Abstract:
INTRODUCTION:
Appropriate understanding of medicine-related advice in a prescription by patients ensures therapeutic compliance and mitigates avoidable medication intake-related errors.
AIMS:
This study assessed how well patients or their caregivers attending a tertiary care hospital have understood medicine-related information in their outpatient department (OPD) prescription.
MATERIALS AND METHODS:
This prospective questionnaire-based observational study was conducted on patients attending outpatient clinics of four departments of a tertiary care hospital. The questionnaire had both open and close-ended questions, which assessed understanding of written information related to the prescribed medicines.
RESULTS:
A total of 380 patients were enrolled in the study. 59.21% (95% CI 54.2–64.04) respondents had an excellent or good understanding of drug dosage. Similarly, 40% (95% CI 35.2–45) about drug frequency and 59.77% (95% CI 54.66–64.7) had excellent understanding of drug duration. However, overall composite understanding of prescriptions was poor in 36.84% (95% CI 32.14–41.8) of study participants. Patients with a higher level of education or from higher socioeconomic groups had a better understanding compared to other educational and socioeconomic categories. Suggestions for better patient understanding included prescriptions in vernacular language and pictorial representations.
CONCLUSIONS:
The study conducted in a tertiary care public hospital in India, reveals suboptimal understanding of medication-related information in OPD prescriptions. Based on the study outcome, measures have been taken to address the issue. Furthermore, there is a need for designing tailored interventions based on the patient profile attending a healthcare facility to facilitate better understanding.
Keywords: Comprehension, India, medicines, observational study, prescription, understanding
Introduction
Effective communication between healthcare professionals (HCPs) and patients is pivotal for optimal patient care and favorable treatment outcomes. However in reality, patients often fail to comprehend the prescriber’s advice as outlined in the prescriptions. In countries like India, majority of prescriptions are handwritten and doctor/patient ratio is unsatisfactory, especially in tertiary care public hospitals. Therefore, prescriptions are neither explained explicitly by HCPs nor do majority of the patients have adequate orientation to interpret them by themselves. The scenario in developed countries is quite different, where despite the availability of an adequate workforce or better patient orientation, this still continues to be a matter of concern. In a study done in Netherland, it was found that after leaving the physician’s office, patients could recall only 50% or less of the information provided.[1] Thus, there is a significant gap in the understanding of medication details among patients. Despite its importance, there remains a dearth of comprehensive research exploring the extent of patients’ or caregivers’ understanding of medication details in prescriptions. Hence, their understanding of prescriptions may be heterogeneous. The other factors could be the workload of the HCP, lack of communication skills, the huge patient turnover in public hospital outpatient settings, or inadequate counseling staff. As a result, there is often a lack of patient engagement in the conversation. Poor understanding of the prescription can lead to poor adherence, medication error, or side effects.[2,3,4,5,6]
As healthcare providers strive to deliver patient-centered care, it becomes imperative to identify the barriers that impede clear communication and comprehension of medication-related information catered through the prescriptions. By searching for the factors contributing to poor understanding, this study aims to pave the way for tailored interventions toward enhanced patient education and communication. A recent literature search showed there are few published papers from India.[7,8]
This observational study was conducted over 3 months at a tertiary care government hospital in Kolkata. The primary objective of this study was to assess how well the patients or their caregivers attending outpatient service in the hospital have understood the information conveyed in the prescriptions served to them and the secondary objective was to find out the association between literacy and other sociodemographic variables and their understanding of information about medicines prescribed in their prescriptions.
Materials and Methods
Study design
The prospective observational questionnaire-based study was conducted as a face-to-face exit survey in the outpatient setting of cardiology, medicine, pediatrics, and ENT departments of a tertiary care teaching public hospital in Eastern India. Approval to conduct this research was granted in February 2023 by the Institutional Ethics Committee.
Study participants
Consenting patients or caregivers (for paediatric patients) attending the above-mentioned OPD clinics, irrespective of age and gender and who were served a handwritten new prescription containing medicines were included in the study. Subjects who were able to read English and Bengali vernacular language and had at least a class 4 level school education were included. Patients unwilling to provide written informed consent were excluded from the study.
Sample size
Sample size calculation was done assuming that the population of eligible respondents would be 15,000, with a 50% approximate responder rate of the surveyed population and a 95% confidence interval with a 5% margin of error. The average daily OPD footfall in our hospital is about 15,000, hence it was used for the computation of the sample population. The calculated sample size was 375 and we rounded it off to 380. The Raosoft (Seattle, USA) online sample size calculator (http://www.raosoft.com/samplesize.html) was used for the estimation.
The study was initiated with prior approval from the Institutional Ethics Committee and the hospital’s administrative authority. The duration of the study was from February to April 2023. All enrolled participants provided written informed consent. We had adopted a purposive sampling strategy due to logistical feasibility, where we took every 3rd patient emerging from the exit of all categories of clinicians in the respective rooms from 10 am to 1 pm on the day. This enrolment procedure was followed twice weekly at the four selected OPD clinics.
Study tool
The study-specific data collection form was designed to capture sociodemographic data such as age, gender, educational status, monthly income, and residence as declared by the respondent. In the next section, information regarding the date of prescription, provisional diagnosis/presenting symptoms, number of medicines prescribed, dose, frequency, and duration of each drug prescribed, and special instructions, if any, about drug therapy were collected. An additional section was for the assessor who evaluated the legibility and completeness of the served prescription. The closed-ended questions included: (a) how many drugs have been prescribed, (b) what is the dose, frequency, and duration of each prescribed drug, (c) whether any prescribed drug has any special instructions to be taken before/after meals or at bedtime. For assessing comprehension of each of these, a score of 2 for each item correctly understood, a score of 1 for partial understanding, and 0 for incorrect understanding were awarded. The total score was computed for each prescribed drug. For computing the total score, the score for the individual drug prescribed was assessed for comprehension about dose, frequency, duration, and any special instructions with relation to food intake, where applicable. The total score was a summation of the individual scores for each drug. Then, the percentage score for the prescription was computed, i.e., score obtained/maximum achievable score x100.
The percentage scores were finally categorized into the following groups
-
(a)
Excellent understanding: >75%
-
(b)
Good understanding: 50–74%
-
(c)
Fair understanding: 25–49%
-
(d)
Poor understanding: <25%
The open-ended survey questions included how well the doctor or any health worker explained the prescription and whether the participants had asked any specific questions to the prescriber related to the medicines prescribed. The questionnaire was validated for content and construct validity with a kappa Cohen value of 0.7, indicative of good validation. Finally, suggestions regarding who should explain the prescription (doctors/nurses/pharmacists/counsellors) and how to improve their understanding were also sought from the respondents. Transcripts of the forms were shown to participants for comments and/or corrections. In addition, the investigator assessed the legibility and completeness of the written prescription on a scoring system.
Statistical analysis
Categorical variables were summarized by frequencies, while continuous data were summarized by the mean and standard deviation (SD). Univariate analysis for comparing the different categories of scores with age, gender, socioeconomic status, and educational status was done by the Pearson Chi-square test. Values of P < 0.05 were considered statistically significant. Statistical analysis is performed using the IBM SPSS (Statistical package for Social Sciences software version 20. (Armonk, New York, USA).
Results
We had approached 410 patients, of which 380 consented to participate, which spanned over 3 months. Table 1 shows the sociodemographic profile of the respondents. The mean age was about 44 years with a marginal female preponderance. About 85% had an education up to secondary school or less. Majority hailed from semi-urban or rural backgrounds and belonged to the lower socioeconomic category.
Table 1.
Sociodemographic profile of the respondents
| Variable (n=380) | Frequency, n (%) |
|---|---|
| Age (years) | |
| <25 | 36 (9.5) |
| 25–49 | 193 (50.8) |
| 50–74 | 147 (38.7) |
| 75 and above | 4 (1.1) |
| Gender | |
| Male | 174 (45.8) |
| Female | 206 (54.2) |
| Education | |
| Up to secondary level school | 321 (84.47) |
| Above secondary level | 59 (15.52) |
| Occupation | |
| Homemaker/unemployed | 185 (48.7) |
| Unskilled/semiskilled worker | 163 (42.9) |
| Student | 21 (5.5) |
| Skilled worker | 11 (2.9) |
| Residential status | |
| Semi-urban | 148 (38.9) |
| Urban | 141 (37.1) |
| Rural | 91 (23.9) |
| Socioeconomic status as per Modified Kuppuswamy Scale 2021 | |
| Lower middle | 226 (59.5) |
| Upper lower | 93 (24.5) |
| Lower | 33 (8.7) |
| Upper middle | 27 (7.1) |
| Upper | 1 (0.3) |
The overall categories of understanding of the prescription are depicted in Figure 1. Individual components of the prescribed drugs in a prescription were further analyzed, i.e., drug dosage, frequency, duration, and special instructions (where applicable), and Figure 2 shows the summary of understanding categories of these components in the study population.
Figure 1.
Categories of overall understanding of medication-related information
Figure 2.
Analysis of understanding of the various components of the prescribed medicines
The mean ± SD of the number of drugs per prescription was 2.97 ± 1.6 with a range of 1–8. Assessment of legibility of prescriptions revealed that 96% were legible and 86% of them were complete as per the National Health Mission Prescription Audit guidelines.[9]
Univariate analysis for determining the association of various score categories with age, education, and socioeconomic strata was undertaken. It was found that age, gender, and higher socioeconomic and educational status categories showed a statistically significant association with the score categories, as shown in Table 2. Respondents ≤50 years had a better understanding compared to those >50 years. Similarly, comparing genders, we found that 39.8% of women had poor understanding compared to 20.11% of men. These differences were found to be statistically significant. Analysis of educational status revealed that respondents with more than secondary level education had a significantly better understanding compared to those who had up to secondary level educational status. About 33% of respondents hailing from lower SE strata had a poor understanding compared to 7.14% belonging to upper SE strata. About 57% of upper SE strata had excellent understanding, while 19.88% of lower SE strata had excellent understanding. These differences were also found to be statistically significant.
Table 2.
Univariate analysis of overall understanding categories with age, educational, and socioeconomic groups
| Understanding category (n=380) | ≤25 (poor), n (%) | 26–50 (fair), n (%) | 51–75 (good), n (%) | >75 (excellent), n (%) | Row total | P |
|---|---|---|---|---|---|---|
| Age (years) | ||||||
| <50 | 64 (25.8) | 64 (25.8) | 57 (22.9) | 63 (25.4) | 248 | 0.030* |
| >50 | 53 (40.15) | 29 (21.97) | 27 (20.45) | 23 (17.4) | 132 | |
| Gender | ||||||
| Male | 35 (20.11) | 56 (32.18) | 44 (25.28) | 39 (22.4) | 174 | 0.000* |
| Female | 82 (39.80) | 37 (17.9) | 40 (19.4) | 47 (22.8) | 206 | |
| Educational status | ||||||
| Up to secondary | 116 (36.1) | 77 (23.9) | 68 (21.18) | 60 (18.69) | 321 | 0.000* |
| Above secondary | 1 (1.69) | 16 (27.11) | 16 (27.11) | 26 (44.01) | 59 | |
| SE status as per Modified Kuppuswamy Scale 2021 | ||||||
| Lower SE strataa | 115 (32.67) | 88 (25) | 79 (22.44) | 70 (19.88) | 352 | 0.000* |
| Upper SE stratab | 2 (7.14) | 5 (17.85) | 5 (17.85) | 16 (57.14) | 28 |
*P<0.05 is significant, aLower SE strata- includes lower, upper lower and lower middle, bUpper SE strata- includes upper and upper middle. SE=Socio economic
Comparative analysis of the understanding of individual components with various respondent socio-demographic characteristics is depicted in Table 3. A statistically significant difference was observed in the understanding of dose frequency in respondents aged <50 years versus those above that age group (P = 0.012). Comparison of educational level also demonstrated statistically significant difference (P < 0.000) as those with higher than secondary education had a good or excellent understanding (64.33%) than those with up to secondary school (35.46%). With regard to duration of drugs, statistically significant differences were noted in the above age, socioeconomic, and educational strata.
Table 3.
Comparative analysis of understanding of individual components of prescription with various sociodemographic respondent characteristics
| Poor, n (%) | Fair, n (%) | Good, n (%) | Excellent, n (%) | Row total | P | |
|---|---|---|---|---|---|---|
| Dosage | ||||||
| Age category (years) | ||||||
| <50 | 75 (30.24) | 19 (7.67) | 54 (21.77) | 100 (40.32) | 248 | 0.078 |
| >50 | 56 (42.42) | 5 (3.78) | 26 (19.69) | 45 (34) | 132 | |
| Educational status | ||||||
| Upto secondary | 126 (39.25) | 22 (6.85) | 62 (19.31) | 111 (34.57) | 321 | <0.000 |
| Above secondary | 5 (8.47) | 2 (3.38) | 18 (30.50) | 34 (57.62) | 59 | |
| SE status | ||||||
| Lower SE strata | 125 (35.51) | 22 (6.25) | 75 (21.30) | 130 (36.93) | 352 | 0.314 |
| Upper SE strata | 6 (21.42) | 2 (7.14) | 5 (17.85) | 15 (53.57) | 28 | |
| Dose frequency | ||||||
| Age category (years) | ||||||
| <50 | 106 (42.7) | 29 (11.69) | 41 (16.5) | 72 (29) | 248 | 0.012 |
| >50 | 73 (55.30) | 20 (15.15) | 19 (14.39) | 20 (15.15) | 132 | |
| Educational status | ||||||
| Upto secondary | 168 (52.33) | 39 (12.14) | 48 (14.9) | 66 (20.56) | 321 | <0.000 |
| Above secondary | 11 (18.64) | 10 (16.94) | 12 (20.33) | 26 (44.0) | 59 | |
| SE status | ||||||
| Lower SE strata | 172 (48.86) | 46 (13.06) | 56 (15.90) | 78 (22.15) | 352 | 0.009 |
| Upper SE strata | 7 (25) | 3 (10.71) | 4 (14.28) | 14 (50) | 28 | |
| Drug duration | ||||||
| Age category (years) | ||||||
| <50 | 66 (27.5) | 17 (7.08) | 40 (16.67) | 117 (48.75) | 240 | 0.003 |
| >50 | 56 (45.52) | 7 (5.69) | 10 (8.13) | 50 (40.7) | 123 | |
| Educational status | ||||||
| Up to secondary | 120 (39.47) | 18 (5.92) | 40 (13.15) | 126 (41.44) | 304 | <0.000 |
| Above secondary | 2 (3.4) | 6 (10.2) | 10 (16.9) | 41 (69.5) | 59 | |
| SE status | ||||||
| Lower SE strata | 121 (36.11) | 23 (6.86) | 47 (14.02) | 144 (42.98) | 335 | 0.000 |
| Upper SE strata | 1 (3.57) | 1 (3.57) | 3 (10.71) | 23 (82.1) | 28 | |
| Special instructions | ||||||
| Age category (years) | ||||||
| <50 | 112 (58.03) | 14 (7.25) | 23 (11.91) | 44 (22.79) | 193 | 0.679 |
| >50 | 63 (59.4) | 4 (3.77) | 14 (13.20) | 25 (23.6) | 106 | |
| Educational status | ||||||
| Up to secondary | 160 (63.49) | 15 (5.95) | 32 (12.69) | 45 (17.8) | 252 | <0.000 |
| Above secondary | 15 (32) | 3 (6.38) | 5 (10.63) | 24 (51.06) | 47 | |
| SE status | ||||||
| Lower SE strata | 166 (59.92) | 18 (6.49) | 37 (13.35) | 56 (20.21) | 277 | 0.000 |
| Upper SE strata | 9 (40.9) | 0 | 0 | 13 (59.1) | 22 |
*P<0.05 is significant. SE=Socio economic
Understanding of dosing showed statistically significant differences across the two education level categories, but age and socioeconomic categories had nonsignificant differences.
For special instructions, age category did not show a statistically significant difference (P = 0.679), but educational status and socioeconomic status showed statistically significant differences.
Discussion
This study evaluated the level of understanding of handwritten prescriptions served to patients attending the OPD clinic of a tertiary care public hospital in eastern India as an exit survey over 3 months in an adult population predominantly hailing from a lower socioeconomic background. Majority of OPD prescriptions served in this hospital are handwritten in English. Overall comprehension of essential components of drugs prescribed such as dose, frequency, and duration, was not commendable as 67% had either poor or fair scores, though more than 95% of the served prescriptions were legible and easily readable. Patients understood the duration of drug therapy better than the frequency terminology and special instructions about the drugs prescribed. This could be attributed to the fact that standard abbreviations used for frequency of drug therapy, such as BD, TD, or BDAC are not explained to the patients and they do not possibly have prior knowledge about them. However, the duration of therapy is written as a number, which they understood better. Younger patients had a better understanding compared to older respondents. Similarly, those with higher educational levels and socioeconomic profiles had a better understanding. Study findings may be attributed to the sociodemographic characteristics of the patient profile of this hospital, which mostly caters to patients hailing from relatively poor socioeconomic status, referred mainly from rural districts and those with an elementary school education background in the vernacular language. Therefore, prescriptions written in English are not well comprehended unless a HCP or counselor explains it to them. Pictorial representation of drug frequency may be understood by such patient groups.
The results of this study were compared with other international and national studies. Despite methodological variations, most of the studies had similar objectives. A cross-sectional exit interview-based study was carried out on 370 patients at an urban health center OPD in Mumbai.[7] The sample size and setting of the above study were comparable to our study. However, the above study reported complete understanding in 68.2% of individuals of lower socioeconomic strata, while in our study, it was only 58%. In our study population, 87% of those who had more than secondary level education had a good or excellent understanding, versus 72% of literate respondents in the Mumbai study who belonged to the same category. The above study did not assess individual components of prescribing i.e., dosage, frequency and duration, so we could not compare these domains.[7]
Another cross–sectional multicity exit survey from pharmacy shops was conducted from Punjab in North India on 264 patients.[8] The age profile of patients of the two studies was similar, but the educational profile was not comparable. In this study, 92% of patients had satisfactory understanding of drug intake timings, while in our study, 40% understood drug frequency well. There were also differences in understanding of drug duration and it was about 71% in the Punjab study.[8] We feel these differences could be attributed to differences in the educational profile of the respondents in the two studies.
We compared our study with a few international studies. The study on 165 patients attending various OPD clinics of a tertiary care hospital in Pakistan observed that 65% had more than 12 years of education. In this group, 26.2% understood drug frequencies well, while our study population was better positioned, as 60.33% of our study population belonging to a similar educational profile understood drug frequencies.[10]
A small-sized study, which was conducted in the USA[11] on patients hailing from low-income communities at primary care clinics, evaluated the understanding of dosage instructions for five common prescription medications. Their study population had a higher age group and a lower literacy profile compared to ours, but gender distribution was comparable. There were no significant differences observed between literacy, gender, source of payment for medications, or number of prescription medications taken daily. Around 63% of the patients with low literacy misunderstood the dosage instructions in the prescriptions, while our study found that 39% with < secondary level education did not understand the frequencies of drugs prescribed. Although this study was done at a primary care level majority of their study findings were otherwise comparable to ours.[11]
The strength of this study is that it has provided a realistic picture of the gaps in understanding of handwritten prescriptions in a large cohort of patients attending a public hospital in eastern India. This is possibly the first study done in eastern India which quantified this problem and also had an in-depth look at the factors associated with poor understanding. It has provided evidence for the hospital administration to take measures and strategies to address them. The limitations of this study are that we could not adopt a random sampling strategy due to logistical constraints, so some selection bias could not be fully eliminated. Finally, the study outcome may have limited utility in settings like developed countries or in patients attending corporate hospitals where all prescriptions are adequately explained by pharmacists or the patients are educated to understand it by themselves.
Conclusion
This study has provided evidence of the current status of understanding of written information in handwritten prescriptions of a tertiary care public hospital in India, which mainly caters to the referral patient population from various districts across the state. The study outcome has assisted the hospital administration in initiating steps to address the lacunae. Measures such as printed prescriptions and display boards in OPD clinics in vernacular language explaining drug frequency terminology, and help desks at pharmacies are being implemented. There is a need to further strengthen the role of counselors to explain and guide patients to understand served prescriptions in busy government hospitals of India, where patients hail from a rural background with suboptimal ability to comprehend written medical orders in prescriptions. A follow-up study following the implementation of such measures shall provide us with evidence of the impact of such interventions.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
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