National initiative to promote public involvement in medicine safety: the use of a cross-sectional population survey to identify candidate behaviours for intervention development in Scotland

STRENGTHS AND LIMITATIONS OF THIS STUDY

The survey included 1000 adults and was administered by an experienced market research company.
Data were derived from a nationally representative sample in terms of age, gender and area of residence in Scotland.
Respondent perceptions (positive or negative) of community pharmacies and/or pharmacy personnel could have been influenced by the increased use and/or awareness of community pharmacy services due to the COVID-19 pandemic.

Introduction

Medicines are the most commonly used healthcare intervention.1 Every medicine has benefits and harms. One of the five objectives of the WHO Global Patient Safety campaign, Medication Without Harm, is to ‘empower patients, families and their carers to become actively involved and engaged in treatment or care decisions, ask questions, spot errors and effectively manage their medications’.2

Our study was conducted in Scotland, where the national health policy3 embraces the WHO’s concept of patients taking active roles in their healthcare, by encouraging citizens to ask five questions during their consultations:

Is this test, treatment or procedure really needed?
What are the benefits and what are the downsides?
What are the possible side effects?
Are there simpler or safer options?
What would happen if I did nothing?

Similarly, the national pharmaceutical care strategy for Scotland4 highlights the need for the safer use of medicines and to increase the use of community pharmacies as suppliers of prescription and over-the-counter (OTC) medicines. Community pharmacies are the most commonly visited healthcare facilities.5 Low levels of advice-seeking from community pharmacy personnel regarding medicines has been reported previously,6–8 particularly with pharmacy users from minority ethnic groups or who were not native speakers within the country.7 8 This might reflect low public or patient awareness of pharmacy services in general.6 The disposal of medicines is also an important feature in terms of public safety and environmental harm. Surveys of the disposal of medicines have reported poor compliance with national guidelines.9 10

There is a need to develop and evaluate interventions to raise public awareness regarding the safe and effective use and disposal of medicines. In 2019, Healthcare Improvement Scotland11 in collaboration with researchers from the University of Strathclyde, initiated the Public Involvement in Medicine Safety (PIMS) study to develop and test new initiatives to promote public awareness and engagement with the safe use of medicines. While the study involved the safety of all medicines, it included a specific focus on newly prescribed medicines, as well as OTC analgesics due to their prolific use12 and their potential for harm, addiction and dependence.13 14

The aim of the first empirical component of the PIMS study was to explore the public’s current awareness of the safe use of medicines and their behaviour in terms of information-seeking and advice-seeking, medicine use and disposal.

Method

Topic identification and prioritisation

Medicine safety is a broad topic. As such, the first stage of the PIMS study was to prioritise the specific areas of medicine safety to target. On 14 November 2019, a face-to-face meeting was held in Edinburgh, Scotland, the participants of which included members of the Quality Improvement in Pharmacy Practice collaborative (pharmacists and other health professionals), patient and public representatives, as well as individuals with specific expertise in relevant topics. The purpose of the meeting was to discuss and reach agreement on medicine safety priorities which would be addressed in subsequent stages of the study. All invitees were asked to respond to the following question in advance of the meeting:

In your opinion, in Scotland, what are the priorities for increasing the safe use of:

The general ‘medicine safety’ theme was discussed first, and additional themes were added thereafter. Each participant was asked to select the three themes that mattered most to them. The same process was used during the discussion of the safety of painkillers (analgesics).

In total, 128 and 113 responses were generated from the pre-meeting questionnaire relating to medicine safety in general and the safety of analgesics, respectively. Nineteen individuals attended the meeting, of whom 18 participated in the ranking exercise (MCW, as the convenor, abstained). The responses were grouped according to common themes and discussed during the meeting. The following six themes were selected for inclusion in a bespoke Ipsos MORI questionnaire, the final version of which comprised 18 items:

Use of community pharmacies to obtain medicines.
Perception and expectations of pharmacists and medicine advice provision.
Advice-seeking behaviour for medicines in general and for oral OTC analgesics.
Use of oral OTC analgesics and management of pain.
Perceptions of risk and medicine use.
Disposal of unwanted or expired medicines.

Survey development

Measuring current behaviours, beliefs and attitudes

A national population survey was undertaken to explore the topics identified from the prioritisation exercise. The questionnaire for use in the survey (online supplementary material appendix 1) comprised mostly closed questions with multiple response options and several with open responses. The range of topics was informed by the prioritisation exercise as well as results from an earlier Citizen’s Panel.15 The population survey was developed in collaboration with Ipsos MORI (a market research company) who then interviewed a sample of 1000 adults aged >16 years in Scotland between 19 and 27 March 2020 using its online panel. The Ipsos MORI panel recruitment process is open to all members of the public and panellists are randomly selected for participation in each study based on their demographics. The sample size (n=1000) reflected the standard size used by Ipsos MORI and the available budget. The sampling method was quota sampling by gender, age and working status.

Supplemental material

Data acquisition

The demographic data collected included age, gender, education, child <18 in household, employment, urban/rural area, social grade and participant’s general health. The total figure and % for each response differed for each question and was not always 100% of the total population (n=1000) because of the differences in participants’ responses (<1000 participants responded to some questions and/or more than one response per respondent is recorded for each question).

Data management and analysis

Survey data were weighted using random iterative method (RIM) weighting16 to the known offline population proportions for age, gender, region and working status. Quotas were sourced from PAMCo data17 from 2019 to 2020, which is a large offline dataset with in-depth weighting based on Office for National Statistics mid-year estimates.

Descriptive statistics are presented. Several responses have been combined from different questions to present the data in the most meaningful manner. The results are presented as % (n) where the denominator was 1000. The % (n/N) is presented for items with less than 1000 respondents. The 95% CIs were calculated using the binconf function in the Hmisc library in R V.4.2.1.

Univariate tests were used to investigate the relationship between demographic characteristics and information-seeking/advice-seeking. The association between selected demographics and behaviour was explored using χ² tests.

Patient and public involvement statement

While patients and public were involved in the prioritisation exercise, they were not involved in the design or analysis of the survey. The survey was completed by members of the public.

Results

The characteristics of the 1000 survey respondents are presented in table 1. Most respondents (78% (95% CI 75.0 to 80.2%), n=777) had used a pharmacy in the previous 12 months to obtain a prescription medicine and slightly fewer (61%, (95% CI 57.9% to 64.0%) (n=610)) had used a pharmacy to obtain an OTC medicine during the same period.

View this table:

Table 1

Participants’ characteristics* (n=1000)

Information-seeking/advice-seeking behaviour

Medicines

Most respondents (≥85%) agreed (strongly agree/tend to agree) with each of the statements that, in relation to medicines, pharmacists are allowed to give advice, that it is their job to give advice, that they would trust the pharmacist’s advice, and that it is within the customer or patient’s rights to ask pharmacists for advice. In terms of barriers to obtaining advice, 11% (n=111) of respondents agreed that they would feel awkward asking for advice and 15% (n=154) perceived pharmacists to be too busy to give them advice. The extent of agreement with these statements did not differ consistently across the respondent characteristics.

New prescription medicines

Only 5.2% (95% CI 4.0% to 6.8%) (n=52) of respondents stated that they ‘always’ discussed their new prescription medicine with pharmacy staff and 29% (n=289) stated they ‘never’ engaged in this type of discussion. Respondents who reported never engaging with this behaviour were older (≥55 years vs 16–24 years, 33% (128/389) vs 19% (25/131)) (OR 2.08 (95% CI 1.28 to 3.38)). Degree-educated respondents were more likely to report never engaging in the behaviour compared with respondents who had National Vocational Qualifications or General Certificate of Secondary Education qualifications (30% (176/583) vs 22% (39/177)) (OR 1.53 (95% CI 1.03 to 2.28)).

The majority of respondents (64.6% (95% CI 61.6% to 67.5%), n=646) expected the pharmacist to tell them how to use the new prescription medicines correctly and this did not vary by any of the demographic characteristics measured. The respondents’ expectations regarding the other elements of information that could be provided, for example, side effects, allergies, were considerably lower, with less than 50% expecting the pharmacist to inform them about any of these aspects of their new prescription medicine. Similarly, whilst 65% (95% CI 62.0% to 68.0%) (n=650) of respondents wanted the pharmacist to tell them how to use their new prescription medicine correctly, up to 54% of respondents wanted the pharmacist to provide information about their side effects, allergies, any other health problems and the best treatment for their problem. This finding did not vary by demographic characteristic (figure 1).

Figure 1

New prescription medicines-respondents’ preferences for information seeking and provision on receipt of a new prescription medicine. *The total figure and % differ for each category and >100% because of the variation in responses (more than one response is recorded for each category by each participant). (1) How to use new medicine correctly (70% (680/975); 65% (650/1000); 65% (646/1000); 31% (298/975)). (2) If the new medicine is safe to use with any other medicines that you use (64% (624/975); 53% (530/1000); 46% (456/1000); 20% (199/975)). (3) If the new medicine is safe to take with any allergies you may have (56% (546/975); 43% (429/1000); 38% (385/1000); 13% (131/975)). (4) About the new medicine’s side effects (61% (594/975); 43% (433/1000); 34% (343/1000); 16% (158/975)). (5) If the new medicine is safe to use with any other health problems that you have (57% (558/975); 40% (400/1000); 33% (333/1000); 13% (131/975)). (6) If the new medicine is the best treatment for your problem (31% (304/975); 20% (203/1000); 9% (95/1000); 8% (76/975)).

Up to one-third (29.8% (95% CI 27.0% to 32.7%) n=298) of participants reported proactively seeking information/advice from a pharmacist on receipt of a new prescription medicine. When specific items of information were sought, younger respondents tended to report this behaviour more frequently compared with older respondents.

Management of pain

OTC pain medication

Just over half (53.6% (95% CI 50.5% to 56.7%), n=536) of the respondents reported using an oral OTC analgesic in the previous month, ranging from daily use to once a month. The use of analgesics did not vary substantially across demographic characteristics. Paracetamol was used most frequently, with 86% (n=858) of respondents reporting its use at least once in the previous month. There was some variation in the type of analgesic used and the age of respondent: younger respondents (16–24 years) were more likely to report the use of ibuprofen compared with respondents aged 55 years and over (69% (91/131) vs 52% (203/389)) (OR 2.08 (95% CI 1.37 to 3.18)). The use of paracetamol-containing and codeine-containing medicines increased with age and then declined in respondents aged 55 years and over. Respondents aged 35–44 years and 45–54 years were significantly more likely to report using these compound analgesics compared with the youngest respondents (16–24 years) and any other age group (42% (62/147) vs 27% (36/131) (OR 1.92 (95% CI 1.16 to 3.19)) and 43% (73/168) vs 27% (36/131) (OR 2.03 (95% CI 1.24 to 3.31))), respectively.

While the majority of respondents reported the appropriate administration of OTC analgesics in terms of dose, dosing frequency, reading the dosage instructions and avoiding the use of multiple analgesics with the same active ingredient (figure 2), a maximum of 65% (95% CI 62.0% to 68.0%) (n=650) of respondents reported ‘always’ engaging with these behaviours.

Figure 2

Management of pain—thinking of all the times you take oral over-the-counter painkillers, how often, if at all, do you do each of the following? (1) Leave the recommended amount of time between doses (65% (623/959); 25% (241/959); 3% (27/959)). (2) Make sure you are not taking a painkiller of the same type already (eg, taking two different painkillers that both contain paracetamol) (65% (608/959); 16% (159/959); 4% (36/959)). (3) Read the dosage instructions (52% (496/959); 26% (254/959); 6% (62/959)). (4) Taking more paracetamol than the stated dose on the packet/bottle (3% (29/959); 3% (28/959); 3% (26/959)).

At least 10% of respondents had inaccurate perceptions of OTC analgesic safety (figure 3). Of note, 18% (n=180) considered the use of codeine-containing analgesics for more than 3 days to be safe/fairly safe; a further 17.9% (95% CI 15.6% to 20.4%) (n=179) did not know whether this practise was safe or not.

Figure 3

Management of pain—respondents’ perceptions of fairly/very safe over-the-counter analgesic use.

The respondents were asked about their use of pharmacies and pharmacy personnel for advice and treatment of pain and 72% (n=724) and 41% (n=406) strongly agreed/agreed that pharmacists and medicine counter assistants (MCAs), respectively, were trained to provide advice on pain management. (MCAs are non-degree trained members of pharmacy personnel who manage many OTC consultations independently or with the involvement of a pharmacist.) While the majority 64% (n=639) of respondents strongly agreed/agreed that they felt they could seek advice from a pharmacy for their pain, only 32% (n=322) indicated that they did this and 39% (n=388) stated that they would not. More than half (57%, n=547) of the respondents said they were comfortable asking the pharmacist if the OTC was safe to use with their other medicines (figure 4). When asked about previous use of pharmacies to obtain OTC analgesics, few respondents reported any of the specific information-seeking behaviours regarding the safe and/or appropriate administration of the medicine (figure 5).

Figure 4

Management of pain—if you needed advice about an over-the-counter painkiller, which, if any of these, would you feel comfortable asking the pharmacist?

Figure 5

Management of pain—when you used a pharmacy to get an over-the-counter painkiller in the past, which, if any, of the following have you ever done?

Medicine disposal

Respondents were asked how they disposed of expired medicines and the perceived harm associated with different disposal methods, and the majority reported using unsafe disposal methods. When asked what they would typically do with expired medicines, 39% (n=391) would return them to a pharmacy, 34% (n=339) would dispose of them in a domestic waste bin. Between 7% and 13% of respondents did not know which disposal methods were harmful. Similar percentages of respondents that is, 18% (n=185) and 19% (n=186), considered disposal via the toilet or sink to be associated with low or no harm, respectively. Nearly one-third (29.3% (95% CI 26.6 to 32.2%), n=293) of respondents considered waste bin disposal to be of low or no harm (online appendix figure 1). Male and younger respondents were less likely to consider waste bin disposal to be harmful compared with female and older respondents.