indonesia-health education program for parents_hepp_rational drugs

7/31/2019 Indonesia-Health Education Program for Parents_HEPP_Rational Drugs

1/8

Health Education Program for Parents (HEPP)

Children in Indonesia face health risks from their medical treatment that would not

be acceptable to you.

Doctors routinely prescribe mixtures of potent antibiotics and medicines with

potentially serious side effects, for treatment of common illnesses.

Where do parents find the information and support needed to challenge theirdoctors, and to receive unbiased and basic information on their childrens illnesses

and how they can be managed?

How can concerned parents and doctors provide this basic information and support

in the face of opposition from the medical and pharmaceutical industry which thrives

on purchase of high cost medicines?

Yayasan Orang Tua Peduli (Concerned and Caring Parents) is trying to support and

inform parents to become partners with their doctors in the care of their children.

1. BACKGROUND

1.1 Organisation

Yayasan Orang Tua Peduli (YOP), is a non-profit, non-government organisation thatwas formed in Jakarta in November 2005. The organisation grew out of the educationand advocacy efforts of Dr Purnamawati Pujiarto, a paediatric-hepatologist. DrPurnamawati became aware of a rise in the number of children suffering from livercomplaints and was concerned about a possible link to irrational use of drugs. In2003, Dr Purnamawati started organising schools for parents to educate them onchild health, illness prevention and appropriate medications which is structured asthe Health Education Program for Parents (HEPP) [see below].

Yayasan Orangtua Pedi

Parents Best Friend

Compassion, Courage, Commitment

c/o Dr Purnamawati S Pujiarto, SpAK, MMPed

web: www.milissehat.web.id


2/8


1.2 What is HEPP?

HEPP is a health education and promotion initiative that is driven by two broad aims:

To empower parents to become informed health consumers; and To promote the rational prescription and use of medicine.

HEPP is an integrated program and provides advice to parents on the followingtopics:

Common health problems in children; Rational use of drugs; Appropriate preventive measures;

Breastfeeding; Appropriate feeding for infants and young children; Immunization;

Growth and development and the rearing process;

Relevant issues such as dengue fever, malaria, avian influenza, sexeducation in children, pregnancy, dental health.

2. RATIONALE

2.1 Why is HEPP needed?

Empowered Consumers. As in many countries, the doctor to patient relationship inIndonesia is often unequal and few parents have basic understanding of the commoncauses of illness among children and simple, effective medications. Typically,parents will leave the treatment of their sick children in the health providers handswithout question and expect instant relief or recovery for their child.

In engendering better informed parents, HEPP is also working to encourage a cultureof consultation between parents and doctors. By no means unique to Indonesia,medical consultations result in the prescription of medication. This results inunnecessary and over-prescribing and a dependency on curative services, bothdoctors and drugs, for healthcare.

Rational Drug Use. The prescription and choice of medication (i.e. trademark versusgenerics) in Indonesia, especially in private practice, rests entirely with the doctor.

HEPP is targeted to parents who use private sector health facilities wherecompliance with national treatment guidelines and rational drug policies is voluntaryand not regulated.

In private medical practice in Indonesia, evidence suggests a number of irregularitiesin prescribing practices. These are listed here and explained below:

1. Polypharmacy;2. Overuse of antibiotics;3. Overuse of steroids4. Preference for trademark drugs and consequent cost; and5. Unnecessary medicines.

The summary of the study on prescribing habit is listed on Table 1 (see below).

1. Polypharmacy is the administration of several medicines together. Most healthproblems in children do not call for polypharmacy treatment. A widespread


3/8


practice in Indonesia is to give children several medicines as a crushed mixturecalled puyer. These concoctions may include appetite stimulants, pain killers,antibiotics, steroids, tranquillizers, vitamins and rehydration solutions. Aninformal assessment of 204 clients in Jakarta revealed that almost 70% ofcases received a minimum of four drugs in powder form. The side effects of theinternal interaction of these drugs among children has not been studied.

2. Overuse of antibiotics is common. In fact, a focussed assessment undertakenin the early 1990s revealed that antibiotics consumed 46% of the central levelhealth budget for drugs. Antibiotics are routinely prescribed for children withfever, diarrhoea, sore throats, respiratory and digestive complaints; thesesymptoms are caused by viral infections and do not need antibiotics.

3. Overuse of steroids is very common. Common health illnesses in children donot need steroid yet the side effects can be major.

4. Preference for trademark drugs over cheaper generic versions. The rate of

generic drug prescription is very low, around 11% only. This unjustifiedlyincreases health care expenditure for parents, with a greater burden on thelower middle classes who prefer but struggle to afford private health services.

5. Unnecessary medicines. The dispensing of multi-drug mixtures is not taughtin tertiary medical education in Indonesia and it has no basis in science.

Inappropriate prescription-use of medication poses the risk of harm to the child andincreased risk of antibiotic resistant bacteria. The preference for prescribing trade-mark drugs places a greater and unnecessary financial burden on families, as doesinappropriate or inefficacious treatments which require repeat visits to the doctor.This combines to undermine the quality of health care and equitable access to it.

Table 1. Overall picture of prescribing pattern

URI (55) Fever (43) Diarrhea (27) Coughs (41)

Total meds 260 186 83 186

Median 5 4 3 4

Max 8 9 7 11

% Puyer 77.4 72.6 55.4 87

% Antibiotics

(% generics)

54.5

7

86.4

0

74.1

5

46.3

10.5

% Generics 16.9 9.7 3.6 19.4

% prescribed med

- Steroid- Anti histamine- Anti Convulsion- Anti Pyretis- Supplement

61.8

50.9

16.4

36.4

21.8

41.9

53.5

55.8

79.1

34.9

44.4

18.5

11.1

29.6

51.9

\

60.9

36.6

14.6

17.1

2.4


4/8


Picture: Preparation of puyer

This prescription is for a toddler with URI. All those medications are mixedtogether and crushed in to powdery form then divided by eyes into smallpaper/sachet.

2.2 What are the benefits of HEPP?

HEPP is currently in contact with close on 9800 members or Concerned Parentsacross Indonesia. HEPP is empathic to parents and understands the position and


5/8


prerogatives of the medical profession at the same time, providing vital information toconcerned parents in order for them to support themselves and each other.

HEPP works to generate the following benefits in the area of infant and child health:

Enabling parents to make informed decisions about treatment options;

Increased appreciation of the health and immunity benefits of exclusivebreastfeeding;

Reduce child exposure to and dependence on medications;

Cost savings from reduced pharmaceutical consumption and fewer visits tothe doctor.

3. HEPP PROGRAM

3.1 Current ActivitiesIn the interests of reach and accessibility, YOP undertakes a range of educationalactivities delivered through classroom-based sessions, as well as electronic and

national media.

1. Group education sessions:

YOP holds interactive information sessions for parent groups. This was thefoundation work of YOP and is structured around practical scenarios and topics thatencourage parent sharing and participation. YOP staff serve as facilitators andreference points for medical information and sources. The packaged coursesconsists of 4 7 meetings (on Saturdays and Sundays). YOP has also done suchpackaged education for private companies or any other parties. YOP also does asporadic (non packaged [topic is based on request, mostly related to RUD] sessions).

Recently, YOP also goes to schools, both for teachers as well as for parents.

The group education sessions are an extremely effective entry point for reaching andbuilding rapport and solidarity among concerned parents. Graduates of the sessionscommonly remain in contact with YOP through the mailing list and have beeninstrumental in raising demand for more courses to be delivered in Jakarta and otherprovincial locations. Some of the graduates become co-facilitators.We also have breastfeeding classes for pregnant women and working mothers oncea month in Jakarta and several other cities.

The education sessions are also requested by companies.List of cities where a package of courses plus the boosters have been conducted are:

-Aceh, Medan, Batam

- Jakarta, Bekasi, Tangerang, Depok- Bogor, Bandung, Solo, Semarang, Jogja, Purworedjo, Surabaya, Sidoardjo- Balikpapan, Samarinda, Makasar

In Jakarta, we have conducted 11 packaged (now is the 12 th packaged). Totalparticipants from Jakarta 2680; Sumatera 489, East Java 980 (Bodetabek 920,Bandung 369), Central Java 948, East Java 290; others 468. Total participants ofHEPP (excluded participants listed in health education below) are 7146 for PESATonly.

List of companies where packaged plus boosters of health education sessions havebeen conducted

-Oil and gas: BP, Vico Indonesia, Conoco Phillips, Medco, Chevron

- Mining: Arutmin, Indocement, Inco


6/8


- Banking: Standard Chartered Bank, Central Bank of Indonesia, Permata Bank- Services: PWC, Law firms, religious events- Manufacturer/Retail: Unilever, Mattel, Astra Honda- Insurance: Axxa, AIG, LOMA Society- Academic: Cikal, Mentari, AlIzhar, Hans Gretzel,

2. Mailing list:

Given the size and geography ofIndonesia, YOP initiated an email-based advice service andexchange so that parents in remotelocations could seek advice of YOPstaff and parents. The mailing listhas close to 9506 (18 May 2010)

subscribers and now almost 12,000members with at least 300 emailsdaily on issues ranging from theverification of medical advice, toqueries on medication and homebased care for children with minorsymptoms.

Members spread from- Sumatera: Banda Ace, Lhokseumawe, Lhokseukon, Medan, Padang, Pakan

Baru, Duri Riau, Palembang, Batam, Riau islands

-Borneo: Pontianak, Balikpapan, Samarinda,

- Java:o Jakarta, Cilegon, Serang, Banten, Tangerang, Bogor, Bekasi, Cirebon,

Bandung, Garut,o Tegal, Semarang, Kudus, Jogja, Solo, Purworedjo, Cilacapo Surabaya, Sidoardjo, Malang, Kediri, Bondowoso

- Sulawesi: Makasar, Palu, Manado- Lain-Lain: DenPasar, Mataram, Ambon, Timika

Since November, we also develop a twitter account and we spread news/issue everyMonday.Since January we also develop a facebook.

3. Radio programs:

Since February 2004, Dr Purnamawati and HEPP colleagues have had regular, hour-long talkshow spots at prime time on two FM stations.

o Radio Delta: middle to upper class of population, professionals includingdoctors (fortnightly); and

o Radio Utan Kayu: middle to lower class of the population (weekly).

Both stations relay the talk shows to several cities in Indonesia and has beeninstrumental in expanding the HEPP membership base in these cities.

Picture: HEPP membership across Indonesia


7/8


HEPP has developed a series of child health sessions to guide the talk showprogramming over the year and they broach a diverse range of topics:

Physiology (common problems in children, bacteria versus virus, symptomsand disease, when hospitalization is needed);

Basic Medical Philosophy(informed consent and the right to information)

Rational Prescribing(antibiotic overuse and sensible use of antibiotics);

Doctor-Patient Relationship (art of asking questions, the meaning ofconsultation, communication between patient and doctor);

Development Issues(global infant and maternal morbidity, womens welfare,safe motherhood); and

Consumer Education (reading medication labels, medical references on theinternet, individual questions from listeners hotline).

4. Publications:

In its efforts to provide medical information in a format that is accessible anddigestible for parents across Indonesia, HEPP has published hard bound andelectronic educational materials. Published Works:

1. My Baby, My Child, a digest on child health for parents was published byHEPP in August 2005;

2. Books no. 2 are based on Q&A correspondence between parents and HEPPover the mailing list. It is called Q & A. Smart parents for healthy children.

3. Resident Paediatrician for a Readers Consultation Column in the monthlymagazine Parenting;

4. Articles for high circulation Indonesian press including for Kompass, JakartaPost, Republika and various national magazines.

Web-based Publications:Since the launch of the HEPP website in August 2005 (www.sehatgroup.web.id butsince February 2010, our web is www.milissehat.web.id ), HEPP has moderated amailing list and published an expanding library on child health resources. Resourceson the HEPP website include:

1. Guidelines on fever, febrile convulsion, UTI, Otitis, fever of unknown origin,TB, IVFD, colic, diarrhoea, atopic dermatitis, varicella, etc;

2. Immunization schedule;3. Dietary and nutrition advice, growth charts

4. Drug information5. Highlight for each month (March 2011, the highlight is related to antibioticresistance)

5. Model Clinic:

Aims:

Provide a demonstration of responsible paediatric care; site for training andresearch;

Provide a cost effective health service for the parents.

Could become self funding in time


8/8


It starts last August (2007) and majority of the patients are from mid-low SES.However, it still needs a lot of support.

6. Studies:

We did some studies on1. Prescribing habit (email based) on common health illnesses2. Prescribing habit on common health illnesses particularly URI and acute GE.

Based on posted prescription by parents3. Survey on the impact of our mailing list4. Survey on baby friendly hospital5. Survey on violation to breastfeeding practices

Contact Information:Web:

-Handadi: [email protected]

- Dr Yulianto: [email protected] Dr Windhi: [email protected]

Mailing list:- Moderator: [email protected]

YOP:- Indira Hadi: [email protected] Nia Kurniawati: [email protected] Dr Purnamawati S Pujiarto: [email protected]

indonesia-health education program for parents_hepp_rational drugs

Documents