By: Erie Gusnellyanti, S.Si, Apt.

Self-medication is the most widely practiced effort by the community to overcome complaints or symptoms of disease, before they decide to seek help from health care facilities/health workers. More than 60% of the community practices self-medication, and more than 80% of them rely on modern medicine (Flora, 1991). The Central Bureau of Statistics' Susenas data also shows that more than 60% of the community practiced self-medication. The results of the Basic Health Research in 2013 showed that 35.2% of Indonesians kept medicine in the household, either obtained from a doctor's prescription or bought over the counter, of which 27.8% were antibiotics. (Ministry of Health, 2013).

If done correctly, self-medication can be a great contribution to the government, especially in national health care. However, on the contrary, self-medication can cause health problems due to misuse, non-achievement of treatment effects, the emergence of unwanted side effects, the cause of new diseases, overdose due to the use of drugs containing the same active substance together, and so on. New health problems may arise causing much more severe diseases. This can be caused by the limited knowledge of the community and the lack of information obtained from health workers, as well as the lack of awareness and ability of the community to seek information through available information sources. To do self-medication correctly, people need clear, correct and reliable information, so that the determination of the type and amount of drugs needed must be based on the rational use of drugs. Self-medication should only be done for minor illnesses and aims to reduce symptoms, using drugs can be used without a doctor's prescription in accordance with applicable laws and regulations.

The CBIA method or “community based interactive approach” is one of the community empowerment activities that can be used to educate the community to choose and use the correct medicine in self-medication. Through this method, it is expected that the community, especially mothers, will be more active in seeking information about the drugs used by the family. Such information can be useful, among others, in order to use and manage drugs in the household correctly. In addition, it is hoped that the goal of self-medication can be achieved optimally. The source of product information can be included on the packaging or package insert/brochure.

The method of community education through CBIA was first developed by Prof. Dr. Sri Suryawati since 1992, a professor of pharmacology from the Faculty of Medicine, Gajah Mada University. Together with her team at the UGM Center for Clinical Pharmacology and Drug Policy Studies, this method has been developed over the years, and has been adopted by several countries in Asia and recognized by WHO. In 2007, in collaboration with the Directorate of Rational Drug Use, Directorate General of Pharmaceuticals and Medical Devices, Ministry of Health, a two-day pilot project was conducted in Pandeglang, Banten.

Furthermore, community empowerment activities using the CBIA method are routinely carried out by the Indonesian Ministry of Health starting in 2008 until now. In order for this activity to be implemented to a wider and more numerous target, in 2010 the Ministry of Health has published a Module for Improving Skills in Choosing Medicines for Self-Medication. This module consists of 2 (two) books, namely Module I for Health Workers and Module II for Health Cadres. This module can serve as a guide for the local government, in this case the Provincial/District/City Health Office and other institutions that are interested in implementing CBIA activities in their working areas.

Implementation of Activities
Unlike other education or training activities in general, community education activities using the CBIA method are carried out by actively involving participants. One study conducted by UGM showed that the CBIA method can significantly increase the knowledge and understanding of participants compared to the lecture and question and answer method (presentation/counseling). With CBIA, participants can remember better because it is done actively and visually through direct observation. Tutors and facilitators only act as guides in the discussion, while further information needed can be delivered by invited resource persons. Thus cadres who have already been trained, or students can also be involved as tutors, while health workers from the Puskesmas or Health Office can be facilitators. Resource persons can be brought in from the pharmacist profession who have experience.

In CBIA, participants may include housewives, health cadres (posyandu), community leaders, PKK team members, or other community elements/organizations. To train how to implement CBIA, a training of trainers (TOT) is conducted while involving health cadres at Puskesmas or community elements as direct education participants. TOT activities conducted in provinces generally involve participants from the District Health Office and/or local Puskesmas health workers as well as health cadres (Posyandu) or other community elements/organizations.

In CBIA activities, participants were divided into groups of 6-8 cadres. The activities carried out are divided into 3 stages, namely:

1. Activity I (group)
Each group is given a specific medicine package that has been prepared, and then participants are asked to :

• Observe the medicine packaging and study the information listed, namely the trade name, name of active ingredient, dosage/strength of active ingredient, main and additional active ingredients in combination drugs.
• Categorize drugs by active ingredient, not by indication.
• Discuss the results of the above observations.

2. Activity II (Group)
This stage of the activity aims for participants to practice finding information from the packaging, by examining any writing available on the product. Some drug preparations in the form of liquids such as syrups, elixirs, drops or external drugs in the form of creams and ointments, include brochures from the manufacturer as product information. Meanwhile, tablet preparations in over-the-counter medicine packages (over the counter, OTC) often only provide product information on the outer packaging.
This stage is an activity to collect the necessary information as a basis for conducting self-medication, including the name of the active ingredient, indications, rules of use, side effects and contraindications.
The Tutor's role in this stage is quite large, to encourage all information needs, namely the 5 (five) main components of information to be found completely.
In this activity, the worksheets provided are used and the number of worksheets does not need to be limited. Completeness of the worksheet is expected to spur participants' activities in the next stage. Led by the group leader, the search for information is carried out together, while comparing the completeness of information from one trade name to another.
Although this activity is conducted in groups, each participant must take notes for his or her own use. While taking notes, participants can also simply review the completeness and clarity of the information presented in each package.

3. Activity 3 (individual)
This activity aims to foster participants' courage to seek information on their own. It is necessary to ensure that the worksheet in activity 2 has been filled in properly. At this stage, participants are asked to work on recording information like activity 2, on the drugs in their homes.
After explaining activity 3, the discussion was closed with a summary by one of the Tutors or Resource Persons, re-identifying key findings obtained in each group, and providing messages to strengthen the impact of the intervention.

Activity Results
Until 2013, Community Empowerment activities using the CBIA method by the Central Government through the Directorate General of Pharmaceuticals and Medical Devices, Ministry of Health have been carried out 32 times in 24 provinces. This activity was carried out in conjunction with the Rational Drug Use Movement activity as well as a separate activity in the province concerned.

Meanwhile, the number of health workers who have been trained up to 2012 is 1,077 people, health cadres (Posyandu) as many as 2,098 people, and the general public as many as 4,657 people. The development of the number of health workers, health cadres (Posyandu) and the public who have been trained is as follows:

The number of health workers, health cadres and communities that have been trained above still does not include the number of training participants organized by the Provincial/Regency/City Health Office. CBIA activities carried out by the Provincial Health Office can be through the APBN budget (deconcentration funds) or APBD. Meanwhile, the Regency/City Health Office generally implements this activity using the APBD budget and community self-help. This activity is one of the programs that is of concern and provides leverage in increasing the role of the community in health, especially in efforts to increase the rational use of drugs, in addition to other public health efforts.

The successful implementation of CBIA activities can be seen through the increase in knowledge of participants, especially health cadres and communities after the training compared to before. The enthusiasm of the community participants can be seen from the discussions and discussions that took place, where participants in all activities expressed their appreciation for the implementation of CBIA activities that can improve knowledge and skills. Health worker participants generally expressed interest in carrying out the same activities in their respective work areas, as part of community education and empowerment efforts, because the methods used are simple, but the results are quite significant.

Benefits of CBIA activities
The benefits that can be received by the community with educational activities through CBIA include:

1. Improved knowledge on how to choose and use medicines correctly, including by understanding that:

• The colored circle logo has a specific meaning that is not explained on the packaging. The public can know that self-medication can be done only for drugs with green (over-the-counter drugs) and blue (restricted over-the-counter drugs) logos. Drugs with a blue logo are accompanied by warnings that must be considered by the public before taking the medicine. Meanwhile, drugs with a red logo with a black K (hard drugs) can only be purchased with a doctor's prescription. The inclusion of this colored logo follows the provisions of the Ministry of Health.
• Information in drug packaging is more complete than in advertisements. Drug packaging always includes information on active ingredients. If there is any doubt about the advertisement, the information can be checked directly on the medicine package.
• The name of the active ingredient is listed below the trade name. Except for certain combination drugs that contain many ingredients, for example, only “multivitamins and minerals” is written.
• Most of the medicines on the market, whether syrups or tablets, contain the same or similar active ingredients. If the symptoms of your illness require a certain type of medicine, you should first check your home medicine supply to see if there is a medicine with the same active ingredient and indication you need, even if the trade name is different.
• There are similarities in active substance content between trade-named drugs and generic drugs. The public can know and realize that generic drugs, which are generally available in government health care facilities, contain the same active ingredients as trade-named drugs that are widely circulated in the market at varying prices. For example, Paracetamol tablets/syrup and Antacid DOEN are available in various trade names, with prices that are much higher than the price of generic drugs.
• There are differences or similarities in the content of active substances between medicinal preparations for adults and children, whose trade names are made similar or similar. For example, Bodrex-Bodrexin, Inza-Inzana, Mixagrip-Minigrip, even though the active substance content is different even though the indication is the same.
• The price of medicines can vary greatly, even if the content is the same. Liquid preparations such as syrups are generally more expensive than tablets with the same active ingredient content. The highest retail price (HET) is stated on the medicine packaging.
• Trade names with the addition of “Forte”, “Plus”, etc., need to be studied for differences in content and strength with regular ones. So that participants can be more careful in the use and can streamline drug costs.
• For promotional purposes, the names of active ingredients are often written with Latin names that are rarely known to the general public, even though common names are available. So it is difficult to recognize whether the drug is the same as a drug with another trade name even though the content is the same. For example, 1.3.7 trimethylxanthin is caffeine, acetaminophen and para-aminophenol to replace paracetamol, and others.

2. People can do self-medication correctly and rationally by understanding that:

• It is important to use the measuring spoon provided in the package when taking syrupy medicine, as it is not the same as a teaspoon or tablespoon available in the household.
• The time to take medicine must be followed according to the rules so that the medicine becomes more effective. Drug side effects are not experienced by all patients who take certain drugs, but can increase people's awareness when taking these drugs.
• Information that the drug cannot be used in certain conditions is listed in the Contra Indications section, which is generally rarely known by the general public.

3. Reducing the inappropriate use of antibiotics by the community because the discussion emphasized that if you have flu, fever or diarrhea, you do not always have to use antibiotics. Inappropriate use of antibiotics can cause resistance.

4. Increase the use of generic drugs by understanding that branded drugs and generic drugs with the same active ingredients must have the same efficacy. So that people can be smarter to choose generic drugs that are much lower in price, but have no doubt about their quality.

Follow-up Plan
Considering that the success rate of community education using the CBIA method is quite significant in efforts to increase the use of rational drugs, the Ministry of Health will continue to increase the target of education and expand the training area in collaboration with the Provincial/Regency/City Health Office and other related institutions or work units. This method will be refined through the revision of training modules and the preparation of monitoring and evaluation instruments for CBIA success indicators. Through community education with the CBIA method, it is expected that the rational use of drugs in the community can increase, thereby reducing errors in the use of drugs.