INTRODUCTION
Medication management is a complex process, comprising few phases such as prescribing, transcribing, dispensing, administering, monitoring and storing (Dilles et al. 2011). Patient safety is crucial in the healthcare system and any errors in medication management process may contribute to the unsafe practice. The use of medication is complicated in elderly population due to their multiple co-morbidities or the atypical presentation of symptoms that often results in polypharmacy.
Meanwhile, the elderly population in Malaysia is increasing and those 65 years and above are expected to increase to 4.4 million in the next few years. There is an increase demand in residential aged care facilities (RACFs) which provide a long-term skilled care for dependent elderly (Ahmad-Nizaruddin et al. 2017). The formal caregivers play an important role in managing aged resident’s daily activities, however, studies on caregiver’s medication management is limited. While some of the RACFs are staffed by trained nurses and supported by a visiting doctor or therapist, majority of the facilities however have the caregivers as the only person-in-charge of the resident's medication (Wei & Omar 2017). This impedes the guidance for policy decisions in medication management area. Thus, assessing the knowledge, attitude and practice of the caregivers on medication management is important to enable proper interventions or recommendations to that specific setting. Therefore, this study was aimed to develop a questionnaire to assess the knowledge, attitude and practice (KAP) of caregivers on medication management at RACFs.
MATERIALS AND METHODS
Based on the concept of 5 Rights of medication, a structured questionnaire was developed and constructed. This concept emphasises medication for the right patient, the right drug, the right dose, the right route, and the right time (Grissinger 2010). The literature search was carried out using relevant journal databases such as Science Direct, Scopus, PubMed, Cochrane database, Mendeley and Medline. Several keywords such as “knowledge, attitude and practice”, “caretakers”, “caregivers”, “residential aged care facilities”, “medication management” and “medication administration” were used throughout the literature search.
After the questionnaire conceptualisation, relevant statements or questions were developed and arranged according to the specific domains. The first draft of the questionnaire was constructed in Malay language. Appropriate scales of measurements and questionnaire layout were decided. The content validity of the questionnaire was confirmed based on the expert opinion of two pharmacists and one medical practitioner. Following that, the questionnaire was given to the translator language expert to conduct a back translation for Malay language and English.
The final questionnaire comprised of five sections, namely demographic (Section 1 and Section 2) with total of 9 items, Section 3: knowledge (22 items), Section 4: attitude (6 items) and Section 5: practice (13 items). The internal consistency reliability measured by Cronbach’s coefficient alpha for knowledge attitude practice was 0.631, 0.666 and 0.575, respectively. Questionnaires were then delivered by post to the two caregivers per center of the 90 RACF listed in the Ministry of Women, Family and Community Development website. Consideration was made to include all possible RACFs from each state in Malaysia. Telephonic follow-up was made to ensure that caregivers received the questionnaire via post. An explanation for the purpose of the research was made available in the questionnaire along with the consent form. The study protocol was reviewed and approved by the University Human Research and Ethnics Committee (UKM PPI/111/8/JEP-2016-523).
Descriptive statistics were utilised to calculate the continuous variables as mean and standard deviation (SD), and categorical variables as percentages. There were 22 validated questions in the knowledge domain. Scoring for knowledge included true/false/not sure responses. Correct responses were awarded 1 and incorrect or not sure response was awarded 0. The attitude domain of six validated questions employed a Likert scale of five points which is “Strongly Agree, Agree, Neutral, Disagree and Strongly Disagree”. The points given varied from 0 to 24. Practice domain was based on 13 questions to measure the level of practice on medication management. Regarding the practice section, ‘Always’ showed a maximum frequency of event and was assigned the highest score which ranged from 0 to 65. All 13 practice questions were calculated by adding up the scores of and taking into account reverse scoring in the case of negatively quoted questions.
In this study, the Chi-square test was used to determine the association between the categorical variables. For the cut-off points, the scores in knowledge, attitude and practice domains were categorised as poor (50% and below), moderate (51 to 69%) and good (70% and above). Any possible correlation between knowledge, attitude and practice was determined by Spearman’s correlation test. The Statistical Package for the Social Sciences (SPSS) software for the Windows version 23.0 was used to analyse the collected data accordingly.
RESULTS AND DISCUSSION
Of all 180 caregivers targeted in this study, the questionnaires were filled and returned by 128 (71%) of caregivers. The mean age of respondents was 41 years and their length of service was approximately 9 years. More than half of the respondents (57.1%, n=73) had attained secondary level education and 48.4% of them (n=62) had not experienced any training on medication management (Table 1).
For the knowledge section (Table 2), majority of the respondents (71.9%, n=92) knew what medication management was. However, only half knew there are ‘5 rights’ related to medication administration. More than half of the respondents (55.5%, n=71) were not sure whether different dosage forms had different storage conditions. Majority of the respondents opted to double the dose when the residents missed any medication dose (77.3%, n=98). About 69.5% of the respondents were not sure of the difference between adverse drug effect and drug side-effect. Close to half of the respondents did not agree that medication management was the main problem in nursing homes (46.9%, n=60) but many admitted that caregivers should receive training in managing medication (84.4%, n=108).
The median scores obtained for knowledge, attitude and practice were 77.27, 70.83 and 68.66, respectively. A scoring system was developed and scores of caregivers for each domain were analysed and further categorised as good, moderate and poor as listed in Table 3. More than half of the respondents possessed good level of knowledge (69.5%, n=89), more than half had a good attitude (57.8%, n=74) and less than half of the respondents had a good practice (46.9%, n=60) of medication management. Factors such as level of education, special qualification and experience of medication management training correlated with good score outcomes (p<0.05). There was a weak positive correlation between the level of knowledge and caretaker`s attitude (p=0.001*, r=0.294) as well as between practice and caretaker`s attitude (p =0.01*, r=0.146). Meanwhile, there was a significant association between knowledge of the caregiver with their education level, special qualification of caregivers and medication management training.
Health problems are a major hindrance of healthy lifestyle for the elderly and a suitable living condition is warranted to help them improve their quality of life (Selvaratnam et al. 2012). There are few settings of RACFs in Malaysia with different practices. Certain RACFs are run as a business of profit by companies while others are run by non-profit organisations and are sponsored by charitable groups or by government agencies. RACFs with experienced and qualified nursing staff tend to result in less medication error (Tangiisuran et al. 2018). Qualifications in providing care to this special community population is important. A lack of in-service training and inadequate knowledge of staff in nursing homes may lead to the medication error (Pape et al. 2005). It is a concern that the personnel handling medication management are largely secondary school leavers, do not hold any special qualification and have not had any previous training in medication management. To enhance patient safety, staff should be closely supervised and provided with continuous education (Wilson et al. 2010). Ongoing education in medication management is essential to ensure primary care systems are age-friendly, with appropriately trained healthcare professionals.
Polypharmacy is often associated with side-effects as well as drug-drug interactions among elderly (Razali et al. 2012). Furthermore, poor physical function was identified as one of the risk factors for frailty in elderly (Badrasawi et al. 2017). With the medication management knowledge limitation pose by the caretaker as observed in our current study, it may lead to medication errors. Notably, RACF residents are at the highest risk of medication errors, including administration and dispensing error as they move between primary and secondary care (Amanda et al. 2016). Medication errors are indeed largely attributed to the poor practices and inadequate knowledge, followed with problems of communication between the caretaker and the elderly (Stefanacci & Riddle 2016). This is important in elderly as drug adverse effects such as hypotension, osteoporosis and hypoglycemia can contribute to falling (Loke et al. 2018).
Our present study also demonstrated a need for intervention as it was shown that there was a relationship between special qualifications, medication management training and education level towards positive attitude and practice behavior. Age-associated physical decrement along with chronic diseases affected the drug-use behaviors of the elderly (Oguzoncul et al. 2018). The caregivers also need to cope up with the difficulties in managing residents with special medication needs (Zamzam et al. 2011). In our opinion, lack of training also brought to the compromising the quality and safety of resident care in RACF. High work burden, shortage of staff and limited expenses allocated in running a RACF may limit the training. However, involvement of other healthcare professional such as community pharmacist may be beneficial to aid in training and monitoring for medication management.
Nevertheless, in this study, as the questionnaire was self-administered, the caregivers may overestimate or underestimate their practice and attitude. Another limitation was the cross-sectional nature of the study that was unable to demonstrate any changes of knowledge, attitude and practice of medication management over time. Several aspects of medication management were also not covered in this present study, e.g. ample, the provision of medicine information and shared decision making in creating management plan. Hence, the study can be extended by developing more questions to measure wider area on medication management.
CONCLUSION
The questionnaire is a valid and practical tool to assess the knowledge, attitude and practice of caregivers on medication management at RACFs. Although caregivers have good knowledge, but much can be improved in the area of attitude and practice, to the establishment of good governance and policies to support the medication management system practiced at the respective RACFs. More support and training may be provided to caregivers on medication management and its system as certain terms such as medication error and adverse drug reaction are unfamiliar to them.
ACKNOWLEDGEMENT
The authors thank Universiti Kebangsaan Malaysia for the grant funding (grant number FRGS/2/2014/SKKK02/UKM/03/1).