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Determinants and Practices: A Study on the Use of Medicines in Amman

Determinants and Practices: A Study on the Use of Medicines in Amman. Qato, Dima PharmD, MPH candidate 1 Badriyeh, Daoud, MS 2 Ruhi, Randa, MS 3. 1 University of Jordan, College of Pharmacy, Fulbright Scholar 2002, Johns Hopkins School of Public Health

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Determinants and Practices: A Study on the Use of Medicines in Amman

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  1. 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

  2. Abstract Determinants and Practices: A Study on the Use of Medicines in Amman Dima Qato, PharmD, MPH candidate1Badriyeh, Daoud, MS2Ruhi, Randa, MS31 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 self-medication) 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 treatment-seeking 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.

  3. 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.

  4. 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.

  5. 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.

  6. 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.

  7. 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

  8. 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 peri-urban 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

  9. 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

  10. ResultsTable 2:Comparison by Prescriber of Medicine, Treatment category and Average number of Medicines Bought by Pharmacy clientele in East and West Amman

  11. 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).

  12. 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.

  13. 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.

  14. 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.

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