Factors Affecting Patients’ Incomplete Understanding of Prescriptions

ORIGINAL ARTICLE

Factors associated with Patients’ Incomplete Understanding of Prescriptions

Gerard Raimon M. Saranza,1 Derick Erl P. Sumalapao1,2 and Isidro C. Sia1

1Department of Pharmacology and Toxicology, College of Medicine, University of the Philippines Manila

2 Department of Physical Sciences and Mathematics, College of Arts and Sciences, University of the Philippines Manila

Introduction
Compliance is defined as the extent to which patients
take medications as prescribed by their health care
providers.1 According to the World Health Organization
(WHO), only about 50 percent of patients take their
medications as prescribed by their doctor.2 WHO
consequently recognizes medication non-compliance as a
worldwide problem which should be addressed seriously by
all health care providers and policy makers.
Several studies have already been conducted regarding
the factors which contribute to medication non-compliance
and these include socio-demographic factors, health system
related factors, therapy-related factors, condition-related
factors and patient-related factors. These studies have
demonstrated that non-compliance affects all ages, both
_______________ sexes and all levels of educational attainment and
socioeconomic status.3
Poster Presented at the 3rd International Conference for Improving Use of One of the important factors identified is the inability to
Medicines (ICIUM), November 14-18, 2011, Antalya, Turkey.
understand the instructions regarding the intake of a
Paper won 2nd place at the Annual Intern’s Research Forum, April 24, 2012, prescribed drug. Lau et al. has shown in their study that
College of Medicine, University of the Philippines Manila. there is a close relationship between treatment compliance
and a clear understanding of prescriptions.4 In a recent study
Corresponding Author: Gerard Raimon M. Saranza, MD
Section of Adult Neurology conducted by Davis et al., patient’s understanding of
Department of Neurosciences prescription label instructions ranged from 53% - 89% of 10
Philippine General Hospital common prescription label instructions.5 In another study
University of the Philippines Manila
Taft Avenue, Ermita, Manila 1000 Philippines conducted by Gottlieb, 60 percent or more of patients could
Telephone: +632 5548400 local 2401 or 2405 not correctly report what their physicians told them about
Email: [email protected] medication use 10 to 80 minutes after receiving the

36 ACTA MEDICA PHILIPPINA VOL. 47 NO. 4 2013

 Factors Affecting Patients’ Incomplete Understanding of Prescriptions

information. 6 In America, it is estimated that more than 90 Tagalog. The study was also thoroughly explained to the
million Americans cannot understand basic health respondents by the interviewer. Patients did not receive any
information.7 There are no such similar studies conducted reward- be it monetary or in kind. They were, however,
locally. The nearest study would be that of Hardon wherein given a chance to ask questions about the drugs they are
the median number of antibiotics dispensed in pharmacies taking and were answered by the interviewers to the best of
was six tablets or capsules, indicating a widespread lack of their abilities.
understanding of proper drug intake.8,9 In another local A total of 392 individuals were purposively sampled
study conducted by Lansang et al., antimicrobial purchases and interviewed from June to August, 2010, after the study
in a district in Manila were made without prescription in received an approval from the Research Implementation and
66.3% of 1608 transactions and that almost 90% of purchases Development Office (RIDO) of the UP College of Medicine.
were for 10 or less capsules or tablets.10 Customers with The sample size was determined using the formula:
written prescriptions purchased a mean of 8 while those
who self-prescribed purchased a mean of 4 units. The
[ p(1-p)
]
n = 0.052 1.962 where 0.05 is the margin of error and
authors concluded that these practices can provide only p=0.5 is the assumed proportion of individuals with a
limited clinical efficacy and favor the emergence of resistant complete knowledge of the proper intake of a prescribed
bacteria. Furthermore, based on the researchers’ experience drug since to date, there are no available similar studies
at the Outpatient Department of the Philippine General done locally. This value for p will yield the maximum
Hospital, there were already several instances when follow- sample size (n=385).
up patients show no improvement in their health status all The researchers allocated the 392 respondents equally
because of a lack of understanding on the proper intake of into four subgroups: patients who sought consult in a
their medications. government hospital (98 respondents), private hospital (98
Lack of medication adherence has serious ramifications respondents), local health centers (98 respondents) and
which range from unnecessary disease progression, disease private clinics (98 respondents). The subgroups were based
complications, reduced functional abilities, a lower quality on the four major sources of outpatient prescriptions in the
of life to premature death. These unwanted end results of country.
medication non-compliance do not only affect one The researchers conducted the interview in the
individual but the entire health care system as well, with all following 11 drugstores or pharmacies: PGH Pharmacy (53
the economic burden that it will bring.11 samples), 3 Drug Stores in front of PGH (62 samples), 1
This study assessed the understanding of Filipino Mercury Drug Store along Taft Avenue (58 samples), 1 Drug
patients regarding the drugs prescribed by their doctors as a Store in UN Avenue (32 samples), UST Pharmacy (38
specific patient-related factor, which contributes to non- samples), 1 Mercury Drug Store near UST Hospital (48
compliance. In addition, this study identified the factors samples), 1 Mercury Drug Store in Bambang (22 samples),
which significantly affect the patients’ understanding of Pharmacies/Botika ng Bayan near San Pablo Health Center
prescriptions. The factors included in this study were (41 samples) and Pharmacies/Botika ng Bayan near Malibay
classified under three major categories: (1) patient-related Health Center (38 samples). These pharmacies were
factors, (2) physician-related factors and (3) prescription- randomly selected to capture patients who consulted at the
related factors. Moreover, the populations at risk were also Philippine General Hospital, Jose Reyes Memorial Medical
ascertained so that whatever strategies will be undertaken Center, Ospital ng Maynila, Medical Center Manila, Manila
by the government to address this problem of non- Doctors Hospital, University of Sto. Tomas Hospital,
compliance in the future, emphasis will be given to these Chinese General Hospital, neighboring private clinics and
vulnerable populations. If the patients' understanding of local health centers. Mercury Drugstore outlets were chosen
prescriptions is to be improved, various social, economic, primarily in this study since Mercury Drug is estimated to
and medical factors must be identified and addressed sell as much as 60 percent of all medicines sold each year in
thereafter. the Philippines.12,13

Methods Data Collection and Variables

A researcher-structured questionnaire (Appendix) was
Study Population administered in the study to assess the patients’
The population in this study included individuals 18 understanding of prescribed drugs. The questionnaire was
years of age and older who consulted a physician and were constructed based on several studies done abroad. No pilot
given prescriptions. These patients should also self- testing was done; however, the results of this study could be
administer the drug prescribed without any form of used as benchmark for future studies. During the conduct of
assistance from a family member or a caretaker. Prior to the the interview, it was the interviewers, and not the respondent,
interview, all respondents were asked to read and sign an who filled out the questionnaire. The interviewers convened
Informed Consent Form, available in both in English and in to standardize definitions and manner of questioning. All

VOL. 47 NO. 4 2013 ACTA MEDICA PHILIPPINA 37

Factors Affecting Patients’ Incomplete Understanding of Prescriptions

clarifications during the actual conduct of the interview were throughout the conduct of the study. A respondent was
addressed by the authors who were present on-site. allowed to terminate participation anytime for any reason.
For a given pharmacy, every third patient purchasing a All respondents who voluntarily expressed their intention to
prescribed drug/s was considered in the sampling participate in the study were able to complete the interview.
population until the desired sample size for a particular In circumstances wherein respondents were found to
study group was obtained. All respondents were have a misunderstanding of a prescription, they were
interviewed in one corner of the pharmacy to maintain advised appropriately by the researchers.
privacy and confidentiality. All results obtained in this study were handled with
In this study, Complete Understanding is defined as confidentiality. The questionnaires were secured by one of
knowing all of the following essential information of the the authors in a locked cabinet. Data were encoded in a
prescribed drug: name (either generic name or brand name room where no other individuals aside from the researchers
or both), formulation, dose, frequency, duration, and route can visualize the laptop monitor or the questionnaires. The
of administration. On the other hand, Incomplete laptop was secured with a password and all electronic
Understanding, is designated if the patient misses at least one documents were secured with a password that only the
of the parameters stated above. researchers can access.
The factors which were deemed to affect the level of
understanding of the prescribed drugs were then identified. Results
Patient-related factors include the age, sex, educational The mean age of the study population is 45.5 years (SD
attainment, civil status, occupation, an experience of 16.93) and out of the 392 participants in the study,
assisting in the administration of a drug to another person, 229(58.4%) were included in the age group 18-50 years old
intake of medications other than the prescribed drug/s, a (Table 1). The study population was predominantly female
previous history of use of the same or similar drug, and the (70.2%) and was well educated with 87.5% of patients
number of drugs prescribed. having at least a high school education. Majority of the
Physician-related factors included in the study were the participants were married (67.3%) and with a large
following: whether the physician is a general practitioner or proportion of the population being unemployed (67.1%).
a specialist and the place of consult. Only 162 (41.3%) participants reported use of other
Prescription related factors included: the manner by medications and 277(70.7%) had an experience of drug
which the physician give out prescription, legibility of the administration to another patient. There were 180 (45.9%)
doctor’s handwriting, whether the prescription contained all patients in the study population currently taking a single
the necessary information mandated by the law (RA 9521), drug and 185(47.2%) patients had previous use of the same
and whether it contained a complete set of written or similar prescribed drug.
instructions regarding proper drug intake. Only a quarter (25.3%) of the total participants sought
consult among general practitioners and the remaining
Statistical Analysis 74.7% consulted specialists. There were four places of
A descriptive analysis was carried out to determine the consult in this study with equal allocation of participants,
proportion of patients who have an Incomplete and they all reported to have received both verbal and
Understanding of the prescribed drug. Crude odds ratios written instructions.
and 95% confidence intervals were calculated according to Most of these patients either had a single prescription
the various study factors mentioned to measure the with a single drug prescribed (45.9%) or had a single
association between each study variable and inability to prescription with multiple drugs prescribed (38.3%).
understand prescriptions. A multivariate logistic regression Majority of the participants found the prescription legible
model was constructed applying a stepwise procedure to (71.4%). It was also found out that 77.0% of the prescriptions
enter variables in the model. The model included did not conform to the provisions of the law and 78.6% of
independent variables that were statistically significant at these prescriptions did not contain a complete set of written
the a priori level of 0.05. Presence of multicolinearity was instructions regarding proper intake of the prescribed drug.
assessed and if it existed between two variables, the variable Among the 392 participants, 219(55.9%) patients had an
showing the stronger association with the inability to incomplete understanding of prescriptions, 176(44.9%) were
understand the prescribed drug was retained in the model. not able to identify the correct dose of the prescribed drug,
The analyses was conducted using SPSS version16. followed by 103(26.3%) who were not able to identify the
name of the drug. Only 60(15.3%) participants did not
Ethical Issues identify the duration of drug administration, 34(8.7%) did
This study was conducted in accordance with the not specify frequency, 14(3.6%) did not understand
Declaration of Helsinki for biomedical research involving formulation and 10(2.6%) did not recognize the correct route
human subjects. No respondent was coerced to be a part of of administration (Table 2).
the study and confidentiality and privacy were observed all

38 ACTA MEDICA PHILIPPINA VOL. 47 NO. 4 2013

 Factors Affecting Patients’ Incomplete Understanding of Prescriptions

Table 1. Characteristics of Participants Regarding Incomplete Understanding of Prescriptions (n=392).

Number of Patients
Odds
Categorical Predisposing Factors Total with Incomplete 95% Confidence
(%) (%) p-value Ratio
=392 Understanding Interval
(n = 219)
PATIENT RELATED FACTORS
Age
18-50 229 58.4 133 58.1 - 1 -
51-60 80 20.4 37 46.3 0.83 0.924 0.447-1.908
61-70 48 12.2 28 58.3 0.177 0.574 0.256-1.285
71 and above 35 8.9 21 60 0.879 0.933 0.384-2.266
Sex
Male 117 29.8 70 59.8 - 1 -
Female 275 70.2 149 54.2 0.303 0.794 0.512-1.232
Highest Educational Attainment
College 195 49.7 97 49.7 - 1 -
High School 148 37.8 88 59.5 0.586 0.005 0.000-733642.3
Elementary 47 12 32 68.1 0.614 0.008 0.000-1087941
None/Illiterate 2 0.5 2 100 0.642 0.012 0.000-1593850
Civil Status
Married 264 67.3 140 53 - 1 -
Single 65 16.6 40 61.5 0.042* 0.396 0.162-.0.967
Separated 12 3.1 8 66.7 0.255 0.561 0.207-1.517
Widow/Widower 24 6.1 11 45.8 0.637 0.701 0.160-3.070
Live-in 27 6.9 20 74.1 0.043* 0.297 0.091-0.962
Occupation
None 263 67.1 143 54.4 - 1 -
Employed 129 32.9 76 58.9 0.395 1.203 0.786-1.843
Experience of Administering Drug to Another Patient
Yes 277 70.7 147 53.1 - 1 -
No 115 29.3 72 62.6 0.084 1.481 0.949-2.312
Use of Other Drugs
Yes 162 41.3 86 53.1 - 1 -
No 230 58.7 133 57.8 0.352 1.212 0.809-1.816
Previous Use of Same Drug
Yes 185 47.2 86 46.5 - 1 -
No 207 52.8 133 64.3 0.000* 2.069 1.380-3.103
Number of Drugs Prescribed
One 180 45.9 92 51.1 - 1 -
Two-four 193 49.2 115 59.6 0.321 0.61 0.230-1.620
More than four 19 4.8 12 63.2 0.762 0.86 0.324-2.281
PHYSICIAN RELATED FACTORS
Doctor
General Practitioner 99 25.3 64 64.6 - 1 -
Specialist 293 74.7 155 52.9 0.043* 1.628 1.016-2.609
Place of Consult
Private Clinic 98 25 51 52 - 1 -
Government Hospital 98 25 48 49 0.389 0.781 0.444-1.372
Local Health Center 98 25 63 64.3 0.198 0.691 0.393-1.214
Private Hospital 98 25 57 58.2 0.38 1.295 0.728-2.303
PRESCRIPTION RELATED FACTORS
Prescription Type
Single prescription with single drug 180 45.9 92 51.1 - 1 -
Single prescription with multiple drugs 150 38.3 94 62.7 0.719 0.836 0.316-2.216
Multiple prescriptions with single drug per prescription 44 11.2 23 52.3 0.558 1.343 0.501-3.602
Multiple prescriptions with multiple drugs per prescription 18 4.6 10 55.6 0.814 0.876 0.291-2.637
Legibility: Patient Can Read the Prescription Without Difficulty
Yes 280 71.4 128 45.7 - 1 -
No 112 28.6 91 81.3 0.000* 5.146 3.030-8.738
Prescription Contains the Complete Information Required by Law
Yes 90 23 48 53.3 - 1 -
No 302 77 171 56.6 0.581 1.142 0.712-1.832
Prescription Contains a Complete Set of Instruction for Proper Drug Intake
Yes 84 21.4 33 39.3 - 1 -
No 308 78.6 186 60.4 0.001* 2.356 1.438-3.861
* statistically significant at 0.05

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Factors Affecting Patients’ Incomplete Understanding of Prescriptions

Table 2. Proportions of the Six Parameters of Complete CI 0.162-0.967) among single participants and 0.297 lower
Understanding Missed Out by the Patients (95% CI 0.091-0.962) for participants with live-in partners.
The odds of incomplete understanding of prescriptions
Parameter Missed Out (n) n (%) were 2.069 times higher (95% CI 1.380-3.103) among patients
Name of the Drug 103 26.3
with no previous use as compared to those who had a
Route of Administration 10 2.6
Formulation 14 3.6 previous use of the prescribed drug. Compared with the
Dose 176 44.9 results from legible prescription, the odds of incomplete
Frequency 34 8.7 understanding of prescriptions were 5.146 times higher (95%
Duration 60 15.3
CI 3.030-8.738) among non-legible prescriptions. An odds
ratio of 1.628 times higher (95%CI 1.016-2.609) was also
The proportions of participants with incomplete
identified among specialists than general practitioners in
understanding of prescriptions across age groups range
incomplete understanding of prescriptions. Patients whose
from 46.3% to 60.0%. Male population (59.8%) has a higher
prescriptions did not contain a complete set of instructions
proportion of incomplete understanding of prescriptions as
regarding the proper intake of prescribed drugs had an odds
compared to females (54.2%). It is important to note that
ratio of 2.356 times higher (95% CI 1.438-3.861) compared to
there is an inverse relationship between the level of
prescriptions complete written instructions.
educational attainment and the proportions of patients with
A number of other variables were notable for their lack
incomplete understanding of prescriptions. Of the 264
of statistical significance and these include age, sex,
married patients, 140(53.0%) had an incomplete
educational attainment, marital status, occupation, use of
understanding of the prescriptions and these proportions
other drugs, experience of drug administration, prescription
did not differ between the employed and unemployed
type, number of drugs prescribed, type of doctor and place
participants (58.9% vs 54.4%), between those who were
of consult.
using and not using other drugs (53.1% vs 57.8%). Higher
Multivariate logistic regression analysis in Table 3
proportions of incomplete understanding were identified
identified only three independent variables to be statistically
among participants who never had any experience of drug
significant predisposing factors to incomplete understanding
administration to another patient (62.6%). Among the 180
of prescriptions: no previous use of the prescribed drug
patients prescribed with a single drug, 92(51.1%) had an
(OR=2.126, 95% CI 1.361-3.320), non-legible prescriptions
incomplete understanding of the prescriptions which did not
(OR=4.598, 95% CI 2.671-7.913) and incomplete set of written
significantly differ among those prescribed with 2-4 drugs
instructions regarding proper intake of the prescribed drug
and more than four drugs (59.6% and 63.2%). Among the 185
(OR=2.108, 95% CI 1.234-3.601).
patients who had a previous use of the same or similar
prescribed drug, 86(46.5%) had an incomplete Table 3. Multivariate Logistic Regression Analysis of the
understanding of the prescriptions. Factors Affecting Patient's Inability to Understand
Patients who consulted general practitioners (64.6%) Prescriptions as Initially Determined by Preliminary Binary
had higher proportions of incomplete understanding of Logistic Regression Analysis.
prescriptions as compared to specialists (52.9%). Among the
different places of consult, local health centers (64.3%) had Categorical Predisposing Odds
95%
the highest proportion of incomplete understanding of p-value Confidence
Factors Ratio
Interval
prescriptions with government hospitals (49.0%) as the Marital Status
lowest. Married - 1 -
Participants who had single prescriptions containing Single 0.283 0.564 0.198-1.603
Separated 0.756 0.832 0.262-2.646
multiple drugs (62.7%) were found to have a higher
Widow/Widower 0.683 1.417 0.266-7.543
proportion of incomplete understanding. This is also noted Live-in 0.351 0.523 0.134-2.041
among participants whose prescriptions did not contain Previous Use of Same Drug
complete instructions regarding proper intake of prescribed Yes - 1 -
No 0.001* 2.126 1.361-3.320
drug (60.4%), non-legible prescriptions (81.3%), and Legibility: Patient Can Read the Prescription Without Difficulty
prescriptions not conforming to provisions of the law, RA Yes - 1 -
9521 (56.6%). No 0.000* 4.598 2.671-7.913
Prescription Contains a Complete Set of Instruction for Proper Drug
The binary logistic regression analysis provides
Intake
estimates of the degree to which certain categorical Yes - 1 -
predisposing variables influence patients’ incomplete No 0.006* 2.108 1.234-3.601
understanding of prescriptions. Results from the logistic Doctor
General
regression model in Table 1 suggest that, compared with Practitioner
- 1 -
results from married participants, the odds of incomplete Specialist 0.361 1.307 0.736-2.322
understanding of prescriptions were 0.396 times lower (95% * statistically significant at 0.05

40 ACTA MEDICA PHILIPPINA VOL. 47 NO. 4 2013

 Factors Affecting Patients’ Incomplete Understanding of Prescriptions

Discussion compensated by the verbal instructions of the doctors. Sano

The patients’ understanding of the doctor’s prescription et al. states that if instructions are given only verbally, the
is one of the essential elements towards a successful patient will likely forget it or mix things up.11 Each
treatment. Previous studies have already demonstrated the prescription should contain a complete set of step-by-step
close relationship between understanding of prescriptions instruction- from the name of the drug to the route of
and treatment compliance.4,10 administration, dose, formulation, frequency, and duration-
In this study, 55.9% of the study population had an and these instructions should be understood by any patient
incomplete understanding of prescriptions. Whether one of whatever level of educational attainment. However,
finds it alarming that only about 50% of the population can written instructions should not be used as a substitute for
understand the doctor’s prescription, similar proportions counseling and patient education.2 In other words, verbal
have been shown in other studies conducted in other and written instructions serve to complement each other. In
countries.6,2,14 Most patients who do not understand the addition, physicians also benefit from writing a complete set
prescription report ending up asking the pharmacist to of instructions because this will also serve as a guide for the
explain to them the doctor’s prescription. Pharmacists have doctor in finding out the cause of a possible treatment
the professional responsibility of explaining to the patient failure. Furthermore, Section 3.4 of Administrative Order
the correct way of using the medicine in accordance to the No. 62 (1989) requires all prescriptions to contain the name
treatment regimen described in the prescription, including of the drug, the manufacturer, brand name if desired, dose,
counseling the patient about information relevant to the and delivery mode. It does not require the writing of the
medicine to be administered. However, prescriptions are formulation, frequency and duration of drug intake. The
not only written for the pharmacists who dispense the findings in our study may be used by the health policy
drugs. The signa part of the prescription serves as a guide makers in the country to amend this law to further enhance
for patients who will take the drug. Moreover, it is also good prescription writing.
important to note that there is no one parameter included in Patients who had no previous use of the prescribed
the study that was not missed by the respondents, with the drug were found to be twice as likely to have an incomplete
dose of the drug being the most commonly missed understanding of prescriptions (95% CI 1.361-3.320) as
parameter. Not knowing the dose of the medication may not compared to those who have already used the drug or a
pose any risk for some patients but for those who are taking similar drug before. Similar findings have been shown in the
drugs with narrow therapeutic index, the 55.9% finding in study by Sung et al, where patients with chronic diseases
this study should be noted by any vigilant physician who who are on maintenance medications are more likely to
cares for their patient. understand prescriptions better.17 While this has been shown
The other objective of this study is to identify the factors to be a risk for non-persistence in another study, our study
which significantly affect the patients’ understanding of has shown that it is protective for incomplete understanding,
prescriptions. Of the fifteen different variables identified in and subsequently non-compliance.1 Together with
this study, there were only three independent variables, acceptance, persistence and compliance are the three main
which were found to be statistically significant in aspects of patient adherence. Compliance refers to patients
predisposing factors to having an incomplete understanding taking the prescribed medication correctly while persistence
of prescriptions. Two of which were prescription-related is defined as the continued renewal of the prescription in
factors and one patient-related factor. A non-legible accordance with the treatment duration.18 This, therefore,
prescription was the strongest predictor of incomplete means that physicians should be more patient and careful in
understanding (OR=4.598, 95% CI 2.671-7.913). Poor instructing and educating patients who will take the
penmanship is a serious problem, which can lead to fatal prescribed drug for the first time.
errors.15 This problem has long been condemned and several The other twelve factors lacked statistical significance in
strategies have already been done to address it yet in this affecting the patients’ understanding of a prescribed drug.
study 28.6% of the study population found the prescription Most of these are demographic factors, such age, sex, civil
non-legible. status, occupation and even the patient’s educational
The other significant physician-related factor is the attainment. These patient related factors were also found to
incomplete set of written instructions on the prescription be not significant in other studies except for the patient’s
(OR=2.108, 95% CI 1.234-3.601). In this study, only 23% of the educational attainment, which was found to be significant in
prescriptions had a complete set of instruction, which is only other studies.3,11,17,19-21 One probable reason for this is that
about half of the proportion reported in a study conducted 87.5% of the study population had at least a high school
in the United States.16 Some prescriptions just contained the education, which might already be sufficient to understand
name of the drug while others still had Latin abbreviations, the instructions for drug intake. Patient counseling and a
which the patients could not understand. Most prescriptions complete step-by-step written instruction will make it easier
contained incomplete instructions, which would just be for patients to understand prescriptions, regardless of their

VOL. 47 NO. 4 2013 ACTA MEDICA PHILIPPINA 41

Factors Affecting Patients’ Incomplete Understanding of Prescriptions

educational attainment.11 In this study, all 392 patients were to be taken on the day of his follow-up. Any medical
reported that they were advised by their physician; this student who has been through Clinical Pharmacology knows
might have compensated their supposed inadequate that this is undoubtedly a case of irrational drug use. In
education. Marital status was also not found to be compliance with the ethical responsibility of our research,
significant, contrary to the findings of the study conducted we advised the patient to seek consult with another
by Cramer et al.22 Furthermore, although the proportion of physician after explaining the possible harm of the improper
patients with incomplete understanding are higher among use of these anti-hypertensive medications. Another case
patients without the use of other drugs other than the would be that of a few patients who reported planning to
currently prescribed medications and in those without buy only a part of the number of pills prescribed due to
experience of administering a drug to a sick family member financial constraints. These patients were carefully advised
or any other patient, these were not found to be significant, about the risk of not complying with the treatment duration.
unlike the findings of Cramer et al.22 No monetary donation was given to these respondents.
Another remarkable finding in this study is that the
number of drugs prescribed was not found to be statistically Conclusion
significant to affect the patients’ understanding of In promoting the improvement of medical care in the
prescriptions. Previous studies have shown conflicting country, this study assessed the understanding of Filipino
results. Older studies showed an inverse relationship patients regarding the drugs prescribed by their doctors. A
between the number of drugs prescribed and compliance successful treatment regimen starts with the patient
whereas recent studies showed otherwise.18,23-27 accepting the regimen, then complying with the current
As to the physician related factors, a consult with a prescription and finally continuing the proposed
general practitioner was found to have a higher proportion management thereafter. Our study focused on the patients’
of incomplete understanding but this was not statistically compliance with the current prescription. The various
significant after considering the other factors in the factors which were deemed to affect their understanding
multivariate analyses. Similar findings were also shown in were then identified to ascertain the populations at risk of
the analyses of the place of consult where consults done at a non-compliance.
local health center were found to have higher proportions of The results of this study suggest that physicians play an
incomplete understanding but this was not statistically important role in promoting a complete understanding of
significant even at the a priori level. prescriptions. Non-legible prescriptions and prescriptions
The type of prescription was not found to be statistically with an incomplete set of written instructions were found to
significant. This finding is important for the health policy significantly affect the patients’ understanding of prescribed
makers in the country. Administrative Order No. 62 issued drugs. Physicians should also be more careful in instructing
in 1989 considered writing more than one drug product in patients who will take the prescribed medications for the
one prescription as erroneous. However, the year after, first time. These information may be used to target the
Administrative Order No. 90 was made to amend the populations at risk of having an incomplete understanding
previous law, permitting doctors to write more than one of prescriptions, which subsequently leads to non-
drug in one prescription form. The findings in this study, compliance and eventually, to possible treatment failure.
therefore, support the latter provision. Moreover, the
technical requirements of RA 5921, which mandates all ___________
prescriptions to contain the name of the prescriber, office
References
address, professional registration number, professional tax
1. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;
receipt number, patient’s/ client’s name, age and sex, was 353(5):487-97.
also not found to be statistically significant. Nevertheless, 2. World Health Organization. Adherence to Long-Term Therapies:
this is still important in preventing the dispensing of Evidence for Action. WHO Publication. 2003
3. National Council on Patient Information and Education. Enhancing
medications without a prescription and in complying with
Prescription Medicine Adherence: A National Action Plan. 2007
the requirements of other laws, which requires a complete 4. Lau HS, Beuning KS, Postma-Lim E, Klein-Beernink L, Boer A, Porsius
prescription to avail of discounts, for example to senior AJ. Non-compliance in elderly people: evaluation of risk factors by
citizens. longitudinal data analysis. Pharm World Sci. 1996; 18(2):63-8.
5. Davis TC, Federman AD, Bass PF, et al. Improving patient
Ethical issues were also encountered during the conduct understanding of prescription drug label instructions. J Gen Intern Med.
of the study. This was the case of a seaman being prescribed 2009; 24(1):57-62.
with Atenolol 50 mg once a day for 5 days to reportedly 6. Gottlieb H. Medication nonadherence: finding solutions to a costly
medical problem. Drug Benefit Trends. 2000; 12(6):57-62.
lessen the patient’s blood pressure so that he may pass the
7. Kirsch I, Jungeblut A, Jenkins L, Kolstad A. Adult Literacy in America:
pre-employment check-up when he comes back to the A First Look at the Results of the National Adult Literacy Survey.
doctor. The patient was also prescribed with 1 tablet of Washington: Department of Education, National Center for Education
Losartan (50 mg) and 1 tablet of Amlodipine (5 mg), which Statistics. 1993.

42 ACTA MEDICA PHILIPPINA VOL. 47 NO. 4 2013

 Factors Affecting Patients’ Incomplete Understanding of Prescriptions

8. Hardon A. Confronting Ill health: Medicines, Self-care and the Poor in

Manila. Quezon City. Health Action Information Network. 1991.
9. Hardon A, Hodgkin C, Fresle D. How to Investigate the Use of
Medicines by Consumers. World Health Organization and University of
Amsterdam. 2004.
10. Lansang MA, Lucas-Aquino R, Tupasi TE, et al. Purchase of antibiotics
without prescription in Manila, the Philippines. Inappropriate choices
and doses. J Clin Epidemiol. 1990; 43(1):61–7.
11. Sano PY, Masorti RR, dos Santos AAC, Cordeiro JA. Evaluation of the
understanding level of pediatric prescription. Jornal de Pediatria. 2002;
78(2):140-5.
12. Cohen ML. Mercury Drug Corporation from Reference for Business:
Encyclopedia of Business, 2nd ed. [Online]. 2010 [cited 2010 May].
Available from http://www.referenceforbusiness.com/history/Lo-
Me/Mercury-Drug-Corporation.html.
13. Ragaza JM, Morales A. Botika ng Barangay Drug Prices Can Still Be
Lower from Vera Files [Online]. 2009 [cited 2010 May]. Available from
http://verafiles.org/main/focus/botika-ng-barangay-drug-prices-can-still-
be-lower/.
14. Kramer JM, Hammill B, Anstrom K, et al. National evaluation of
adherence to beta blocker therapy for 1year after acute myocardial
infarction in patients with commercial health insurance. Am Heart J.
2006; 152(3):454.e1-8.
15. Akoria OA, Isah AO. Prescription writing in public and private
hospitals in Benin City, Nigeria: the effects of an educational
intervention. Can J Clin Pharmacol. 2008; 15(2):295-305.
16. US Food and Drug Administration. Medicine Information Received by
Consumers. U.S. Food and Drug Administration [Online]. 2006 [cited
2010 May]. Available from http://www.fda.gov/cder/Offices/
ODS/y2ktitle.htm
17. Sung JC, Nichol MB, Venturini F, Bailey KL, McCombs JS, Cody M.
Factors affecting patient compliance with antihyperlipidemic
medications in an HMO population. Am J Manag Care. 1998; 4(10):1421-
30.
18. Fletcher SW, Fletcher RH, Thomas DC, Hamman C. Patients’
understanding of prescribed drugs. J Community Health. 1979; 4(3):183-
9.
19. Beardon PH, McGilchrist MM, McKendrick AD, McDevitt DG,
MacDonald TM. Primary non-compliance with prescribed medication in
primary care. BMJ. 1993; 307(6908):846-8.
20. Williams MV, Parker RM, Baker DW, et al. Inadequate functional health
literacy among patients at two public hospitals. JAMA. 1995;
274(21):1677-82.
21. Kalichman SC, Ramachadran B, Catz S. Adherence to combination
antiretroviral therapies in HIV patients of low health literacy. J Gen
Intern Med. 1999; 14(5):267-73.
22. Cramer J, Rosenheck R, Kirk G, Krol W, Krystal J. Medication
compliance feedback and monitoring in a clinical trial: predictors and
outcomes. Value Health. 2003; 6(5):566-73.
23. Taylor DW, Sackett DL, Haynes RB, Johnson AL, Gibson ES, Roberts RS.
Compliance with antihypertensive drug therapy. Ann N Y Acad Sci.
1978; 304:390-403.
24. Sclar DA, Chin A, Skaer TL, Okamoto MP, Nakahiro RK, Gill MA. Effect
of health education in promoting prescription refill compliance among
patients with hypertension. Clin Ther. 1991; 13(4):489-95.
25. Monane M, Bohn RL, Gurwitz JH, Glynn RJ, Levin R, Avorn J. The
effects of initial drug choice and comorbidity on antihypertensive
therapy compliance: Results from a population-based study in the
elderly. Am J Hypertens. 1997; 10(7 Pt 1):697-704.
26. Shalansky SJ, Levy AR. Effect of number of medications on
cardiovascular therapy adherence. Ann Pharmacother. 2002;
36(10):1532-9.
27. Grégoire J, Moisan J, Guibert R, Ciampi A, Milot A. Predictors of self-
reported noncompliance with antihypertensive drug treatment: a
prospective cohort study. Can J Cardiol. 2006; 22(4):323-9.

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Appendix

Researcher Structured Questionnaire

Note:
1. Font size of the questionnaire was adjusted to fit in the page.
2. During the conduct of the interview, it was the interviewer, and not the respondent, who filled out the questionnaire.

* Legend: HCP- Health Care Professional; Non-HCP- Non-Health Care Professional; ROA- route of administration

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