Knowledge, attitude, and practices of rational use of medicines among the postgraduate residents of a tertiary care teaching hospital in North Karnataka: A facility-based cross-sectional study :Nishtha Malhotra, MS Shivaswamy, Indian Journal of Health Sciences and Biomedical Research KLEU

ORIGINAL ARTICLE
Year : 2023 | Volume : 16 | Issue : 1 | Page : 71--78

Knowledge, attitude, and practices of rational use of medicines among the postgraduate residents of a tertiary care teaching hospital in North Karnataka: A facility-based cross-sectional study

Nishtha Malhotra, MS Shivaswamy
Department of Community Medicine, Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belagavi, Karnataka, India

Correspondence Address:
Dr. Nishtha Malhotra
Department of Community Medicine, Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research (KAHER Deemed to be University), Nehru Nagar, Belagavi - 590 010, Karnataka
India

Abstract

BACKGROUND: The overuse, underuse, or misuse of medicines by the postgraduate residents results in wastage of scarce resources and widespread health hazards. “Rational use of medicines” (RUMs) would bring health care within the reach of the poor by reducing costs. This study was conducted to assess the knowledge, attitude, and practices of RUMs among the postgraduate residents of a tertiary care teaching hospital. MATERIALS AND METHODS: A facility-based cross-sectional study was conducted for a period of 6 months (November 2019–April 2020). With the help of universal sampling, a self-developed, prevalidated, semi-structured questionnaire was distributed to 200 residents, to obtain information about the knowledge, attitude, and practice of RUM. Written informed consent was obtained from the participants after explaining to them about the study. RESULTS: About 92.5% of the participants were aware of the term “RUM” and 84% were aware of the term “Essential Medicines.” Sixty-one percent of the residents had good knowledge about RUM, and 51% had good practice of RUM. Logistic regression analysis showed statistically significant results that postgraduate students of the nonsurgical departments were more likely to have good knowledge and practice RUM than postgraduates of the surgical departments. Juniors (1^st Year postgraduate residents) among the postgraduates also seemed to have an increased likelihood of practicing RUM. CONCLUSIONS: The knowledge gap and lack of good practice of RUM observed among the postgraduates can be reduced by imparting education regarding RUM more efficiently in the medical colleges, to inculcate it into daily clinical practice.

How to cite this article:
Malhotra N, Shivaswamy M S. Knowledge, attitude, and practices of rational use of medicines among the postgraduate residents of a tertiary care teaching hospital in North Karnataka: A facility-based cross-sectional study.Indian J Health Sci Biomed Res 2023;16:71-78

How to cite this URL:
Malhotra N, Shivaswamy M S. Knowledge, attitude, and practices of rational use of medicines among the postgraduate residents of a tertiary care teaching hospital in North Karnataka: A facility-based cross-sectional study. Indian J Health Sci Biomed Res [serial online] 2023 [cited 2023 Mar 23 ];16:71-78
Available from: https://www.ijournalhs.org/text.asp?2023/16/1/71/368341

Full Text

Introduction

“Drug” is defined as a substance intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease.[1] The WHO definition of rational medicine use: “Medicine use is rational (appropriate, proper, and correct) when patients receive the appropriate medicines, in doses that meet their own individual requirements, for an adequate period, and at the lowest cost both to them and the community. Irrational (inappropriate, improper, and incorrect) use of medicines is when one or more of these conditions is not met.”[2]

The WHO estimates that more than half of all medicines are prescribed, dispensed, or sold inappropriately, and that only about half of all patients take them correctly.[2] The overuse, underuse, or misuse of medicines results in wastage of scarce resources and widespread health hazards such as grave morbidity and mortality in infections and chronic diseases such as hypertension and diabetes. This affects ill and vulnerable individuals more such as children and the elderly with morbidities. Iatrogenic diseases can also occur due to the adverse effects of essential drugs and unnecessary drugs. Antimicrobial resistance (AMR) is one of the most severe public health problems which results in extended illness and hospitalization. The treatment of AMR requires the use of drugs other than first-line drugs which can increase the burden of out-of-pocket expenditure.[3]

”Rational use of medicines” (RUMs) would bring health care within the reach of the poor by reducing costs and significant patient harm in terms of poor patient outcomes. Access to health care and, therefore, to essential medicines is a human right.[4],[5]

”Essential medicines” are those that satisfy the priority health care needs of the population. Thus, if they are available, affordable, are of good quality and are used properly, medicines can offer simple, cost-effective answers to many health problems. There is, therefore, a need to develop educational strategies for health-care practitioners and consumers in the RUMs.[6]

”Essential medicines list” (EML) is an integral part of RUM and was defined by the WHO in 1975 as a major step toward promoting RUM.[7] The first WHO (EML) was published in 1977 with revisions every 2 years. The WHO has also published a guideline, “Selection of Essential Medicines at country level” (March 20, 2020).[8] In India, the Ministry of Health has revised the “National List of Essential Medicines of India” (NLEMI 2011) in 2015 using the WHO model list of essential medicines. It contains 376 medicines.[9],[10] EML has shown to improve the quality of prescribing and cost-effectiveness of health-care delivery.[11] Although the majority of residents and doctors realize the importance of RUM, but the application is lacking in their routine medical practice.[12]

Personal drugs or “P-drugs” are the drugs that are chosen to prescribe regularly, and with which the doctor has become familiar. They are the priority choice for given indications and helps doctor avoid repeated searches of good drugs. P-drugs should be selected from NLEM.[13],[14]

Studies have been done to assess the perception of RUM among different groups like nurses, students, interns, clinicians, pharmacists, and prescribers.[15],[16],[17],[18],[19],[20],[21] Medical Postgraduate residents are exposed to a variety of prescribing patterns under the guidance of different consultants in the teaching hospitals. Even though the hospital guidelines recommend the use of EML for prescribing medicines in the outpatient departments of various clinical departments, it has been perceived that the application of RUMs is lacking in their routine medical practice. Some PGs had also expressed informally that they were not aware of rational drug use.

Medical postgraduate residents will become future physicians and specialists. Therefore, it is important that by the end of 3 years of residency, they should inherit good knowledge of RUM and develop the best prescribing attitude and practices. Few studies have been conducted to assess the knowledge, attitude, and practice of postgraduate residents about RUM.[15] Hence, the present study was conducted.

Materials and Methods

This was a cross-sectional, questionnaire-based study conducted among the post-graduate residents at tertiary care teaching hospital in North Karnataka for a period of 6 months (November 1, 2019–April 30, 2020). Ethical clearance was obtained from the Institutional Ethics Committee for human subjects' research of the medical college, Ref no MDC/DOME/324 dated 01.01.2020.

A self-developed, prevalidated, semi-structured questionnaire consisted of questions on sociodemographic details and sections on knowledge, attitude, and practice of RUM with a total of 22 questions. Questions were also asked to assess the awareness of postgraduates on p-drugs, Safety, Tolerability, Efficacy, Price (STEP) criteria, and Schedule-H drugs. The questionnaire was first pretested in 10 postgraduate residents and was suitably modified before distributing it to the participants.

After the postgraduate residents gave written consent for participation, they were explained about the study. The predesigned and structured questionnaires were distributed to the participants in hard copies as well as in online digital formats (Google forms). Appropriate instructions about filling out the questionnaire were given. The personal identity of the residents was kept confidential.

Nonprobability convenience sampling was done, in which 200 questionnaires were distributed among the postgraduate residents of all clinical departments of the teaching hospital. Postgraduate residents who were on long leave at the time of data collection and residents who could not be approached even after three attempts were excluded from the study.

Data collected were coded and entered in Microsoft excel software and tables, graphs, and charts were prepared. IBM SPSS Statistics for Windows, Version 20.0. (Armonk, NY: IBM Corp.) Data analysis was performed using rates, ratios, and percentages. Scoring was done for assessing the knowledge section by giving 1 score for each correct answer. Scores ≥6 (out of 10) were categorized as good knowledge. Scoring was also done to assess the practice section by giving 1 score for every correct answer, for which questions 16, 19, 20, 21, and 22 were included. Scores ≥3 (out of 5) were categorized as good practice. Statistical analysis was performed to check if there was any association present between independent variables of gender (male/female), surgical/nonsurgical departments, juniors (1st years)/seniors (2nd and 3rd years), and outcomes of knowledge and practice of RUM among them. The statistical tests used were Chi-square, independent t-test, and regression analysis.

Results

Out of the total of 250 postgraduate residents in 11 clinical departments, 200 responded giving a response rate of 80%. The remaining 50 PGs who could not participate, were mostly from final year and departments such as anesthesia, ENT, and Ophthalmology. They did not consent to participate in the study as they were busy in dissertation/CME work, etc., Among the 200 respondents, 55% were female and 45% were male. The maximum number of participants was 1st-year residents (48%), whereas 2nd- and 3rd-year residents were 26% each. Department-wise distribution of residents is shown in [Figure 1]. The demographic characteristics are described in [Table 1].{Figure 1}{Table 1}

Knowledge assessment about RUM among the 200 residents showed that 92.5% of the participants were aware of the term “RUM” and 84% were aware of the term “Essential Medicines.” About 65% of the respondents responded that they did not have “NLEMI” at their workplace. Ninety-one percent of the participants were aware of the ingredients of the drugs they prescribe. Only 54% of the residents agreed to be able to name the parts of the prescription correctly, of which merely 18% could actually do it. While only 52% of the respondents were aware of the term “Personal drugs” and only 44% knew about the “STEP” criteria for selection of P-drug, 73% of the participants were aware of “Schedule-H” drugs [Table 2.1].{Table 2}

The assessment of knowledge also included scoring for good knowledge and it was found that 61% of the residents had good knowledge about RUM. The mean knowledge score value was 5.95 ± 1.948 [Figure 2].{Figure 2}

To check if there was any association present between knowledge scores and independent variables of gender (male/female), surgical/nonsurgical departments and juniors (1st years)/seniors (2nd and 3rd years), Chi-square test was performed, with all the required assumptions of the test fulfilled. The association between knowledge scores and postgraduate students of the surgical or nonsurgical departments was found to be present and statistically significant with Pearson Chi-square, χ2 (1) = 3.866, P = 0.049. The surgical departments' group (n = 98) included General Surgery, Orthopedics, Ophthalmology, ENT and OBG, whereas the nonsurgical departments' group (n = 102) included General Medicine, Pediatrics, Dermatology, Psychiatry, Anesthesiology, and Community Medicine. There was no difference found in the knowledge scores of postgraduates based on their gender or seniority.

[Table 2.2] shows the assessment of residents' attitudes and practices about various aspects of RUM. About 96% of the residents agreed that there should be an “EML” in each clinical department. Ninety-five percent thought that regular training is needed about “RUM” after the MBBS course during the internship. Although 56% of the residents prescribed essential medicines frequently, only 47% prescribed as per “NLEMI.”

Only 24% of the participants preferred to prescribe new drugs over old drugs. Most of the residents (80%) prescribed new drugs after consulting their senior physicians, 67% of residents prescribed new drugs after gaining their own experience with the new drug, 65% after attaining adequate scientific evidence about the efficacy of the drug, and 43% prescribed new drugs through knowledge and information gained by medical representatives. Sixty-nine percent of the residents responded that they always inform the patient regarding disease, drug therapy, regular follow-up, and monitoring of drug therapy. Fifty-three percent of the participants prescribed the drugs by both generic and brand names.

The assessment of good practices of RUM among the postgraduates showed that 51% of the residents had good practices of RUM. The mean practice score value was 2.44 ± 1.11 [Figure 3].{Figure 3}

Statistical analysis was performed to check if there was any association present between practice scores and independent variables of gender (male/female), surgical/nonsurgical departments, and juniors (1st years)/seniors (2nd and 3rd years). The Chi-square test was performed with all the required assumptions of the test fulfilled. The association between practice scores and postgraduate students of surgical or nonsurgical departments was found to be present and statistically significant with Pearson Chi-square, χ2 (1) = 5.099, P = 0.02.

Logistic regression was performed to ascertain the effects of gender, surgical/nonsurgical departments, and juniors (1st years)/seniors (2nd and 3rd years) on the likelihood that participants have good knowledge and practice RUM. Postgraduate students of the nonsurgical departments were 1.775 times more likely to have good knowledge about RUM than postgraduates of the surgical departments (P = 0.05, 95% CI 1.00–3.153), and 2.014 times more likely to practice RUM than postgraduates of the surgical departments (P = 0.016, 95% CI 1.137–3.567). Juniors among the postgraduates seemed to have an increased likelihood of practicing RUM by 1.801 times (P = 0.04, 95% CI 1.017–3.19) [Table 3].{Table 3}

Linear regression was also carried out to investigate whether knowledge scores about the RUM of the postgraduates could significantly predict participants' practice scores of RUM. The results of the regression indicated that the model explained 5.8% of the variance and that the model was a significant predictor of RUM practice, F (1,198) = 12.267, P = 0.001. Knowledge about RUM contributed significantly to the model (B = 0.14, P = 0.001, 95% CI 0.06–0.216). The final predictive model was, Practice score = 1 − 618 + (0.138 × Knowledge score)

Discussion

The “RUMs” contributes to high-quality health care while irrational use leads to health hazards and wastage of resources that are already insufficient in the majority of health-care systems.[6] Various studies have been done to assess the perception of RUM among different groups such as nurses, students, clinicians, pharmacists, and prescribers.[15],[16],[17],[18] The present study evaluates knowledge, attitude, and practice about RUM in postgraduate residents working at tertiary care teaching hospital. This will be helpful in promoting RUM and improving health-care services.

In this study, it was found that 92.5% of the participants were aware of the term “RUM” and 84% were aware of the term “Essential Medicines.” However, only 47% of the participants prescribed essential medicines as per NLEMI. The knowledge regarding “Personal drugs” and its advantages, STEP criteria, parts of a prescription, and NLEMI revision was limited. The findings are similar to other studies conducted on the knowledge, attitude, and practices (KAP) of RUM.[19],[20],[21]

Even though the concept of “P– drugs” has been included in the pharmacology curriculum of medical students in their 2nd year of MBBS course, still the knowledge regarding it was not found in almost half of the postgraduate residents. This indicates that the P-drug concept has remained confined to pharmacology and its implementation in clinical practice is still poor in our country. Similar findings were found in other studies as well.[15],[20],[22] This may be because the P-drug concept is rather a new concept and in India it has started gaining importance in the last few years.[13]

The EML promotes RUM by stressing the importance of the three important aspects, i.e., safety, efficacy, and cost. Improvement in the quality of health care following the use of EML and standard treatment guidelines has been reported by some studies.[23] Hence, measures should be adopted that encourage its use.

[Table 2] shows the assessment of residents' attitudes and practices about various aspects of RUM. The majority of the participants preferred to prescribe old drugs over new drugs. Almost all the residents (96%) believed that there should be an “EML” in each clinical department and regular training is needed about “RUM” after the MBBS course during the internship. These findings are similar to other studies conducted on the KAP of RUM.[19],[20],[21]

Most of the participants informed their patients regarding the disease, drug therapy, regular follow-up, and monitoring of drug therapy. EML encourages prescribing drugs by their generic names.[23] In 2016, the Medical Council of India had issued a notice to all the doctors in India to prescribe drugs only by generic names.[24] This was done to ensure rational prescription and use of medicines. Shows us that almost half of the participants were prescribed drugs by both generic and brand names. It has become a common practice for doctors to prescribe drugs by brand names.[25],[26]

Forty-three percent of the residents prescribed new drugs through knowledge and information gained from medical representatives. Drug information provided by MRs is often biased for the benefit of their pharmaceutical companies, leading to irrational prescription behavior and irrational use of medicines. The prescribing decision of the physicians is influenced by MRs on the pretext of some incentives in the form of free samples, gifts, or various kinds of support.[27] Residents should be provided with authentic and unbiased sources of information such as drug bulletins and drug formularies, which can help in decreasing this form of irrational prescribing.[28]

Postgraduate students of the nonsurgical departments were more likely to have good knowledge and practice RUM than postgraduates of the surgical departments. This could be because CMEs/seminars on the importance of RUM were more frequently organized in nonsurgical departments than surgical departments.

Juniors among the postgraduates were found to have an increased likelihood of practicing RUM. This could have been due to a limitation in the data as more number of juniors participated in the study compared to senior PGs.

Limitations

The study was conducted only in one private hospital. The study could have been extended to other government hospitals to acquire comparative data from all sectors of health careThe study questionnaire included only close-ended questions. A qualitative component (Focused Group Discussion) comprising open-ended questions could have provided more insight into the reasons behind the unsatisfactory practice of RUM among the postgraduatesThe study participants included only the postgraduates. The inclusion of consultants and senior faculties could have provided comparative and complete data and also trickle-down effect to the junior residents.

Conclusions

The knowledge about RUM and Essential Medicines, though found to be good among the residents, their practice of RUM and drug prescription was found to be unsatisfactory. The education regarding RUM has to be imparted more efficiently in the medical colleges to inculcate it into daily clinical practice.[28],[29],[30] These interventions can be helpful for developing countries like India where resources are limited.

Recommendations

Individual level: The residents should read the current national or institutional (if available) guidelines for prescribing medicinesDepartment level: Workshops should be conducted for the residents on RUM at the department level or college/teaching hospital levelInstitutional level: Medical colleges/teaching hospitals should formulate their own essential list of medicine (ELM) and annual training should be provided to the new batches of resident doctors to bridge the knowledge gap and improve RUM practice.State/national level:The Government of India/State government can design/update periodically their ELM following WHO guidelinesMCI/NMC should formulate policy for inclusion of RUM/ELM in the clinical PG curriculum/revised UG curriculum 2020 to develop competency in prescribing drugs rationally.

Ethical approval

The study protocol was approved by the Institutional Ethical Committee for Human Subjects Research of JNMC, Belagavi, Karnataka. Informed consent was obtained from the participants form before recruiting them in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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