E-DRUG: The terms compliance and patient (cont)
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[seems some earlier moderated messages have gone missing in the
Healthnet server. Resending this one to E-drug. WB]
Herewith I would like to contribute to the ongoing discussion on compliance
and react especially on John Urquart's contribution. Too often is the
cultural context of prescribing absolutely ignored. Compliance and
concordance are western concepts, more or less useful in the western world
where patients follow, comply with or act concordant within a "western"
sick-pills-better frame of reference. My recent experience as a prescriber
in Africa (Malawi) taught me that both non compliance and poor prescribing
have their roots in the cultural setting of the health seeking behavior of
patients and the prescribers role.
Let's explain this cryptic sentence: I tried to change so called unrational
prescribing behavior in our district hospital and the health centers but
there was a severe resistance to change the prescribing patterns. For
example antibiotics were always combined with chloroquine even in the case
of an obvious skin infection. Also patients always tried to get this
combination dispensed and if one of drugs was out of stock they would try
to buy the drug on the market. It took some time to understand the
underlying frame of reference. In Malawi an infection is a disease that
makes the body hot and both prescribers and patients know that it should be
treated with an antibiotic (a very strong, coloured and hot medicine). Both
the prescriber clinical officers and nurses) and patients know that it is
dangerous if the body becomes overheated and the most rational way to
prevent overheating is the combination of antibiotics with a drug that
cools the body temperature down: chloroquine (a very strong white, bitter
medicine that cools down the body). This makes sense and you could even say
it is rational within that specific cultural setting. It seems that
prescriber and patient act within the same framework and with the same
concepts and perspective. Prescribers in Malawi used a "laymens"
perspective ( a combination of traditional and western beliefs) and this
was the root of the relative poor and sometimes dangerous prescribing
behavior of the health professionals.
Accepting the existing "hot-cold" paradigm, it was not difficult to change
above mentioned irrational combination into a more acceptable one: the
combination of antibiotics with a short course of Asperin (also white,
bitter and strong "cooling" effects) .
Anyone who invests in improving concordance or compliance can learn a lot
from medical anthropology and social psychology.
A useful model to study health seeking behaviour and to start any
improvement in the e-drug situation in non western countries is Kleinmans
framework ( A.Kleinman, Patients and healers in the context of culture,
UCLA Press Berkly, 1980). Though this model would gain in strength if it
would change into an interaction model to facilitate the study of the
incorporation and influence of traditional elements on western bio-medicine
and to describe the interaction between the different sectors in the health
sector (folk, popular and professional) and of the influence of the context
(beliefs, cusoms and perspectives) on illness, disease and the use of drugs
and medicine.
It is a pity that too often prescribing courses or quality assurance
programs in e-drugs are designed without any input from useful disciplines
and without any idea of the different local frame of references of both
patients and prescribes. It is not a surprise that they are a guaranteed
failure.
Lucas Pinxten ,MSc, MD, MPH
Netherlands
Email: lpinxten@knmg.nl [manually added by moderator; WB]
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