To our knowledge, this study is the first study on home medication management problems in psychiatric patients. The study revealed that patients who consumed alcohol were highly associated with inappropriate storage of medications at home, consistent with the result of a secondary study of cohort data by Bryson et al [19]. This is most likely due to the effect of excessive alcohol consumption which can impede brain functions and result in cognitive as well as behavioural impairments [20]. The effect of alcoholism on cognitive function coupled with the nature of psychiatric disease itself could have caused direct detrimental consequences on patient’s drug management; namely drug storage condition and medication adherence.
The study also found that smokers were more likely to not have a medication administration schedule. Although there is currently no literature available to support any association between smoking and the presence of a medication schedule, many studies have demonstrated smoking to be highly associated with poorer adherence to medication [21–22]. As medication schedule serves as an aid for better adherence, a lack of it would most likely give rise to unsatisfactory adherence to medication. This could be due to the fact that smokers, who are already engaged in a chronic unhealthy lifestyle habit, may find it difficult to commit themselves to a fixated medication administration routine which requires certain degree of discipline. Moreover, there appears to be a general consensus that smokers portray significantly lower quality of life (QoL) in the physical, psychological, social and environmental dimensions of health. Problems of self-care and usual activities were found to be among the highest reported problems among smokers [23]. Self-care is defined as the ability of individuals, families and communities to promote health, prevent disease, maintain health, and to cope with illness and disability with or without the support of a healthcare provider while the usual activities dimension evaluates the severity of problems in their usual activities such as work, study, housework and family or leisure activities [24–25]. Therefore, smokers who are generally incapable of promoting and maintaining their health by themselves, along with difficulty in conducting their daily activities, are expected to fail to adhere to timely medication consumption.
Kapplan et al. stated that ethnic minority patients were much more likely to record higher non-compliance, independent of other demographic factors [26]. Furthermore, South Asians in western countries were also found to more likely record non-adherent behaviour to oral medication as compared to white Caucasians [27]. To elaborate, studies have found that language barriers in healthcare led to miscommunication between healthcare workers and patients, leading to a compromise in the quality of healthcare delivery and a threat to patient safety [28–29]. Tideman et al. also found language barrier to be a long-term problem in Malaysia’s healthcare system due to the population’s different ethnicities [30]. Therefore, misinterpretation of information on medication storage condition during counselling sessions is plausible. Interestingly, while other studies showed that ethnic minorities to be practicing poorer quality of medication management, this study showed that the Indians as minority race were more likely to have better medication storage as compared to the Malays. Further studies are needed to identify other possible causes that could have led to this finding.
The study also showed that patients from lower household income were more likely to have poorer medication storage and lack of administration schedule at home. This finding is similar to the study finding by Martins et al. where they found that lower household income was close to reaching statistical significance as an independent factor in increasing the risk of inadequate medication storage, though no explanation was given [31]. In Malaysia, there are about 2.7 million households in the B40 category, of whom 44% are in the rural areas and 56% are in the urban areas [32]. Poor medication management among this group could be attributed to their living environment where only the bare necessities are available in their homes. Some homes do not have furnishing such as tables and refrigerator to store their medications and many do not possess a mobile phone which could serve as a reminder for their medication schedule. Sadly, some do not even have a working clock at home to tell them the time. Although Boron et al. claimed that compensatory strategies such as associating medication schedule with meal times is important to improve adherence, the reality is that some underprivileged households in Malaysia struggle to have three fixed main meals a day [33].
The study also found that poor insight was associated with inappropriate medication storage and lack of medication schedule at home. While there are no studies that have linked poor insight with inappropriate storage of medication as well as lack of medication schedule, previous studies have demonstrated significant relationship between poor insight and poor adherence as well as poor adherence and inappropriate storage of medication at home. Novick et al. and Misdrahi et al. claimed that patients with lack of insight in their diseases had higher risk of non-adherence to their medication [34–35]. Jimmy et al. also stated that having a medication administration schedule serves as an aid to improve medication adherence [36]. Thus, it is plausible to infer that those without a medication administration schedule are deemed to have poor adherence to their medication. Smaje et al. affirmed that poor medication storage was negatively associated with adherence to medication [37]. A possible explanation for this could be that patients with better insight towards their diseases will undeniably have a more positive attitude towards their medication, thus resulting in better medication management such as proper storage of medication as well as having a medication schedule at home. Therefore, patients with better insight transpose to better medication management and subsequently, better medication adherence [38].
Part-time HCPS was found to be one of the factors associated with both inappropriate medication storage and lack of medication administration schedule among patients as compared to full-time HCPS. These two medication management problems are heavily affected by patient’s cooperation on daily basis. Leach MJ affirmed that good rapport with patients essentially leads to stronger therapeutic alliance with patients and can significantly improve the effectiveness of healthcare services [39]. Therefore, a good rapport between the HCPS pharmacists with the patient and family is important in order to secure their trust and cooperation to practice better medication storage and administration schedule. However, this requires continuous follow up visits and higher contact time between the pharmacists and the patient as well as their family. Unfortunately, the nature of part-time HCPS makes this rather difficult, which supports the findings of this study. Studies have shown that HCPS can enhance patient understanding, prevent medication accidents and lead to patient benefits, provided the service is well performed and utilized appropriately [40–41].
Recommendation
Overall, our findings indicate that full-time HCPS shows more benefits in regards to patients’ home medication management which could further attribute to their medication adherence as well. Thus, raising the question as to how the Ministry of Health Malaysia can further improve this service for the benefit of patients. As one of the key strategies to boost population health is through community-based services, it might be beneficial to give HCPS due attention as there is definitely room for improvement for the well-being of patients. The roles of pharmacists have shifted towards services-based and patient-centered, but emphasis is usually given for services within health facilities. By expanding these services to patients’ homes, HCPS can help fill the gap which may hinder the effectiveness and care provided at heath facilities. A complete and updated protocol on HCPS is in place but it is not fully utilized as the service is usually considered secondary. One strategy is to allow appointed home care pharmacists to concentrate on their service rather than giving more emphasis on counter services. This can be done through better human resource management within the Ministry of Health as the main reason given deterring the pharmacist to conduct home visiting is lack of manpower. More studies on the benefits of full-time HCPS in countering the long-standing non-adherence and poor medication management issues would be helpful to systemically quantify its outcomes both clinically and economically.