How pharmaceutical companies in India can provide Information therapy
Information therapyIndia is deemed an economic powerhouse, comparatively insulated against recession butopen to investment. While population is the strength in terms of domestic consumption it isalso a deterrent in reach of literacy and health care services.Epidemiological transition has bestowed India with the entire gamut of healthcare problemsranging from infections to lifestyle diseases. So we are blessed with an increasing lifeexpectancy with chronic ailments. The healthcare scenario is such that fertility rate needs tobe tackled to keep population at bay and on the other hand infertility treatment is a gallopingsegment.Healthcare institutions, governmental bodies and NGOs are fighting to improvise the reachand quality of healthcare, although the effort is limited due to lack of funds, inadequate reachand lack of insurance coverage to majority of the population.This unique scenario is juxtaposed with the rising awareness, internet and expectation ofbetter service standards by the literate population. Information if it is available to the rightperson at the right time can play a significant role in improving the prognosis and meeting theservice expectation. This can have a direct impact on adherence to treatment and thereforeoutcomes which ultimately reduce the economic impact to the individual, the family and thesociety at large. To the health care practitioner it can provide more satisfying practice, moretime available for the new patients which in turn improves patient flow.As we are all are patients at some point of time an understanding of the patient related factorswill help us to assess the situation and suggest methods to improve the outcomes.Patient-related factors represent the resources, knowledge, attitudes, beliefs, perceptions andexpectations.Some of the patient-related factors reported to affect adherence are: forgetfulness;psychosocial stress; possible adverse effects; low motivation; inadequate knowledge; lack ofself-perceived need for treatment; lack of perceived effect of treatment; negative beliefsregarding the efficacy of the treatment; misunderstanding and non-acceptance of the disease;disbelief in the diagnosis; lack of perception of the health risk related to the disease;misunderstanding of treatment instructions; lack of acceptance of monitoring; low treatmentexpectations; low attendance at follow-up, or at counselling, motivational, behavioural, orpsychotherapy classes; hopelessness and negative feelings; frustration with health careproviders; fear of dependence; anxiety over the complexity of the drug regimen and feelingstigmatized by the disease1.Perceptions of personal need for medication are influenced by symptoms, expectations and 2experiences and by recognition of the illness . Concerns about medication typically arisefrom beliefs about side-effects, disruption of lifestyle and from worries about the long-termeffects and dependence. They are related to negative views about medicines as a whole and 3,4suspicions that doctors over-prescribe medicines as well as to a broader “world view” 5characterized by suspicions of chemicals in food and environment and of science, medicine 6and technology .Patients may also become frustrated if their preferences in treatment-related decisions arenot sought and taken into account. For example, patients who felt less empowered in relationto treatment decisions had more negative attitudes towards prescribed antiretroviral therapyand reported lower rates of adherence7.According to WHO, increasing the effectiveness of adherence might have a far greater impacton the health of the population than any improvement in specific medical treatments 8.The IMB model9, 10– Information motivation and behaviour puts information at the priority tochange patient behaviour, however by itself information is insufficient and motivation is a keyfactor in the transition to bring change in behaviour. Therefore therapy which providesinformation and motivation will be the successful therapy.
The successful use of information therapy will therefore depend on1. The ability of clinics and associated health care personnel to share information on patients’behaviour2. The type of systems adopted will determine the level of communication with patients andtheir relatives.3. Ongoing communication efforts that keep the patient engaged in health care may be the 11simplest and most cost-effective strategy for improving adherence . • Considering the information is vital, every clinic visit will be preceded or followed by information therapy prescriptions. Making the right information accessible before the clinic visit and providing information after will ensure that the patient is not prey to inadequate and dangerous half knowledge. • Every medical test and surgery will be preceded and followed by information therapy prescriptions which will increase trust. • Efforts to engage patient and family support through information therapy prescriptions.Prominent interventions to address patient related factors which can lead to informationtherapy are:-1. More instruction for patients, e.g. verbal, written, or visual material programmedlearning and formal education sessionsThis method has the rate limiting factor of literacy. Some of the methods adopted areorganising free anaemia detection camps conducted through support staff at nursing homeshave attempted to use visual material to demonstrate the adverse effects of anaemia onhealth and pregnancy. Regional languages have been increasingly used to reach to a largeraudience.Private hospitals have been organizing weekly meetings on nutrition in pregnancy, diabetesrelated complications etc.Camps have also been organized for diabetes detection among susceptible population, forneuropathy in diabetes OPDs through trained personnel. However the lack of continuity andlack of long term commitment severely impedes the estimation of success of these methods.
2) Counselling about the patients’ target disease, the importance of therapy and compliancewith therapy, the possible side-effects, patient empowerment, and couple-focused therapy toincrease social support.This method has been tried in India in improving outcomes in asthma by counselling campsorganized through a club with community service as one of its missions. This methodprovides the route which is trusted by the recipients since they are directly involved in thedecision making.Uses of simple concepts like cartoons have helped patients to understand complicatedprocedures in IVF treatment and help making a decision.3) Automated telephone, Manual telephone computer-assisted patient monitoring andcounselling and information websitesIn India this method has been adopted successfully by Institutions and companies thatprovide treatment of vascular ailments. Organizations which provide support in logistics,content and feedback have sprung up in response to these ailments in India.Patients are contacted through reminder text messages on their mobile phones after theyhave registered; Sops to stay connected include information, free medication on continuationof the treatment, invitations to counselling and free checks.In hypertension management involving patients more through self-monitoring of their bloodpressure, reinforcement or rewards for both improved adherence and treatment response hasbeen in practice. Improved compliance is recognized and rewarded through reducedfrequency of visits and partial payment for blood pressure monitoring equipment.Interactive websites dedicated to treatment in different disease groups enables patients withaccess to internet, to access information. In developed countries regulatory bodies andassociations of practitioners provide comprehensive data at a single source. Patients have adedicated link to resources on websites of NIH and American Diabetes Association etc. In ourcountry, this is beginning to happen and some associations, NGOs and companies havepatient education resources on their sites.
4) Group meetingsObesity management has utilized this method to foster motivation and improved self imagewhich translates into better outcomes. There are also support groups for Thalessemia, AIDS,prostate cancer and other conditions.Group meetings are also the norm in de-addiction methods.5) Family interventionCan be particularly useful where behavioural changes are required by the patient to combatillness or where the patient is a child.Bedwetting is an unusual problem not considered to be an illness but parental informationtherapy does a long way in alleviating the lack of self esteem in the child.Family intervention in diabetes is also important so as to create an atmosphere where thepatient’s craving for sweets is reduced by the entire family abstaining from consumption ofsweets at the dinner table.Family intervention is a particularly important method in smoking and alcohol cessationespecially by the pregnant woman and her spouse. The family intervention can provide theright estimate of the change in the smoker from unwillingness to willingness and considerationof options in view of the harmful effects on the unborn child.6) Simplified dosingIn the treatment of inflammatory bowel disease, the dosing used to be cumbersome. Threetimes daily dosing has been tackled with once daily dosing granules which can deliver thecomplete dose. Information therapy can help reduce the morbidity through better remissionrates achieved through better dosing form and compliance.As it can be expected in a highly competitive environment, Insulin companies responded tothe patient requirement and have benefitted from both the simplified painless injection as wellas the dosing schedule.The dissemination of the information in the right media and the reach is critical as simplifieddosing without information does not lead to improved usage or outcomes.Reminders, programmed devices and tailoring the regimen to daily dosing could also helpprovided it is programmed as information therapy. 7) Augmented pharmacy services. Internationally the pharmacist has already adapted to anew role in providing augmented services especially in counselling. In India mostly this is aself motivated approach where the pharmacist if he/she is a registered health practitioner,
takes an active interest in dosage form, compliance and other issues to be explained to thepatient.Again as the situation could demand, use of special needleless devices, orthotics andprosthetics has made the Pharmacist an important part of the health care chain. Formal andinformal training provided to these personnel has increased awareness and provided valuableinformation therapy by better usage.8) Different medication formulations, such as tablet versus syrup, granules versus tablets,and spray versus tablets have been introduced to favourably impact the patient’s attitudetowards medicine.9) Crisis intervention conducted when necessary, e.g. for attempted suicide, aggressive anddestructive behaviour with information therapy can reduce the chances of a relapse of thebehaviour.10) Direct observation of treatments (DOTS) by health workers or family members.In T.B the DOTS program has been implemented with the help of WHO. Information andposters are available in 11 regional languages on the government of India websitehttp://www.tbcindia.org/11) Various ways to increase the convenience of care, e.g. provision at the worksite or athome.Vaccination against swine flu is now part of the organizations which has employees whotravel abroad frequently. Some organizations have provided check ups and information oncholesterol, mammograms to executives. Polio drops have reached homes and residentialareas with information and vaccine.A successful implementation of programs in information therapy stems from conviction andwillingness to long term commitment. Results can be obvious and parallels can be drawn fromthe west where successful programs have been put into place. Pharmaco-economics will betrending in India soon, recognition of this important gap and successfully implementing aprogram can bring in tangible benefits. The challenge is to overcome the formidable barriersof language, geographical and demographical differences in different states. Since Doctorsare at the centre of the health care system and part of the local ethos, a practitioner centricinformation therapy could yield meaningful results quickly.
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