the development of a transdisciplinary approach to...
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• The Development of a Transdisciplinary Approach to Promote the Rational Use of Drugs: The Indonesian Experience
J()lw~~ I'. Prawitasari l-bdiyono
TIlt" ill'lppropri,nc ll~C or IllL'lliLincs is a LOllltllIJIl prohlem ill dcn:lopill)! c"lInlri~'< ... The ide •• o f ;) lllulti-coulHn dlilr\ to address the iSSlIl- II,IS
illili.dh disCllSS(;d in (;(;f1l1;1I1,'" in .!llly lIJi'!C) a1 a llle!.:I;I1)! of dinil"l l ph.lI"Ill,u.;olu!!isls from Asi,m ;lIlt! ,'\friGl1l t:ountr ics ,md rcpn.:scnl'llilcs of \I:iIl 'li!l'I1\Ctl[ S<.:icnc(;s ti.T Ile,llth (:\ IS I-i). ,I US-hascd non-pmfit IW,llth '-"Il, uh in)! cwn!',lIlY, Ih(; Ilrll;! Pllli<.:~ (;roup of l-lan-anl Mcdic,t1 Schuul, ,111.1 11ll' IkpOlnmc111 lit" Inh:rnalional lk,lhh CU"C Rcsc'lro.:h of K"rulins\.:;1
In'l ll Ull", SI\'l'dcll. T he In1<;rn,ltiunal Nctworl.. lin" R,l1iollal CSI: of I)TU);:"S
I I 'HL I ») lIas I:sl.lhlished hul'T in Ihl: S'lllle ~1:<1 1" II ilh Ihl: );:"0.11 of promolin);:"
11ll" 1":lli"II'11 usc uf phan\l;I..:etllic;I L~ (l{oss- Dq;n'1I1 d a1. HJ(2). Slr'llq(1cS
';,rI11111:1,,;d 10 ac hi":l"e Ihis !,(oal ,In:: (I) adopting an il11cl"discil'lin'lr~ fi 'CIIS,
l i l1~il1;< dinici l and so..:;,11 SCiClh.:c..;; (.~) cn~\~ing: in acli,ilies ol'i);:"in,"ill);:"
11'''111 rOllll1T.I - hasc.l ..:ore g:roups of imlil"iduals rnull minislril:s of hc,dlh,
\ll1il \-r,ilil·s. non-gOl..:rnnH:nul "T~'l11izali"ns allli pril",u e sc..:tor inS1i1utions
1\ 11" .11"1" l"IlillInincd 10 sll;\rin~ rL"lev;\ 111 npl:riem:es and tl'chn iC<1 1 (,'0-
"I,\'r. llil,n; (.'\) cmphasizing till" import.lIIec of IImlcrslanuin!,( bch,,, ilJural
,1"1"'< '1'. of drill! utilization ,lIld prcM:rihing:; (4) prollloting thl.: llc\"dupmclll
"I' IH"I! lksi;::l1l:d 1'..:se:l1"ch swdies leading 10 rl'p ro;lucibk ill1l'I"\'l:n1ions 10
irnpl'I'Il' drug: us..:; ;Hld C;) dcveloping: lIseful wols ti)r resl.:an;h , including
sl ;l l,d;l1"<1 IlK'lh~)ll~)lo~ies, simpli liell sampling: and .l<ll<l c~lllection siralq:-ics,
,111(1 IN'r .1(-n' ~sibk computer sufiwarc (l l'\RU O :">Jews HNr;l)_ AI pn;sclll,
si\ \'-ri\ ':II ) l'''lllllrics (G h 'IIl;l , NigLTia, Sudan, T an;(;1nia , Ug-'l1H.la ,1Il1l
Zilnh,thll\'j ,Ind fi,c A~i'm c~ )ulllr ics ( Ban !!l:ldl:sh, Imj('lll.:s i,l. N q);II, Philip
l,it1~" ,I1UI ·J ·h:lil:. nd ) 'Irl' illl.:mh..:r o)ulllrics ~,r thl: nI:1\I'~' I' ~, " hie h h()lds
l!1"h,tl :ll1d rq.:- ion,tI Illcdings,'
TI l<." r'lli"n:ll uSl' of elTU)!S lias ddim;d ill II)K5 h~ \ VI-IO l'~]lcrls as l h"sl:
il1~1 'lIln'" \I hl'lt : 'pal iCllIS r,,:cl:il l' I11nl ici nc acn ,rdi n!! 10 the ir clinica l ncnls.
III d,,,,,', Ih,11 Illl",1 thl"ir ~)I\n illdi\iduaJ rl:q\l;l'l:ll1l'lll~, lilT ,In "dcq"'l lc
A Transdlsclplinary Approach to Rational Drug Use 67
pniod of time, ami ,11 the lowesl cost to them ,md tl!!,: eommuTlit~' (WI-IO IflX7 in Santoso ((liIS,I), Irration,ll prcsnihinl!: r)(xurs. ,IS S,mloso (H)f) S;])
notes, when no dru~ thcr.lpy is imlicllnl or 'wi th Idru~s llflunprnlTn dlil~KY or lI1H:cruin S;l/ety St,lilIS; with \l'mnl!: liosa)!es, auminislr,lIion '\llli l iur,lIion: '!!llithe I:liluf\; to prl'scril~ a I\di-~nf>l\' n S;ltC, effi:clilc ,md morl' ,lfli,n lab1c dru!!' , irral i<lIl;li presnihini! as indica led h~ Sanlilso (11)1);;'1) is common in Indom:si'l. Accord in)! to a swdy dOlle h~ Ihe I\ l inisl1"~ of 11o.:allh of Ihe Republic of In<lom'sia ( , ,)XX), in eolla!wr;lIion with i\ l SI I alill Y'l~'aSaTl Indonesi,l Sl'j'lhln'l, various fi)rms of iU'lpp1'Opri,lIe USl' of tlnl)!s wcre nhsen'ed, indudinf(" polypharm'K.I' and 1lI'eT-USl' or ,l11 l iilioli<.:s and injn:rions (prim;lrily ,mlihiolics in jn:lcd withou t proplT di'l~nosis). It was l(lUnd Ih,lI oler flo per <':l'l1I of palil'T\lS rCl"cil'CII ,II 1c,ISt line injection, ami thaI the lise of injt.:ctions did 1\lIt "ary lIilh dia~nosis
Imlrl Tlesia C<ITe ~rrilip ml'mlllT~ ,,1' I,\IRU I) itKlude medicI I dilclI,rs, phartll'Ki:-'IS ,1tld mysdl: ,I dinil',d psu'hlllo)!isL Sinc!.: 1t)1}(}, lie h,lll' eollahoratell on hlo m'ljor f1.'seareh prujcrls III imprme Ihe 'Ippmpri'lle U:-'l' 411' (Int !!" in puhl il: hl',ll , h Ell'i liril"S, (jill' ~ r ud~ it110ll ed ,I con i ro lled trial 01 st\l'111l!nlup I:K!.:- III-Lln: l"llul'ali<J!1al intcrl-ell1;llns Il'rsus lil1"nl,11 sl'minars in i1l1prm i n~ the l',lIion,ti lISl' of dntl!:S in actll e di ,lt'Thlle,1 (S'1tlIOSO el ,II. 1I)~)(I).' The seco nd \I',IS a comrollt-d Irialusin!! a heh,wioUT'l1 intl'T\l'miotl, spceilil:'l ll~ Itltl'!",tcli"n,ll (irrlup I )iSClissillll (I( ,I )), III reducl' till' ltSl' .ol injecti~ JIl :-' in puhlic hea lth EKilitil'S (])r'lwit 'lsari 1] 'ldi~IJtll) el al . II)~)(I ). '
f\ thi rd '1l'li\"ity ulldl'rtah'n h.1 INHU]) l·II)"!.: l!rt)UP 11ll'mhl'rs \I,IS t~,
;l"sist Ihe I)istric! Il e;llrh Atlm inistr,ttinn til oper'lliol1'llizl' dnl)! liSt· indicllilfs in its he,llrh ddil't.:r~ s~stl'm (llimn t'I al. 11)1,-*). Thl' aelil il il's 10"]; p!;Kl' in (iutlllt1)!kidu ll )islricl, ,1h,,\11 4.:; ~illl tlletn.:s frnm Y"!!_l:lbrl 'l, whnc plll~ph;lrm'lc.I :IS wd l as tht.: IJllT-use r.f init.:ctilHlS :lnd 'Inlihiot i e~ IInc common prohll'ms (Him" l·t al. t l)1)4), ·rlll'st.: ,ll:t il"i t il'S hq::;l1l in J une 1~J9J
:tnd eOnlitllll'{1 until Auplst 11)9;; . As a dinic.tI pS~l'holo~is.t, I .~all joining I'\IRU I ) as 'ltl opportltl1it~ 10
employ hehaviour;1 1 assessment ,ltld intenenlion methods 10 promote the r,ll ion:ti use of drUb'S, cspec i ~lIy 10 enh:nKe Ihl, untll'rslallllin)! "f presaihil1)! ,ltld drug- usc beh,n-jour. One of thl' ~reatcst challen!!,es was il-,Irnint(" how 10 coliahor,lIe sucl:essfully with he:llrh seiemisls, esp!.:ci'll1y me{lil'al dlll'tllTS, as l'qu ,t l parlllt.:rs. Psych<)I~)!!i s,s II"llrking in mcdiGI I Sdl( lois 'Ifl' itll"olwd in a broad raTlf("e of clinic,d, le:1ehinf(" and rc~carc h aclil·ilies. olien umkr tilt.: kadcrship of their tlledic,ti colk'lples. As a mcmhcr of Ihe Facult y of PS~l'h ol"I!:~', (iadjah ,1\-\;1&1 U nil'ersir.l· (GMU ), I enjoy !!realer auto no11l) and ha\'e tll"re har!;'li ning pOller in del'id in!! thc n,l1l1rc of 1ll ~
coliahor,lIi\e rescarch ,lI:li\"ities ,h,111 my sol';,11 SCil·tll'l' colleagues, who 'II'!,: Med ic,ll School I;Kllh~ memhers. T o collailor;lIc on an equal lilillin)! dcnunds sdf-nHllidencc, SCCltre kl1lJ\\'lnl)!l' '1IllI a lI il lil1gtless Ir. ic,lrn :ll1d
Asia and the Pacific .s !.:(Jmmun i !.:J r ~' ,L(.:roSS discipline hound'Lries on rhe P,Lrt of ,III h:,LIlI 1\l~'lIIhers This colbhor:llion Ie;Lds (0;1 multidis6piin'lf) ,Lppro;\eh in the hegin nillt:". ;tII i ntadi ,~!.:ipl i na ry 'Lppruaeh in 11K' prou'ss ,l1\J, ide;LIi), ;L Ir;HlsJisciplina ry approadl in the loug run, JS sug~csred by Rosenfidd (1l)l)l) ;Hld Alhreeht c r aL(ltJt)H)
Building Collaboration: Towards a Transdlsclpllnary Approach
Different dist.:iplines may ust.: tile S;Lme term in difTcrcnl tontexts or wit h ;L , liffen:nT intelltk,1 me;mint:", For c~;lmplc, heahh s(.:ieTltisls often indude, ;LS qllJl ir;Lt il'e methods, any methods designed to measure non- t'\Ilgihk phYS1cJ I mailers. l!eh;11 iour,LI me,lsun:rm:nt, :Ilthough it uses scoring systems ,md llunK'r i(.::ti \;tlues, is (.:ollsidered b) hc.:;llth st.:ie rLl ists 10 he a qualitalive r'Lther th'lll qu,Lntitatil·e method, For heh:l\ioural ~nd social scientists, !.Ju'Lfit,Lli \'e mt.:tho,ls ,Lre tcchniqucs of iTllcstig;Llion tll ;1I prod uce tex tual r.Hh~>r Ih,l1\ numeri..:;!1 dat,\. AuitUlks, heliefs and hchaviours Ihal arc St.:o rt.:d in tams of str~'llgth or int~'nsit~ II) l]uesli01l1uir~'s or OhSl'T\;tlion tt, r ms, wh ile sn'n as qu,tlltit:Ltin: meth()ds h~ lIeh;\1 i~!ur;11 st.: ien tists, arc llC\erthcless srill rdcrred to ;IS Ilu,Lliu ti\,\: mt.:th(){ls h~ h~"llth seienlists, T his dinerence in point of \'iew needs to he ebl' ili~'d e;Lr1~ in , hl ' eolhlhoration or sig:niliGLllI miSUlldast'Lnding GLn r~'su f t
!\nother i ~sue th,!! ,tI'i.~es e'lr!~ in tht: t.:ol1;lhur,ltion is llt.:g-oliatioll of !!fO\llHI rules. An imporLLlLI !!rouml rule is sharing ;1 commi tment to the ~,hje(.:li\"C ()f e,L(.:h 'K,til it~. If there aI'\.' t:4mtlit.:ting interests, the c4!llahnral ion will he jeop,lflli/.nf ,HId h'l~ic t rust ;lllWUj! Ihl.' t:"l'OUp memhers will be des troyed, enllill~ If", 1'0fl,[hor,l\ion hdilfe it hel!ins, Respct't ,lIld fairness Jre rhe guiding- prilLl'iples hehiml '\llIIther ground rule, Responsihility musl Ill' sh;Lrt.:,1 from Ihe oUlser ,11111 he h'Lsed on Ihl.' e:l.pert ise of l.':Kh tl.'am ml'mht:r. He:llrh sl'ientists m'L~ not I.no\l illili'lfl~ Ilh,\1 10 e.\peCl hom social sdl.'ntists in tCfmS of IIKif P01l'1\li;,1 contrihutil)1\ It! the prolet.:t, \'il.'\\ing their p,lflieip'llioll ,LS 'Iol.en' - relluirell h~ Ihl.' fllLHling terms of som~' i nt~:rnJt i on,d '1g-~' I Kit.:s' rese'l rch proj!r;unmes, This de\'ai llation til thl' sod'll scienTists' l'ontl'ihUlion (.:;In 1c,Ld to confusion ,lIld fr llsl r,lIion filt" rlK' sud.Lf scientists 'Ihou t their role ;IS le:llll memhers. OPl.'l1 COI11-llLll1li (.:;Llion ,[ IlIong- the te;un members must he estahlished in the hq:inlling-10 id l' llIi(\ Ihe ri!!ILls ,JIld respollsihil ities of e,lch member, Open ,md shared
\Vi ll in!!ness to le;Ll'1I ,lilt! 10 eO!l1lllllllie,\le ;LCross dist.:iplin:lI,) hOllll(hlries is ,\Iso a ll ci;L I 10 s lle(.:t:ssful (.:olbhor ,\ ti oll , To le,l rn means to open olle's mind to new ,uHI seemi ngly str,lngt' ide,Ls, Ih:maining grtlu11Iled \\ithin olle's own disl'iplinl.', hOlle\'t:r, is important. T lw t:olbhor;uioll. it is 10 he hoped, wi ll t:h'Lnj!1.' the 'Luit udl.' of Ie;LIll memhers 100\;lrds their colle;lg-ues'
A Transdisciplinary Approach to Rational Drug Use 69
ellticav(IUrs. Ileallh ~e i elllisls Ililh ,\ eririeal vinl" (If rUIIl -medicaIIKrspn:lives 011 Ihe proh!cm ma) ;tn/uire ,I more open 'lII iHlllt-. T he p\l"e hologisl or the soci;l/ scientist m,l)' hecume more coner~·re in Ihe \\',1) she or he presents i(leas, r,lIher th,Ln usc leehnical j'lrgon or abslraci lerms. If leam nKmlKrs arc I\illing 1(1 learn Ii-clm cme ,molher, c(lnlmunic;uion IIc)\\s and ,I 'common language' emerges. This Vi l·\\' ,Iceords lI'i lll Ihe liruli n:,:s of;\ slud~· by J eHell cI al. (ltJ9h) in which Ihey dernonsl r:lle 11ll" import'11lcl· 01 in-group norms and Ihe power of Ihe group !II ddinc Ihe self amI gll idl' oehaviour. The co/lahoralion hegins in earnesl onCl· thl' le:1111 memlK1"S can lIIulersl,1rld eKh other's hl11j!u,\gc and est,\hlish h;lsic trust. U rukrsund ing l~ach other's messages, openness to others' ideas, supponin)! e,lch olher's \Iork, ,lIul, at times, support ing one ,l11other in person,t1 mailers :Ire norms Ihal ensure the !!; rou p's prcl(luctilit ~. Likcllise, Su rY,lw'l [i (11)97) IlClleS Ih:l l an eq ual commitment, all equ;d upenncss ,lIld ,I II i/lin g- ness 10 fespecl ol lwr opi nions arc nce(led in order /(Ir the tr'lIlsll is..:iplin;lr) rcse,Ll"ch le:l11l 10 he success ful . She adds, ho\\"el"er, th'l t the contrihution of e:u,:h [LIlli mC11l her does not hale 10 he equ,d, hut II ill dcpcnd upon proje~·1 nel·ds rh," IU\"l· heo.:n agTe~'d fnUll Ihl: St'll·" One l11elllhcr docs not h,lle I() !Cd cli sl;lIL1LIg;~·d
I\hl·n her or his contrihu[ion to Ihe projcc t is less cenlr,1 1 The pru.xss of hll il<ling- a solid c<lllah-or,lIi lln t,lkes time. Iktclre joining;
the IN RU lJ l"ollt1tr~ o.:ore !!l"OllP, I \\"a~ ill1ite~1 h, rhe he'lith sc.:1elllisr K,Lm leadn to ptTSl,1lI a papcr on the Jls~l" h olug-il":ll aspccr.~ of uhesil~ ,rl ,r Sel11in'l r. T ho.: inten t of Ihe inyit:ltioll, :l lthulIj!h I did not lnllll il ;It Iho.: time, I\;IS 10 :lSSCSS whcthl:r I w(lul.! he ,\ comp,lIihle te,11ll mc.:m hl"l". A
Lo/l"hor,llion is ,lII:llog;ous 10 a mania!!e. Altholl!!h the practi~·~· might sound Slr,l1I!;e 10 non-Imlotll"sians, j;lI 'l11eSC tradition allows till· prospel·ril e hr ideg-rootn in ,I pre-'lrrangnl tIl,ltTi:l!!;e ,md his E!mil~ to obsene the hrille ,11
a )!'lIherin [!: 'trI~l1I g-l'll h~ (l t h<.;r rami!.\" ml·mbns in onler IU dccide Ilhcll1\· r she 1I(llild mah· :l ~lIil'lhle wife ami d'Htl!hter- in- law. A fell months ,1 t"tlT Ih ~· Setllin,ll" I lias iL1lill'll to join IN RCD. I .ike :l '):II';l 11ese hrille'. I
'Icccpled, naiycl~ perhaps, lnolling; lil i le ahoul the hcalth scientists who h,rd asked nIL· 10 join tlll"ir tcam , nor l"\act l ~ \l'hal I was expected III conl r ihute. My jud!;etllent lIas thaI joini nl! IN RU D was a challeng:i ng 0pp01"wni ty to n p'lIld the application or ps~c hnlog-ical :lssessme1l1 ami intc1"\"(:ntio1\!11 [he fid d of dfllg- IISC. Jnining Ihis group lI·ollld a/so prmide ,In opportunity to colbhorall· ill\Cfllal ionally. T hesc IWO o.:onsidcr.lliollS f(lrrncd th<.; h:lsis of m y cwn milment to join 1I1l" g-roUJl One lessnn learned 11·om this c\peric.:nco.: is Ih,ll prospec.:lil't· ~ul" i al scientisl 'hr ides' necd to c011sider whc.:[hef thcy II ill he cn~lIrl'll an oppor1unilY 10 enrich their own profession,11 growth hdclre Ihc.:y decide If) e l\g :l l!~' in a 'marriage' wilh the hcahh sciet1t ist.~. I .ike marri,l!!c p,u·,nt·rs, 1l1emlwrs of ,\ l"olbhoral ile rese;l rc.:h te;lm h,llC to bc comp'Llibk· lI'i th on~· ano[hcf.
Asia and the Pacific 7. During the inaugur,llion of INHUD in J()(JO in y(li:\"\akart~. I su~gesH:d
ill\"ol l'inj! p,Hiell ts 10 promote tl1l' rational use of drugs and usi ng sma ll group discussions as hoth :11l assessmcl1! and imcncnrion \001. Focus Group D iscussions (rGDs) could he Il.~ed 10 ;ISSCSS prescrihers' and consumers' hcl id~ and pr:lct i(;es rCf.(:mling d rug- ll"~(; in rhe comnHllliry. A second seri(;s of FGD~ i;tt(;f r~'name(1 Interactional Gnlup D iscussirms (I liDs), I\'ould funct ion :IS an inlc1"\'enrioll b~ brill!;ing lOj!ether patienrs :l1ld prescribers to discuss findings from the prior rGDs. l1y parr i(;iparing in the S,[ llle group discussion. prescribers and patients could learn from sharing poi l1ls of view. The bcilit;nors, who would be clini (; ians and heh;wiouf;l l scien tists, could cdul~ lIe members (If the grou p in the appropri;He usc of mcdil"inc. Th is id~"1 met with rcsista lKc fro m the di nici,l1ls, to whom it represented a \lifTcren t way of :lpproaching the prohlenf. T he sour(;c of cliniei;ms' r(;SiS(;mcl' deril'ell mostl y from th(; fad lh.1( p;l1ie11 ts wcn: (onsidcred ignor,mT :lhoUT appropriate druj! usc. It was also cOilsidercd ullethic,Ll :IS wcll as impractical to bring togelher p:nicllls ,lIll] p1"(seril)l..·rs in the S;lIl1l' group. since prescrihers h,ll-e ;I hi j!her s!,l1l1s in !he communit y l h<l1l do p,L1icllts. C linicia ns lIere afraid th,]1 the paTiellts would h~' i n timidaT~·d h~
the di fferent ial P\lWer relat iOl1.~hip ;l1ld 1I0t S,I) ;l11ything. I 'ldrlOwletlJ:("cd their objections hut lI"()rked hard to C011lince them of the ml"TiTS of till" idca. By the sam(; t"ken.this kiml of" (;o!I:Lhol";Ltion, in which s, lt." i,11 Sl"ielllisTs panicip,lIc not onl~- in deline;l lill )! th(; prohlem hUI ,Lis" in lk-velopi ng solUTions. \I";IS lI ~'W to m~' - 'IS it 11l,1~ he to othl' r soci'll scientisTs workin g wit hin a nllrit idisciplil1:1r.l· framellork. ,VI any soci;LI scientiSTS I'ie\\, their role as deTached ohserl"Hs ;Ind cri t i(s of hcalth pr;l(;t iecs wilhout uffer inJ:(" solUTions. AS :I clinic]1 ps~'( holo~ist, r I\;IS ,L1lr'll" tl'd hy the 'Il"tinn-orientell approach of INRU I) ;]mlthc opportunit y iT ,Lfli)nlcll ti )r intl'g rating- soci;11 scicm'(: perspecT il-es in1ll tindinj! solutions 10 hl',llt h prohk-ms ra ther than criticizing- the li mit,lIiolls of th\; hiolllellic.11 nHH.lel
Thl: tirsl (oILlhor,lI il(; projcC! undcr taken W:lS an ela luation of thc dkctivcness oj" tll"O IlifTcrent edu(;,uional intl'fI"Clllion meThods - n;l1nel~,
the large grou p sCllli lur and sn1:l1l grou p bee-To-fan' discussion in the t reatment (If ;Kllte diar rhoc,1 in ehildn'n (S'lIltoso el .11. tW)ll) . The proposal was del-eloped hefore I joined tile te:lm. Thus il h,ld heen decided hy rhe team leader thaI my ini ti'll task wo uld hc 10 wriTe the FUD guides amI lead the collect ion and analysis of q uali tat il'e data on hcl icts and perceptions rchl1ed 10 Ihc tl"e'L1m~·nt of JCUll' diarrhoc:I in children. Alt hough all team mcml1efs were pres(nt durin g the d;l\;\ colleCT ion, my psycho l ()g~
colleagues ;lTl J 'lOok responsibility ri)r co nducting: III F li])s wi th mothers, p.lramcdics ,lIld mcdical doctors in si x health districts. I)at.[ !"romthl' F U Ds wcre used to (kl"ciop inten"cnt ion ma terials_ T his difTerelll iat ion of t.lsh .Illd sep;[fJTion of responsihili ty at the start of the projecT be T r;I ~ 'ed a
A Transdlsclplinary Approach to Rational Drug Use 71
muhidis..: iplin:lr} learn appro:ld, in whi..:h (':Ieh team rnemlx:r llUrked eonseeuti\'eI~ IIr enneurrenlly fmm :1 slll"(;i fi c di~iplinary pcrspcetin: 10 a~l<Iress a common problcm (RIlSl'nfielJ 11,.,2).
In dl."Signing :1I1d impl{'menting The in t..:r l"cntion, Ihc r('s('arr.; h le:Ull :ld~l rl'ssed Ihe problem from :111 intcrdis..:ipJ inary fr:lml·work . The in tervent ion strategies {'mplu),cd large group scmin'ITS conducted in :1 kU urc formal nnd faCC-III- tll:C di.~cus.~i l ln s. ' I'he ini1i:11 imcrvcnl ioll s tl":l leg-y, a singk r:u.:e- to-faee in len'cill ion, was mod ified to accllrnmml:ite my sug)("t'Sliun that sm:tll group discussions would he morc dlicicllI bce:lU.~c Ihey wuuld :llhm the te,un to cmcr eaeh health e('ntre in a single 'isi!. TO)!l'lIler. Ihe Te:rnl planned hull' IWO super\' isors from two dislriCI IW:lhh uflic('s \Ioult! l,;a rry out tbl' slllall grou p diseuss i(1n .~. The le:1111 thcn tr.lined the tl\\I supl·nisurs. who IX'C:llllc Ihe gmup f:lci lilalUrs :uul :Isscsscd :IIHI re l'ised Ihe Irnining formal. It II':IS :It this I}oint th:1I thl' tealll hc~an 10 fum;liun in a tr :rn s~li sciplin :lry m:mner. Te:lln lIIell1hcr~ mOI'ell from lIorling jointl~ hut from :1 dist.:iplinary-sJln.:ifi l.: h:lsis to l\Orki ng jo i n1 l ~ using:1 :-h:lred ee)f1cl'll1u:lf fr:ln1ewclr k th:11 tin;\\' tllgelher di.~eip l inlr~-spn' i f ie Illl'Mies, eemCl.: pTS :ll1d :lppnl:ll.:hes tel ld~lrl'ss the pnlhlel11 (Rost'n field 1 (11)1; IJS I). T his nWn"llwn l :In:onl:- Il ith wh:lI Alhrcehl et al. (llJ'CIK (10) lkserihe in the S\."(;IlI1(1 aj}pm:u:h to d{'ldopin){:I. trans~li:-ciplin:l ry rl's(';.lreh tl'lln1; ' Iliscip ji n :lr~ huund:l ries :In' blurred as n ."S(·:m:hcr:- work eoo]'H.:r:l1iwly 10 hrin),:: tu)!clher illlo snme unifiell fr: lml.:worl the di" erse l"icnll'lll :- uf :1 tol:ll l' \" pbnaticll1. inelutling the (lhjn·til"e amI :-uhj..:t.:ti\·e. Ihe n:dut' lic1I1istie :md holi.~ li c and su on ... under :1 sh:lred enl1eeplual frll11l'l\urk, lliseiplinc huund:lri(·s dis:lppe:lr :Jltog-t' llwr or :lre "tran<;l'ellllcd" :1IId :1 n~' \\ or " tr:II1Sdisl.:ipl illar) ,. I\:IY of e\"pbin ill)! :1 prohlem i~ ere:lIl·d .'
A Tran.dl sclpllnary Approach to Changing Prescriber Behaviour
T he :-ceond project umkrt:lkCI1 h~ the group W:IS nJl1 ~hCl·tl"l1 el1 l irc1) l\i lhil1 a tr:lIl sdi~t'i]llinar~ fr.lll1e\l w-k (I'r:JlI'ilas:lri I bdiyunll t·t :11. ICjI,r.). T hc Icalll e.\ p:lI1ded fU inciu,k IWO nCII ph)sil'ian te:llll 11l('mhcrs - onc from the uni\cr~il" amI the uther The me~l i l':l l unieer (MO) in Ih .. · Dist rict I-I e:lli h Office (1)1:10). T he i(k a 1 presented durin){ the in<1u!'ur:l1ion of IN RU D in It't~ W:JS formall y followed up in 1tJ92 in this study limed :11 n:dul' ing tlw Ol"er-USl' of injections in puhlic health fae;lili..:s. Although most health res(':lrch pmicel~ :Irc led hy :1 he:llth sciel11ist, I Iwe:une the prineip:11 inl('slig-:lIor and rt'eeil"e,llhe fu ll supporl of the hC:llth scien l i~l~
on the tC:ll1l :IS wel l :IS health st.:ientiSI.<; in the Districi Il c:l h h f\~l minis
trlticm (D II}\) oni(x·. T he pro i~,(·t W:IS first offercd III a dist rict he:llrh oniee in Centr:11 Jal·,I. where Iht, injet.:lion rate with no specific dill!! lIo~i:-.
11':1.'0 high . (T he dc1i\'ery of the inject ion itsel f was seen h} bOlh pa liellis
Asia and t he Pacific 72
and providers - who arc mo~ll~ p'lr,unedies - ;IS ~ cure for rhe p,uienls' cOlll plaints. Pat ient~ were injeete\i Ilith lit'lmins.) When it "'iled to gener'lIe \'n thusiaslll from the MO there, the ~llId) II,IS o i "ll~rl' d 10 (ju nullgkidul Dist rict. where the injection r,l1e II'IS 'Ilso high . T he tl .. ml worke\1 in a hi)!"hly interKlil"e way, ~haring thc t,L.sks of" wriling the propos,d, den'loping the int eTl'em ion procedure, collect in!! and ,m'llysing Ihl' \bla ,md writ in !! the nwnuslTipt IiII' publ ic;Ition. Durin!! the wri t inl! period, lhe Il\" RUD support groups in Boston , UcnC \" I and Newc,lstle 'let i n~ly rCl' itll"ed and provided \',ll uable inpul 'Ill the m,uluscripl .
Santoso (H)<)j h ) ob~en cs 111;11, 'I/\Cruse of injl'cl ions oftcn stems fro m miscolH.:ept iulis of thcir v,llue and \Jtie'lc)' hy bUlh the preseriher and the patient' To pilot- tcs t their dl"et.:tilencss in modifYing p'llienl ,l1ul prl'scriher hchal'iour wi th respect 10 injn:lion dnlg usc, ·1(jDs I\t.:rl· conducted wi th p rcslTihers !i·,lm Y,lgy,ll..arta alld l'llull tecr p'llients. l(i l ) p'lrlicip,lnls lI'en~ lllediGd dot: tors, paramC\!il's ,HId p'It icnlS, Illw Ilcre most ly nwthns. T hl·i l cumposition, in whit.:h mcmbcrship is helel"Ogl'\l\:OUS, differt"nli,\Ics thcm fi'olll F(ills, in Ilh idl mcmhership is hOlllog"cnous. ' l'l ll" ohjl·eli\"<.: of Fe , l h is 'Ihtain in)!" in lilrmalioTl, Ilhcre,Is Ih,l t of lli l)s is illl)l'lrtillg infflrm,ll ion . ' 1\10 trial I(i Ds II ere conducted ,11 the F'K"ulr~ 01" Ps}!;holo~~', l, !\II;. T he tirst lU I.) Iri,11 e.\jleriellced somc di tl icu lril·s. Tlw bcilil:llors IIcrl' per!;eil'c\1 as at l;1Cking thc perS(Ul,ll PI";h': l iee 'If" p;ll"lit.:ij);HlrS \I ilh resl lcl'l I,) iniel ri(ln lise. T he prescrihers, in p'Lrlit.:llhll", bcct ille ddcn~ill·. Idc'l lI} lhe di~cussion has to hc plc'I~;1I\1 so Ih,l1 no onc in lhe g l"Oup loses b ce. The 1<..,]) \I';lS, ho\leler, infi)fI\l,l t ile till" Ihe p'llienls Ilho g'lincd knlllllc\lgl'l lf lhe cirellnlslal1Ces in wh ich illiet.:lion.~ 'Ire ncceSS,lr), such ,IS l'm~'r~enc~' l",lTl' or tlK' t reatment of 1l1'Ijor inlCction. Thc tirst Il" i,Ll prmidcd;1Il opportunity till' Ihe le,11II to \Iorl.. together in relisin~ Ihe discussion pruee\l urc. T he strate)!) lIas dUll)!ed in Ihe seco\H1 !liD Iri,l l 10 diOl.ISl· lhe ddcnsilencss of Ihe medicd doclon; ,uHl eneour'lge Iht:m to p'lrt ieip;lll' in tC;lchint(" the p<1r;lIll~' dies ;Hld p;l1icn ts ,\holll the proper IISC of injcl·liolls.
In the !l\,lill stud~, l(j ])s pl"Ol'ell effeclil"e ill rnluci ng lhl' U~l' of injel'tilHlS. ' i'he h) p'llhes; ~.ed nwch,mism ()f hcluli'"1r dungc inl"l)II'ed re'llil~
lest ing ;ISSlIHlPli 'I IiS "h'llll l)alit:1I1 hdids, imp;\rtin[\" scil'n t ific inforlll ,uilHl ;thout cftic;lc~ of injections, and cst;\blishing )In'r norms arouml OIl"]"e!;1 injection usc hehal iour (Prawil'Isari H,u.lil"llno l'l :11. 1l)1}()). Six prescrihers ,Uld six jl;lIiell ts (mostly Illolht:rs and ,I SIlI:llI llumlx'r of Ellhers) IXlnil'i pail"d in c,lch lU I} Pl"l'scribel"s lI'el"\' ph)siei'lll lI\;ma)-t"l'rs of he'llth Cl'ntrl'S, p;lr:un cllics 'lml olher medie,11 doetol"s . . \ ps)cholog"isl ,md a diniei;tnl ph'lr m'lcologisl bciliUted thc discussions 111;\1 look plan' ill a rCSUULHII in \\-"IIIl'ls;Iri, liullun[\"kidu l (sel' Pr,\I\ il,\S,lri Hadiyoll,j l'l al. 1"li) till' lit-tails). Fi ndings fro lll prcvious llnplIl~;shl'll F(il ) rcsl';lrch identitic\1 !!'Ips helll"n'n prcscrihers' ;11\(1 eIIHSllIIK"rS' Pl"I"l'l'plions reg:uding" Ihc lise of injl'clions in
A TransdiscipUnary Approach to Rational Drug Use 73
health Cl'llIres. Prescribers ehlilllell Ih:1I it was p'lticnts II"ho asked for injec tions. In contrast, patients s,l id tha i it II' :IS the prescrihcrs who rccommemlcd givi ng in je<:t ions. on) tcSI Ilw real il)" of the si tua t ion, at the hcgi nning of the diSl.:lIssion the f,\cilit:Hors aske{l holl' many of the patients l·it lll' r prdcrred rl"\:ei\'ing injc<.:lions or rcqueslcd Ihc1I1. T his in/clr1l1ation then became the fl){;uS of dis<:ussion. Group 1l1cIllhl'rs were a lso guided tn disl·tlss the pruper lise of injections :mtl Ihe possihle risl..s of misuse. At the enll of the I GIl~ prcso.:ribcrs :Igrccd to rl'duce the misusl' of injc<:tions ami patients agrl"C{1 to inform their family and neighhnurs about their experieno.:c in the group ami not to 'lsk for injcetions un necessarily. This agrl"Cment supported the de\'c!opmcnt of pn'r norllls ahMII correct usc of in je<:tions
To assess thccffc<:til'el1t'sSof fG I)s, prescrihing su r veys wcre condu<.:ted in ;q hC;ll1h centres in the swdy :In:a three months hdilre and thrcc months after the IGDs. T hese hl',llth cen lres II'l're r..11ldnl1lly :lssigned to interl"ention and con trol grnllp.~, Presn ihcfS fmm twch e hea lth rennes partil'ipated in I(iDs :md thnsc from thl' other twd\"c health <:entres scn'ed as o.:o ntl"Ol groups. T wehe prcscrib..:rs in c,l..:h he:llth Cl'ntn' n'<:rui\(:d twd l'e p:l\iell ts. T he patients wert' ..:~ch'l11ge{1 bl' lwel'n IG I) groups s() th .. t the prcsu ihers would not he in the SMlle g roup as their patients. The preso.:rihing sun!:), was (lone rClrospect il'ciy ,It t Ill' end of the nilsen'ation period h) usi ng he;llth o.:cnlre re<.:ortls. F.;h.:h prl'suihing sun'cy, a l minimulll, <,:o]lsisled of
the last 100 c\ses of Ihe month from c:Il"h health centr e. Fijturc -1-. 1 shows a signifi!:ant lIl'crease in the use of injeo.:tions in thl'
inlerl"el1 t ion groups comparcd with Iht, control groups. FollO\ling the [(iDs, there II ,tS:1 r;lpid :lnd slahk reduction in the IISC of injectiolls from
100
~ :~ 80 , ___ -
• :2: 60
~ ~ !l:2 40 11 ~
Coolrol (n=12)
IGD(n=t2)
20+--~-~----j--+---.--~-~ Aug Sep Oct Nov Dec Jan Feb Mar
Flml HE.t.J ljst'ofilljectiunhcf'jre :l1luaft<.:r IGDs
... . Ia and the Pacific 74
the pre-illtenellt iull r;lI l' of (11.).5 ller n 'm W:.In :.I\·cngc of ,12 .3 per ccnl during Inc posi-inten ·elltion pcriud in 11K' in tl'n·ention groups. Injection u.~e also dedined from 75.6 per cent at h;\sdinl· ttl 67. I per cell I al lollowup in the conlrol g roups, hut the red uction was statistically grc;lt er in the inteT\'emioll groups (I'r ,lwitasari Ibdi )olw et al. 1cJ96) . These ch l:\ \\"ere presented 10 ;\ 11 health centre .~tarf during the fL-eJ hacl; sl·min:.lr in April teJIlJ in Ihe Gunungl;idul District I k ahn onicc.
T he coll:.lboral iull with Ihe 1\ 10 of till' GUllungkidut Uistrict HC'Jlth Onice cCflllinucJ into ;1 third project 10 adllress locally the glohal IN RUD priorit), conccrns of polypn:.lrmacy and the ()\'er-use of antihiolies ;.IIlII inject ions. Two members of Ihe IN RUD cmrntry curc group jtlincd the projccl !cam. Both afe mellical doctors.. One works \\ ith a non-~mernmenl;\l
instiluliun ;1111.1 Ihe other at the Dl'I)artment uf I lcalth .~
Twu go;\ls were juilltl~ addressell: the development of sdf- moni toring pmcedu Tcs for ra tiunal drug usc (Bimu C1 :.1 1. [(194) ;l1lJ IL"S tin~ the ;Ippliell 'ield [IlethOlls manu;11 devdoped h) IN RUL> SOCi;11 scientisb 1~ l r use in dru~ ut iliz<lI ion studies (/\rhinful el :d. IUI.). In mid- te)tjJ, thl" IN RUD tl";1111 tra ined thl" G unungkidul distl·i" he;cith administr.um s (DI-I As) in de\'eluping" tlll~ir 0\\ 11 insl rulllen ts to self-Illonitor drug pret-oe rihing. The IrJ.ining inehlt1cd all in itial wur\"'~hop in the 1)1'/\ otlice to oril"nt sl;lff 10
Ihe urgency IIf Ihe prohlem and to llll'lIl1itati\ e dru~ use ililliGllors (\VI 10 1 DAP H~H) as Ilell ;IS sdecte(1 ;Ippliell fleld 1Il(,thods, SUdl :.lS fiM,:uS group di~cussion s, in-lkpth interl iews, .~t r ucl ureJ obser\"a lic'll and queSri(Hl Il;lires. T he workshop p,l rli rip;ulls ;\bo ;Igreed to cnndU(;1 ~ prcscrihill).[ .~ur\"ey tl) asse1>S drug lise in Iht, healt h cent res. 1);11 ;\ were obtained on thl' usc of ;1I1tihiotics, injections ;lnlll"H)I~ph;lr11lacy and Ihe utllkrl~ in g: f:1CtorS illl-llIiliell through ;) pp l i e~1 lidd methods.
t\ core 01 1/\ Il';l m eomprise~1 of DHA lx'NlIlnel and ;1 Illelli(.:;ll (ItM,:lur from ;1 health centre ~ n ll "lIolher from the district hospital I\;IS d ivioe(1 intol wu groups. Ol\l" group \1 ,IS tr.llnell in developing 11uanti t;ui\·e llrug usc indicators (\V I 10 1 I)A I' HJIJ.I), wh ile Ihe other was tr.lined in de \'d nping: in~lrume li ts h,lSCll on applicll fil'i ~1 methuds. The (.:ore group then tr.lincd appointnl prcsc.:ribers al e,lell health cent re to usc the in .~ trumellIs.
T h(' rcsultin~ sd f-monitoring procedures included: (I) :t monthl) random sune), of 30 l';lSeS al each heahh centre and .10 cases at each of the suh-healt h (.:cntTl.'S 10 measure Ihc usc of :.I lltibiot ics, injections and polypharmaq: (2) 1llc'ltlthly obser vat ion of clinical encounters bel ween p;JT;ulll:dics and p;lIil·nls hy Ihe heahh cen tre nl~n;\ger; (J) nlollthly interliell'S with par:nnl'dics and p:Ltiell ts done hy Ihe hc;\lIh ccnlre's own tcam; (4) mon thl y liisclission Ililh ;11I1ll"llth eenlre sl·alT ahout ;Ippropriatc solutions 10 the problems fuuml; :md eli) Illllnlhly llleclin6'S of hea lth (Tnlre mana gers It the D I II\ to ~I iscllss till' cen tres' self-muni toring result s.
A Transdlsclplinarr Approach to Rational Drug Use 7. In I\ugust liN]. four h(':llth <:elll res wen: scleclell :n which Ihe
in:o.rrU01el1 ts wen: piloted. t\ 1:lIIagl'rs of those four health <:elll rl'S and :Ippoint<:u p:lr:lTlleJic.s in ~.It:h of Ihe fa<:i lil il'S Ilerc Ir:lim'i.l tu administer the pnM.:eJurc. .. h) ,h{'llistriel l'orl' tC:I01 . Pra\\ il:IS:lri Hadi}ollo :lnd S ur)':I\\:lIi's (11)9-1) follo\\ - up slUlly ind icatnl lh:1I wilh in Ihr{T Illolllhs of 'IJopling' the prot.:edures, Ihal.: W:IS l signijil.:Ol ll t irnprO\ cllwlll in dr ug prl.:scrihillg :IS rdlccled ill the rnluelioll of polyph:lrm:I<:Y (].S±O.2 10 2J)± O.I; P<.05),
,lIuim icrobial usc (45.S '}(,±tj.2 to zlt ~ ' )( ,±2.J; P<.05), :II1U illj l.:<: Iiun (35J'! ' }"±20.1) to 17.4 %±t'.7; 1'<.05)' Thesc l' l1couragi n),: rl'Sults led Ihe D I-II\ 10 implcl1ll'IlI Ihc sc1f-mt)nilOrin~ proceJures in all 21) health ccllIrcs in lhe llistrict, as reponed hy Su nanol1() lnd Oarmilllo (Santoso 1t)t}Sc).
Ililen i{'wS wilh thc distriel tm·dical hcalth officer, ll is trio curl' Icam mClllht.'rs, m:mal'ers alld prl'Sl:ri'~r.~ ill\oh'ed ill Ihe pilut slUd ~ rCI't.'a1c11 t"'lI, OIerall, they Ilcrc pkased Ilith IIll' IlfOl:l·duf{.'S. The~' reported Ihal Ihc pnM.:<:dun:s helped 'hl~m suhstalllially in lI1ana ginl; Ihe lISC of drul'S in IllI'ir fa<: il ilics. (l!lcslionnaires lIscll 10 ubl:Jill und erlying infiormalion l'l'l;anlin~ lhc usc ,If antibilui t:s, injcel ilO1ls :l lld p()lypharm:t(~, h(III'el'er, Il'l're fi Ollml to be less ust:fu l Ihan in-depl h intl'r\'icII .~ in lel'lllS of Ihe richness of the informati!!11 !lIe) l id ded. Additionally, it 11:1:0. found Ih:1I l11<1nthly dis,,:ussio ns al Ihe DIIA t:realctl pl't:r pressure to wnf\lTm Itl Ihe tarl;ets SCI by the h"'~J lth centres Ihcmsehes. Reports musl l~ l1l;lde prior III this I)I-IA mon thly Illeel ing. "Ii) aloid embarrJssment durinl' the I11celinl', e:lCh h"'~Jhh t:ell!rt: st rul'e to Ilieel its m"nthly targcts in t.,()l1lpl i:lIlt:e lIith the lllonilOrinl; procedures, as reJlorted b) SUI1<lftollO ;t ll il DarminttJ (Santo)S\) 1t,1},:;e. It)'},:;d ).
The sdf-lilon iloring procedures Ilel'e .,u hseli llent l) :Id"plell h} I Ill' Ik p:l l'fmen i 1,1' Ilcahh III' the Repuhlit: .11' Imhonesia in delelopin~ 11l:tIl;tgcmen I gui dd incs till' ra tion:ll medi<:ali(Hl u!>c in health n 'j( nldn, wa ru(ljo et a1. 1t}t}fJ). I.)i ~eussion , inteTl'iew and ohsenalilln llledlOds Ilerc ind ude.1 ;n the mOllitorinl; prnccdurcs, atong wilh .Irug usc indi"'':Iturs. CIc;lrly, the Ihird prujet:t lias suct:cssful in del'elnping pro\.:cdurcs for impnll'ing presl:rihing in the I1:lIional he,lt th delivery s)':. tcm.
In 1t}1)-I , INRU O corc g roup memhers began a foort h stUll) in eullaboration II ilh Do:nn is Ross-Degn:ln, tine of the sUPllOrt group memhers from I'i:t rl'anl Universit); 10 examine drug utilizat ion rates in health ecnt res filllnwing the initi:11 in tervcntion in 1t,92 :I1lU thc implcmcnl:llioll of the sclf:'nlOniloring pr()(;cdures in I(}ln :mrJ 1t}94 .' Results of ;t lime series an:ll ysis indit:ateu that the lise of injections in gencT<ll, wi lh no specific typc uf 1I'e:lll11ent, was :o. UhStollll i:llly redu .... cd from 72 pcr Cl'1l1 tu 16 per <:en l in health centres thai were im'oll'ed lI'ilh the IGIJ, and from fiX per <:cnl \II
.ll per ... -en t in the health (;entres initially at: ting as colltrol groups, There \Ias less of a reduction in the usc of antibiotics, but the trend was nne of
Asia and the Pacific
100 IGO
J J Dissemination of IGD results
J District-wide
Control (n" t2)
Healtt>c:entresundelWenC:-, ~-~, IGO(n"t2)
10 15 20 25 Monl h
7.
decrcasin:; usa!;e. NUl1lher of drl1 f..'"S pre~erillL"d tendnl to dn:rease as weil. The l inK series ,lT1 ,llys;s shllws tlut lll'h,]lioural in ler l'enli l)l1s ( IG I) and sel f-monitoring) h,wt· h,ld ,I s ll h~t,l nti,11 impKt in impnlving appropriate prescri hing in he;llth n'nl ]"es in (;lInlln~k i dlll 1) 11 1\, l'sptcially wilh res]lCl.:t 10 Ihe usc of injections. II is t'ondu dnl th;lt heha\"iull ral ;1l1e]"\"entioIlS combim:d \Iilh m'Hlageri,.1 in let"l't' luions an: effective in n:dm:ing the o\'erllSl' of injeelio ns alld imprming OWLI II prescrihing. F igure 4.2 shows rhe t ime series a n ;l l ~sis wilh n:spt·U 10 injcction usc till1uwing heh,1\' io l1 ral an d mana gerial iuterl"t"lltil llls
It ind iGl\t's a deerc;\se in ;nj t'cuhlc drug usc hOlh in tht· KiDs as wdl as control ~!TOUPS ,I lkI' till' l(;D Ii.."edhad semi nar in i\pri l IIJtJJ. !\hholl gh bUlh experimen tal ;lI Hl control groups Icnded 1IJ rClluce Ihe usc of illjeuions to a minimal lelC!. Ihe eXIll"rillll."ntal grou ps dill so morl." th,Hl thl." eonlrol groups. From Ihis il can Ill" coneiudnlth;lI the llissemination seminar also h;ld a significan t cfl i:cl on injccl ion prescrihing in all he;llth centres. While it is not possihle to sep;lf;l1e the imp,lct (If Ihe IGDs from th ;11 of the subself uent imp1cTllcllf;lticm of Ihe sclf-mon iroring pn»ce(lures, the existing li teraw re in hch,ll' iollral sciences offers dues ahout hoI\' e;lch of the s tr:lt egies might h,1\e ill(\un·d changes in prl."scrihi ng: hchaviollr.
Influencing Changes in Prescribing Practices
SWllies in social psychology indicate Ih;\ t group memhership e;Hl result in bdu l' iouf ch;lI1g:t· hy ind il iduals wbo lend 10 comply with g:roup norms
A Transdlsclplinary Approach to Rational Drug Use 77
and IlL"(: r pres.~tlre (l\bek i(' d al. JI}9o). In :I<I<li l ion, l;IHlpcr:n ioll , l;ollsenSliS and confnrmilY arc promoled (Orlwll el al. H)SS; \Vri~h t cI :\1. J()9o:Jetlell el :\1 . 11'1)(')' Group rno.:mhership has imporunt me;rnin J;:' filT inuonesi:ll1s As a oroad cul tural generalizarion, Indonesians hdic\'C in harmony. They arc deserihed a.~ hal'ing a rdativd y passi\'e aHitude t(J\\',mls life, crnph:lsizing qu iet secu fit y, self-control, nmfimnity and grnup-orie1llcd beba\'iour (I-bd iyono and Kahn I I)Xj). Joining thc IUDs sels up norms II) he 'Iweed upon and J()lIowed. At the end of each IGD, parlicip'lIlts IOgelher usuall y prod'limed their commilmen! 10 red ucing injeL'lioll us~' in their Elcili t ies Patients also COlll mi lled 10 share their expe ri ence in Ihe g-roup and teach their neighbours aoout Ihe unnecessary usc of injet.:Tions. T his Illi!!ht be why memhers of hc,llt h centres inl'olwd in the IGDs reduced their usc of injections rnore than did the c(l11lrol groups.
Group norms ami peer pressure werL' likdy to h,m: also contributell to Ihe success of the IGO fcellb,lCk semin,lr in hri nging aholl! chan ge in prescrihin g hehal"ilJu r. This ,se,;minar 1I",1S co nductell in a scmi-fi,rm;11 way al Ihe DH /\ office. In the fi rst halC \I,l1a on injectioll d rug- USl' in indivillu:11 heal th centres were presenled, while the second half was usell lilT O IKIl
discus~ion. SurY;lw;II'i hegan her presentation h~ cOl'ering the names of the he;tlih centres with !he,; highest r;lIes of injection. T he audienec askl'll her to 1'I:mlll'e the cover, which she did with Ihe permission of !hosc asscmhled . E\e,;rymle II'JS "ble to sec which health I.:l·nlrcs had the highcs! rJte of injeL'l ion drug usc. Auuience me,;llIhers st;\fted to mock one anOlhcr. );11 anesc culture permits the usc of hUlllour as a Illeans of mOlli r~' ing heh'lI'inur. T hc rule is Ihat eOKh part y OKcep!s the mocking as humour; ofli.:nce should not he giwll or t'lken. Control group memhers jok i ngl~ eomplainl'd :Ihout !he fact that they lI'ere nOI invited (0 thl' n:st,Hlran t where the IGDs werl' held. Food ,In<l wget herness lilr j 'll'anes(' arc wry impOfl anl. S uch;j group ;\I mosphere is :1 vehicle for persuading people to til!lOW cer!,l in norms.
The impact of self-mon itoring nn prescrihing hehal'iour may lil' in its st rcngt h as a technillue filr modifying se,;lf:"'colll rol. l-kh,1I'iuur Illodi licat ion theory (lpcr,nionalizes heh"viour,l] problems as hehavioural lldicits (the loll' occurrene,;e of an appropriate behaviou r) aml/ ur bch;lvioural excesse,;s (t he occurrence of hehaviour is too high) (Martin and Pe;lf 111(2). Polypharmacy and the over- usc of antibiotics and injections C;1I\ he viewed as heh,lI' iour:11 excesses ,hat C;1rl he nlOdilied hy systenl'l licllI y observi ng one's own behaviour (Kazd in 19(4)
Systematic sclf-obser l',uion was employed in the G UTlungkidu l scl f ~
mon itorin g: prol;ed ures. First, c;leh mont h health ce111 res eompktell observation forms that .I IIOlI'ed suiT to cllmpare drug lise from lllonth t" mont h . The lilTm was also sent to Ihc Ol-lt\ lilT rev iew. To ensure that !II\' procedure is carriell 0111 , there is a weekly sT;IO' llleeting of Ihe (listriUl'lH"l'
Asia and the Pacllic 78
tcalll, tu tliscuss thc results (If each he~lt h cem re's moniwring-. Second, ,1 Illonthl y D I-\A level mcet ing- fo r healt h centre managers is held 10 ]"l'p"rt on ,md discuss monitoring- results. Thi rd, random feedback and su pervisory visi ts arc 1ll,IJ e to he,l1th centres hy th<: distr ict core te,II11, ,IS reponed h) S unart( ln(1 and lh rminto (S,llltosO I()())C)
From ,I transdisciplinary perspective, ti le success of the i1l1 erventiolls in ad(lressing; ra t ion'll drug: us<: in he~lth cent res 1ll,1)' be hugely due to the acti\'e P,ITti<:ip,lI ion and bro,ld <:o lhlhor.nion of the te,lm memheTs. T he ao.:adem io.: ians pTovide teelmical ,Issist,mee in developing the fCcdh<h.:k system ,HId su pporting ti lilow-up hy .~ending visitors to ohseTl'e the he,llt h dc1 i\'ery system in Gunu ng:kiJul Jistr i<:!. T h<: district m,Hl,lgcTS havc imeg:r,lted rest',ITch methods into thcir l\I,mageri,d f<:edb,lck proecdure~. l\lan,lgers in health centres fac il it,lIc di scussions in their OWI.\ f,lciliti<:s regard ing prohlems arising e,l<:h 1II0n th. T h<:se month l), discussioils allow prohlems 10 he ,lddr<:ssed as soon ,IS they .. rise. Sun:lrtono et al. (HJij7) ,Idvisc [h,1I fcedb'lo.::k fmm the 1)11.1\ is 10 h<: continuousl)' eondu<:l<:d celch mon th to prescnc th<: ch,mg"<:s in drug; usc in Thc heellth centres. T he r<:suh ing lr,ms(l isciplin'lry 'Ipproach pJr,ll lcls the 'Ipprmdl deserilK'd by AlbrelhT et al. ( II)\)X), II'h<: r<: ,11 1 members ()fThl' tealll IIl' re ,lc[il'l'ly In\,oll'<:d in (lcvc1uping eommnni [y-b:lse(1 IWelr [ (l ise;lse pre\"e l ltl~m illltl,ltll'es.
Impacts of t he IGD, Feedback Seminar and Se lf-monitori ng
IlItl·f\·ellt ioll .\ IILI~ prmhu.:c ill iendl"li a.~ \l'dl ,IS Uninlcnde(l impacts .nld e,IUSl' h,lrlll ill addiliull 10 Ill·nelits. Positin- impacts of the inter\'en l iuns ill G UlI lllll!kidlll illcilldl' 'Clerell ehallges ill hC:llt h Cl'ntf<: clillieJ.1 pracl ie<:. TIll' prl·serih..:r\ hq~all to lise lTeatlllelll guidelines llIore freq uently in ';elrilll! 1<11' t lw palil·lIIs. Making simplilic{l gu idel ines el\'<li lahle in e,leh of [he health lTll trt'S 1lI;\.I support more aeeumte dia t;nosis and Ie,td to :t ppropri:ltl' dru~ prl·scribillg. Greater !"".ltionalit) ill the usc ami supply of d ru),:s ill etch health bcili t} can lead TO cost s,l\'ings
Prescrihers ind iGtted d uring the I Gl)~ th,lI they feared losing patients if thq (l id not meet patient deman ds lin injection. T heir fears proved to be lInlilllnded. Patient allendance at health centres d id not decl inc. In fact, it rema innl the same in all hcalth celll res. In a FG I) fo llow- up study wi th prescribcrs in April 11195, some sub-health cCnlrcs rcported that they lost p:ll ient s ali er red ucing their usc of in ject ions. I lo\l'el'er, they could not provillc CXKt numbers of patients to support their cla im.
Anot her unantici pated, yeT posit ive, impaCl Il aS:1Il apparent i n (fca~e in com muniTY health ed ucation. Consu ltation Time increased from two minutes to five minllles. Providers began to explain how to lise the d rugs given, thc side-efli::cts, and also the Il lllri tio nal fac tors Thai ~holiid be cunsidered by
A Transdlscipllnary Approach to Rationa l Drug Use 7 9
the p'l tiell1. Sur)'<l\\';\t i and I ohserved this dming 1(llIow- UIJ nbsena tions ami interviews in April and May of llJl).j. lI'ith providers in fimr he,l lt h ce1l1n:s in voked in the IUD as well ,IS the self-lllonitoring pro..:ellures." We 1e,lnled in ,Ill int<.:r \' icl\' with th..: medicil offi..:n of the distri..:! health offiee Ih,lI he in tenti ..:d 10 im plement the self-monitoring pnK.·edures in all hcalth n :l1 t r..:s ill Ciunungkidul dis trict so th,Lt his suteessors migh t fo llow it. Alt hough he 1l10\cd to another distril:t 19lJ5. the system is s till ill ph1o.:l' .
T he ..:onti nucd use of the system is ,[ Iso supported hy the fa..:t that (1M U Centre for Clinicl l Pharmacology and I)rug Polic) Studies has serve(1 as a Wi lD coll,loorJ ting ..:e ll tre since 11)95. G uests fro m Imlia. lv\pnmar. Nepal , Vielnam and dsewhl·'·C h;lVc visitcd the dis tr ict \I) karn how the system optmtes. These visits helpcd to rcillliJr..:e thl' system's merits ,lmlHlg (I i~ t r i ct he;Llth per.sonncJ
T he mellical doctors who part icip,ltcd in tlw li)lIo\\"- up F U Ds ill April 1l)1)) SUted that the) had I1c\·er IIc;\nl of IGD. When ash·d ahout prescrihing injcl."tiom. they s~ i ll th;Lt p,lt icnts did lw t ;LS\.. fi)r spe..:ilic tre,lImeli t llr injeet ilHls. \\'e cln h~' pothesize that ,Incr thc IG l ls, patil·n ls· :lwarcness improved rcganlin~ injet.:t ion usc. The mothers, man~ of Il hom Ilerc communin hl:alt h ead rcs. may ;Ibo h,I\·C ed ucated community membcrs rcg;ml ing- the u n no.:ccss~ry usc of injcetiolls. This hypot hesis. hOll"e\"er. needs to bc pro\"ed in a further study.
Despite Ihe pnsi l ice impacts, sereral Illl;llltieipatcd nq;atil·c imp;lcls \\"l"i"e nOled.Ouring thc fi lilow-up r U J)s in ,;\ pri l [()95, paramellil:s inloll"ed in thc sl·l f-monitoring procedures eompbinell tha t they hall to tnl\'cI to collecl lLua anll t:lke lengt hy notes in c,lch health ":l·ll1re. T hey felt that the proel . ."ss W,IS l imc-consuming ,llld bunlenSU!Ill· with no adcq u;l1c ince l1t i\l~.
T he paralll l"lli..:s also commented th,ll Illore patient s now go to othcr hcalth cent res :Hld private practices to obt,lin injeL·lilJlls. SOIl1 l: rel"ca!cll th,1t p'Lr'lnlclli..:s halc begun huying . hcir IHI n syrill!;"es in Ill·llcr tl) satisfy jl ;! t ieTlls (lell1,lI1ding injc..:t ions through their priv,l1e pra..:tice. Thesc reports dL·monstr.lle an ,!b rming inco ngruenc)' in the p;ua111edi..:s· he;11111 l:cntrc ,\nd priv,!tc prao.:t icc hehaviour. T he extent tu which this pra<: tice occu rs necds furt her inl"estigat ion
As Figure -+.3 demollStr.ltcS, each of thc swd ies to date h;ls !cd to a fo llow-u p inl"estig;!t illn, provid ing ncw Ic\,cr:ll;e ror su hseq ucnt 1I"0rk. Q uam ilal ive and q U<llitatiw rCSl·ar..:h methods arc used in Etcl -fi nding;1s wdl as impact assessment. Jnnov:uiuns in inten·enlinn stratcgies;lfe tcstell in c;1ch sllld y, provid ing anuther leverage poi lll for dC\doping a new proced urc. 1\11 t r:msd isciplin;lry tC:lm members arc active in c;leh study and work together to implement ,lnd support the fi ndings in their own c;1pacity.
Asia and the Pacific
GMU RaTional Use 01 Drugs TO Team: clinical pharmacologists, behavioural scientists, district health managers, health centre managers, medical doctors.
paramedics, pat ients
FlGlIRt: 4. J 'l 'ransdisl'iplil1;lry :H.:Ti"n rcsuu:h ~ ,\Tl~s
80
A fransdisclplinary Approach to Rational Drug Use 81
Future Directions
Many lasks lie ahe.u.! for OlLr tr;lm(l i st:iplinar~ re~c;lrch Il' ;1rll. One is to reline our intervention desi)!n Mid sh;lre it \\'it h other resc'lrchers. We h;ll e presentell \Jur stu(lies ;11 it](erTl;lt ioll;11 eo nfcrenccs, and jl,lrt ieipants hal e asked tior ;Hhiee in replie;lIing' our stlld) design. We h'lvc ,~upportell full) sw.:h reqlLests by prnvidin )! ncce~sary ;lssist;lnce, inelulling;1 rellUl'st from a Vie1!\;\lIlese group Ilho haH' replicated the sel f-monitoring pron'dures in their health ,~ystem
Currell t ly, Sur),aw;lIi . two other junior tC;lill mcml)l'rs and myself arc developing eIHllmUnil)' educ;lt ion intl'l'\'ention materi;lls to rellll l:l' injection u~e in pri n];lry he;llth C;IrC f;lcilities. Thes(' m;l1eri;l ls ,ITe l1csigned to complement the health elluc,l1 ion cond ucted h~ the he;l llh centrl' s\;llr themselves, In this ~ludy. funded hy the Ministry of I lc:llth, ()Ill' of Ihe intervention methods pilot- test cd is ,I heh;\I'iour,\1 slr;lteg'~ using surrn)!';lIe patien ts to monitor the usc of inject ions in he:llth centl'es ;I1HI presenl their limlings, wit h the ,\ssistance of the ill;\ll;lg'er, 10 prescrihers. Th is method, calle\1 KiD PillS, howeler, prOleJ too cost I) ;Intl II;IS fc,lrell tl) intlUl: l1n' the morhidit y patter n if usell Ilidel). \Ve decided inste,ld 10 impkme1l1 ;1 comhilled method consist in)! of brief k cture, IliD ;1Ilt! postl'rs, ;\lHI Ihis \\;IS fillllld to he as elTect i"e ;IS IGD Plus (S\lr~;l\\'\li lI)l)!'')
1tl(lnnesian early-e;l rt'er rcseMchers in dr u)! USl' s1ud ies h;IH' ,tlso emerged, ' I ' h e~ 11;\\'e llclelopl'd inleT\'en li lm stratt'j!ies III impnlle thl' llualit~· of me(l ic;lIions for ellildren uwd both in hllSpi l;I!S 'l1ld he;dlh Cl:n tres. ' 1\\'0 pre-proposals h~; senior stutlcnts ,\I liMU ,\l edie;d SdlOOI ami a ~ra(luat c studenl in the Ci M U ;\\;}nagelllellt ;\llli Drug' J>o l i e~ Stud ies t!:raduate pro!!ram mc were amon!! the [)Cst t(;n, and one I\;IS ;\lllonj! the hest . X suhm ittt'd, T his competition II;IS held llurin g';1 joint workshop on dn1t!: usc illlc1'l entioll propus;d dCI-dopnlelH husted hy lN RUI) Il lllonesia, the WHO Colhrhoratin)!, Centre for Rese;lreh ;ulli T r;lin ing 011 Itllion;1i J) rul! Usc an d (i 'Hljah i\hd;1 U ni\'ersit~ and sponsored h) thl' }\ pplil'd Research (In C hil(1 Health (AR(]!), the \V I I<) Aelion I' roj
Asia and the Pacific 82
Acknowledgements
I ~m gT~leful ti'r tinallei,,1 ~ul'p"rl frun> !\I'Nt:'!" and IFS.') I-I I" ~Ih.;ml Ilw Social Sei~'IIC\' ,u,d j\ lnli~i,1\' Imcr,uI;ulul C"ntcr,·",·c in s.."'lbnd ;n Sq"~')lh .. :r I'Nf' a l whid, .• prdiminary \"<:r~i"n of lhis d.aptcr ,,~~ I'r" '''''·I11,·(1. Sr,,:eial th,mLs .II"\' . h,c 1" Dr l\'id Il i)(llinhutham, \\llOJ!:lI\: etll"\lur;l gcn1l'," ,i nl"lI l"Cl".LI ~u l'l'''rI "",I ;'lsi)(ln iu wril ing lhe I'J I'".; r. Than!. } "U a' ",,11 I" ,\Is Na'1l"~ J(th n ~un I .... "tiiling Ih'·l'r", iUllsdra li . I -'lSI hUI
nul lcast, m~' greal Ih.ml:~ arc due I" OT H"u;vn" S:inl"s", D r !:ir; Sur):lw:u; and Dr Iknn i.~ f{"ss- I >t.~nan , "I." (r"'lu"nll ) Sl imulatemr lhUUll '" al1<' uL-;l l il iJ ) lu..:"n lrihlll..: f<l lly I" IIll" lid.! "r rali""JI usc"f drub'S.
Notes
I. ( ~,u n lr~ ..:url' J!" " 'I' ",,·mh.:h aT<" as~i~I,·.1 h~ '''PI'''rt )( .. " ,I'S <:"I"l'ri,illg ;ndhit.! tla l~ fmtn ,\lS Il ( S '\): Drug Pul i.) (iWllp, lIaha rt.! ,\k.lil":ll Sdl<M.1 (USA): U"" "rl1m:111 tlf Inl"rnali"nJI til-allh ( ~ r<' I(" ""an:h an,1 SO" ial ·\k,lid,,,,, Kamlinsb h"III1U<:1 (S",~k,,); Ik l'JTlnu:nluf elinil":.!! jl h:lrtn~.:ulu)(), .... In,h ~ "I' .\k<li.·in,·, t..:ni,<: • .,.il) "f )\c\\l":l"k (l\u';lral ;;o): ami '\<:li"l1 I'r")( T~ mnl<" un ES"<C111iJI I)nl )(~ and ( ;"nlrul "I'I );arrh"al '111 .1 I( ", piml"r~ I)iw"~" s l'r" I(""'''''\'' \\ "rld I k,hh (lrg.",i/_" i,,, •. (i~lw'" (S"ill.erbml) (IN NI I) 1\'("11'1 '(~J lh) . ' r h" nClw"rl ;,..:," ,.tiin<11<"11 hy \ISII.",,) rcn'; '<:s Iin.,n,,:' ,1 1 "'1'1"'1'1 fn"" WH() / I IAI', !','" ( ;h .lrila l ~" Tr"~I' .l1ltII MN II ),\ (1,;1;")( ""/1)
J . Thi.~ ~1l,,1~ "." ("nd\~1 h~ 111<" :\p ll lie,1 I );arrh"al I )i "'-J~' Rn,'n.:h (A I)] )1( )
1' .. ,j\'C. <of th" Ilan a .. 1 ' ns,; , ul,' r"r I nI~rual;"n,,1 I k,d"pu1<"nI Ihr"lI )(h ~ (~"'pt:rJti,"' I\ )( r~·,:nu:m ,,;Ih Ih,· Llni"'lI Sla ' \'S -\)(""') I"T Inl'·T II"Ii"ual l >o.·'e1"l'm"nl .
.\ , Financial .'''I'I'',T( lor . hi., .,tu,\I <":IU,,' Ii-um lh~ I\<"Ii,,,, 1'I"t,)(r, .. "m" u" 1·:"""nliJI l )rlO,,",,- \\urld lkalll, ()r)(lln i/;1l i"n thr.,ul(h IN I(Ut).
of. This I'roj"('1 ""11,,' "'ll " I d.e Ihi .. d ""rbh"l' of IN I( UI> in H.u l .II(I"~, 1.")("" ~i!,ai,lin "N.!. I1\I(LI),·,,,,,,,,iltnllo r,, ,,.Ilhi'llr,,jce' 1.,11.,
5. Th;s pl"<ti'~·I, "u lil k ,1 n,,' I ,.· ,~r TUII<' S",;"s In(J/t'sis'" !:" ·(J lmll,· Slr(Jlq,I.·S I" l"'I'".n RIII,.",,,l 1 $,' "l Om.c.<. \\J.' fllmlnl h~ I Ia Tl~,,1 Un;, ,,,.,,i ,} and II", US/\ll> t\1'1'1i..'tl ' );aTrl"-;l II)i"'~",· I( """'JT<· h (,\I)I )I(I I!T<,!(ramm"
I, 1\ ,m,,11 ~nl"lIn1 or fumlilll( w,,' m .;"j, c,' ( .. "111 h,, Ihi" I'.w;t;,· N"""'Tl ( ,\I'NET ) .. I' Ih,· Ionerna li" n:1] t'; 'TlU" fUT S,,,,,,,I S,·i,·, ...... .,., III I k J ITh (tI ' SS] [) I " .. " ",IUCI ,his "u.r ~
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A Transdlsclplinary Approach to Rational Drug Use 83
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j\linislT\ , ,( l k,lllh, Rq,uhlk-"f Induucsia, Y:l)"aSlIl1I,,,]unl's;a S.:j"]Hl'ra ami !\b ll,'gl'l1H:nt .'iei""""s to,r H\'allh ( r'lilNl Child Su,rh"/I'h"",,"ullllmi> '" 11II/'III( .• i(I I',tr/ If: " -lIai' lJ"n tI" , 7;'mI C!'r!lIIf (;"r, J akarla: Minist r r "I' \ kalth "f lnd U1l<'si3
()rhcll, J, :\'1., 1\ _.1_ C ,',III lie KT~gt alld R. 1\ 1, 1).'I'cs (1"SIl) '1':~pLr;ni"g disCllssi"ll iml'l<'cd <:""'pl'f:1!in,,',J"lml,,1 ,~"I','mlJl"Ii,J' (/1111 SlJ(ud I'swlml"!!)' H(S): NI I - 1',1
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