Many factors contribute to patients not taking medicines as directed. Australian professional research papers often investigate compliance as an adjunct to other research goals. Consumer research looks at the broader range of factors and issues that might contribute to how consumers use their medicines. This research often identifies questions people say they would like to ask their doctors, such as 'What is the medicine for?' and 'What are the likely effects?'. Sometimes patients will forget to ask, are held back by language or social barriers or are reluctant to trouble a doctor. Effective communication with doctors helps consumers to use their medicines appropriately and this improves their satisfaction with treatments and health care providers.
There has been considerable research measuring compliance and ways of improving it. There is less research on consumers' reasons for not taking their medicines as advised. Consumers have maintained that adequate information enables them to make better decisions about treatment.1 To gain more insight into consumers' behaviour and experiences with prescription medicines, a literature review of both consumer and professional literature was recently completed.2
How the literature search was done
Literature was retrieved from both professional journals and the publications of Australian consumer organisations with an interest in health issues. Key professionals and consumer organisations were consulted to assist in constructing broad subject areas and in identifying search terms. Electronic databases and the catalogues of two major metropolitan universities were searched for relevant professional publications dating from 1980. Consumer-authored books, reports and papers were identified with the help of peak consumer organisations. Only those with a formal methodology were included in order to provide a standard consistent with the professional literature. Forty-six Australian professional papers and 24 consumer publications qualified for inclusion.
What the literature showed
The professional literature usually included the consumer perspective as a comment or an adjunct to some other research goal. Consumer publications often focused on issues around use and experience of medicines in a broader community setting that might include different experiences for women, older people, children, people with chronic conditions and people with specific illnesses. The relationships with the prescriber, other health care providers and institutional and other settings also influenced consumer experiences with medicines. The project provided an opportunity to compare the two literature sets and examine their findings for consistency and differences.
Both the professional and consumer literature identified the importance of consumers and health care providers sharing information to achieve positive health outcomes. Consumers frequently wanted to ask doctors similar questions about medicines (see box). They often wanted written information to take home and read later.
Not having a shared language was reported as a barrier to communication in both literature sets, either because the patient and the doctor came from different ethnic origins or because the medical terminology used by the doctor was unfamiliar to the patient. Communication problems also occurred between hospitals and health care providers in the community. This was a particular problem for patients when they were discharged because hospitalisation often meant more medicines or changes in medicines.
Use of medicine
Different groups of consumers have different experiences with medicines. There is a strong association between medication use, age and gender. Older people and women in particular are much more likely to have medicines prescribed. While this may be associated with particular health conditions, there are reports in both literature sets that prescribers may assume that these groups expect a prescription.3,4
Compliance is probably the most commonly researched area in professional reports of consumers' use and experience of medicines, but it is not a term used in consumer research. From the consumer perspective, 'failure to comply' effectively places the responsibility for not taking the medicine on the consumer, but this may not be solely the patient's responsibility. The review indicates that 'non-compliance' may also arise from the prescriber not communicating instructions in a way the patient understands, poor explanation of adverse effects, or social barriers such as cost. In the light of evidence about over-prescribing and polypharmacy, 'non-compliance' may even represent a rational and responsible decision by the consumer.
Much of the professional literature on compliance extrapolates data from overseas studies to the Australian context. This may not be accurate since some Australian studies suggest that compliance among older people may be better than usually assumed.5 Good compliance is associated with good communication. This in turn influences the quality of the relationship between prescriber and consumer.6,7
Adverse effects and adverse events
The consumer literature reports that medicines are frequently prescribed without sufficient information about alternative strategies or explanation about risks. Adverse events and adverse effects are important issues for consumers, representing a significant health risk as well as influencing compliance. Prescribers and pharmacists may unwittingly contribute to these problems through hesitating to communicate effectively with consumers about risks. Both literature sets identify polypharmacy as a significant problem particularly associated with age, gender and hospitalisation.4,8 Despite the risks of adverse events and poor compliance associated with polypharmacy, studies suggest that prescribers may often be unaware of the number of prescription and non-prescription medicines their patients are taking.8 Consumers might not realise it is important to tell their doctor about all their medicines, especially over-the-counter and complementary medicines.9
Where research is needed
A significant finding of the review was that there are very few Australian publications that directly address consumers' use or experience of medicines. The review identified considerable agreement between the two literature sets on key issues relating to consumer use. These include associations between use, age and gender, the need for improved communication and information and problems such as polypharmacy, compliance and adverse effects.
The consumer literature provided more focus on particular needs groups such as indigenous people, those of non-English speaking background, carers and the homeless. It also focused more on the broader experience of taking medicines such as social issues, access and cost. This illustrates the more holistic view taken by consumer researchers, recognising that medicine use and experience is not simply about the condition or the prescription, but includes a range of social factors.
The review provides evidence of a significant potential for Australian consumers to use their medicines more effectively. It shows that a key to this improved health outcome is improved clarity in communication about medicines between prescribers and consumers, particularly through better information and education. To support verbal communication doctors could provide written information for later reference. Electronic prescribing packages and electronic Consumer Medicines Information should make this easier for doctors to provide. Improved consumer outcomes also depend on better communications between health care providers and different parts of the health system. Collectively, the literature shows that when effective partnership and communication occur, the quality use of medicines improves and patients are more satisfied with their treatment and health care providers.
The Literature Review Project, Understanding Consumer Behaviour and Experience in Relation to the Use of Medicines, was conducted by Consumers' Health Forum as part of the Pharmaceuticals Project with funding from the Department of Health and Aged Care.
Web sites: www.chf.org.au
- Graham JD, Kwok YS. What consumers want to know about medicines. Aust Prescr 1995;18:10-11
- Consumers' Health Forum. Understanding consumer behaviour and experiences in relation to the use of medicines. Literature review. Canberra: Consumers' Health Forum of Australia; 1999.
- Cockburn J, Pit S. Prescribing behaviour in clinical practice: patients' expectations and doctors' perceptions of patients' expectations - a questionnaire study. Br Med J 1997;315:520-3.
- A script for change. A consumer perspective on the quality use of medicines. Melbourne: Health Issues Centre; 1995.
- Simons LA, Levis G, Simons J. Apparent discontinuation rates in patients prescribed lipid-lowering drugs. Med J Aust 1996;164:208-11.
- Hustig HH, Norrie PD. Managing schizophrenia in the community. Med J Aust 1998;168:186-91.
- Winefield HR, Murrell TG, Clifford J. Process and outcomes in general practice consultations: problems in defining high quality care. Soc Sci Med 1995;41:969-75.
- Atkin PA, Stringer RS, Duffy JB, Elion C, Ferraris CS, Misrachi SR, et al. The influence of information provided by patients on the accuracy of medication records [published erratum appears in Med J Aust 1998;169:468]. Med J Aust 1998;169:85-8.
- Consumers' Health Forum. Choosing your medicine. Making an informed decision about complementary and non-prescription therapies. Canberra: Consumers' Health Forum of Australia; 1999.