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5a. Access: Assessing Access to Medicines at the Household Level
Social Determinants of Access to Medicines in 3 Central American Countries
1PANAMERICAN HEALTH ORGANIZATION, United States of America; 2OSDWALDO CRUZ FOUNDATION, Brazil
Problem statement: Health systems’ equity, efficiency, and quality as well as patients’ satisfaction will be difficult to achieve without making medicines accessible for all those who need them. One of the biggest gaps identified in reaching the MDGs by 2015 is the progress towards achieving access to essential medicines. Although this issue has been analyzed from different perspectives—such as price, availability and quality of medicines—the factors that influence people’s behavior regarding access to medicines have been poorly explored. This study examines social determinants that affect people’s behavior in relation to seeking and obtaining the medicines they need.
Objective: Assess the impact of social determinants on access to medicines
Design: Cross-sectional study
Setting: The study was conducted at the national level in Guatemala, Honduras, and Nicaragua. It examines both the public and the private sectors.
Study population: A total of 2,779 households were selected through a random sample. An average of 36 public health care facilities with their respective pharmacies, 5 public warehouses, and 30 private pharmacies per country were selected through a convenience sample.
Intervention: Data collection conducted from December 2007 to April 2008 included household and health services surveys and review of secondary sources. Stakeholders of all 3 countries and local PAHO officers were involved in all phases of the study. Each country was a unit of study and the results were compared among them.
Outcomes measures: Impact of the economic condition and characteristics of the household as well as sex, age, ethnic background, education level, and employment status of the head of the household over the seeking behavior/demand for and access to health care and medicines
Results:The outcomes of the multivariate logistic regression model using principal components show that the main determinant of exclusion from access to medicines is the lack of access to institutional care (OR 4.102, CI 95%); other determinants of access to medicines are the characteristics of the household (OR 0.747, CI 95%), the head of the household being employed in the formal economy (OR 0.707, CI 95%), and the socioeconomic condition of the household (OR 0.462, CI 95%)
Conclusion: Formal employment, good socioeconomic conditions, and basic amenities in the household (potable water, sanitation, electricity, adequate number of bedrooms) foster medicines seeking behavior and increase the probability of accessing medicines. On the contrary, exclusion from health care is a powerful predictor of lack of access to medicines. Policies to improve access to medicines should take this findings into account.
Funding source: Swedish International Development Agency
Household Drug-Storing Practices Among Community Residents in Paknaan, Mandaue City, Philippines, 2010
1Cebu (Velez) General Hospital, Philippines; 2Cebu Institute of Medicine, Philippines
Problem statement: The unrestricted access of home-stocked medicines promotes the practice of self-medication, which is strongly associated with irrational drug use.
Objective: To determine the prevalence and describe the nature and determinants of the practice of household drug-storing
Design: Analytical cross-sectional study
Setting: Community-based study in Barangay Pakna-an, Mandaue City, a local community adopted by the Cebu (Velez) General Hospital for its community-outreach health services
Study population: 1,209 adult respondents from households representing 80% of the total household units in the community from April to July 2010. Stratified proportionate sampling by zone of residence followed by simple random sampling was done. The median age of the respondents was 34 years (IQR: 26–44). Most respondents were females, unemployed, and had some high school or had completed high school.
Method: Face-to-face interviews were conducted using a structured data collection form with ocular inspection of the stored drugs and storage areas within the houses. Survey results were validated by a focus group discussion with one participant representing each zone of the barangay. The study was approved by the Ethics Review Board of the Cebu Institute of Medicine, and informed consents were obtained from each respondent
Outcome measure(s): Prevalence of household storage of drugs
Results: The majority (81%) of the households stored drugs. This included expired drugs and drugs without expiry dates or identifying labels. Commonly stored drugs were symptomatic medications, vitamins, and antibiotics. Drug acquisitions were over-the-counter purchases, left-over medications from previous prescriptions, donations from various agencies during free clinics and inter-household drug exchange. Most drugs were kept inside areas associated with eating such as cabinets in dining rooms and in the kitchens. Disposal of stored drugs was commonly done by throwing them in the garbage in their original form (86.5%). Reasons for storing drugs other than for maintenance for a chronic illness included convenience and immediate availability for treatment of common symptoms. Storing drugs in the homes was associated with chronic illness in the family (p<0.001) and vocational and increasing educational attainment of the respondent (p=0.05).
Conclusion: Prevalence of household drug storage was 81%. Symptomatic drugs were most commonly stored. Kitchen and the dining room cabinets were the more common storage places. A family member with chronic illness and increasing level of educational attainment were significantly associated with home storage of medications. Storage of expired medications for future use, unlabeled medications, and medications without expiry dates were also prevalent. Disposal of drugs was most commonly done by throwing them into garbage bins in their original form. This study provides support for improved patient education regarding proper drug use, storage, and disposal.
Funding source(s): None
Practice and Predictors of Self-Medication Among Urban and Rural Adults in Sri Lanka Three Decades after Market Economic Reforms
Ministry of Health, Sri Lanka
Problem statement: Self medication is practiced in all communities to varying degrees and information about it in Sri Lanka is scarce in the period of post-market economy reforms.
Objective: To describe the current practice and predictors of self-medication in a selected urban and rural area
Study design: Community-based, analytical cross-sectional survey
Study setting: The predominantly urban Gampaha district has a well developed health and pharmaceutical care network whereas the rural Polonnaruwa district has a less developed health and pharmaceutical network with poor access to medicines.
Study population: Adults over 18 years of age, irrespective of sex , permanently residing in the selected districts over a period of 1 year. A population sample of 1800 adults were selected by a stratified, multi-stage, probability proportional sampling procedure.
Outcome measures: Medication use in the 2-week period prior to the interview was ascertained. Additionally, access to medical care and satisfaction with available pharmaceutical care were measured. To determine the predictors of medication use, medication use was modeled as a function of predisposing, enabling, and need variables.
Results: Self-medication was practiced by 12.2% of urban and 7.9% of rural adults (p < 0.05). A majority had self-medicated for acute onset conditions of short duration (urban 58%; rural 67%) and conditions perceived as non-severe (urban 55%; rural 64%). Fewer symptoms, perceived low acceptability of services, and being a member of a small household emerged as significant predictors of self-medication in the urban sector. Inability to afford medical care, perceived higher technical competence of the pharmacy staff, and fewer symptoms were significant predictors in the rural sector.
Conclusion: Prevalence of self-medication, which is higher in the urban sector, is lower than the estimates reported for developed countries. Adults self-medicate mainly for conditions of acute onset, short duration, and less severity. Although medical services are available, poor acceptability of services prompted urban individuals to self-medicate. Inability to afford medical services and perceived higher technical competence of pharmacy staff prompted rural individuals to self-medicate. Findings are important to shape policy changes related to the implementation of the cosmetic devices and drug act in the country and design programs to educate consumers who are moving towards self-medication, especially in urban areas where the pharmacy trade is thriving as a profit maximization business.
Funding source: By the authors
Exploring Traditional Medicines Use by Ghanaian Households
London School of Economics, United Kingdom
Problem statement: In Ghana, traditional medicines use is both frequent and common, but up-to-date, quantitative data are not currently available, despite the National Drugs Policy actively encouraging the integration of traditional medicines and its practitioners into mainstream, orthodox systems.
Objective: The study explores utilisation of medicines from a household perspective. The primary aim is to address the gap in demand data to complement existing supply and regulatory data. (1) How does need for medicines (both orthodox and traditional) differ from actual utilisation? What characterises those who seek health care from formal institutions and traditional medical practitioners? (2) Given the same need, are the rich more likely to use orthodox medicines than the poor, whilst the poor use traditional medicines? (3) How deep is the inequity in the utilisation of medicines?
Design: The study uses a mixed method approach. The original contribution is quantitative, supported by qualitative reviews of literature. The questionnaire is based on an existing WHO household survey. Cross-sectional data were collected in September and October 2010.
Setting: The survey was administered in two vastly contrasting regions, Greater Accra and Upper West. In each region, two districts were selected.
Study population: 771 households were randomly selected in two purposively chosen regions (four districts) of Ghana. In accordance with WHO methodology, 4 public reference facilities were chosen in each district, from which household clusters were randomly selected. Households and their informants were then chosen according to eligibility criteria.
Outcome measure(s): Utilisation rates and changes in perceived benefits of using traditional medicines measured by satisfaction scores; concentration and horizontal indices to measure inequity
Results: Initial findings suggest that rural households are more frequently using traditional medicines than urban households, but do so in conjunction with accessible formal institutions. Given need, the level of utilisation of is surprisingly high. This is hypothesised to be due to the health insurance system, which covers around 95% of all illnesses in Ghana. Individuals typically use more than one source of care, mixing and matching modern and traditional medicines. In most cases, traditional medicine is a second choice. Utilisation of modern systems in general are biased towards the rich, however, whilst the poor use traditional medicines more often. Such disparities in utilisation are attributable to “non-need” factors (i.e., income) rather than severity of disease and age-sex differences. The perceived benefit and common uses of traditional medicines, however, is very high, especially in rural areas.
Conclusions: Traditional systems—particularly in rural areas—serve as critical sources of health care for many Ghanaians. Income is a key determinant of utilisation. Policymakers cannot afford to ignore this finding. In addition to the cultural importance and reliance on traditional medicines, the role income plays in health care choice will necessarily affect the utilization of orthodox medicines.
Funding source(s): Funded in part by the London School of Economics as part of a PhD project.