospital, Pokhra, Nepal in collaboration with USPDQI/USAID.5:1; 2007. |
|11.||Gharpure K, Thawani V, Sontakke S, Chaudhari K, Bankar M, Diwe R. Effect of information, education and communication intervention on awareness about rational pharmacy practice in pharmacy students. Indian J Pharmacol 2011;43:381-4 [Last accessed on 2013 Jun 17]. |
|12.||Haayer F. Rational prescribing and sources of information. Soc Sci Med 1982;16:2017-23. [Last accessed on 2013 Jun 17]. |
|13.||Auerbach SM. Should patients have control over their own health care?: Empirical evidence and research issues. Ann Behav Med 2000;22:246-59. |
[Table 1], [Table 2]