Article Text

Analysis of the third WHO Global Safety Challenge ‘Medication Without Harm’ patient-facing materials: exploratory descriptive study
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  1. Kisshante Subakumar1,
  2. Bryony Dean Franklin1,2,
  3. Sara Garfield1,2
  1. 1 UCL School of Pharmacy, University College London, London, UK
  2. 2 The Centre for Medication Safety and Service Quality, Imperial College Healthcare NHS Trust, London, UK
  1. Correspondence to Kisshante Subakumar, UCL School of Pharmacy, London, UK; kisshante.subakumar.16{at}ucl.ac.uk

Abstract

Objectives To evaluate patients’ views on the content and use of the ‘Five Moments for Medication Safety’ materials developed as part of the WHO’s ‘Medication Without Harm’ Global Patient Safety Challenge. These comprise a booklet, flyer, infographic poster, pamphlet and mobile application. They include recommended questions for patients to ask healthcare professionals to gain a better understanding of their medication.

Methods Structured interviews were conducted with members of the public who entered an outpatient pharmacy in a London teaching hospital, using a combination of open and closed questions. Qualitative data were analysed thematically. Quantitative data were analysed descriptively. χ2, Fisher’s exact, Mann-Whitney U and Kruskal-Wallis tests were used to test for associations between responses and variables such as age.

Results We approached 147 people; 100 (68%) agreed to take part. Of these, 83% thought that the materials would be ‘quite’ or ‘very’ useful. Potential barriers to their use were patients being of the view that they already ask healthcare professionals about their medicines or that there would be limited time available to answer their questions during consultations. Fifty-nine per cent of participants stated that they would prefer to be given the materials in waiting areas before seeing a healthcare professional; 61% thought they should be displayed on television screens in general practice surgeries. Age was significantly associated with preference for the mobile application (χ2 test, p<0.01), with younger people preferring this format.

Conclusions Patients’ views of the Five Moments for Medication Safety materials were generally positive. Our findings suggest that they should be displayed on television screens in waiting areas and given to patients prior to appointments. More advice is needed for patients on how to incorporate the questions suggested in the resources into a brief healthcare consultation.

  • education
  • pharmacy
  • pharmacy service
  • hospital
  • safety
  • teaching
  • medical errors
  • public health

Data availability statement

No data are available. Participants did not consent to having their full data publicly available. However, anonymised excerpts are available from the authors who may be contacted via email.

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Introduction

Patient safety has been identified as the most important quality improvement activity in healthcare1 and a priority among patients.2 An estimated 237 million medication errors occur each year in England alone, with 66 million of these clinically significant.3 The resulting burden of definitely avoidable adverse drug reactions has been estimated to be £98.5 million in NHS costs per annum.3

Patient involvement has been advocated as an important way to improve safety.4 5 An English Department of Health report stated the need to create a clear role for patients in helping to achieve safety goals.6 Previously, strategies to reduce preventable adverse events have been targeted mainly on changing systems of care and professional behaviour, but there also is a growing interest in involving patients in safety initiatives.7 8 Several international safety initiatives have demonstrated the importance of patient engagement.9 10 Research suggests that communication breakdown between healthcare professionals and patients is responsible for over 60% of all reported medication errors and adverse effects and that medication safety can be improved by effective patient engagement about medication.11

‘Patients and the public’ has been identified as a specific domain to target in the third WHO Global Patient Safety Challenge ‘Medication Without Harm.’12 This aims to reduce severe avoidable medication-related harm by 50% globally within 5 years, by 2022. As part of this campaign, the WHO developed the ‘Five Moments for Medication Safety’ patient engagement tool, which focuses on five key moments where action by the patient and/or carer can reduce the risk of medication-related harm: ‘starting a medication’, ‘taking my medication’, ‘adding a medication’, ‘reviewing my medication’ and ‘stopping my medication’. There are multiple patient-facing materials that portray the Five Moments for Medication Safety message, comprising a booklet, flyer, infographic poster, pamphlet and mobile application. These materials suggest questions that a patient can ask to enable them to have a better understanding of their medications and treatment. Each moment includes five questions, some of which are for the patient to ask themselves and some of which are for patients to ask healthcare professionals.

There is limited evidence exploring the patient’s perspectives of educational campaign materials,13 with most studies focussing on readability.14–17 We are not aware of any published evaluations of the Five Moments for Medication Safety engagement materials, and it is not clear how they should best be used in practice. We therefore aimed to explore patients’ perspectives of the WHO resources and their views on how they would like to receive them.

Methods

Study design and setting

This was an exploratory and descriptive study in a convenience sample of patients in the outpatient pharmacy and nearby coffee shop of an NHS Trust teaching hospital in London. Data collection took place between November and December 2019.

Study population and sample size

Participants comprised patients and the public who entered the outpatient pharmacy and were willing to participate. Non-English-speaking patients and children under 16 years were excluded. We aimed to conduct 100 interviews to allow exploratory analysis of associations between variables. A pragmatic approach was used to determine sample size, taking into consideration the time frame for data collection.

Data collection

A structured interview schedule was developed that focused on participants' views of the patient-facing materials. Participants were asked their views about the materials, their preferences for the different formats and how they would like to receive them (online supplemental file 1), using a combination of open and closed questions. The interview schedule was piloted, after which minor adjustments were made.

Supplemental material

Potential participants were identified by a researcher and approached after they had been assisted at the pharmacy counter. Participants were also approached if they were seen waiting within the pharmacy or adjacent hospital coffee shop. Participants were given a brief explanation of the study and were invited to take part. If they wished to participate, they were then handed the different Five Moments for Medication Safety patient-facing materials: the booklet, pamphlet, flyer, poster and mobile application (loaded onto a researcher’s smartphone). After reading through the resources, the patient was verbally asked each question from the interview schedule.

Data analysis

A combination of quantitative and qualitative analysis was used. Data from open-ended questions were analysed to identify recurring patterns of meaning using inductive thematic analysis. This involved familiarisation with the data by repeated reading of the interview schedule to identify emerging themes; data were then coded against these themes. A second researcher checked the themes and coding.

Quantitative data were coded and entered into an SPSS database V.26 and summarised descriptively. Inferential analysis was then carried out to explore whether there were significant associations between patients’ views regarding the materials and their age, gender, level of education and ethnicity. χ2 test and Fisher’s exact test, Mann-Whitney U test and the Kruskal-Wallis test were used as appropriate; p<0.05 was considered statistically significant.

Results

Response rates

In total, 147 people were approached, of whom 100 (68%) agreed to take part. Of those declining, nine reported that they were too unwell to take part; eight said they did not speak English; seven did not have time; three were too tired or had waited too long; two had completed too many questionnaires/paperwork already; two did not want to sit down and read through the resources; one was not interested in the resources; and one reported that they had received bad news and so did not feel like talking to anyone. Fifteen did not give a reason.

Table 1 presents descriptive information on participants’ demographics.

Table 1

Participants’ characteristics

Respondents’ views of the Five Moments for Medication Safety materials

Participants generally viewed the materials positively, with 83% (of 100) stating that the materials were ‘quite useful’ or ‘very useful’. Responses to open questions suggested that they were of the view that the materials were informative. However, some expressed concern about how to integrate the suggested questions into a short consultation with a healthcare professional. They were of the view that they might forget the questions or that there would not be enough time for healthcare professionals to answer them all. One participant expressed the opinion that this may be a specific concern during telephone consultations. Some were of the view that there was too much information on the materials. Others were of the view that the materials would be less useful for those who already asked questions.

Would be informative for some people, just not for me as I tend to ask these questions anyways. Really useful for some people. (Participant 76)

This is useful to some people; more useful to older people. It is less useful to those who can advocate for themselves. (Participant 45)

A minority view expressed by some participants is that they did not have the authority or did not feel the necessity to question healthcare professionals.

I assume the doctor wouldn’t prescribe things that interact. (Participant 52)

The poster was the most popular format overall. However, different participants expressed preferences for different materials. Box 1 outlines themes that were identified with regard to each of the poster, flyer, pamphlet, booklet and mobile application. Box 2 summarises general themes around how the materials could be improved.

Box 1

Respondents’ views of the different materials with example quotes

Participants’ views about the ‘Five Moments for Medication Safety’ poster

  • Liked how it had ‘more visual illustrations’ and was ‘concise’.

  • Provided a ‘good overview’ while still being ‘engaging’ and ‘user-friendly’.

  • ‘Easier to read’ as it contained ‘less information’ and was ‘all on one page’.

  • ‘Simplistic’ and ‘not overwhelming’, which allowed the ‘message to easily get across’.

  • ‘Attracts more of the general public’.

  • ‘Can put on wall’.

Suggestions for improvement

  • ‘Make poster bigger size’.

  • ‘Remove the small print’.

Participants’ views about the Five Moments for Medication Safety flyer

Amount of information

  • ‘Contained all the information on one page’ so they could ‘quickly scroll through’, and they liked how it was ‘easy to read’ and ‘to the point.

  • ‘Too much information’, ‘ I would put the flyer in the bin straight after’.

  • ‘Too much on one page’.

Suggestion for improvement

  • ‘Break down the information into subsections’ as currently, it is ‘not very eye-catching’.

Participants’ views about the Five Moments for Medication Safety pamphlet

  • Felt it was a ‘bit of a faff’, especially if ‘having to open it up in public areas’.

  • There was ‘no need for the notes pages’ provided in the booklet; instead can just ‘write underneath if needed’ (minority view).

  • ‘Don’t need the extra back pages’.

  • There was ‘no need for the pamphlet or booklet’ (minority view).

Suggestions for improvement

  • ‘More information about the purpose of the material’.

  • ‘More welcoming front page’.

Participants’ views about the Five Moments for Medication Safety booklet

  • Liked that it was ‘small, compact’ so ‘easier to manage’.

  • It looked ‘like too much’ (minority view).

  • There was ‘no need for the pamphlet or booklet’ (minority view).

Notes pages

  • Participants appreciated the extra ‘notes pages’, especially helpful for the ‘elderly’ and ‘those with short memory’. The majority who liked the booklet stated it was because of the ‘space for notes’

Participants’ views about the Five Moments for Medication Safety mobile application

  • ‘Easier’, ‘more convenient’.

  • ‘Saves paper’.

  • ‘Easier to access’ as ‘phone is on person a lot of the time’.

  • Others stated they ‘didn’t use apps’, instead preferring to ‘write by hand’.

  • ‘Aimed at younger people’.

  • ‘Not everyone has access’.

Suggestions for improvement

  • ‘Have voice recognition so when the doctor speaks, the app turns it straight into text. This makes it easier for the patient and doctor, as they are useful questions’.

  • Contain ‘more personalised information about their specific condition’ and possibly ‘have the ability to link with doctor and have everything on one app’.

  • Have ‘drop-down options rather than just free text for applicable questions (eg, for dosing). Then data collection can be done from the app to improve medicine information and can use this to improve the app after a pilot.’

Box 2

Respondents’ general suggestions for how to improve the ‘Five Moments for Medication Safety’ materials

Information provided on the materials

  • ‘Reduce amount of information … make materials more concise’.

  • ‘Highlight’ or ‘bold the main questions’.

  • ‘Provide some form of contact details to access extra information’.

  • ‘Make more personal for (patient) rather than just general questions’.

Title

  • Five Moments for Medication Safety is ‘vague’, ‘misleading’ and not very ‘informative about what the questions were about’.

  • Title should be ‘more direct’ and ‘punchier’. It should be ‘patient-friendly’ but also ‘informative as to what the materials are about’.

  • Ideas suggested were ‘Do you have questions about your medications?’ or ‘Questions you could ask GP (General Practitioner) to improve your standard of care’

  • One participant commented that especially since it has the term ‘safety’, patients ‘wouldn’t understand what the material is about’.

Making materials more available for patients:

  • ‘Have resources come up as the top result when searching related terms on a search engine’.

  • ‘Have it on the (National Health Service) website’.

  • ‘Make as small, laminated cards to hand out instead of A4 paper’.

  • Make it ‘more durable by making it into a ring-bound book’.

  • The ‘paper should be compatible with writing, therefore not laminated’ (minority view).

Improving accessibility

  • ‘Have materials available in larger print, braille etc.’

  • Make ‘language/ words easier to understand’ ‘for those who don’t have a high level of English’.

Timings and settings for receiving the Five Moments for Medication Safety materials

Table 2 shows patients’ preferences for where and when to receive the materials.

Table 2

Participants’ preferences for receiving the patient-facing materials (patients were able to select more than one option)

The majority of participants expressed a preference for receiving the materials before going into a consultation, such as in the waiting area. Two suggested the materials should be sent out with appointment letters. Participants also suggested the materials be handed out at the pharmacy when patients were given their medicines. Other public settings suggested were bus stations, train stations, billboards, public toilets in NHS settings, universities, gyms, healthcare centres and support groups such as those run by the charity Age UK. The majority were of the view that they would want to take the materials home so they have time to read through them. However, some participants stated that they would not take them home and would prefer to only use them for the current consultation.

Associations between demographics and preferences for different campaign materials

Gender

Women were significantly more likely to express a preference for the booklet than men (p=0.03, Fisher’s exact test; table 3). There was no association between gender and other preferences.

Table 3

Participants’ gender compared with their preferences for materials (patients were able to select more than one preference)

Age

There was a statistically significant relationship between age and preference for the mobile application (χ2 test, p=<0.01), with visual analysis (figure 1), suggesting that younger participants preferred the mobile application. There were no significant associations between age and preference for the other materials.

Figure 1

Effect of age on preference of patient-facing materials (patients were able to select more than one preference).

Ethnic group

There was a significant association between a participant’s ethnic group and their preference for the poster (Fisher’s Exact test, p=0.01) and flyer (Fisher’s Exact test, p=0.04). Black / African / Caribbean / Black British people had the greatest preference for the poster. Patients who preferred the flyer mainly described themselves as being from ‘other’ ethnic groups.

Highest level of education completed

Participants who had ‘higher education’ as their highest education level were significantly more likely to prefer the poster (Fisher’s Exact Test, p=0.03). There was also a significant association between a patient’s highest level of education being ‘A-Levels or equivalent’ and their preference for the mobile application (Fisher’s Exact Test, p=0.02).

Participants’ demographics and its effect on their opinions regarding the usefulness of the campaign materials

There were no significant associations between perceptions of materials’ usefulness and age (Mann-Whitney U, p=0.18), gender (Mann-Whitney U, p=0.6) or level of education (Mann-Whitney U, p=0.54).

Discussion

Most participants were of the view that the Five Moments for Medication Safety materials were useful. They found the resources informative and were of the view they should be made available. Preferences for materials differed between participants. Some preferred materials that contained all the necessary information on one page as on the flyer, whereas others preferred it broken up into sections. Having different types of patient-facing materials is therefore advantageous.

However, patients reported concerns over how they would integrate the suggested discussions into a healthcare consultation. In addition to this, a minority reported complete trust in their healthcare professionals and/or were unwilling to question them. Such patients may believe that healthcare professionals have the sole responsibility to provide safe, high-quality care. Healthcare professionals need to proactively engage with patients11 as patients are more willing to participate in discussions if encouraged by a healthcare professional.18–20 Nevertheless, in agreement with previous literature,2 there were also many participants who stated that they do generally ask questions about their medications and are not satisfied with having a passive role in their health.

Implications for practice

Our findings suggest that the Five Moments for Medication Safety materials are valued by patients and should be used in practice. Healthcare professionals need to play a role in engaging patients and helping them integrate the questions into consultations.

The finding that ‘one size does not fit all’ in terms of the different materials may also be relevant to other patient resources and fits with the findings of previous research.21 Having a range of materials and formats for patient facing materials is therefore an important consideration. A suggested improvement to the materials was that they would have been more beneficial if the materials were more personalised for the patient. This may be difficult to achieve in practice but this also supports a more individualised approach to patient safety rather than a ‘one size fits all’ approach.13 22

Strengths and limitations

This study took a holistic patient-centred view of patient education materials rather than focussing on the technicalities of the materials, such as word count and sentence length. Another strength was that the different patient-facing materials portrayed the same message and reiterated the same content, allowing direct comparisons to be made to identify patient preferences.

Limitations were that the study was only conducted in one hospital, only in the outpatient pharmacy, and that convenience sampling was used. As a result, it may not have been representative of the whole population. Additionally, non-English-speaking patients were excluded. This could limit findings as non-English-speaking patients could benefit from the materials if translated. Another limitation was that this study did not explore patients’ understanding or retention of the information or the actual use of the behaviours promoted. Finally, as this was an exploratory study, we did not have sufficient power to carry out multivariate analysis to test for confounding factors, for example, interactions between age and highest level of education attained.

Conclusion

Participants generally had a positive view of the Five Moments for Medication Safety materials, with different people having preferences for different materials. Further work is needed to help patients integrate the questions into a short consultation with a healthcare professional.

What this paper adds

What is already known on this subject

  • An estimated 237 million medication errors occur each year in England, often resulting in avoidable adverse drug effects.

  • Communication breakdown between healthcare professionals and patients is responsible for over 60% of all reported medication errors and adverse effects.

  • Medication safety can be improved by effective patient engagement about medication.

What this study adds

  • Eighty-three per cent of patients interviewed thought that the WHO materials, which have been designed to engage patients in asking healthcare professionals about their medicines, would be ‘quite’ or ‘very’ useful.

  • However, more advice is needed for patients on how to incorporate the suggested discussions into a brief healthcare consultation.

Data availability statement

No data are available. Participants did not consent to having their full data publicly available. However, anonymised excerpts are available from the authors who may be contacted via email.

Ethics statements

Patient consent for publication

Ethics approval

This study was approved as a service evaluation at the relevant NHS trust. All participants provided verbal informed consent (Imperial College Healthcare NHS Trust, Clinical Audit Team Registration number 403).

References

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Footnotes

  • EAHP Statement 5: Patient Safety and Quality Assurance.

  • Contributors All authors contributed to the conception and design of the project. KS collected and analysed the data and drafted the paper. All authors contributed to the editing of the paper.

  • Funding This work was supported by the National Institute for Health Research Imperial Patient Safety Translational Research Centre. This report presents independent research.

  • Disclaimer The views expressed in this publication are those of the authors, not necessarily those of the NHS, the National Institute for Health Research or the Department of Health and Social Care.

  • Competing interests BDF reports personal fees from the WHO, outside the submitted work.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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