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   Table of Contents      
ORIGINAL ARTICLE
Year : 2020  |  Volume : 6  |  Issue : 3  |  Page : 204-210

Patients Knowledge of Prescribed Medications and Factors Affecting it in a Tertiary Care, Public, Teaching Hospital in New Delhi, India


Department of Pharmacology, Maulana Azad Medical College and Associated Hospitals, University of Delhi, New Delhi, India

Date of Submission22-May-2020
Date of Decision29-Jun-2020
Date of Acceptance18-Jul-2020
Date of Web Publication16-Dec-2020

Correspondence Address:
MD, PhD Vandana Roy
Director Professor and Head, Department of Pharmacology, Maulana Azad Medical College, New Delhi-110002
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mamcjms.mamcjms_45_20

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  Abstract 


Objectives: To study patients’ knowledge about their prescribed medication and factors affecting it. Patients and Methods: An observational, cross-sectional study was conducted in 500 outpatients in the Medicine department of a tertiary care teaching hospital. The patients were interviewed about prescribed medicines using a structured questionnaire. The average consultation time and average dispensing time was also recorded for 100 interactions each. Results: Among 500 patients interviewed, 55% were females. Hindi was the primary language in 99.6% of the patients and majority of the patients 75.2% could not read English. The mean total score for patients’ medication knowledge was 38.87 ± 10.42 (maximum 60). 95% of participants had ‘Adequate to Good Knowledge’, and 5% had ‘Poor Knowledge’. Only 1.8% of the patients surveyed had complete knowledge of their prescribed medications. Various factors like age > 60 years, female gender, illiteracy, inability to read English, the doctor informing the patient only in writing and the pharmacist not explaining the medication information were associated with lower scores. The average consultation time was 284.6 ± 172.87 seconds and the average dispensing time was 60.45 ± 22.3 seconds. Conclusion: Overall the patients appear to have an adequate basic knowledge of their prescribed medications despite inability to understand the language and less time given for doctor patient pharmacist interaction. Interventions are required to improve health care providers understanding of what is required to educate the patients about the same. This is especially so for patients with risk factors contributing to their low knowledge about prescribed treatment.

Keywords: Communication, medicines, patients’ knowledge, prescription


How to cite this article:
Roy V, Tayal V, Kansal A. Patients Knowledge of Prescribed Medications and Factors Affecting it in a Tertiary Care, Public, Teaching Hospital in New Delhi, India. MAMC J Med Sci 2020;6:204-10

How to cite this URL:
Roy V, Tayal V, Kansal A. Patients Knowledge of Prescribed Medications and Factors Affecting it in a Tertiary Care, Public, Teaching Hospital in New Delhi, India. MAMC J Med Sci [serial online] 2020 [cited 2021 Apr 13];6:204-10. Available from: https://www.mamcjms.in/text.asp?2020/6/3/204/303589




  Introduction Top


Patients’ knowledge about prescribed medication can affect their adherence with treatment.[1],[2],[3] Thirty to fifty percent of patients do not adhere to their prescriptions due to incomplete knowledge.[4],[5] Multiple factors can affect patients’ knowledge and thus, adherence to his treatment including doctor patient communication, pharmacist patient interaction, patients age, gender, level of education, income, primary language, nature of illness.[6],[7],[8],[9] Knowledge of the drugs prescribed is a key indicator for health literacy in a patient. Non-adherence to the treatment can result in a decrease in efficacy of medication, therapeutic failure, adverse drug events and increase the problem of drug resistance.[5],[10],[11],[12] India has a population of 1.21 billion and one out of every four patients is illiterate.[13] There is paucity of data on health literacy from Asia, particularly India. Further, there is lack of studies from India which correlate factors that can impact patient’s knowledge of the prescribed medication. Our hospital provides free healthcare and medicines to patients. Many of the patients utilizing the health facility have a low socioeconomic background and are illiterate.

The present study aims to assess the patient’s knowledge regarding prescribed medication and factors affecting it in a tertiary care, teaching government hospital in Delhi, India.


  Material and Methods Top


A cross-sectional, observational, study was conducted in the Medicine Outpatient Department (OPD) and Pharmacy of a tertiary care, teaching hospital in Delhi, India between May to July 2017. The study was approved by the Institutional Ethics Committee. Written informed consent was obtained from all the patients.

A convenience sample of 500 patients of either sex, aged 14 years and above receiving outpatient treatment in the medicine department of the hospital were included in the study. Patients were excluded if they had been interviewed before, were unable to verbally communicate due to any cause or if they had visual or auditory impairment that hindered their ability to understand instructions. Patients were assessed using a pretested, structured, validated, interviewer-administered questionnaire as they exited from the pharmacy after getting the medicines.

The questionnaire was divided into five parts: Patients’ demographic details, nature of illness, knowledge of prescribed treatment, source of information about prescribed medication and understanding of the treatment prescribed. Validity of the drug information provided by the patient was cross-checked from their prescription cards. Patients’ knowledge about each medicine prescribed was scored out of 60 [[Table 1]]. Depending upon the total score achieved, the patient’s knowledge was graded as poor (<20), adequate (21−40) or good (41−60).[9] The content of knowledge a patient is expected to have served as the basis for development of the questionnaire (Appendix 1).
Table 1 Scoring criteria and knowledge scores (Mean ± SD) for patients knowledge about the prescribed medication

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Completeness of the written information about prescribed medications was noted from the prescription cards. A prescription was considered complete if name, dose, frequency and duration of therapy about all prescribed medicines were written. The following health facility indicators. (i) Average consultation time (time between a patient entering and leaving a doctor’s room) was recorded for 100 patient consultations in the medicine OPD. (ii) Average dispensing time (the time spent by a patient with a pharmacist) was recorded for 100 pharmacist patient interactions in the pharmacy.[14]

Statistical analysis

The data was compiled in excel sheets and analyzed using SPSS version 21.0.0.0. The results are expressed in totals, percentages, ranges and mean ± SD wherever applicable. Categorical variables were analyzed using Chi Square Test (Fischer’s exact used wherever applicable) and continuous variables were evaluated by independent samples test. A P-value < 0.05 was considered as statistically significant.


  Results Top


Patients demographics

Majority of the patients (70.2%) were in the age group of 20-59 years and 55% were females. Nearly half of the patients (46.2%) were illiterate. Only 14% of the patients had a level of education of either secondary education or above. Hindi was the primary language in all except 3 patients and majority of the patients (75.2%) could not read English [[Table 2]. One third patients had comorbidity and 62% patients had chronic diseases. More than 50% patients were follow-up cases [[Table 2].
Table 2 The demographic variables of patients in relation to their knowledge scores (n = 500)

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Source of information and the patients understanding about the prescribed medication

The main source of information about the prescribed medications was the dispensing pharmacist in majority of the patients (86%). Only 7.2% patients identified the prescribing doctor as their main source of information. Few patients (3.2%) had not been informed about their medication and were, thus given this information by the interviewer. Remaining patients received information from miscellaneous sources like their family members, chemist, etc.

With majority (86.6%) of the patients, doctors had provided the information in writing, without any verbal explanation. The information about the medications was clear and understood by 85.4% of the patients. For the remaining patients, the reason for not being able to understand were inability to read English (12.4%) and illegible handwriting (2.2%). The patients own perception of their current knowledge on prescribed medicines showed that majority of the patients (83.4%) felt that their present knowledge was satisfactory [[Table 3].
Table 3 Role of doctors and pharmacists in educating the patients and the patients knowledge about prescribed medicines

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Details of prescription information

The average number of medicines per prescription in the study was 3.8 ± 1.8. Less than half of the prescriptions (42.8%) were complete [[Table 4]. A total of 1888 medicines were prescribed, of which the prescribing information was incomplete for one-third medicines. Few medicine names (0.58%) were illegible. Nearly 50% of the patients were prescribed more than three medicines.
Table 4 Details of prescription information written about individual medicines

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Patients’ knowledge of prescribed medication and the associated factors

Of the total number of patients surveyed, only nine (1.8%) patients had complete knowledge. Majority had adequate (54%) to good (41%) knowledge. Remaining 5% patients had ‘Poor Knowledge’ about the medicines.

Of the prescribed medicines (1888), the patients knew the name of only few medicines but they could identify majority of medicines [[Table 5].
Table 5 Patient’s assessment about prescribed medications

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The mean total score for patients’ medication knowledge was 38.87 ± 10.42 [[Table 1]. The score was higher in male patients in comparison to female patients (P = 0.002) and in people aged 14−39 years compared to other age groups (P < 0.05) [[Table 2]. Further, patients who were able to read English, had higher education level or higher monthly income had better mean knowledge scores (P<.001) [[Table 2]. Similarly, follow-up patients had a significantly higher mean knowledge score as compared to new patients (P = 0.001). Patients in whom only written information was provided by the prescribing doctor had a significantly lower mean knowledge score compared to those who were explained both verbally and in writing (P = 0.018) [[Table 3]. Similarly, verbal explanation of the medications by pharmacist resulted in a significantly higher mean knowledge score in 91% patients (P<0.001). Patients with prescriptions with complete information about medicines had higher knowledge (P = 0.029).

Health Facility Indicators

The average consultation time was found to be 284.6 ± 172.87 seconds while the average dispensing time was observed to be 60.45 ± 22.3 seconds.


  Discussion Top


One of the major principles of rational use of medicines (RUM) is to adequately inform the patients about their medication(s) as well as the diagnosis and make the patients share the responsibility of the therapy.[15] The patient’s involvement in understanding of the treatment prescribed is of utmost importance for effective health outcomes.[9],[16] Public health facilities (HF) in India are overcrowded with time for an effective doctor-patient relationship being abysmally poor. Patients utilizing these HF also come from poor socioeconomic backgrounds, many not having a formal education. The situation makes it a difficult proposition for patients to be adequately informed about their prescribed medication. This is the first study performed in a large public tertiary care hospital in India which assessed the patients’ knowledge about the prescribed medication and also attempted to identify the factors affecting their knowledge.

When assessing patients’ knowledge of medicines, the following are regarded as essential parameters for safe and effective use; the names of the medicines, the purpose (indication) of therapy, the duration of therapy, the dose and frequency of administration and important side effects.[17] We assessed all these parameters except the knowledge about side effects.

Majority of the patients had adequate to good knowledge overall of their medications although only 1.8% of patients surveyed had complete knowledge. The patients were less aware about the medicines name, exact dose and the indication why the medicine was given. The name and exact dose were known for only 19.9% and 27% of the medications. Similar findings have been observed in studies in Asia.[2],[8],[18] Patients awareness about these factors have been higher in Western studies.[7],[9],[11],[15],[16],[17]

Poor knowledge about prescribed medication was associated with female gender, age > 60 years, illiteracy, inability to read English and lower income of the patients. The education of females may not receive the same attention as for male children.[22] For elderly patients, age related factors such as a decline in cognition as well as multiple chronic diseases which necessitates use of numerous medications may attribute to their low knowledge scores. Majority of the patients were illiterate or had studied up to middle school and were unable to read English. Hence, many patients (75.2%) were unable to read and understand the drug information in the prescriptions. Similar observations were made in an earlier study which revealed that 54% patients were unable to understand drug information and only 1% of the patients were able to read drug names because of their inability to read English.[8] Limited English proficiency has been attributed as an important reason for poor health outcomes as these patients have lower access to health care.[23]

A prescription has to be communicated, (both written and verbal) to a patient in a way the patient understands. Most prescriptions in India are written in English and many patients are not conversant with it. One way of overcoming this problem could be the doctor making illustrations on the prescription to explain or writing the important parts in a language the patient can read. One cannot do away with writing a prescription in English as many people may not understand the local language and English becomes the unifying language.

New patients also had a lower score than follow-up cases as it is likely that follow-up cases would have been told about their medications multiple times. Likewise, patients with chronic diseases also had a higher mean knowledge score though it was not significantly different from the patients with acute conditions. However, patients with more than one co-morbid conditions had less knowledge score, likely because of more number of drugs prescribed to them. Our findings are also in agreement with results of earlier studies which indicated that patients with no education, unskilled workers, new patients and patients taking more number of medications had inadequate medication knowledge.[2],[8] The authors also discussed that most of these socio-demographic characteristics associated with low knowledge scores are non-modifiable. However, these predictors can help in early identification of patients at a higher risk of lower medication knowledge scores and, therefore, more focused interventions by health care providers targeted at these groups can lead to improvement in medication use.

Health care providers like doctor and the pharmacist play an important role in educating the patient about the prescribed medication. The doctor’s involvement in educating patients on drug information was inadequate as only 7.2% of the patients revealed that doctor was their main source of information about medicines and only 13.4% patients received information both verbally and in writing by the doctor. These patients were found to have a higher mean knowledge score indicating that doctors while writing prescriptions are not explaining the same to the patients. Similar results were reported from a study which revealed that doctors contributed to the patient knowledge in only 33% of patients and this was associated with significantly improved patient knowledge.[8] Majority of the prescriptions were found to be incomplete which was associated with a lower mean knowledge score as compared to patients whose prescriptions were complete. More so, the average consultation time with the doctor was found to be 4.74 ± 2.88 minutes which is very less. This further contributed to the diminished comprehension of patients about their prescribed medication. A recent systematic review which collated primary care physician consultation length of 67 countries revealed a striking finding that 50% of the global population spend 5 minutes or less with their primary care physicians which adversely affects patient care, the workload and stress of the consulting physician.[24] Their review highlighted that longer consultations are better and that more primary care physicians will be required to give patients more time. In India there is one government doctor for every 11,528 people.[25] The load of patients in the hospitals is very high. Due to the poor doctor patient ratio and consequent enhanced workload, doctors are unable to give adequate time to educate the patients about appropriate use of their medicines. Also, a one-way paternalistic type of communication is prevalent in Asia.[26] A good communication between the physician and the patient is a must to improve compliance and thus therapeutic outcomes.

We did not correlate the effect of short consultation time and dispensing time with patient’s knowledge. This was due to practical difficulties of recording the consultation time, dispensing time and surveying the same patient for patient’s knowledge. It is likely that had we been able to do so, a positive correlation with duration of consultation /dispensing time and patient’s knowledge may have been observed.The pharmacists are also an important source of information about medications to patients. This is evident by the significantly higher mean knowledge score for patients who were informed by their pharmacists. But again, because the pharmacy counters are overcrowded, the dispensing time, which was observed to be just over 60 seconds is not sufficient for the patients to understand and remember all the information. The World Health Organization has emphasized that adequate consultation time given for patients, both by physicians and the dispensing pharmacists is critical for proper understanding of why and how medicines are to be taken, for what purpose and for how long they are to be taken.[27] An earlier study from South Africa also revealed that majority of the patients including those with lowest levels of education and the poorest socio-economic backgrounds who were informed about their illnesses by their doctor or nurse took their medication correctly.[28]

One way of improving the scenario could be the introduction of medical social workers who interact with the patients after the pharmacists have dispensed the medicines. They could explain the prescription adequately to the patients, in a language they understand.


  Conclusion Top


Patients appear to have adequate basic knowledge of their prescribed medications despite low consultation and dispensing time as well as inability to understand English. Age, gender, level of education, low income of the patient and lack of instructions about the prescribed treatment by the health care provider are impacting patients’ knowledge. Focused interventions for patients who are at a high risk of lower knowledge as well as education of doctors and pharmacists about their role in improving patient’s understanding of prescribed medications are required to improve medication use in the health facility.

Authors’ Contribution

Dr. Vandana Roy contributed to the concept, design, definition of intellectual content, manuscript preparation, manuscript editing and manuscript review. Dr. Vandana Tayal contributed in literature search, data analysis, statistical analysis, manuscript preparation, manuscript editing and manuscript review. Dr. Anirudh Kansal contributed literature search, data acquisition, data analysis, statistical analysis, manuscript preparation.

Disclaimers

We authors, undertake that the views expressed in the submitted article are our own and not an official position of the institution or funder. Manuscript has been read and approved by all the authors, and each author believes that the manuscript represents honest work.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional Ethics committee of Maulana Azad Medical college (Reference no. F.17/IEC/MAMC/17/No.70 dated 5.5.17).

Informed consent

Informed consent was obtained from all individual participants included in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Appendix 1: Questionnaire for assessing patients knowledge about medications and the associated factors

A. Patient’s demographic details

1. Patient’s CR Number: ______________

2. Type of patient: Old/New

3. Age

i) 14–20 years ii) 21–40 years iii) 41–60 years iv) 61-70 years v) 71 years & above

Gender- i) Male ii) Female

Primary language i) English ii) Hindi iii) If Other, Specify ________

Education level

i) Illiterate ii) Primary School (Up to class 5)

iii) Middle School (Classes 5–10) iv) Senior Secondary (Classes 11–12)

v) Graduate vi) Post graduate

Able to read English i) Yes ii) No

Income

i) Formal job- Yes/ No

ii) Monthly income (in Rupees/month)

a) 2000 and below b) 2001–6000

c) 6001–10000 d) 10001–15000

e) 15001 and above

B. Patient’s Nature of illness

1. Diagnosis _____________

Number of co-morbidities _____

2. Illness- i) Acute ii) Chronic

C. Source of information about the prescribed medication

1. Who/What is the major source of information about the prescribed medication?

i) Prescribing doctor

ii) Dispensing pharmacist

iii) Reading prescription card

iv) Family member

v) Others

2. How did the Doctor educate the patient?

i) Only verbally

ii) Only in Writing

iii) Both verbally and in writing

3. Did the Pharmacist explain the prescription? Yes/No

D. Patient’s understanding of the prescribed medication

• Is the information about the prescribed medication clear and understood? Yes/No

• If the patient is unable to understand drug information, what are the reasons for that?

i) Illegible handwriting

ii) Inability to read English

iii) Or both

iv) If other, specify ___________

E. Patient’s perception of their knowledge of prescribed medication

• Does the patient feel that his/her knowledge of prescribed medication is satisfactory? Yes/No



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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