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clinmed/2002050003v1 (May 16, 2002)
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A survey of drug use patterns in western Nepal

Shankar PR, Kumar P, Theodore AM, Partha P, Shenoy N.

Dr.P.Ravi Shankar MD Mr.A.M.Theodore MSc

Department of Pharmacology Department of Community Medicine

Manipal College of Medical Sciences Manipal College of Medical Sciences

Pokhara, Nepal. Pokhara, Nepal.

Dr.Pawan Kumar MD Dr. Praveen Partha DNB

Department of Community Medicine Department of Medicine

Manipal College of Medical Sciences Manipal Teaching Hospital

Pokhara, Nepal. Pokhara, Nepal

Mr. Nagesh Shenoy M.Pharm

Department of Community Pharmacy

Manipal Teaching Hospital

Pokhara, Nepal.

Name of departments to which the work should be attributed:

Departments of Pharmacology , Community medicine AND Internal medicine

Manipal College of Medical Sciences

Pokhara, Nepal.

Name and address of corresponding author:

Dr.P.Ravi Shankar

Department of Pharmacology

Manipal College of Medical Sciences

P.O.Box 155

Deep Heights

Pokhara, Nepal.

E-mail: mcoms{at}mos.com.np

pathiyilravi{at}rediffmail.com

Sources of support: None

Abstract:

Background: In Nepal, traditional health care providers have an important role to play in the provision of health services. Non-doctor prescribing of allopathic medicines is commonly carried out by compounders, health assistants and other practitioners. Self-treatment in which herbal remedies play a large role is also common. Most of the previous studies have been carried out in the Kathmandu valley. As studies in the Pokhara valley are lacking the present study was carried out. Methods: The study was carried out in Pokhara sub-metropolitan city and the surrounding villages in the month of September 2001 using a semi-structured questionnaire by the health workers of the community medicine department. The pattern of drug use in the preceding 6 month period was noted. Differences in the proportion of patients using self-medication and complementary medicines according to age, place of residence and socioeconomic status of family were analysed by the z test of proportions (p<0.05). Findings and conclusions: 112 households were surveyed during the study period. 120 individuals from these households had been prescribed medications during the study period. There was a total of 164 encounters with the health care system. Self-medication was practiced by 39 families during the study period. Home remedies accounted for 18.9 % of the drugs used. 71.6 % of the respondents using prescribed medications had used modern medicines. Self-medication was more common among rural households. Improving accessibility to medicines, improvement of the government health care system and greater integration of traditional and modern health care systems are recommended.

Keywords: Drugs, Drug-Monitoring-methods, Non-prescription-therapeutic use, Self-medication-statistics.

Introduction:

Health care in Nepal is provided by both allopathic and traditional health care providers. Health care services are most effective if they are compatible with the needs and aspirations of the people. Allopathic services in Nepal can be provided by private practitioners, compounders and the government health centres. Compounders are usually persons without a formal medical education who have been working under a registered medical practitioner helping him prepare medicines, dressing the patients and doing other jobs in the clinic. They usually start their own clinics after gaining a few years experience. Traditional health care providers are classified as: a) Faith healers: 1) Dhami-Jhankri 2) Ojha 3) Pandit-Lama-Gubhaju-Pujari and 4) Jyotishi and b) Medical providers: 1) Baidhya-Kabiraj 2) Jadi-Buti wala.1 Dhami-jhankris are faith healers who by beating a drum and ritualistic chanting puts the patient into a trance. Pandit, Lama, gubhaju and pujaris are the priests of the different ethnic and religious groups of Nepal. Baidhyas and Kabiraj are ayurvedic practitioners who use herbs along with other elixirs, metal preparations etc. Jadibuti walas are herbalists who use only herbal preparations.

In Nepal due to historical, socio-cultural and economic reasons a modern health care system is not widely prevalent. So there is an increased dependence on traditional systems of medicine. Even in the developed world the use of complementary and alternative medicines (CAM) has been steadily increasing in the previous decade.2,3 In the developed countries, patients preferring CAM are generally female, of a high socio-economic class and with a more holistic approach to life.4,5 In Nepal about two decades ago studies has found that the hill people turned to their Dhami-Jhankris for much of their health care needs.6 However, these studies were mainly concentrated around the Kathmandu valley and major political and socio-economic changes have taken place in the past two decades. Many new medical colleges have come up all over Nepal and the number of trained doctors has increased substantially.7 Previously it was found that most local people preferred private dispensaries owned by so-called compounders to the free health services at the government operated health centres.8 Unfamiliarity with the medical personnel and absence of medicines were the reasons cited for not preferring the health centre. In Kaski district and other selected districts of Nepal a community fund has been set up to ensure that the health centres are well stocked with medicines.

Self-treatment of common illnesses by lay people is common in economically deprived countries.9,10 Common reasons cited for self-medication are inaccessibility of health care facilities, economic constraints and previous experience of illness. Since drug-use studies in the community and factors influencing the drug use patterns are lacking in Pokhara valley the present study was carried out.

Methods:

The study was carried out in Pokhara sub-metropolitan city, western Nepal and the surrounding villages during the month of September 2001. The respondents were interviewed by the health workers of the department of community medicine who were briefed before hand. A semi-structured questionnaire was used for the interviews. The ethnic group, occupation, average monthly family income, the number of members in the family and the address of the respondents were noted. The pattern of drug use in the families in the six month period preceding the date of data collection was noted. Details about the patient who had used medicines in the previous six months, the system of medicine preferred, the practitioner and the source of medicine was also collected. Details about the medicines, the patient outcome and the approximate expenditure on the medicines were noted. If relevant the reason for preferring complementary and alternative medicines(CAM) were also noted. Respondents were asked about any self-medication episodes in their family during the preceding six months. The reason for not consulting a doctor and details of the medicines used for self-medication was collected.

Differences in the proportion of patients using self-medication and complementary medicines according to age, place of residence and socio-economic status of family were analysed using the z test of proportions. A p value < 0.05 was taken as statistically significant.

Results:

One hundred and twelve respondents were interviewed using the questionnaire during the study period. Eighty seven of the 112 households surveyed (77.7 %) were male headed. The commonest ethnic group encountered in the study was Brahmins 34(30.3 %). Other significant groups were Gurungs 15 (13.4 %) and Chettris 13 (11.6%). Sixty one of the total of 112 households were engaged in non agricultural pursuits.

Fifty two households were middle class by Nepalese standards with an average monthly income between 1000 and 3000 Nepalese rupees (13 and 40 US dollars). Twenty two households were poor with an average monthly income less than 1000 rupees (13 US dollars). Majority of the households (66.9 %) had less than 6 members. Eighty households were urban and the rest were rural. Seventy four households (66 %) had used prescribed medications during the study period. One hundred and twenty individuals had been prescribed medicines during the period. Forty three of the total of 120 individuals who had used medicines were aged between 20-30 years. The next commonest age group was between the years 40-50.

The 120 respondents had a total of 164 encounters with the health care system in the 6 month period preceding the study. Modern allopathic medicines were prescribed in 118 encounters. The patients had visited more than one practitioner for an episode of illness. The doctor and the health assistant were the commonly visited practitioners and accounted for 28 % and 27.4 % of the total visits. Twenty eight % of the visits were to a CAM practitioner. The medical shop was the commonest source of medicines for the respondents of the study. The medical shops sold drugs both on prescription and also on demand from the respondents without a prescription. The medical shops generally sold allopathic medicines along with a few CAM remedies. In the 164 encounters a total of 217 drugs were prescribed giving an average of 1.32 drugs per encounter. Traditional medicines constituted 32.2 % of the total drugs consumed. The commonest allopathic medicines consumed were antibiotics and paracetamol accounting for 24.3 % and 18 % of the total drugs prescribed. The approximate family expenditure on medications during the preceding six month period was less than 100 rupees (1.25 US dollars) in 32.9 % of the cases and more than 250 rupees (4 US dollars) in 34 % of the cases.

Self-medication was practiced by 39 families of the 112 surveyed in the study. The commonest drug was paracetamol accounting for 41.3 % of the drugs used. Traditional home remedies accounted for 18.9 % of the drugs used for self-medication. The common sources of drugs used were the medical store and herbs and roots from the surrounding forests and also obtained from the courtyards of the houses. Among the 39 families who had taken self-medication and home remedies in the preceding 6 month period, 24 families had spent less than 75 Nepalese rupees (1 US dollar), 12 families had spent between 75 and 225 Nepalese rupees (1 and 3 US dollars) while 3 families had spent over 225 Nepalese rupees (3 US dollars).

A significantly greater proportion of individuals above the age of 30 years had used complementary medicines compared to those less than or equal to 30 years of age (z=2.46, p<0.05). CAM usage was also significantly higher among families with an average monthly income less than 1000 rupees (13 US dollars). The commonest reasons cited for using CAM remedies were faith in the practitioner and less side effects.

The reasons cited for the use of modern allopathic medicines from practitioners other than doctors were non-availability or decreased accessibility of doctors or the doctor was expensive. The reasons given for self-medication were simple illness, previous experience of treating a similar illness and medicinal herbs were easily available in the courtyard of the house.

Discussion:

The commonest ethnic group encountered in the study were Brahmins followed by Gurungs and Chettris. This corresponds to the data in the District development profile of Nepal.7 Most of the respondents in the study were engaged in non-agricultural occupations and this could be because 80 % of the respondents were residing in Pokhara city.

A total of 217 drugs were prescribed during the 6 month period which was studied. This is difficult to compare with previous studies as the population and socioeconomic parameters are different. 71.6 % of the respondents using medicines had used modern medicines. In a previous study based on the meta-analysis of literature more than 50 % of people in Nepal had used CAM remedies.1 The higher use of allopathic medicines could be due to our study population being more urban and the economic development indices of Kaski district being higher than of most other regions in Nepal.7

The respondents had visited more than one practitioner during an episode of illness. Common reasons cited were the illness was not cured, personal attention was not given by the practitioner and the patient did not have sufficient faith in the practitioner. The respondents preferred CAM remedies especially for chronic illnesses which is similar to the findings in previous studies.12,13

The doctor and the health assistant were the commonly visited practitioners. Doctors in private practice accounted for 60.2 % of the total visits to doctors. The utilisation of government health facilities was lower than that reported by previous studies in Ethiopia14 and Thailand.15 In a previous study in Nepal private practitioners were found to be more popular than the government health personnel.8 The reasons cited for the preference were the private practitioners were local people and were more accessible at any time of the day or night. A proportion of the respondents had visited government doctors as private patients when they were doing private practice in the evenings.

CAM remedies continue to be popular both as home remedies and on prescription by a CAM practitioner. Herbal remedies as shown in a previous study16 are easily available and in Nepal knowledge of herbal remedies precedes that of western medicines. CAM practitioners are usually village elders and occupy a high place in the society. Their position can be used to increase the acceptance of modern medical practices including immunisation among the rural population. There should be greater integration of modern and traditional medical systems which has been achieved to large extent in the far eastern Asian countries.17 The medical shop was the commonest source of medicines. Medical shops are common in both the urban and rural areas of Nepal and training of the drug retailers has been tried as an approach to improving the quality of medical care.18,19 The use of CAM remedies was significantly higher among persons above the age of 30 years and among families of low socioeconomic status. The use was also significantly higher among rural households. So economic criteria, lack of accessibility to modern health care systems and easy availability of herbal remedies were the common factors predisposing to the use of CAM remedies in Nepal.

Self-treatment and home remedies are a common and often necessary part of health care. The reasons commonly cited for self-medication were easy availability of herbs, previous experience of treating a similar illness and economic constraints. These were similar to the reasons cited in previous studies.11,19 Thirty nine families surveyed had used self-medication which is similar to reports in the literature.15,21 Analgesics were the commonest drugs used for self-medication. Self-medication was more common among rural households (z=3.2, p<0.05) compared to urban ones. Drug hoarding has been reported in the literature14 and distance is an important factor influencing the utilisation of health services.8 Because of the difficulty in reaching health care services and because the medical shops are widely distributed in the villages the rural population may be more prone for self-medication practices.

Increased accessibility to medicines, improvement of the government health care system and a greater integration of traditional and modern health systems will help to improve the health status of the population. Further studies to assess drug use patterns and health care needs of the population are urgently required.

References:

  1. Gartoulla RP. Alternative medication practices (dissertation). Darjeeling( India). Centre for Himalayan Studies, North Bengal University, 1992.
  2. Nilsson M, Trehn G, Asplund K. Use of complementary and alternative medicine remedies in Sweden. A population-based longitudinal study within the northern Sweden MONICA project. J Int Med 2001;250(3):225-33.
  3. Kessler RC, Davis RB, Foster DF, Van Rompay MI, Walters EE, Wilkey SA et al. Long term trends in the use of complementary and alternative medical therapies in the United States. Ann Int Med 2001;250(3):262-8.
  4. Mitzdorf U, Beck K, Horton-Hausknecht J, Weidenhammer W, Kindermann A, Takaes M et al. Why do patients seek treatment in hospitals of complementary medicine. J Altern Complement Med 1999;5(5):463-73.
  5. Furnham A, Kirkcaldy B. The health beliefs and behaviours of orthodox and complementary medicine clients. Br J Clin Psychol 1996;35:49-61.
  6. Shrestha R, Lediard M. Faith-healers: A force for change. UNICEF, Kathmandu, 1980.
  7. Sharma HB, Gautam RP, Vaidya S. (Eds.) District development profile of Nepal. Informal sector research and study center, Kathmandu, 2001.
  8. Dhungel B. Accessibility to social services in rural Nepal: a case study in Kavre district (dissertation). Bangkok. Asian institute of technology, 1983.
  9. Chaulagai CN. Community financing for essential drugs in Nepal. World Health Forum 1995;16(1):92-4.
  10. Saradamma RD, Higginbotham N, Nichter M. Social factors influencing the acquisition of antibiotics without prescription in Kerala state, south India. Soc Sci Med 2000;50(6):891-903.
  11. Sclafer J,Salmet LS, de Visscher G. Appropriateness of self-medication: method development and testing in urban indonesia. J Clin Pharm Ther 1997;22(4):261-72.
  12. White P. What can general practice learn from complementary medicine? Br J Gen Pract 2000;50:821-3.
  13. Eisenberg DM, Kessler RC, Van Rompay MI, Kaptchuk TJ, Wilkey SA, Appel S et al. Perceptions about complementary medicine relative to conventional therapies among adults who use both: results from a national survey. Ann Int Med 2001;135:344-51.
  14. Amare G, Gedif T, Alemayehu T, Tesfahun B. Pattern of drug use in Addis Ababa community. East Afr Med J 1997;74(6):362-7.
  15. Osaka R, Nanakorn S. Health care of villagers in northeast Thailand—a health dairy study. Kurume Med J 1996;43(1):49-54.
  16. Geissler PW, Nokes K, Prince RJ, Achieng RO, Aagaard-Hansen J, Ouna JH. Children and medicines: self-treatment of common illnesses among Luo schoolchildren in western Kenya. Soc Sci Med 2000;50:1771-83.
  17. Zhang X. Integration of traditional and complementary medicines into national health care systems. J manipulative Physiol Ther 2000;23(2):139-40.
  18. Kafle KK, Gartoulla RP, Pradhan YM, Shrestha AD, Karkee SB, Quick JD. Drug retailer training : experiences from Nepal. Soc Sci Med 1992;35(8):1015-25.
  19. Adjei DO, Arhinful DK. Effect of training on the clinical management of malaria by medical assistants in Ghana. Soc Sci Med 1996;42(8):1169-76.
  20. Habeeb GE, Gearhart JG. Common patient symptoms: patterns of self-treatment and prevention. J Miss State Med Assoc 1993;34(6):179-81.
  21. Oranga HM, Nordberg E. A longitudinal health interview survey in rural Kenya: potentials and limitations for local planning. East Afr Med J 1995;72(4):241-7.

Table 1: Sources of medicine sought by the respondents during health encounters

 

 

Source

No. of encounters

Medical shop

61

Health post

41

Traditional practitioners

32

Home remedies

24

Hospital

6

Total

164

 

Table 2: Number of visits to a complementary medicine practitioner according to the age of the patients

 

 

 

System of medicine

Age of patient

 

Total

£ 30 years

>30 years

Modern

66

52

118

Complementary

16

30

46

Total

82

82

164+

* z value = 2.46, p<0.05

+ The 120 persons who had been prescribed medicines in the 6 month period under evaluation had made multiple visits to the practitioners

 

Table 3: Complementary medicine use according to the socioeconomic status of the family

 

 

Average monthly income (Rs.)

System of medicine

Total

Modern

Complementary

<1000

17

19* ,* *

36

1000-3000

58

12

70

>3000

43

15

58

Total

118

46

164+

 

* z = 2.7, p<0.05 compared to the group with average monthly income greater than 3000

* * z =4, p<0.05 compared to the group with average monthly income between 1000 and 3000

+ The 120 persons who had been prescribed medicines in the 6 month period under evaluation had made multiple visits to the practitioners

 

Table 4: Rural-urban differences in the frequency of self-medication

 

Place of residence

Self-medication

Total

Used

Not used

Urban

15*

58

73

Rural

24

15

39

Total

39

76

112

* z value =4.55, p<0.05

 

 





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Right arrow CLINICAL:
Medicine in Developing Countries

Right arrow Drugs:
Pharmacology and toxicology


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