SELF-LEARNING FOR SELF-MEDICATION

An alternative to improve the rational use of OTCs

Sri Suryawati and Budiono Santoso
Department of Clinical Pharmacology, Faculty of Medicine, Gadjah Mada University
Yogyakarta, Indonesia

BACKGROUND
Self-medication is beneficial for the treatment of minor ailments only if there is sufficient knowledge
about the proper use of medicines of interest. There are at least 5 components of information
required for appropriate self-medication, i.e., information about the active compound, indication,
dosage and administration, side effects, and contraindications.
A survey has been carried out in Yogyakarta (Rustamaji et al., 1993), involving different groups of
respondents, i.e., mothers (Group A, n=139) and university students, consisting of medical
students (Group B, n=57), and non-medical students (Group C, n=14). Respondents were
interviewed regarding the most familiar non-prescribed (over the counter OTC) drug they
commonly use. Percentages of respondents who could provide information about the 5
components were calculated, and the answers were scored within a range of 0-10. The results are
shown in Table 1. Although the sample size is relatively small, the data obviously show that the
level of knowledge about drugs among users is low to support the safe and effective selfmedication.
The most common feature lacking in drug advertisements is information regarding the active
compound. OTC users consequently miss one important piece of information; they only know the
brand name of drugs marketed to address a certain symptom. The direct effect of this deficiency
can be seen in the drug consumption pattern in households, where several brand names with the
same active compound are used concomitantly (Suryawati & Santoso, 1993).
Table 1.
Percentages of respondents who know each component of information and the scores of knowledge needed for safe
and effective self-medication.
Percentage (%) of respondents who knows:
Active compound
Indication
Dosage and administration
Side effects
Contraindications
Averagage score of knowledge (range 0-10)

Total
24
47
71
9
5
5.21.2

Group A
4
45
65
2
2

Group B
68
51
87
23
13

Group C
50
57
64
14
6

4.00.1

6.31.8*

5.30.7*

*Higher compared to Group A, P<0.05

This is a waste of money, and ironically, many studies show that the key factors motivating selfmedication is cost-efficiency. Another impact, which cannot be measured in dollar terms, is the risk
of using drugs incorrectly, e.g., long-term use of analgesics for keeping healthy, or the risk of
contraindications. In other words, the potentially good results of self-medication could switch to
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disaster if done improperly.

If there is a need for information to enhance the quality of self-medication, there must be an effort
to equip users with the capability of seeking information rapidly and correctly, using any source of
information available. Actually, the five main components of information are already available on
the drug package or package insert. Why is such information being wasted? In Indonesia, this
information is considered reliable, since it is approved by the Ministry of Health. If such information
is used optimally, people will have adequate information for appropriate self-medication.
An educational module has therefore been developed, aimed at improving mothers knowledge and
skills to select OTC-medicines. The training method, called CBIA (Cara Belajar Ibu Aktif. Mothers
Active Learning Method), utilises a problem-based approach and self-learning process. Information
printed on the pharmaceutical package or package inserts is used as training material. The
intention of this training is to empower mothers to seek and critically assess information of drugs
they commonly use.

OBJECTIVES
The specific objectives of the CBIA educational module are that the OTC users:
1. Understand that drug information found on the package or package insert,
2. Understand that several drug brand names have the same or similar active ingredients, and be
able to identify the main active compound among the additional ones,
3. Are capable of finding information about the active ingredients, indication, dosage and
administration, side effects, and contraindications,
4. Are capable of making a simple assessment of the quality of drug information.
The outcome of this training is to increase the capability of OTC users to select medicines
according to the needs, and furthermore, to increase drug procurement efficiency.

METHODS
Design
This intervention utilises a self-learning process, in a form of small-group problem-based intensive
discussions followed by individual assignment. Members of each small group should be limited to
6-8, and each intervention should ideally involve no more than 6 small groups. Tutors act as
discussion facilitators, and show the way to find or solve the problem if necessary. They do not
interrupt the discussion, except in situations where the dynamics of the discussion do not develop.
A resource person (if available) is responsible for responding to scientific problems found during
the discussion. In the absence of a resource person, tutors should mention that participants always
consult pharmacists or physicians for any problems regarding OTC-drugs.
Participants
Such an activity could be carried out as a regular program of womens organisations, as well as in
other arranged gatherings. Mothers, fathers, and teenagers are capable of participating in the
activity.

Tutor and Resource Person

Medical students, pharmacy students or others familiar with the contents of drug packages can be
recruited as tutors. It is also possible to invite tutors form the target groups after they themselves
have been trained in the method. Before carrying out the activity, tutors should undergo a short
exercise, to familiarise them with problems of each drug package being used in the activity. An
interested pharmacist or physician might be invited as a resource person.
Training Material
An activity guide, worksheets, and reusable sets of OTC-drugs are needed. Each group works with
one set of 40 OTC-preparations in their original packages with price labels, consisting of
antipyretics/analgesics, vitamin/mineral, and cough remedies. Each set costs approximately US$
20-30. The worksheet can also be used by participants as record forms for information they found
after the sessions.
Place
A spacious place is more comfortable, to allow each small group to seat themselves in a circular
position, allowing the tutor or resource person to move easily from one group to another. If the
writing activity is not possible, discussion should be allotted more time.
Sequence of Activity
The activity takes 2-3 hours, depending on the group dynamics; it should, however, not exceed 4
hours. One tutor begins with a prologue on the advantages/disadvantages of self-medication, then
participants are requested to form small groups. Group leaders (elected from each group) conduct
the discussion, and tutors help if necessary. Worksheets are distributed to participants, and group
leaders hold the activity guide. The activity consists of 3 sessions, the first and the second are
conducted during the meeting, and the third session is carried out individually at home. Writing is
not allowed during the first session.
Session 1:
Using the OTC-set, each group has to:
1. Observe where they can find information on active ingredients,
2. Learn the name of active ingredient(s) and how to distinguish main ingredients from additional
substances if the drug consists of more than one substance
3. Group the OTCs based on their main ingredients (not the indications). Be aware that
participants are usually more familiar with indications rather than active compounds,
4. Discussion
Discussion points should include:
1. Active ingredients are always written on the package or package insert, and this information is
hardly found in drug advertisements. Incomplete and unclear information in drug
advertisements can be clarified by consulting the drug package or package insert.
2. The main ingredient can be identified as the first ingredient cited in the list, not the one has the
biggest amount.
3. Among the many drugs offered in the market, there are sometimes syrups or tablets, some of
which can contain the same or similar active ingredients. If the ailments or symptoms need a
certain drug, it is necessary to check the preparations on hand to see if they contain this active
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4.

5.
6.

7.

ingredient, whatever the brand name is.

Participants can identify the differences and the similarities of active ingredients of preparations
for adults and children. Though the brand names for adults and children are often similar (e.g.,
Bodrex-Bodrexin, Inza-Inzana, Mixagrip-Minigrip), the active ingredients are different.
Participants should be careful of those differences. They should also learn different dosages
for children and adults.
Drug prices vary, although they contain the same ingredients. Syrups are more expensive than
tablets. Participants can also learn the difference between brand names with Forte, Plus, etc.
compared to the conventional forms.
Drug purchasing can be more efficient if they think about the prices in relation to the amount of
active ingredients or the dosage forms of the preparations. In equal dosage syrups are
sometimes ten-fold more expensive compared to the tablets. Brand names with Forte may
cost four times more expensive compared to the conventional one, although there is only a
slight difference in the amount of the active ingredients. Although syrups are more tasteful,
there might be a situation that someone does not have enough more to buy the syrup;
choosing the tablet form is the best solution.
For commercial purposes, the names of active ingredients are often hidden in other names,
which are not commonly known by lay people. For example, 1,3,7 trimethylxanthine is used for
caffeine, paracetamidophenol for paracetamol, orthohydroxybenzamide for salicylamide.
Vitamin B1 sometimes is written in its long chemical name. Common active substances may be
registered by patented names; for example, dextromethorphane in the old package of Vicks
Formula 44 Syrup is written as Silentium.

Session 2:
The activity in this session is to collect information needed for appropriate self-medication, i.e., (1)
active ingredient, (2) indication, (3) dosage and administration, (4) side effects and (5)
contraindications. Each participant should make her/his own notes, using as many worksheets as
needed. Group leaders assist in collecting and comparing information among OTC preparations. At
the same time, participants are examining the clarity and completeness of information found on
each package. The expected impact of this Session is to encourage participants to read all
information critically. The tutor should encourage each participant to find and write down all of the
five main components of information.
Session 3:
At the end of Sessions 2, it is important to check whether the worksheets have been filled in
correctly. Participants are then asked to conduct the same activity as Session 2 for the OTCpreparations they have at home. By doing this, participants are expected to become more
confident in searching information. They are given a clear explanation about what they should do at
home, and they are asked whether they want to have the next gathering. Important findings
identified by each group should be highlighted before closing the Session. Suggestions are given
to sustain the impact of the intervention. Participants are encouraged to ask questions about OTCpreparations of any physician or pharmacist, as they are the resource persons in the community.

RESULTS
This module has been field-tested and evaluated in a controlled study, compared to a more
common form of education, a large seminar (Suryawati & Santoso, 1993). One hundred twelve
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(112) mothers of low to moderate levels of education were recruited for the study, and randomly
assigned to 3 groups. Group A received CBIA, Group B underwent a large seminar to train them in
the same skills, and Group C served as controls
The results showed that the scores of the five main components of knowledge increased
significantly in both Group A (4.9 0.3 to 8.30.2; P<.001) and Group B (4.50.6 to 6.40.3; P .
05), in comparison to controls where there was no change ( 4.20.4 to 4.80.3;NS). In addition,
the increase in knowledge in the CBIA group was significantly greater (P<.02) than among mothers
attending the large seminar. Furthermore, the brand names of OTC-preparations used in
households in a one month period were reduced significantly in Group A (5.30.3 to 1.50.3;
P<.001), while in the other groups the number of medications did not change (Table2)
Table 2
Scores of knowledge and number of OTC brand names consumed in one month before and after the intervention.

Score of knowledge (range 0-10):

CBIA Group (n=38)
Seminar Group (n=42)
Control Group (n=32)
Number of OTC brand names
consumed in one month:
CBIA Group (n=38)
Seminar Group (n=42)
Control Group (n=32)

Before intervention

After intervention

T-test

4.90.3
4.50.6
4.20.4

8.30.2
6.40.3
4.80.3

P<.001
P0.5
NS

5.30.3
5.70.4
5.60.6

1.50.3
4.31.2
5.20.7

P<.001
NS
NS

Not only was the CBIA approach effective in increasing knowledge and reducing the number of
products used, but all of the mothers who underwent CBIA intervention reported that they found
this type of problem-based learning enjoyable.

FOLLOW-UP ACTIONS
The intervention guide has now been reported to the Ministry of Health, and it has also been
disseminated to relevant parties for their feedback. The module works well with groups of mothers,
fathers, elderly, teenagers, as well as primary school students. However, the best results of training
are achieved in mixed groups. Experience reveals that a forum consisting of mothers, fathers, and
family members living in an immediate neighbourhood gave the best results and the impact lasted
longer.
This module has been introduced to colleagues in Zimbabwe, Uganda, and Tanzania, and has also
been communicated in several international meetings. A practical guide for conducting the
intervention is available both in Bahasa Indonesia and English. Medical students of Gadjah Mada
University include CBIA in their public service program, a part of their formal training in the final
year.

REFERENCES
Flora KT, Rossi S & Suryawati S (1991) Correlation between level of mothers knowledge about
drugs and self-medication. S1 Research Work, Faculty of Medicine, Gadjah Mada
University, Yogyakarta.
Rustamaji, Hidayati S, Aryanti R & Suryawati S (1993) Levels of knowledge about drugs needed for
self-medication among mothers and university students. Abstract Book, Asian Conference
on Clinical Pharmacology & Therapeutics., Yogyakarta, 1-4 November 1993.
Suryawati S & Santoso B (1993) Improving mothers knowledge and skills in selecting medicine
using CBIA method (field-test result). Abstract Book, Asian Conference on Clinical
Pharmacology & Therapeutics. Yogyakarta, 1-4 November 1993.
***