Abstract
Background
Medication-overuse headache is prevalent, but in principle preventable.
Objective
To describe the Danish national awareness campaign for medication-overuse headache.
Methods
The Danish Headache Center, the Association of Danish Pharmacies, and headache patient organizations implemented a four-month medication-overuse headache awareness campaign in 2016. Target groups were the general public, general practitioners, and pharmacists. Key messages were: Overuse of pain-medication can worsen headaches; pain-medication should be used rationally; and medication-overuse headache is treatable. A range of communication technologies was used. A survey on the public’s awareness of medication-overuse headache was conducted.
Results
The Danish adult population is 4.2 million. Online videos were viewed 297,000 times in three weeks. All 400 pharmacies received campaign materials. Over 28,000 leaflets were distributed. Two radio interviews were conducted. A television broadcast about headache reached an audience of 520,000. Forty articles were published in print media. Information was accessible at 32 reputable websites and five online news agencies. Three scientific papers were published. Information was available at an annual conference of general practitioners, including a headache lecture. The survey showed an increase in percentage of the public who knew about medication-overuse headache (from 31% to 38%).
Conclusion
A concerted campaign to prevent medication-overuse headache can be implemented through involvement of key stakeholders.
Introduction
Medication-overuse headache (MOH) is a global problem afflicting about 60 million people worldwide (1). In Denmark, it is estimated that 100,000 people (1.8%) suffer from MOH (2). This has substantial socio-economic consequences (3–6). Costs of MOH are three times greater than the costs of migraine due to sick leave, lost productivity, medication use, and health-care utilization (3).
This major public health problem could in large part be avoided by prevention of MOH and promotion of appropriate use of acute medications for pain. Studies have shown that patient education can be effective in reducing MOH prevalence. A Norwegian population-based cohort study with a 1.5-year follow-up showed that simple advice about MOH from general practitioners (GPs) is very effective in reducing the number of days per month with acute medication use (from 22 to 6) (7). Most MOH patients treated at specialized headache clinics prefer receiving verbal information about MOH (8). However, reading printed information could be just as effective in preventing medication overuse in less severely affected headache patients (9). There is a huge potential for prevention and treatment of MOH in primary care (10,11). MOH can be prevented by reinforcing GPs’ knowledge on headache diagnosis, appropriate treatment (12–14), and how to educate patients about medication use.
MOH is clearly a preventable condition (15–17). While there is some research on preventing MOH in clinics, there is very little literature documenting how MOH awareness among the general public can be improved (18). “Lifting the Burden: The Global Campaign against Headache” has been leading efforts to increase awareness about headache disorders (19–21). One campaign example is the Russian Yekaterinburg initiative (22) involving GPs, pharmacists, and the general public.
Few studies on preventing MOH in cooperation with pharmacists have been published despite their important role in health promotion (23,24). In the Danish healthcare system, pharmacists are expected to advise clients about correct medication use. Their role is crucial in recognizing “red flags” that might indicate medication overuse, and consequently advising clients to consult a GP.
Lack of literature on how awareness campaigns can be designed to reach out to a broad audience represents a huge gap in public health efforts, considering that MOH is among the top 20 causes of disability worldwide (1). All other conditions in the list of top disabling diseases (e.g. chronic pain, sense-organ diseases, psychiatric disorders, asthma, COPD, falls, and gynecological disorders) are well known to the general public, and have significant resources allocated towards health promotion campaigns. The aim of this paper is therefore to describe the implementation of the Danish national awareness campaign for MOH, which hopefully will inspire future public health campaigns in the headache field.
Methods
Campaign organization
The campaign was organized by the Danish Headache Center (DHC) in collaboration with the Association of Danish Pharmacies (ADP). The Migraine and Headache Patient Organization also contributed in later phases of the project. Regional networks for GPs were consulted. The campaign title was “When painkillers cause headache” and the launch was planned for European Migraine Day of Action, 12 September 2016 (Figure 1).
Target groups
The campaign was national in scope. The Danish adult population is approximately 4.2 million people (www.dst.dk). The primary target group was the general public; more specifically, women aged 30–50, for whom MOH prevalence is highest (2). The campaign was also designed to reach two groups of health professionals: GPs and pharmacists.
Campaign messages
Three key messages were agreed upon: a) Overuse of acute pain medication can make headaches worse; b) MOH prevalence can be reduced through rational use of pain medication; and c) MOH can be treated.
It was emphasized that all kinds of painkillers could potentially worsen headache if used too frequently. A maximum intake of painkillers (2 days per week) was recommended. A more nuanced message about limits for analgesic use was addressed to GPs following the International Classification of Headache Disorders diagnostic criteria (25). It was also recommended that physicians pay special attention to patients being treated for other pain conditions who later develop headache.
The campaign promoted the DHC’s treatment protocol for MOH, which is reduction or complete stopping of analgesic use for a two month period (26). This message was accompanied by information on what one might expect during detoxification, such as initial severe rebound headache and other withdrawal symptoms. The campaign advised on when it was safe to detoxify on your own, and when this must take place in specialized care (i.e. overuse of opioids, previous failed attempts, or significant physical or psychiatric co-morbidities). It was highlighted that support from relatives, friends and workplaces was important for completing detoxification, and sick leave for two weeks is often necessary.
It was stressed that the first step in preventing medication overuse was to document medication intake using a headache calendar (26). People suffering from debilitating headache were encouraged to consult a GP with the goal of optimizing treatment. Treatment guidelines and case studies were prepared for GPs, focusing on optimal treatment and preventives (pharmacological and non-pharmacological). The campaign also provided information about patient organizations that can be contacted for further help, support, and sharing of experiences.
Media and campaign forms
Overview of campaign components.
The online campaign used the following platforms: The homepage for the Association of Danish Pharmacies (www.apoteket.dk), Facebook, YouTube, Twitter and LinkedIn (on DHC’s LinkedIn profile).
All 400 pharmacies in Denmark were invited to participate. Danish pharmacies are privately-run corporations, and could not be required to take part in the campaign. However, previous campaigns on other public health issues often showed that pharmacy personnel were receptive to information materials for themselves as well as their clients.
Specialists from the DHC would serve as experts for media interviews. ADP members were tasked with contacting local and regional newspapers. Publications in local peer-reviewed journals for physicians and pharmacists were planned. DHC staff targeted participation in a national conference for GPs (14–18 November 2016) in collaboration with volunteers from the patient organization for cluster headache.
Measuring effectiveness
A survey on MOH awareness was developed for implementation one week before campaign initiation and again four to five weeks after the initial phase (Figure 1). The survey consisted of a web-based questionnaire with five questions, and was conducted in collaboration with a professional management consulting agency (Table 2). All survey participants were volunteer members of a panel commonly used for surveys and statistical investigations in Denmark. Participants had an opportunity to win gift cards. There was no need for approval from the Ethical Committee.
Timeline of the campaign in the autumn of 2016. Questionnaire from the survey. Note: The questions were originally formulated in Danish. The analgesics were explained by the common selling names.
Data management
SAS Enterprise Guide 7.1 was used for data management calculation of descriptive statistics, and preparation of graphs. The Fischer chi-square test was used for statistical comparison of categorical variables. p < 0.05 was considered significant.
Results
The campaign duration was four months (September to December 2016), with most activities conducted around the European Migraine Day of Action the 12th of September (Figure 1).
Online campaign
Self-administration test for risk of medication-overuse headache.
Note: The test was available at the campaign website via the homepage for the Association of Danish Pharmacies.
Campaign at pharmacies
All 400 Danish pharmacies were invited to participate in campaign activities for one week in September 2016 (Figure 1). Employees were encouraged to watch a PowerPoint presentation about MOH, and teach their own colleagues about management of MOH during their weekly education program. Materials for clients of pharmacies were produced: Posters, leaflets, and small business cards with links to further information. Thirty thousand copies of leaflets were printed and distributed through the 400 pharmacies and patient organizations. These were also handed out by volunteers from patient organizations at high schools, libraries, hospitals, and the national conference for GPs (Figure 1).
Several pharmacies were inspired to make very visible decorations during the campaign week, and several also prolonged the campaign period by keeping posters visible even after September. The ADP published a paper about the campaign in the pharmacists’ journal, Farmaci (27).
News media
Information about MOH was available on 32 websites, and was featured in 37 local and regional newspapers. Three nationwide newspapers and five news agencies covered the story. Headache specialists from the DHC were interviewed on local radio stations twice. Danish Television produced a feature about headache treatment at the DHC, which also included a clear message about MOH. The ratings were 520,000 during the television broadcast and there were additional views via online streaming, but the number of online viewers is not available to the authors.
Information for general practitioners
Three Danish-language articles about MOH were published in scientific journals during the campaign period (13,28,29) (Figure 1). The purpose of the articles was to update physicians about new MOH research, and to provide guidelines on diagnosing and treating patients with MOH.
In addition, the campaign was announced in a monthly journal for GPs and in the newsletter for GPs in the Capital Region. Physicians were therefore made aware that potentially more patients would consult them with questions about headache and analgesic use.
Over 3000 GPs and other health care professionals attended the national conference in November 2016. A 3-hour lecture by headache physicians from DHC was attended by approximately 90 GPs. Approximately 100 people visited the stand, where leaflets and links to websites with further information were handed out.
Survey results
One thousand randomly selected people were asked to answer a web-based questionnaire before, and four weeks after, the campaign. The two samples were independent but were designed to be similar with respect to age (35.3 in the first survey and 35.4 years in the second), proportion of women (65.3% and 60.8%), and education level (highly educated, 28.3% and 24.8%). Three times as many women as men were asked to participate due to the higher MOH prevalence among females. Participants were provided with correct answers to a quiz, so campaign messages reached about 2000 further individuals.
Results are summarized in Figure 2 (2.1–2.4). MOH awareness increased by 7% among the general public (from 31% to 38%) during this period. Despite a tendency towards increased MOH knowledge, none of the changes detected were statistically significant.
(2.1–2.4): Results of the survey before the campaign and 4 weeks later. 2.1: Awareness of headache types; 2.2: Information source about MOH; 2.3: Analgesics potentially worsening headache; 2.4: Recommended frequency for analgesic use. TTH: Tension-type headache; MOH: Medication-Overuse Headache; SoMe: Social Media; OTC: Over-the-counter drugs, including paracetamol and NSAIDs.
Discussion
The purpose of this paper is to describe how a national awareness campaign to prevent MOH was planned and implemented in Denmark, to hopefully inspire similar initiatives in other countries. To our knowledge, national MOH campaigns targeting both the general public and health-care providers have not been previously described, and so we did not have an existing campaign model. Nevertheless, this campaign is in line with the initiatives of Lifting The Burden: The Global Campaign against Headache (20), which aims to reduce the burden of headache worldwide. In describing and evaluating the campaign, we used elements of a model developed by the Center for eHealth and Wellbeing Research (30). This model consists of five components: contextual inquiry, value specification, design, operationalization, and evaluation.
Contextual inquiry
The campaign was initiated shortly after publication of epidemiologic data on MOH in Denmark in 2014 (2). MOH prevalence was estimated as 1.8%, but was higher among certain population segments: Middle-aged women, people with low socio-economic status, and non-ethnic Danes. The majority classified as having MOH overused over-the-counter medications, but registry data suggested that prescription medications (including opioids and triptans) were also used to a greater extent among a subgroup of people with chronic headache (31). The data emphasized the necessity of increasing awareness of MOH among the general public (specifically segments with the highest prevalence) and health professionals, particularly physicians and pharmacists.
Collaboration with the ADP opened an opportunity to conduct a national campaign via pharmacies. Information could thus be sent directly to community pharmacists, as well as their clients.
Danish citizens and long-term residents have universal and free access to a primary care physician. These physicians receive publications of the Danish Medical Association (DMA) and attend the annual national congress of primary care physicians, which was held during the campaign period. Scientific papers written in Danish were published in national journals of the DMA and ADP.
Three conditions – the population’s easy access to mass media, universal access to primary health-care, and organized networks of physicians, pharmacists, and patients – increased the likelihood that target audiences were exposed to the campaign nationwide.
Value specification and design
The campaign focused on raising awareness by providing clear and reliable information. This was done through use of different media channels and communication technologies. Although neither stated nor expressly agreed upon during the campaign, on hindsight, several key principles guided planning and implementation.
It was important for the DHC and ADP that campaign messages were
Another central aspect of the campaign was how to give
Another aspect of the campaign was
In contrast to the value placed on anonymity, people reached
Campaign messages were designed using a
There were opportunities for
Another guiding principle was that materials should be
Operationalization
The organizations involved had not previously collaborated on a national campaign. Despite this, all planned activities were implemented.
The two primary stakeholders, DHC and ADP, worked closely during the planning phase, campaign period, and evaluation process. DHC contributed content experts. ADP had access to a broad network of pharmacists, and had extensive experience of conducting campaigns on rational medication use. Initial ideas about campaign form and extent came from ADP with scientific input from DHC. Decisions about major aspects of the campaign were made collaboratively.
Patient organizations were not involved in the early planning process. However, their support was essential in the design phase (especially for printed materials), and during implementation. Patient organizations promoted the campaign via social media and their network of members and volunteers.
Future campaigns could involve public health institutions (e.g. the Ministry of Health), schools and universities, and other professionals (e.g. nurses and physiotherapists).
Evaluation
The campaign was evaluated using several metrics: Number of published articles, distribution of campaign materials, number of pharmacies involved, television viewership, online views, and change in number of people who were aware of MOH. Using these metrics, the campaign exceeded expectations.
The online campaign had the widest reach in the short term. The YouTube videos in total reached over 500,000 people compared with the expected 150,000 in a 3-week period. The primary targets of the online campaign were younger people and women aged 30–50. Use of online technologies seemed relevant and appropriate for these target groups. The TV broadcast reached approximately 10% of the Danish population, and likely reached an older demographic.
The purpose of the survey was to evaluate baseline MOH awareness, and to measure the early impact of the campaign. The increase in awareness of 7% is modest, and must be followed-up by interventions that change health behavior and optimize treatment for headache. The survey was conducted at a very early stage of the campaign and big changes were not expected. Nonetheless, we found it encouraging to identify even a small increase in awareness. Future campaigns targeting awareness and health behavior change may contribute to reducing the burden of MOH. Another goal of the campaign was to develop a system for future monitoring of MOH awareness.
According to the survey, most people received information from social media compared to other sources (i.e. pharmacies and GPs). This suggests that information shared through social media has an immediate, measurable effect, although it is unclear if this leads to lasting behavior change. Involving pharmacists and GPs is essential, since they have direct contact with the general public and play a central role in providing trustworthy and reliable advice on correct headache treatment, contributing to health behavior change.
The implementation of our campaign needed funding primarily for materials design, production, and distribution. The project was supported by volunteers and managed by the staffs of DHC and ADP, who were involved part time. Publication in medical journals, air time (in radio or television) and the opportunity to speak at the GPs’ conference, were not paid for. Use of social media platforms, news media, and scientific journals seemed to be the most cost-beneficial interventions.
Several aspects of the campaign were not evaluated. There was no systematic end-user evaluation of how messages on social media were received by the general public and if these actually changed behaviors. GPs were not asked if information in the scientific journals changed approaches to headache treatment or if pharmacists found the educational materials useful. Feedback was received through informal channels among professional peers, or through online comments. No resistance or negative reactions from the public have been registered.
Transfer of information from pharmacist to client and physician to patient was not systematically evaluated in terms of whether these were effective in influencing behavior change.
Conclusion
MOH is a preventable debilitating disease. The long-term goal is to lower MOH prevalence. Currently, there is a lack of awareness of the condition, which contributes to irrational use of acute medications for headache.
A concerted campaign for rational use of acute medications for headache can be implemented through the involvement of key stakeholders. Systematic use of social media and partnership with patient organizations, pharmacies, and health care professionals, are strongly recommended in future campaigns. Long-term changes in health behaviors, prescription patterns, and pain medication consumption should be continually monitored.
Clinical implications
Medication-overuse headache is a preventable condition. Increased awareness among the general public and health care professionals is essential in preventing medication-overuse headache. Large-scale awareness campaigns can be implemented by using different communications technologies, and by collaborating with health professional networks and patient organizations.
Footnotes
Acknowledgements
We thank all our collaborators, especially the chairman of The Migraine and Headache Patient Organization, Hanne Johansen. Thanks to the Patient Organization for Cluster Headache for sharing their stand with staff from the Danish Headache Center at the National Conference for General Practitioners.
Declaration of conflicting interests
The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: LN Carlsen and M Bisgaard received funding from the Tryg Foundation. ML Westergaard and JB Schytz have nothing to declare. RH Jensen has the following disclosures: Lectures for Pfizer, Berlin-Chemie, Allergan, Merck, ATI and participation in clinical trials for ATI, Electrocore, Eli-Lilly and Linde Gas. RHJ is also a director of LTB, trustee of IHS and past president of EHF.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The campaign was funded by the Tryg Foundation, the Association of Danish Pharmacies and The Migraine and Headache Patient Organization. The campaign did not receive funding from pharmaceutical companies.
References
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