Drug use and the role of patients and prescribers.

In order to move towards rational drug use in any national or local setting the methods of inquiry have to be expanded. Both the public and private sector have to be addressed. In the latter the pharmacists might be studied using a tracer, fictitious client. One important factor influencing prescribing, drug information, has rarely been assessed scientifically. Experimental studies using group randomization are, however feasible even in developing countries. The individual human being must be in the focus of drug studies and health care and health in the foreground. The combination of qualitative and quantitative methods will assist us to achieve rational drug use that is culturally acceptable, economically feasible and pharmacologically sound.

PIP: In the effort to improve rational drug use in local or national settings, especially in developing countries, the behavior of prescribers and users is the subject of the least research. The effectiveness of drugs depends on a complex set of factors involved in the situation of prescription and acquisition. One aspect that needs examination is the information given to prescribers by drug advertisers and detailers, a deficiency being addressed by an international network of prescribers. In many countries, the largest outlet for drugs is the private sector pharmacies, where drugs are often dispensed without prescription. A simple inexpensive way of researching prescription behavior is to use fictitious tracers to follow case management of given conditions, such as infant diarrhea. There are many factors involved in prescribing; the process must be studied with an epidemiologic approach, i.e., by description, analysis, intervention and evaluation. Standard treatment schedules, essential drugs lists, targeted intervention with treatment guidelines should be audited by local therapeutic committees. Drug information should also be scientifically evaluated by the same analytical principles. The experimental method of group randomization is suggested as a feasible choice for developing countries. In this technique groups of physicians are observed or interviewed, and quantitative outcome data are collected. Behavior of individual users is best studied by combining anthropological and biomedical approaches, from the case-study perspective. An example of a problem amenable to this approach is the possible use of shorter courses of antibiotic treatment to lessen the risk of development of resistant organisms.

A nonmedical approach to fertility reduction. An experimental contraceptive service unit.

PIP: A preliminary report if given of results of 3 walk-up Contraceptive Service (CS) Units started in Forsyth County, North Carolina, by the Behavioral Science Center of Bowman Gray School of Medicine that tried through an experimental and nonmedical approach to reduce fertility among young poverty-level females by focusing on young sexually active males. 552 new and 874 returning clients visited the CS units during the first 7 months of the experiment. 90% new and 98% returning clients have been male. The first clinic was opened September 1, 1968, 3 hours each evening except Sunday. In November a second clinic was opened in March. Each was staffed by a nonmedical trained counselor. A choice of condoms, foam, or jelly and instruction in proper technics in using these methods provided at no cost. Male clients have been highly responsive, entering freely into discussion. Objections to mechanical methods were removed by instruction in proper use. Most requested condoms and foam. Location accounts different degrees of success and will be evaluated in a future report. CS effectiveness should be measured in lower venereal disease incidence. Further evaluation will include excess fertility analysis and numerator anaylsis.^ieng

The role of pharmaceuticals in the total health care of developing countries.

PIP: Following an overview of the less developed countries (LDCs) and their health problems, attention is directed to what pharmaceutical companies have been doing to develop tropical disease medicinals: past and current programs for the development of pharmaceuticals; the relationship of pharmaceuticals to other health problems; criticisms of the pharmaceutical industry; problems and constraints in developing drugs by pharmaceutical firms, particularly for tropical diseases; and strengthening incentives to pursue tropical medicine research in the future. There are 31 countries in the less developed category and they have 4 things in common: poverty; a high birthrate; a young population, and a low life expectancy. At the top of the list of the major health problems in developing countries are malaria, diarrheal diseases, and malnutrition. For malaria, there is a need for something new for chloroquine resistant infections, but research looks promising. Meanwhile, the use of presently available medications in much of the world would go far towards alleviating suffering and death from this disease. For diarrheal diseases and malnutrition the principal problems lie elsewhere than with development of new pharmaceuticals. For tuberculosis and leprosy, the 4th and 5th major health problems, therapy has improved markedly in recent years, yet there is room for improvement. Of the sexually transmitted diseases, only for sexually transmitted herpes is the industry missing a solution. On balance, it seems clear that the need for new pharmaceuticals, although important, is not as critical as some of the other needs of the LDCs. If this individual is correct in maintaining that the most important problems in the LDCs are pure water, adequate food, basic sanitation, and a distribution system for already available pharmaceuticals, then the question is why is the drug industry singled out for so much criticism. The principal charges, which are discussed in detail, are as follows: inadequate research on the endemic diseases of the developing and least developed countries; the practice of "dumping" drugs in developing countries that do not sell or sell for different indications at home; labeling of products differently than in the US; permitting over the counter sales of drugs that a prescription only goods in the US; selling products whose stated expiration date has passed; and charging high prices and reaping excessive profits. The critics are the UN agencies, consumer groups, trade unions, and media writers. Much of what is said is in defense of the pharmaceutical industry. but shortcomings are also noted.^ieng

Characteristics of condom use and associated problems: experience in Bangladesh.

Data from the 1983 Bangladesh Condom User Survey (BCUS) are analyzed for patterns of condom use and various problems directly influencing their effectiveness. The survey was undertaken to explain an apparent gap between reports of the number of condoms distributed in certain areas compared with prevalence of users as reported in contraceptive prevalence surveys. These data are analyzed from behavioral and management perspectives to identify various factors influencing utilization, with potential implications for understanding and improving family planning and AIDS/STD prevention service systems. Patterns of use are related to differences in source of supply through public, free or private-priced systems, differences in urban or semi-rural place of residence, and differences in perceptions of men or women. The problem with condom use most often identified by the respondents was breakage.

PIP: This study examined patterns of condom use reported in the 1983 Bangladesh Condom User Survey, stemming from a gap between high condom distribution figures and low use reported in the Contraceptive Prevalence Surveys of 1979 and 1981. In order to study populations with high enough prevalence to analyze, only certain young, urban and semi- urban, high and middle-income groups in Dhaka and surrounds were sampled. In these subjects, condoms were the most prevalent method in urban, and pills the most common method in semi-rural couples, who used condoms 4th after tubectomy and the safe period. 20% of urban, and 30% of semi-rural couples purchased their condoms, even though free supplies were available. Reasons cited were to save time, convenience, and embarrassment over accepting free condoms. 56-60% stated that they used condoms at every coitus; 14-20% said most of the time. 66-71% of urban and 22-49% of semi-rural people reported switching methods, mainly because of side effects and complications or fear of side effects. Breakage was reported by 43% of men and 30% of women, or a mean of 3-5 breaks in a 2-3 year period. Over 10% of urban women reported allergic reactions. Implications of these findings for program managers included: charge a nominal fee for condoms in many locations; teach people that condoms have no side effects; educate new users on how to avoid breakage; possible problems with shelf-life.

The availability and cost of antibiotics for treating PID in the Central Region of Ghana and implications for compliance with national treatment guidelines.

The availability and cost of antibiotics for treating pelvic inflammatory disease (PID) were assessed in 17 drug-dispensing outlets in 5 districts of the Central Region, Ghana. The outlets included the dispensaries of 2 regional and 4 district hospitals, 4 privately-owned pharmacies and 7 chemical seller shops. The most common antibiotics available, including co-trimoxazole, metronidazole, benzylpenicillin, amoxycillin, chloramphenicol and gentamicin, were also the lowest-priced drugs. Conversely, the most expensive antibiotics including ceftriaxone, ciprofloxacin, cefuroxime and spectinomycin, were also the least commonly available. Recommended anti-gonococcal antibiotics (ciprofloxacin, ceftriaxone) may not be prescribed if they are not available in the districts.

PIP: This paper assessed the availability and cost of antibiotics used for treating pelvic inflammatory disease in 17 drug-dispensing outlets in five districts of the Central Region, Ghana. The outlets included the dispensaries of 2 regional and 4 district hospitals, 4 privately owned pharmacies, and 7 chemical seller shops. The most common antibiotics available, including cotrimoxazole, metronidazole, benzylpenicillin, amoxycillin, chloramphenicol, and gentamicin, were also the lowest priced drugs. In contrast, the most expensive antibiotics, including ceftriaxone, ciprofloxacin, cefuroxime, and spectinomycin, were also the least commonly available. Recommended anti-gonococcal antibiotics (ciprofloxacin, ceftriaxone) may not be prescribed if they are not available in the districts.

Seattle pilot project makes emergency contraception available directly from pharmacists.

PIP: In February 1997, the US Food and Drug Administration (USFDA) endorsed the use of certain oral contraceptives for postcoital emergency contraception (EC). The board of pharmacy, Washington State Pharmacists Association, University of Washington School of Pharmacy, PATH, and a public relations firm are now collaborating upon a 2-year pilot project launched in the Seattle area which enables pharmacists to provide EC under protocol. State legislators, insurers, physicians, pharmacists, and other health care groups are represented on the project's advisory board. Patients in need of EC can locate pharmacy providers, physicians, and clinics by telephoning the national hotline or through the World Wide Web. More than 200 pharmacists, mostly from chain community pharmacies, have been trained for the project. While individual pharmacists may choose not to participate, they are required to refer patients to other providers. Health system providers have thus far not applied for protocols for EC. The University of Washington School of Pharmacy will participate in evaluating the project's effect upon access to EC and reducing unintended pregnancies.^ieng

Access to health care in urban areas of developing societies.

Emphasis on rural health problems has led to a relative neglect of urban health issues in developing societies. Yet the fact that a large proportion of the limited financial and human resources is allocated to urban health care makes it imperative for researchers and health planners to evaluate the effectiveness of the urban health care system. This paper examines data on health care utilization from a sample survey of 1500 households conducted in three areas of Accra, Ghana in 1982. The factors that influence the use of three types of health care services (clinics, drug vendors, and traditional healers) are examined. Suggestions are made for increasing the effectiveness of the health care system in Accra, with the aim of making medical care more accessible to all families.

PIP: This paper examines data on health care utilization from a sample survey of 1500 households conducted in 3 areas of Accra, Ghana in 1982. Emphasis on rural health problems has lead to a relative neglect of urban health issues in developing societies. Yet the fact that a large proportion of the limited financial and human resources is allocated to urban health care makes it imperative for researchers and health planners to evaluate the effectiveness of the urban health care system. The factors that influence the use of 3 types of health care services (clinics, drug vendors, and traditional healers) are examined. An analysis of morbidity in the sampled households shows that it is relatively high. About 88.9% of the households reported 1 or more episodes of illness within the preceding month. Out of this 88.9%, approximately 60.0% reported 1 episode, 17.0% 2 episodes, 5.4% 3 episodes, and 6.9% 4 or more episodes. The mean number of reported episodes was 1.4. Most of the morbidity consisted of poverty-related, preventable diseases. The most significant variable among the enabling factors is area of residence in Accra. At the household level, those who live in Kaneshie and Kotobabi are less likely to use the services of traditional healers than those who live in James Town, a place occupied predominantly by the indigenous ethnic groups. This observation, coupled with the fact that migrants are less likely to use the services of traditional healers, suggests that many urban residents may not know how and where to obtain such services.

Mexico's population policy turnaround.

PIP: Until 1972 Mexico's officials seemed to believe that the annual population growth rate of 3.5% was not really a problem as long as the economic development rate could be kept ahead of the population growth rate. The General Law of Population of 1947 was actually promoting population growth. It was only during the 1960s that elite opinion shifted, and privately funded family planning programs became increasingly active. By 1972 the population had reached 54 million, from 20 million in 1940. President Echevarria, till then a traditional pronatalist, announced in 1972 the creation of a national family planning program, and, in 1974, the creation of a national population council. Since then the Mexican government has embarked on ambitious programs of mass communication and sex education to make the population receptive to its new attitudes. The plans have worked: by mid-1979 estimates put the population growth rate at 2.9%, within sight of the 2.5% target set for 1982 by new president Lopez Portillo. According to a survey conducted by the National Fertility Survey, by late 1976 41.50% of Mexican women of childbearing age were practicing contraception. Within the 41.50% of active contraceptors, 14.9% use the pill, and 7.8% the IUD. New channels of information and of contraceptive delivery are being explored to reach Mexico's widely scattered rural population, and to bring the average family size down to 2 children from the average of 6.5 children per woman for 1973-1975. The government goal is of a 1% population increase by the year 2000.^ieng

Indonesia's family planning story: success and challenge.

PIP: A historical overview and descriptions of family planning programs in Indonesia are presented. 85 million of the 135 million inhabitants of the Indonesian archipelago are concentrated on the island of Java, which comprises about 7% of the Indonesian land mass. The Dutch colonial government preferred a policy ("transmigration") which advocated the redistribution of population from Java to the other islands to relieve overpopulation. This policy was also advocated by President Sukarno after the Indonesian Revolution of 1940. The need for family planning was recognized by small groups, and official policy supported national family planning programs to replace transmigration programs only after Sukarno became president in 1966. The focus of the program was on Java and Bali, the 2 most populous islands. Local clinics became the locus for birth control efforts. Fieldworkers affiliated with the clinics were given the job of advocating birth control use door-to-door. Fieldworkers "incentive programs," area "target" (quota) programs, and "special drives" were organized to create new contraceptive "acceptors." A data reporting system and a research program increase the effectiveness of the family planning drive by ascertaining trends in contraceptive use which can determine where and how money and effort can best be applied. "Village Contraception Distribution Centers" bring the contraceptive means closer to the people than do the clinics. Figures from the years 1969-1977 show the great increase in acceptance of contraceptives by the inhabitants of the Java-Bali area. Steps are now being taken to alleviate the large monthly variations in the number of (often temporary) acceptors caused by the "target programs" and "special drives." The average acceptor is 27-years-old, has 2.6 children, has not finished primary school, and has a husband of low social status. Bali has shown the greatest success in family planning. It is a small island with a highly developed system of local clinics. The strong community structures on Bali encourage birth control use. Bali, which is predominantly Hindi, is more receptive to the IUD than Java, which is predominantly Muslim. In East Java, the authoritarian bureaucracy makes efficient use of its money. Central Java is making slow but steady progress in family planning. In West Java, fieldworkers are teamed with paramedics; there, door-to-door contraceptive supply was more effective than the clinic system. In many areas traditional methods, i.e., herbs, massage, total abstinence for long periods of time, etc., were favored. More educated women often do not use contraceptives for fear of side effects. The need for family planning on the outer Indonesian islands is not as great, but programs are being set under way. These programs are the beginning of an attempt to alleviate problems that could be encountered if Indonesia's population growth continues unchecked.^ieng

Condom sense and privacy.

PIP: During the last 5 years college campuses across the US have experienced safe sex educational initiatives. Commonly these programs promote the use of condoms for contraceptive use and help prevent the spread of STDs including AIDS. A significant problem with distributing condoms is developing a distribution system that ensures privacy. It people have to publicly acknowledge that are trying to obtain condoms, they will be less likely to do so than if it can be cone discreetly. At the University of Florida condoms have been sold inexpensively to students through the pharmacy at the student health clinic for over 10 years. A new initiative was started to encourage condom use and the clinic developed a new system of distribution that has proven to be very successful. Students obtain confidential request forms to order a variety of contraceptive products including condoms. The forms look like prescription forms and are placed on tables near health literature and magazine displays in the pharmacy waiting area. More than 50% of condom requests are made using these confidential forms. The student checks off which products are desired and turns the form into the pharmacy window. The order is filled and the product is placed in an opaque bag. A sales slip is generated, given to the student, who then takes it to the cashier. The slip does not identify the product whether it is prescription or over the counter (condoms). If the product is not currently available, the cashier points to the item on the slip and asks if another product should be substituted. The cashier is careful never to say out loud what any of the products are. A 100% increase in condom sales over the 1987-88 fiscal year after this new program was started.^ieng

The use of mail reminders in STD contact tracing in Ibadan, Nigeria.

Contact tracing has become the most important tool in the control of sexually transmitted diseases (STDs) world-wide, and different strategies have been introduced into it in recent years to improve its effectiveness. Of all these strategy components, index patient counselling and co-operation to do their own contact tracing by themselves has been identified as the most important one. In Ibadan, it is the only component of the contact tracing strategies that has proven worthwhile. This study has assessed the contribution of supplementary mail reminders to defaulting index patients and their defaulting contacts to our control efforts in the first two years of its usage. It demonstrates that, like the other components of the contact tracing strategies, it is not successful in improving the contact or defaulting index patient attendance, thus only contributing to success in 7 of 141 patients. The intensification of efforts towards encouraging the index patient in contact tracing must therefore be ever more strongly emphasised as the top priority in STD control in Nigeria and similar developing countries for the success of this strategy.

PIP: Contact tracing has become the most important tool in the control of sexually transmitted diseases (STDs) world-wide and different strategies have been introduced in recent year to improve its effectiveness. Of all these strategy components, index patient counselling and co- operation to do their own contact tracing by themselves has been identified as the most important one. In Ibadan, it is the only component of the contact tracing strategies that has proven worthwhile. This study has assessed the contribution of supplementary mail reminders to defaulting index patients and their defaulting contacts to our control efforts in the first 2 years of its usage. It demonstrates that, like other components of the contact tracing strategies, it in not successful in improving the contact or defaulting index patient attendance, thus only contributing to success in 7 of 141 patients. Of the 141 letters sent to defaulting index patients, 38% and 19% of them were returned as untraceable addresses by the postal services in 1985 and 1986. The remaining 103 letters were assumed to have reached their correct destination. Only 7 of these 103 index patients attended the clinic on account of mail reminders, while non of the 39 contacts to whom slips were sent came for follow-up. 11 of the non-responding 96 index patients were later traced physically. 7 of these 11 were found, 6 of whom would not return to the clinic because they felt cured. Efforts must be intensified towards involving index patients in contact tracing as a top priority in STD control in Nigeria. (Author's modified).

The economics of pharmaceutical policy in Ghana.

Pharmaceutical expenditure in Ghana accounts for about one-third of the total recurrent costs of the Ministry of Health, but in isolation this figure is a misleading indicator of economic importance. In the primary care sector up to 75-80 percent of the running cost of a health center may be accounted for by pharmaceuticals, and because the Ghanaian currency is heavily overvalued, even these proportions understate the true value of resources used on important drugs. An apparent lack of central control of drugs expenditure led to a study of the existing allocation procedures and prescribing practices. The results suggest large-scale wastage through overprescribing, often in response to patients' preferences for more costly medication. Approaches to improved planning of drug use, including the setting of expenditure norms based on recommended prescribing routines, are detailed, and it is concluded that the resultant savings could allow a sizable extension of the coverage given to rural populations by the primary health care system.

Preventing unwanted pregnancies.

PIP: This editorial comments on the recent report of the Royal College of Obstetricians and Gynecologists on unplanned pregnancy. This report followed up an earlier report which recommended that the NHS make freely available contraceptive services. Even though this came to fruition, abortion rates continued to rise. In 1990, 174,000 legal abortions were performed in England and Wales, of which 33% were women 20 years. The current report reviewed education and contraceptive services with particular emphasis on teenagers. Unwanted teenage pregnancy was attributed to the lack of education on family planning and related issues in schools. The proposal is for a flexible sex education curriculum with specially trained teachers. Curriculum would be established in national guidelines. A suggested improvement was the addition of seminars for parents and school governors on sex education, even though this means competing with GCSE's. The media should take responsibility for focusing on contraception as a benefit if it continues to promote the delights of sexual intercourse. It is pointed out the emergency contraceptive knowledge is poor. A Family Planning Association (FPA) survey reports that only 1 out of 2 pharmacists receives requests about emergency contraception. Another FPA unpublished study shows that 500 out of 1000 women receiving legal abortions did not use any form of contraception before conception. The need for emergency contraception an appropriate clinic facilities is emphasized. The report also strongly disagrees with the closing of clinics which has been ongoing since the 1974 transfer of FPA clinics to the NHS. The district health authorities must function on a restricted budget while general practitioners in FP are paid from unrestricted funds. Community family planning clinics and general practitioners in the NHS differ considerably in the services offered. Practitioners offer oral contraceptives generally, while clinics provide a wide range of methods. NHS family planning services for contraception, sterilization, and abortion must be reoriented. The recommendation is that senior specialists oversee the community clinics and general practices and coordinate the provision for legal abortion. This specialist might serve as a focus of skill and professionalism for coping with changing social values and medical techniques.^ieng

On a national drug policy for Bangladesh.

PIP: On April 27, 1982 the Ministry of Health of the government of Bangladesh, set up an 8-man expert committee to evaluate all the registered pharmaceutical products presently available, and to formulate a draft National Drug Policy. Objectives are: 1) to provide support for ensuring quality and availability of drugs; 2) to reduce drug prices; 3) to eliminate useless, nonessential, and harmful drugs from the market; 4) to promote local production of finished drugs; 5) to ensure coordination among government branches; 6) to develop a drug monitoring and information system; 7) to promote the scientific development and application of unani, ayurvedic, and homeopathic medicines; 8) to improve the standard of hospital and retail pharmacies; and 9) to insure good manufacturing practices. 16 criteria were agreed on as guidelines for evaluating the drugs on the country's market. Drugs in Bangladesh have been classified into 3 categories. The 1st is drugs that are positively harmful. They should be banned immediately and withdrawn from the market. There are 265 locally manufactured drugs and 40 imported drugs in this category. The 2nd, drugs to be slightly reformulated by eliminating some of their requirements. There are 134 drugs in this category. The 3rd is drugs that do not conform to 1 or more of the 16 criteria/guidelines. There are over 500 drugs in this category. The new drug policy will produce a saving of 800 million taka (US $32.4 million). Drug supply in Bangladesh is a problem. The public sector distributes 20% of the total. In the private sector, drugs are supplied through import and local production. Investment for research by the pharmaceutical companies is essential. The principles laid down by the International Federation of Pharmaceutical Manufacturers Associations for the supply of good medicine needs to be put into practice.^ieng

Variation in response to drugs: Part II. Environmental and nutritional variables.

PIP: The importance of environmental factors for drug metabolism has recently been established. This paper reviews the major environmental and nutritional sources of variation in drug response. Environmental variables examined include drug interactions, alcohol, cigarette smoking, marijuana, other socially used drugs, steroid oral contraceptives (OCs), and agricultural industrial contaminants. Drug-drug interactions act chiefly by induction or inhibition of the microsomal metabolizing enzyme system. The effect of alcohol on the metabolism of other drugs depends on the drug, the dose of alcohol, the duration of exposure, and possibly diet and the presence of disease. Cigarette smoke affects the biotransformation of several drugs, and smokers often require higher doses of oxidized drugs. An additive effect of cigarette smoke and marijuana has been observed, resulting in the halving of the half-life of some drugs. Caffeine may serve as a competitive inhibitor of microsomal enzymes. Chemical pollutants such as chlorinated and polycyclic hydrocarbons can alter the hepatic drug metabolizing enzyme activity. The nutritional variables examined include malnutrition, anemia, vegetarian diets, dietary contaminants, and specific microconstituents of diet. Total dietary protein has a more critical effect on drug metabolism than fat or carbohydrate. These findings indicate that many factors in each patient are capable of altering drug response. Assessment of these variables permits more rational prescribing practices. For example, most patients over age 70 or vegetarian OC users require half the usual dosage of most drugs, whereas smokers and industrial workers require higher than recommended doses. Plasma measurements are of value in such assessments. Developing countries are advised to encourage rational use of a restricted number of drugs through an understanding of the sources of variation in drug response. This requires communication between clinical pharmacologists, other clinicians, pharmacists, government agencies, and patients. A prescriber's formulary tailored to local needs is an essential component of any plan to improve drug therapy.^ieng

An action research in the delivery of primary health care through community based distribution.

PIP: In adhering to the spirit of primary health care (PHC), the Varanasi District in India began its community based distribution (CBD) project of oral rehydration solution (ORS) packets in Chiraigaon block in 1979. The CBD later included Cholapur, Kashi Vidyapith, Sewapuri, Araijiline, Haurah, Pindra, and Niyamatabad during 1980-1981. In 1989, an honorary project director headed the project and its cadre of regular paid staff. At the main office, staff included a project coordinator, technical consultant medical officer, field supervisors, and field assistants. 754 depot holders or kendra kalyan sanjojak (KKS) worked at the community level. They came from all segments of the society, e.g., farmers, teachers, individuals in business, etc. The KKS implemented the CBD and its policies. Individuals at the headquarters prepared ORS packets using the standard WHO formula. They included health information brochures about ORS written in the local language in each packet. Field assistants delivered these packets to the KKS each month at a no profit no loss cost. The depot holders then sold the packets at a marginal profit. From 1980-1983, the number of packets increased from 1725-9660. From 1980-1985, CBD workers distributed a total of 29.862 packets to all 8 blocks. Rigid social marketing criteria adopted in 1984 brought about a downturn in distribution, however. The number of families trained in ORS preparation varied from 80 in 1980 to 1688 in 1985. The number of families totaled 6919. Health education activities, such as group discussion and individual contracts, flourished at the community level which stimulated demand for ORS packets.^ieng

[The pharmacy: a health resource]. / La farmacia: recurso de salud.

In Guatemala, as is the case in many of the other Central American countries, the pharmacy is often the only health resource used outside the household. This paper analyzes knowledge, attitudes and practices of the personnel from seven pharmacies located in marginal-urban areas of Guatemala. It also studies their interaction with 3,277 users related to all diseases, specifically those related to diarrheal disease and its treatment. Findings revealed that the pharmacies' personnel handle diarrheal disease in an empirical way, using medicines to treat the cause of the diarrhea, instead of trying to prevent dehydration. There are limitations and deficiencies of knowledge and practices related to the use and abuse of non-indicative medicines, insofar as the pharmacies' personnel and users are concerned. Findings also revealed that the Oral Rehydration Salts (ORS) are not used, and prepared oral serum is used in very small amounts, because these do not fit in popular expectations of a medicine that reduces diarrheic evacuations.

PIP: Knowledge and practices regarding diarrheal disease and its treatment were assessed among workers in 7 pharmacies located in marginal urban areas of Guatemala City. In Guatemala, as in many developing countries, the pharmacy is often the only health resource utilized outside the home. Intensive observation of interactions between pharmacy personnel and interviews with 18 of the 20 owners and workers allowed evaluation of knowledge of diarrhea among the workers and consistency between theoretical knowledge and actual treatment practices. Home visits were made 5 days after observation in the pharmacy to all households containing children under 5 for whom diarrhea remedies were sought. The observations and interviews occurred between January-June 1987. The 7 pharmacies were the only ones in the area they served. 2 covered a population of approximately 64,688 and the other 5 served approximately 106,955 residents. The pharmacy owners had worked and average of 19 years and the workers an average of 4.9 years in pharmacies. 15 of the 18 stated they had learned their trade through daily practice. Few had any formal pharmacy training. The principal sources of information on drugs were visits made to introduce new drugs. The pharmacists also used the literature accompanying the medications and the reference work "dictionary of Pharmaceutical Specifications". 14 stated that their recommendation for treatment of diarrhea depended on the signs and symptoms described to them. A wide variety of possible treatments were mentioned, but in practice the antidiarrheals were most often prescribed. Only 4 of the 18 routinely explained to the mother the type of diarrhea, why the specific drug was chosen, and how to administer it. 9 provided instructions for administration only, and the other 5 provided no information. 16 of the 18 cited nutritional signs of dehydration, and lower proportions mentioned other signs. 11 of the 18 stated that oral rehydration solution should be given to prevent dehydration, 3 stated that oral or injectable solution should be given, and 4 said that the cause of dehydration should be combatted. None appeared to know how to prepare homemade oral rehydration solution. 6 pharmacies sold oral rehydration salts, but only at the customer's request. A total of 3277 contacts between pharmacy workers and users were observed in 97 hours of observation, for an average of 34 contacts per hour. 80.3% of clients requested a self-prescribed medication, 4.6% had medical prescriptions, and 7.8% followed the advice of the pharmacist. 26.4% of clients were unable to obtain their 1st choice, 15.1% because it was not available and 11.3% because they lacked sufficient funds. 112 cases of diarrhea were observed in children 12 and under and 440 in adults.

Community-based distribution with class.

PIP: The Community-Based Distribution (CBD) programs are an effort to increase the accessibility and use of contraceptive methods which do not require medical services - the oral contraceptive and the condom particularly. In those countries where community-based distribution programs are being implemented, individuals from all walks of life are usually trained to advise, motivate, and supply their peers with contraceptive information and methods. At times this is associated with various forms of financial, material, or other incentives. Although these programs usually result in an increase in contraceptive acceptors and a decrease in fertility rates, some who are dissatisfied with the results recommend business tactics. For example, 1 family planning program distributes condoms free, and they have become an accepted form of payment for bus fares and tips in many places. This same organization runs contraceptive ''supermarkets'' at bus terminals, and sells T-shirts and bikinis with family planning mottoes. In a society in which sex is a restricted subject, such tactics as these can succeed in dispelling the fears and inhibitions that have made family planning such a formidable task.^ieng

The oral contraceptive: past, present and future use.

PIP: The continued use of oral contraceptives (OCs) in the U.S. will depend in part on the response of women and physicians to the results of prospective studies concerning the risks of OC use. As of now, concerns regarding clinical risk and possible influence on permissiveness of sexual behavior have influenced OC use in this country. 8.4 million American women used OCs in the U.S. in 1978, but users of such agents have never exceeded 16% of the population within the reproductive age group. In 1977, only 12% of women between the ages of 15 and 44 in the U.S. were using OCs. The percentage has been higher in countries in Western Europe, the UK, and Canada. On a global scale, the factors which influence decisions regarding the future role of OCs in fertility control are possibly weighed differently. The basic fact is that if world population stability is to be realized by the year 2000, the number of couples who use effective contraception must increase markedly. Exclusive of China, population stability necessitates that the users of family planning in developing countries increase from the approximately 80 million couples to about 300 million. OCs can be expected to have a role in world population control, for they are, in fact, the most effective agents for reversible regulation of fertility. In the less developed countries exclusive of China, there are now about 15 million users who obtain OCs over the country. More and more the program administrators in developing countries have recognized that it is not possible to duplicate the involvement of physicians. Given the risk-to-benefit equation in most developing countries, provision of OCs through trained personnel in community-based distribution schemes or commercial retail sales programs may be justifiable when the alternative would be denial of this means of fertility control. In terms of hazard, the incidence of risk factors implicated in OC use (e.g. vascular disease, smoking, hypercholesterolemia, and breast disease) may be less in developing countries. In 1981 the Central Council of the International Planned Parenthood Federation reaffirmed that community family planning services "are well suited for distribution of oral contraceptives." The growing acceptance of these risk/benefit considerations is shown by rapid increases in distribution of OCs through nonclinical programs. OC use offers considerably less risk for most of the world than the risks of pregnancy, labor, and delivery.^ieng

The access to contraception and sterilization.

PIP: The various countries of Europe have similar conditions of access to contraceptive methods. In eastern Europe, however, the supply of contraceptive pills, coils, spermicidal products, and condoms is less than the demand (except for Hungary and the Czech and Slovak republics), particularly in Poland, in the former Soviet Union, and in Romania. Sweden and Turkey have authorized midwives to prescribe contraceptive pills or to insert coils. In Turkey, Bulgaria, Romania, and in the former Soviet Union, the dispensing of pills without prescription is tolerated. Spermicidal products can generally be dispensed in pharmacies without a prescription. Condoms are sold even in Ireland. France dose not allow the advertising of contraceptives in nonmedical journals, while Denmark encourages such advertising. Today a number of European countries regulate contraceptive surgery. In Finland, a minimum of 3 children is the prerequisite and age conditions are set (over 18 years in Turkey, over 25 years in Austria, Denmark, Iceland, Norway, Portugal, and Sweden, over 30 years in Finland, and over 35 years in Croatia and Slovenia). Sterilization for contraceptive purposes constitutes a statutory offense of mutilation in France, Ireland, Austria, Greece, Malta, and Poland. Sterilization is carried out in Spain and Italy, less so in Ireland and Malta, and there is slow progress in this regard in Belgium and France. Voluntary sterilization is legally allowed in Hungary and Romania, practiced on a small scale in Albania, and prohibited in Bulgaria. The Netherlands has the highest number of couples protected by sterilization. Most often the public family planning services are integrated in other services, such as community clinics, hospitals, and pre- and postnatal clinics. In Europe as compared with the developing countries, a very large number of private practitioners have the responsibility of informing and prescribing.^ieng