Population awareness of risks related to medicinal product use in Vientiane Capital, Lao PDR: a cross-sectional study for public health improvement in low and middle income countries

In this population-based study, the majority of the respondents were unaware of modern
medicine risks. Most of the respondents qualified as aware had an inadequate awareness
since most thought that modern medicines can be harmful only in overdosage. As for
modern medicines, the awareness of traditional medicine risks was limited. Half of
the participants were not aware of the existence of poor quality medicines in the
market.

The median age (47 years old) of our population is higher than that of the population
at national level since 75 % of people were aged between 15 and 45 years old in 2005
18]. More women than men were interviewed mainly because interviews were performed during
working hours. Nevertheless, even if our population does not strictly represent the
general population of lao adults, 85 % of the respondents were the heads of household
or their husband/spouse, who play an important role in healthcare choices for the
whole family in L/MICs 19]–21]. No citizen refused to participate in the study. Government staffs have a strong
influence on citizens in the Lao PDR. The 100 % response rate can thus result from
the first contact of the citizens that was made by the head of the village or his
mandated assistant. Whereas these latter were present during some interviews, they
agreed to stay apart. However, when the interviews were performed in the households
it was difficult to maintain strict confidentiality, as other family members or neighbours
sometimes came to listen.

In our survey, only one-fourth of the population is rural. As 71 % of the population
of the Lao PDR lived in rural areas in 2007/2008 22], we can reasonably assume that the awareness of the general population of Lao PDR
regarding the issue of medicinal product risks is lower than that observed in our
study. This is highlighted by the significant differences of awareness observed between
the districts, respondents in the rural district having a higher risk of being unaware
than those in urban districts. Further data 18], 23] have shown that the distribution of health facilities was different according to
the districts. Private clinics – run by medical doctors with university degree –,
and class I community pharmacies – run by pharmacists with university degree –, are
more prevalent in the urban districts of Xaysetha (84.1 and 40.0/100,000 inhabitants,
respectively) and Sikhottabong (44.0 and 13.0/ 100,000 inhabitants respectively) than
in the peri-urban district of Naxaithong (30.8 and 1.7 /100,000 inhabitants, respectively)
and in the rural district of Sangthong (24.8 and 4.1/100,000 inhabitants, respectively).
Therefore, we suggest that whereas people in rural areas have access to health facilities,
urban residents have a better opportunity to receive information from healthcare providers
of higher level of training. Whereas respondents in the urban district of Sikhottabong
have a significant higher awareness than those in the rural district of Sangthong,
there were no differences with those in the peri-urban district of Naxaithong. This
could be explained by the distribution of health facilities in Sikhottabong that is
in between that of the peri-urban district of Naxaithong and of the urban district
of Xaysetha. In addition, as suggested by Syhakhang et al. 16], people in urban areas may have better opportunity to receive information on medicines
from the regulatory authority. More investigations are needed to assess other potential
factors that might explain the differences between the districts.

In the absence of validated questionnaire to assess the awareness of the population
on medicine risks when they are used with normal doses, our questionnaire was developed
for the purpose of this study. While its reliability and validity have not been tested,
the questionnaire was submitted to four experts in public health, epidemiology and
pharmacology for an opinion, before being translated into Lao. The term ADR is defined
by the WHO as “a response to a drug which is noxious and unintended and which occurs at doses normally
used in humans”24]. It is used for communication on drug safety in validated sources of information on
medicines (i.e. summary of products characteristics and leaflets). However, when this
term has never been heard by a villager, it does not necessarily mean that he is not
aware of medicine risks. We thus combined this question to a second one (‘Do you think that modern medicines can be harmful in case of normal use and normal
doses?’) to define our outcome of interest.

We observed that even when they were qualified as aware of medicine risks, the large
majority of our respondents think that modern medicines are potentially harmful only
in overdosage. In addition, the majority of the respondents in our study considers
traditional medicines as safe or has no opinion, even in overdosage. Therefore, strategies
to raise awareness of the population on drug safety, without scaring patients from
using medicinal products are needed, with special attention to rural areas. This is
particularly important in a country where most medicines, even the most harmful, are
readily available OTC. Mass media campaigns have previously shown promising results
in health promotion in L/MICs 25], 26]. Adequate key messages on drug safety, for example targeting medicinal products commonly
involved in ADRs could be relevant. For this purpose, drug safety data in the Lao
PDR are needed.

Half of our respondents had never heard of poor quality medicines. Although efforts
made by the government since the implementation of the National Drug Policy 8] have allowed reduction in the proportion of poor quality medicines in the market
27], the threat is still real 13]. Most of the people being aware of poor quality medicines had been informed through
media in our study. Initiatives to raise awareness of the population such as the ‘Mekong
Cartoon Contest’ in 2011 (“Beware of counterfeiting, danger is calling!”) with online
diffusion of the cartoons 28], need to be continued.

Half of our participants could not name the last medicines used within the last year.
This can be due to recall bias, illiteracy concerns or non-adherence to prescribed
medications (with regard to chronic diseases medications). This could also result
from a lack of identification of medicines, as previously observed in two studies
in which half of the medicines sold in private or public pharmacies had no label 9], 29]. As accepted important sources of information on drug use and safety 30], the provision of labels and package inserts should be endorsed. It should be mentioned
that a new article (2012) of the Laotian law on drug and medical products states that
medicine users should receive clear and complete information from medicines suppliers.
However, package inserts are often written in medical jargon and too many information
is generally provided. They are thus difficult to understand 31]. When printed in foreign languages, they can be incomprehensible for patients, especially
in rural areas 7]. Distributed by pharmacists and other health professionals, well-adapted model sets
of minimum information developed in a way that is relevant to each population – e.g.
using regional languages and illustrations 32] – have previously shown good effectiveness 33], 34]. The best effects on patients knowledge are evident when both written and oral information
on medicines are provided 35]. In a previous study by Stenson et al. 9], oral information were not transmitted for more than half of medicines sold in laotian
pharmacies of low level (class III). Engaging all healthcare professionals in providing
adequate oral information is essential – especially in the context of high illiteracy
– , not only to improve patients’ understanding of their medication, but also to build
trustworthy health system 36]–38]. Enhancing the training of pharmacist and medical students on drug safety communication
seems necessary in the Lao PDR.

In line with the efforts to improve the use of medicines, the Lao PDR has recently
(2013) become an associate member of the WHO Programme for International Drug Monitoring
39]. Drug safety monitoring requires the involvement of healthcare professionals. In
addition, central, provincial or district level drug information centers for patients
who seek information on medicines could help transforming medicine users from passive
recipients to active partners 40]–42]. In remote areas, community health workers or community leaders have proved highly
effectiveness in promoting health 43], 44] and could constitute mediators between the population and a drug information center.
At last, mobile technologies and web-based systems have recently proved good performance
in health care processes in Asia 45], 46].