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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 8  |  Issue : 2  |  Page : 65-72

A study of medication compliance and medication safety among geriatric patients in rural areas


1 JSS Medical College, JSS Hospital, Mysore, Karnataka, India
2 Department of General Medicine, JSS Hospital, Mysore, Karnataka, India

Date of Submission11-Jun-2019
Date of Acceptance05-Jan-2020
Date of Web Publication18-Apr-2020

Correspondence Address:
Dr. B Durga Srivalli
Flat No. 303, Leo Poojitha Apartments, 3rd Main Road, V. V. Mohalla, Mysore - 570 002, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AJIM.AJIM_4_19

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  Abstract 


Background: Non- adherence is a major clinical problem in the management of patients with chronic illness. This problem is compounded with regard to the elderly, as they are prone to multiple health issues and therefore are at a higher risk of poly-pharmacy. Medication safety is also a particular concern for the elderly as they are exposed to the risk of increased drug interactions and their potential for side effects. In India, around 69% of population is rural based but there is a very limited research on the impact of rural status as a factor in adherence pointing to a need for more research in this area. Aims and Objectives: This project researched compliance levels around the rural areas of Mysuru, and the awareness of medical safety requirements. Materials and Methods: A cross sectional, interview based survey was conducted, performed by house visits. Elderly patients, above the age of 60 who were on medication for a non-communicable chronic illness were selected for this study. The data was analyzed using SPSS Version 22.0. Results: The results are broadly consistent with the findings of other studies in this area. Among the rural population sampled (118 subjects), 46.6% were fully adherent to the prescribed medication. The factors that were found to significantly influence adherence were forgetfulness, duration and cost of medication, polypharmacy and absence of caregivers. There was no statistically significant association between adherence and the factors of age, gender, educational qualification, distance from the pharmacy and co-morbidities. There seemed to be a good level of awareness regarding medication safety requirements. Conclusion: Thus, the study revealed that: While a good number of patients are compliant to their medication requirements, a substantial number [53.4%] lay outside the complete-adherence spectrum. For those who lay outside the adherence spectrum, strategies around care-giving, and technology to regularly check on the patients could help increase the adherence. Suitably simplifying the current practice of polypharmacy requirements, and minimizing costs might aid the adherence among the elderly.

Keywords: Compliance, geriatric, medication, rural, safety


How to cite this article:
Srivalli B D, Pereira P. A study of medication compliance and medication safety among geriatric patients in rural areas. APIK J Int Med 2020;8:65-72

How to cite this URL:
Srivalli B D, Pereira P. A study of medication compliance and medication safety among geriatric patients in rural areas. APIK J Int Med [serial online] 2020 [cited 2020 Jul 11];8:65-72. Available from: http://www.ajim.in/text.asp?2020/8/2/65/282842




  Introduction Top


“Keep a watch…on the faults of the patients, which often make them lie about the taking of things prescribed. For through not taking disagreeable drinks, purgative or other, they sometimes die.”

  • Hippocrates, Decorum


Medication compliance or adherence, as per the World Health Organization (WHO), is “the extent to which a person's behavior – taking medication, following a diet, and/or executing lifestyle changes corresponds with agreed recommendations from a health-care provider.”[1] Though the words “compliance” and “adherence” are used interchangeably, compliance is used to imply a passive role and simply following the demands of a prescriber, while adherence denotes an active role in collaboration with a prescriber.[2] Medication safety was defined by ISMP Canada (2007) as “freedom from preventable harm with medication use.”[3]

Adherence to medications has always been a challenge among patients. As per the WHO, nonadherence is a major clinical problem in the management of patients with chronic illness.[4] This problem is compounded with regard to the elderly, as they are prone to multiple health issues and therefore are at a higher risk of polypharmacy. Nonadherence results in the need for frequent visits to hospitals due to deterioration of the medical condition increased health-care costs, and even overtreatment.[5] On the other hand, a study in the US found that patients with adherence rates of 95% or higher had about 15% lower health-care costs than those with adherence rates of 80%–95%.[6]

Rates of nonadherence, in general, are estimated to vary from 15% to 93%, with an average estimated rate of 50%,[7] and this may range from 47% to 100% in the elderly.[8] Medication safety is also a particular concern for the elderly as they are exposed to the risk of increased drug interactions and their potential for side effects. Furthermore, the effects of aging cause bodies of older adults to process and respond to medicines differently than those of younger people.[9]

Reasons for nonadherence can be many and are broadly classified into patient factors, medication factors, health-care provider factors, health-care system factors, and socioeconomic factors.[10] Recognition of such multifactorial nature of poor adherence has resulted in increased awareness for a sustained and coordinated effort to ensure optimal adherence for the realization of full benefits of therapies. Regularity in health checks and review of prescriptions is one critical part of such an overall process, and for the purpose of this study, it is assumed that the greater the adherence, the better is the medication-safety.[11]

In India, around 69% of population is rural based,[12] and studies have revealed that the quality and reality of life for the elders in rural areas is lower as compared to those in urban areas.[13],[14] Research has also revealed that the disease pattern in India in general and particularly, in rural India underwent a significant shift over the past 15 years and that the incidence of chronic noncommunicable diseases (or NCDs) in rural India now looks largely similar to that in urban India.[15],[16] While a good number of studies have been conducted on the general aspect of levels of medication adherence in the elderly, there is a very limited amount of research on the impact of rural status as a factor in adherence. Moreover, there is no consistency in the findings of different studies, pointing to a need for more research in this area. In this project, therefore, it was proposed to examine if rural locations in and around Mysuru have any significant influence in the level of compliance of geriatric patients and their awareness of medical safety requirements. For this study, an elderly person is anyone who is aged 60 years or more.

Aims and objectives

The study objectives are:

  1. To undertake the study of medication compliance/nonadherence among geriatric patients from rural areas
  2. To assess the awareness regarding medical-safety requirements
  3. To analyze contributing and constraining factors; and
  4. To evaluate mechanisms that can promote medication compliance and medication safety in rural geriatric patients.



  Materials and Methods Top


Ethical approval was obtained for the study from the Institutional Ethics Committee of JSS Medical College/University, Mysore.

A cross-sectional, interview-based survey was conducted in the rural areas of Karnataka in the villages of Suttur, Meghalapura, Yelandur, Yergamballi, Dasanahundi, and Gumballi. The study was performed by house visits during August, September, and October 2018. Assuming an adherence rate as 50%, with a margin of error of 10% and a confidence level of 97%, a sample size of 118 was estimated. The sampling technique used was purposive sampling. The inclusion criteria for the selection of the study participants were: elderly patients, above the age of 60 years, and of either gender, who were on medication for a noncommunicable chronic illness or those who consent. Patients who exhibited severe cognitive impairment, poor hearing, visual impairment, or those too ill to participate were excluded from the study.

A structured interview scheme was designed for the purpose of this study. The scheme comprised of three sections. Section 1 elicited sociodemographic details and clinical characteristics of the eligible patients, such as age, gender, educational qualification, clinical diagnosis, duration of medication, number of drugs taken per day, and any comorbidity. Section 2 elicited information regarding medication safety and factors affecting adherence and compliance, whereas Section 3 comprised the 8-Item Morisky's Medication Adherence Scale (MMAS-8) to measure the level of adherence.

MMAS comprises 8 items. Items 1 through 7 have response choices “yes” or “no” whereas item 8 has a 5-point Likert response choice. Except for item 5, where response “yes” is scored as “1” and “no” is scored as “0”, in items 1 through 7, each “yes” is scored “0” and each response “no” is scored “1”. For item 8, response “0” is scored as “1”, response “4” is scored as “0”, and responses “1, 2, 3” are scored as “0.25, 0.75, 0.75,” respectively. Thus, the total MMAS-8 scores can vary from 0 to 8. The adherence has been categorized into three levels namely high adherence, moderate adherence, and low adherence. A score of 8 is taken as “high adherence.” Scores between 6 and <8 are taken as “moderate adherence,” and scores <6 are taken as “low adherence.”[17]

Informed consent was obtained from all the study participants after fully explaining the study procedure to their satisfaction, in the local language (Kannada). The interview was also conducted in Kannada.

Based on the above, 118 participants were interviewed. The data collected were entered into Microsoft Office XL 2010 and statistical analysis was performed using the Statistical Package for the Social Sciences version 22.0 (IBM). Basic descriptive statistics using mean and standard deviation were presented for numerical data variables such as age and adherence scores. The categorical data such as age, gender, educational qualification, presence of comorbidity, duration of disease, and number of drugs taken per day were presented as frequency and percentage. The association between compliance and different variables was assessed using the Chi-square test. P < 0.05 was considered statistically significant.


  Observations and Results Top


The demographic factors are presented in [Table 1]. Of the 118 study participants, 62.7% were female and 37.3% were male. The average age was 69.11 ± 7.89 years. The majority of the study population (64.4%) was uneducated. About 64.4% of the study population lived together with kids or in a three-generation/joint family.
Table 1: Demographic factors

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The frequency of various morbidities in the study population in represented in [Chart 1].



The most common presentation of illnesses in this study population was the co-morbidity of hypertension (HTN) and diabetes followed by diabetes mellitus alone and HTN alone. Other morbidities seen were cardiovascular disease, arthritis, epilepsy, and chronic obstructive pulmonary disease. Other diseases include hypothyroidism, chronic kidney disease, and other NCDs.

The average duration of medication [Table 2] in the group that was studied was 5.43 ± 4.93 years. The average number of drugs being taken by the study participants was 2.10 ± 1.26 drugs/day.
Table 2: Frequency distribution of duration of medication and number of drugs taken

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The frequency distribution of different classes of adherence is presented in [Table 3]. An average adherence rate of 6.94 ± 1.32 was observed.
Table 3: Frequency distribution of adherence

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[Table 4] shows the association between various demographic parameters and adherence scores.
Table 4: Association between adherence and demographic parameters

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Based on the above, it can be seen that the gender, age, and educational qualification do not hold a significant relationship to the adherence score, while the living condition appears to bear some influence. The same are analyzed further in the latter part of the study.

[Table 5] shows the relationship between adherence and other variables.
Table 5: Association between adherence and other variables

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[Table 5] indicates a significant relationship between the presence of caregivers, duration of medication, number of drugs taken per day, perception of expense, and forgetfulness with adherence. The presence of comorbidity or distance from the pharmacy (accessibility of drugs) does not seem to bear a significant relationship with the level of adherence.

Factors contributing to nonadherence were further analyzed; the results are presented in [Table 6].
Table 6: Factors contributing to nonadherence

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An analysis of the above shows that of the nonadherers (which includes those with moderate and low adherence scores) 50.8% forget their medication, 49.2% have been taking medication for >5 years, 41% perceive medication to be expensive, 16% are prescribed over 4 drugs (polypharmacy), and 11% do not have caretakers.

Medication safety

Information gathered regarding medication safety awareness is presented in [Table 7]. It presents various qualitative factors that play a role in medication safety and indicates the level of awareness of patients toward it.
Table 7: Frequency distribution of factors to assess medication safety

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All the participants of the study stated that they took the medicines promptly, as suggested by their doctor.

About 72% of the study population stated that they never forgot doses and were very punctual with the medication routine. 16.9% admitted to missing medication on rare occasions. The remaining 11% forgot to take their medication on a more frequent basis.

About 15.3% of the study population had reasons, apart from forgetting, for missing their medication doses, of which the most common reason was the inability to afford the drug. Of the 18 patients who fell into this category, 9 patients (50%) cited the reason as the cost of medicines, and another 9 (50%) felt indifferent on certain days.

Seven (5.9%) of the participants completely stopped taking the medication. Three of them could no longer afford the medicines. Two of them stopped the medication because they felt better and no longer felt the need for medication. The remaining 2 were disinterested in continuing the medication and hence stopped.

Only 6.8% of the patients reported that they forgot to carry medication during travel.

Of those who missed a dose of medication (a total of 38 participants), the majority of them (37 participants) stated that on missing a dose, they ignore it and continue taking the medicines as per routine. Only 1 participant stated that they inform the doctor.

About 2.5% of the study population said they sometimes felt worse on taking the medication. They informed the doctor of the same.

About 17.8% (21 participants) of the study group did not go for regular checkups. 41% (8 participants) of them stated distance as a factor for not going for regular checkups.

Four participants stated that they have changed drugs due to the unavailability of the prescribed drug. They take the alternative suggested by the pharmacist without informing the doctor of the same. One participant stopped taking the drug entirely due to its unavailability.

15% of the study population had taken drugs without prescription form a doctor. They self-prescribe medication mostly for fever, headaches, and body aches. The most commonly self-prescribed drug was paracetamol.

81% of the patients did not have the contact details of their nearest Primary health centre (PHC) or health center.


  Discussion Top


Medication adherence

In this study, among the rural population sampled, 46.6% were fully adherent to the prescribed medication. There was a statistically significant association between the duration of medication, the number of drugs taken per day, the presence of a caretaker and forgetfulness. About 31% of the individuals who were on medication for over 5 years exhibited a low level of adherence to the medication. 45.5% of the individuals taking 4 or more drugs and 30% of those who perceived medicines to be expensive showed a low level of adherence. About 55.6% of individuals who did not have a caretaker, showed a low level of adherence. There was no statistically significant association between adherence and the factors of age, gender, educational qualification, distance from the pharmacy, and comorbidities.

The results are broadly consistent with the findings of other studies in this area and a comparison with the results of a couple of other studies done in South India is presented in [Table 8].
Table 8: Comparison between adherence levels in current study with other similar studies

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A comparison of the factors affecting adherence in studies performed in other areas of India is given in [Table 9].
Table 9: Comparative analysis of factors affecting adherence in other Studies with the current study

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The variations in the results may need more investigation to ascertain the causes thereof, but it is clear that more than 50% fall into medium/low compliant scores, thereby calling for more concerted efforts to help them become properly compliant. Regional variation seems to influence the factors contributing to nonadherence. Influence of medication factors and social factors is found to be consistent among all the studies. The results are varied with regard to patient factors, health-care provider factors and health-care system factors. In the current study, a good level of patient awareness and easy accessibility to both health-care provider and system certainly improved the adherence levels. The converse as seen in other studies, that is, poor patient awareness and lack of easy access to facilities, negatively impacting the adherence, is also true.

Medication safety

About 100% of the study population was found to take medicines at the advised time. This indicates willingness to comply with medical advice. 82.2% went for regular checkups. When patients go for regular checkups, it gives the health-care professionals an opportunity to reassess the patient's condition and to revise the medication as maybe necessary. This ensures patient-safety and increases the scope for the effectiveness of the treatment.

Although 2.5% of the patients seemed to have suffered adverse effects, they informed the doctor and got the prescription revised. This demonstrates that the patients are aware of what needs to be done in the event of an adverse effect.

The practice of self-medication was reported by 15.3% of the study population. They usually take medicines suggested by the pharmacist for common ailments rather than visiting the medical practitioner. This shows a need for further education of the elderly as they seem to be unaware of the potential for harmful drug reactions that might result because of such self-prescribed medications.

In general, on interviewing the patients, there seemed to be a good level of awareness regarding medication safety requirements.

Suggestions

Failure of memory comes up as a serious factor. This is so not only in the current study but also in many others. Hence, cognitive assessment of the patient before prescription of medication can be done, and if a patient is found to be cognitively impaired, the prescription and due instructions must be given to the caregiver instead.

Wu and Ozok[25] noted, based on the results of an online survey with senior participants, that senior communities manage their medication in three ways: (a) manage based on memory or routines, (b) assisted by medication management tools, or (c) helped by other members in the family. Granger and Bosworth[26] found that while increasing automated reminders will certainly aid in helping patients not to forget their medication, they cannot replace the benefits seen with in-person communication for medication-taking. Therefore, they felt that the integration of in-person contacts with technology-driven adherence reminders may improve medication adherence.

Thus, in the Indian conditions, for those who do not have caregivers, appointing caregivers assisted by communication technology to regularly check on the patients could help increase the adherence.

The medical profession may also pay attention to the aspect of suitably simplifying the current practice of polypharmacy requirements and also examine the scope for minimizing costs. Encouraging physicians to prescribe drugs from the essential drug list, which is a list of drugs available for subsidized rates at PHCs, enables the affordability of medication.

The “Pradhan Mantri Bhartiya Janaushadhi Pariyojana“[27] is a government scheme that aims to bring down the health-care budget of every citizen of India through providing quality generic medicines at affordable prices. Jan Aushadhi Stores are set up under this scheme. Promoting this scheme and setting up Jan Aushadhi Stores at each district hospital, community health centre (CHC), and PHC can further ease the medication costs.

Limitations

  1. The sample size, in the current study, is not nearly large enough to generalize the results across India and to develop necessary guidelines. The time and funding was inadequate to further analyze the data, for example, the relationship between safety awareness and adherence levels
  2. There are various methods for the measurement of medication adherence[28] as seen in the study by Brown and Bussell which
    1. Subjective measurement-asking patients, family members, caregivers, and physicians about the patient's medication use;
    2. Objective measurement-counting pills, examining pharmacy refill records, or using electronic medication event monitoring systems
    3. Biochemical measurement-adding a nontoxic marker to the medication and detecting its presence in blood or urine or measurement of serum drug levels.
    The current study, using the MMAS-08 scale, only used the subjective method of measurement.
  3. Causes of variation in results among different studies (such as regional variation) require further analysis.



  Conclusion Top


The study reveals that while a good number of patients are compliant with their medication requirements, a substantial number lay outside the complete-adherence spectrum. Increasing adherence among this group requires more sustained and innovative effort on the part of the administration and care-providers – such as enhanced interaction with patients, electronic supports, and better optimized medical prescriptions. These will also help to educate patients about the potential harm of nonadherence, self-medication, and other medication safety parameters. Such interventions, if appropriately designed and implemented, can improve the effectiveness of investments in rural geriatric care, and also improve patient safety parameters.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

ICMR-STS 2018.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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