Research On Medication Taking Behavior And Compliance Of Elderly Patients With Chronic Diseases In Shandong Province

BackgroundChina is the most populous country in the world,and it is also the country with the largest elderly population.According to international standards,China entered an aging society in 1999.Up to now,China’s population aging situation has been deepening with the following distinctive characteristics:the absolute number of elderly population is large,the development trend is rapid,the aging trend is intensified,and the elderly living alone and empty nests are growing rapidly.According to statistics,by the end of 2017,China had 240 million people over the age of 60,accounting for 17.3 percent of the total population,of whom 11.4 percent were aged 65 or above.It is estimated that by 2020,the number of people over 60 years old will increase to about 255 million,with 118 million of them living alone or empty-nest.Different from most developed countries,China has entered into an aging society when its economy is still underdeveloped.The situation of population aging is getting more and more serious,which becomes an inevitable social problem.With the acceleration of population aging process,the prevalence and mortality of chronic diseases increase rapidly,which has become an important threat to the health of the elderly.According to the data of the National Health Service Survey,the prevalence of chronic diseases among the elderly over 60 years old in China increased from 50.1%in 1993 to 71.8%in 2013.At present,86.6%of the total deaths are due to chronic diseases,and more than 60%of the life loss of the elderly comes from chronic diseases.The resultant diseases burden accounts for more than 70%of the total,which has become a major public health problem affecting the economic and social development of the country.At present,drug therapy is still an important means for the prevention and treatment of chronic diseases.Elderly patients with chronic diseases usually need to take drugs for a long time or even a lifetime to treat or alleviate their diseases.In addition,their physical and psychological characteristics make them a special group of drug users.According to the survey,51.33%of elderly patients with chronic diseases need to take medicine every day,among which 18.74%need to take three kinds of drugs every day,and 2.52%need to take more than six kinds of drugs at the same time.Long-term drug use and mixed use of multiple drugs,coupled with the lack of correct medication taking knowledge,easily leads to the failure in following the doctors’ advice for correct drug use,which generates problems such as patients’ improper medication taking behavior and poor medication compliance.According to World Health Organization statistics,one in seven elderly people around the world die not from diseases or natural aging,but from improper use of drugs.Domestic scholars have carried out relevant researches on elderly patients with chronic diseases,mostly focusing on theoretical review,pharmaceutical care,drug burden,free basic drug policy or medication compliance of patients with certain chronic diseases,as well as on patients’ lifestyles and rational medication use of medical staff.From the existing literature,only a few researches involve the cognition of the basic drug system,drug availability,medication taking cognition and medication taking behavior and compliance.The data processing methods are mostly limited to single-factor and multi-factor regression analysis,while few studies have established structural equation models.Few cross-sectional studies have been conducted on cognition,selection,purchase,reserve,taking method and compliance of healthy medication for elderly patients with chronic diseases.Therefore,this research,based on literature review and analysis,aims to comprehensively understand and analyze the medication taking behavior and influencing factors of elderly patients with chronic diseases through large-scale field investigation in Shandong Province.At the same time,medication compliance is also the most important content of medication taking behavior,and has direct impact on the effectiveness of drug treatment.Hence,this research also focuses on the analysis of medication compliance and its influencing factors in elderly patients with chronic diseases.The research on medication taking behavior and compliance can provide basic theoretical data support for guiding elderly patients with chronic diseases to standardize medication taking behavior,improve medication compliance,enhance drug treatment effect,and perfect policy suggestions.Meanwhile,it can provide references for relevant studies in other provinces and cities.ObjectivesThe overall goal of this study is to conduct a large-scale cross-sectional baseline survey of elderly patients with chronic diseases in Shandong Province through multi-stage stratified sampling and household surveys with self-developed questionnaires.It mainly analyzes the current situation of medication taking behavior and compliance of elderly patients with chronic diseases and related influencing factors,and provides scientific basis and policy recommendations for promoting standardized medication taking behavior of elderly patients with chronic diseases and improving compliance.The specific research objectives are as follows:(1)To evaluate the status of medication taking behavior of elderly patients with chronic diseases and to analyze its influencing factors.(2)To evaluate the current situation of medication compliance of elderly patients with chronic diseases and to analyze the affecting factors.(3)To propose policy recommendations to improve medication taking behavior and compliance of elderly patients with chronic diseases.Materials and Methods(1)Data Sources:The study was part of a National Natural Science Foundation project(The Design and Empirical Study on the Reimbursement for the Use of Essential Medicine at Primary Health Provinders among Elderly Patients with Chronic Diseases under the Background of Builing Hierarchical Medical System,No.71673169),and the data was obtained from field surveys.A total of 7070 elderly people aged 60 and above were investigated.Patients with chronic diseases diagnosed by doctors(including hypertension,diabetes,coronary heart disease,copd and cancer)were selected from the total of 7,070 elderly people.After eliminating the records of missing data and logic errors,4,372 elderly patients with chronic diseases were finally selected as the sample of this study.(2)Research Methods:The main research methods used in this research include:literature review method,descriptive statistical analysis,t-test,analysis of variance,rank sum test,chi-square test,generalized linear model and structural equation model.The demographic characteristics of the survey samples are analyzed by descriptive statistics.t-test,analysis of variance,and chi-square test are mainly used for comparing the differences among groups.By fitting the generalized linear model,univariate and multivariate analysis of influencing factors of medication taking behavior and compliance was conducted.A structural equation model was constructed to explore the path of interaction between medication taking behavior and compliance,and latent variables such as socioeconomic status,information acquisition and physical health.Main ResultsThis research involves 4372 elderly patients with chronic diseases,ranging in age from 60 to 101 years old,with an average age of 70.10±6.29 years old.Among them,37.51%are male and 62.49%are female.1405 of them come from Weihai City,1332 from Weifang City,and 1635 from Heze City.(1)Investigation on elderly chronic diseases patients in Shandong Province.Among the 4372 elderly patients with chronic diseases,74.75%of them are mainly educated in primary schools and below.78.55%of the patients live in rural areas or towns.The proportion of single elderly is 18.85%.80.22%of the patients have no more than 2 people living in their homes,of which 14.47%are living alone.77.95%of the patients reported that their economic conditions are in general or poor.97.25%of the patients join the social medical insurance,and only 1.3%of them buy the commercial medical insurance.7.39%use smart phones,and the percentage of people who can access the Internet and use QQ and WeChat is less than 5%.The proportion of patients suffering from one,two and more chronic diseases is 52.54%,33.80%and 13.66%respectively.2.97%of them could not take care of themselves or could only to a little extent.The proportions of elderly patients reporting good,average and poor health status are 42.95%,33.33%and 23.72%.(2)Medication taking behavior and influencing factors of elderly patients with chronic diseases.① Medication taking cognitionCognition of the national basic drug system(or the zero margin drug profit policy):According to the survey,88.95%of elderly patients with chronic diseases do not understand the national basic drug system(or zero margin drug profit policy).The main channels for elderly patients to learn about the national basic drug system are mainly through television(47.24%),doctors(41.72%)and newspapers(28.22%).In terms of the cognition of the basic drug system,from the aspect of education level,the percentage of patients with junior middle school education or above who understand the basic drug system is 9.33%,higher than those without schooling(0.81%)and those with primary school education(2.69%),and the difference is statistically significant(χ2=137.086,P<0.001).In terms of residence,the proportion of patients living in rural areas who understand the basic drug system is 1.85%,which is lower than that of the elderly living in towns(5.9%)and cities(9.28%),and the difference is statistically significant(χ2= 15.054,P<0.001).The proportion of patients with better economic conditions who understand the basic drug system is 8.92%,which is higher than that of those with average economic conditions(2.48%)and those with poor(0.29%),and the difference is statistically significant(χ2=97.094,P<0.001).In terms of the satisfaction level of the basic drug system,the proportion of good,average and poor is 78.55%,16.97%and 4.48%respectively.Regarding the views of the price of basic drugs,27.15%of elderly patients with chronic diseases believe that the price is high.The proportion of patients who regard the price as general and low is respectively 40.92%and 31.93%.As for the quality of essential drugs,76.78%of elderly patients with chronic diseases think that the quality is relatively high.In terms of the attitude towards free use of basic drugs,98.45%of elderly patients with chronic diseases support the free use of basic drugs in primary health care facilities.Medication cognition:Of the 4372 elderly chronic diseases patients surveyed,the average score of health medication cogniton is 1.45±1.04.The proportion of elderly patients with chronic diseases with good,average and poor cognition is 20.61%,58.60%and 20.79%.39.5%of the elderly chronic diseases patients agree with the statement that "the higher the price,the better the effect".In terms of the view "the new drug is definitely better than the old one",42.89%of the elderly chronic diseases patients hold the same opinion.62.74%of the elderly chronic diseases patients agree that“it is better to take several drugs together than to take one alone".Stratified analysis shows that older patients over 80 years old,not attending school,not living in rural areas,or with poor economic conditions are more likely to agree with this view than other groups.The difference is statistically significant(P<0.05).② Medication selectionThe average score of medication selection among the 4372 elderly patients with chronic diseases is 0.16±0.51.The proportion of the patients,whose medication selection displays a good,average or poor performance,is 88.75%,9.81%and 1.44%.At similar prices,96.65%of elderly patients with chronic diseases prefer essential drugs.Under the condition of similar efficacy,96.57%of elderly patients approve of the priority choice of essential drugs.Under the condition of similar quality,90.85%of elderly patients with chronic diseases prioritize the choice of essential drugs.③ Medication purchaseOf the 4372 elderly chronic diseases patients surveyed,the average score of medication purchase is 0.27±0.47.The proportion of the patients,whose medication purchase displays a good,average or poor performance,is 73.83%,26.10%and 0.07%.When it comes to whether the medication purchase is affected by advertising,2.77%of elderly patients with chronic diseases are affected,and 97.23%are not.According to the stratified education levels,patients with junior high school education or above are more likely to be influenced by advertising,and the difference is statistically significant(χ2=12.294,P<0.05).In terms of whether they have purchased drugs online,1.24%of the elderly chronic diseases patients have,and 98.76%of them have not.Through stratified analysis,it is found that elderly patients with a junior high school education or above,or who live in the city or have a good economic condition are more likely to purchase drugs online than other groups,and the difference is statistically significant(P<0.001).In terms of "whether to buy drugs from primary medical and health institutions",76.58%of elderly patients choose to buy drugs from primary medical and health institutions.Through stratified analysis,it is found that patients with a junior high school education or above,or who live in the city or have a good economic condition are less likely to purchase drugs in primary medical and health institutions than other groups,and the difference is statistically significant(P<0.001).④Medication reserveIn terms of "whether to store some drugs at home",58.60%of the patients choose to store some,and 41.40%do not.Through stratified analysis,from the aspect of educational level,residence and economic status,patients who have a junior high school education or above,or who live in the city or have a better economic condition,are more likely to reserve drugs at home than other groups.The difference is statistically significant(P<0.001).⑤ Medication taking methodsIn terms of "When your medication can be taken orally or by injection,do you prefer oral medication?",48.83%of the patients choose oral drugs.By stratified analysis,it is found that patients with a junior high school education or above,or who live in a city or have a better economic condition are more likely to choose oral drugs than other groups,and the difference is statistically significant(P<0.001).⑥Overall situation and influencing factors of medication taking behaviorThe average score of medication taking behavior among the 4372 elderly patients with chronic diseases is 5.1 7±1.67.The proportion of the patients,whose medication taking behavior displays a good,average or poor performance,is 15.42%,77.97%and 6.61%.The results of multivariate analysis by generalized linear model show that age,education,residence,economic status,number of people living at home and cognition of the basic drug system are the main influencing factors of medication taking behavior of elderly patients with chronic diseases.The partial regression coefficients of age,education level,residence,economic status,number of people living at home and cognition of the basic drug system are all positive values.Patients with higher ages,worse economic situation and poor cognition of the basic drug system,or whose education level is primary school or below,or who live alone in the countryside or towns,are more likely to have higher medication taking behavior scores.The results of structural equation model analysis show that the standardized path coefficients of socioeconomic status,information acquisition ability and physical health to medication taking behavior are 0.19,-0.17 and-0.14 respectively,suggesting that socioeconomic status has a positive effect on the medication taking behavior of elderly patients with chronic diseases,and information acquisition ability and the physical health have a negative effect on the medication taking behavior of the elderly chronic diseases patients.(3)Overall situation and influencing factors of medication compliance.According to the survey,90.14%of elderly patients with chronic diseases think medication compliance is important.The average score of medication compliance is 1.41±1.38.The proportion of the patients,whose medication compliance displays a good,average or poor performance,is 38.45%,34.47%and 27.08%.About whether or not they have ever forgotten to take medicine,45.47%of the patients have.36.18%of the patients sometimes do not pay attention to taking medicine.In terms of "whether or not to stop taking drugs when subjectively feel symptoms get improved",36.64%of them do.And 23.08%of the patients have ever stopped taking drugs after they subjectively feel symptoms get worse.The results of multivariate linear regression analysis show that age,education level,residence,economic status,activity of daily living,and whether or not using smart phones are the main factors influencing medication compliance in elderly patients with chronic diseases.The partial regression coefficients of age,activity of daily living and using smart phones to medication compliance are negative,suggesting that factors of age,activity of daily living and using smart phones have negative effects on medication compliance.The partial regression coefficients of educational level,residence and economic status are all positive,which indicates that the factors such as educational level,residence and economic status have a positive effects on medication compliance.It is also found through structural equation model analysis that,the path coefficients of socioeconomic status,information acquisition ability and physical health on medication compliance are 0.14,-0.10,-0.05 respectively.It shows that socioeconomic status has a positive impact on medication compliance,and information acquisition and physical health have a negative impact on medication compliance.Conclusions and SuggestionsConclusions:(1)Elderly patients with chronic diseases support free use of essential drugs in primary health care facilities,and they also have a low awareness of the basic drug system and a weak ability to obtain information through the Internet.Through investigation,it is found that the education level of elderly patients with chronic diseases in Shandong Province is generally low,and the means and ability of obtaining information online are poor.The patients get to know about the national drug system mainly through television,doctors and newspapers.The vast majority of the elderly chronic diseases patients do not understand the national basic drug system and policy.Elderly patients living in rural areas or with poor economic situation,or whose education level is primary school or below know less about drug policy than other groups.However,the vast majority of elderly chronic diseases patients support the free use of essential drugs in primary health care facilities.(2)The medication taking behavior of elderly patients with chronic diseases is generally at a moderate level,which can be improved with the help of doctors.The medication taking behavior of elderly patients with chronic diseases is analyzed from such dimensions as medication taking cognition,medication selection,medication purchase,medication reserve and medication taking methods.The results show that the medication behavior of elderly patients with chronic diseases is at a moderate level.Generally speaking,the percentage of those whose medication taking behavior displays a good performance is only 15.42%.Elderly patients with chronic diseases have a moderate level of medication taking cognition.Only 20.61%of the patients have a good medication taking cognition.Elderly patients over 80 years old,or not attending school or living in rural areas with poor economic conditions have poorer awareness of healthy medication taking cognition than other groups.Medication selection of elderly patients with chronic diseases is in a good level.More than 90%of patients will give priority to choose the essential drugs when the price,efficacy and quality of the drugs are similar.Medication purchase of elderly patients with chronic diseases is also in an overall good level.73.83%of the patients are in a good condition.The vast majority of patients do not buy drugs online,but choose to buy medicines in primary health care institutions and are basically not affected by drug advertising.The dimentions of medication reserve and medication taking methods of the elderly chronic diseases patients are also in a middle level.According to the survey,60%of elderly patients choose to store some medicines at home,and nearly half of elderly patients will prefer oral medication.Patients with junior high school education or above,or those who live in cities,or those with good economic conditions are better than other groups in terms of medication reserve and medication taking methods.This research finds that age,education,residence,economic status,number of people living at home and understanding of the basic drug system are the main influencing factors of medication taking behavior of elderly patients with chronic diseases.The results show that the older the people,the worse their medication taking behavior.Elderly patients who have not attended school or have only attended primary school have worse medication taking behavior than those with a junior high school education and above.The behavior of people who live in rural areas and towns is worse than that of those who live in cities.There is a positive correlation between economic foundation and medication taking behavior.The behavior of the elderly with good economic status is better than that of the elderly with poor economic status.Compared with those who live with three or more people at home,elderly people living alone have poorer medication taking behavior.Compared with those who know the basic drug system well,patients who do not know the system have poorer medication taking behavior.The analysis results by constructing the structural equation model show that the socioeconomic status has a positive effect on medication taking behavior,suggesting that the higher the socioeconomic status,the better the medication taking behavior of elderly patients with chronic diseases.Information acquisition and physical health have a negative impact on medication taking behavior,suggesting that the stronger the ability to obtain information or the better the health status of elderly patients,the worse medication taking behavior of elderly patients with chronic diseases.(3)The medication compliance of elderly patients with chronic diseases is at a moderate level,which should be paid enough attention to.Medication compliance of elderly patients with chronic diseases is generally at a moderate level.Nearly half of the respondents have such behaviors as forgetting to take medicine,paying no attention to taking medicine and stopping taking medicine by themselves.The majority of elderly patients with chronic diseases have medium or lower level of medication compliance.Elderly patients with poor economic conditions,or living in towns or villages are prone to drug withdrawal regardless of their symptoms getting better or worse.It is found that age,education,residence,economic status,activity of daily living,and whether or not using smart phones are the main influencing factors of medication compliance in elderly patients with chronic diseases.The older patients with chronic diseases have better medication complicance than younger ones.Education is also a protective factor for medication taking behavior.Compared with the patients with lower education,patients with higher education level also have better medication compliance.Compared with those living in rural areas or towns or with poor economic conditions,elderly patients living in cities or with good economic conditions have better medication compliance.Patients with low activity of daily living or not using smart phones are more likely to have better medication compliance.The analysis results of the structural equation model show that socioeconomic status has a positive effect on medication compliance.The results suggest that the higher the socioeconomic status is,the better medication compliance of elderly patients is.Information acquisition and physical health have a negative impact on medication compliance.The results suggest that the patients with stronger information acquisition or better physical health tend to have worse medication compliance.Suggestions:(1)Strengthen policy publicity of the national basic drug system;promote the cognition of healthy medication taking of the elderly chronic diseases patients;popularize common knowledge of medication taking against chronic diseases;help improve medication taking behavior.(2)Promote the construction of hierarchical medical system with emphasis on strengthening primary health care facilities;let general practitioners(GPs)play the role as health "gatekeeper" to improve medication taking behavior and compliance of elderly patients with chronic diseases.(3)Explore the implementation of free drug supply system and conduct reasonable compensation for elderly patients with chronic diseases in order to improve the essential drug accessibility and medication compliance.(4)Focus on serving elderly patients with chronic diseases and create a healthy and supportive social environment to enhance self-efficacy of elderly patients and promote the effect of drug therapy.(5)Improve the system for the prevention and treatment of chronic diseases and promote the standardization of healthy medication taking behavior among elderly patients with chronic diseases,in combination with the construction of the "National Comprehensive Prevention and Control Demonstration Zone for Chronic Diseases" in Shandong Province.Innovations and InadequaciesInnovations:(1)This study is based on the pilot implementation of the basic drug system covering all the government-run primary health care institutions and free supply of chronic disease drugs in Shandong Province.It uses a multi-stage stratified random sampling method to select samples in Shandong Province.The cross-sectional baseline survey of medicine taking behavior and compliance is performed in the special medication group of elderly patients with chronic conditions.It provides empirical evidence for taking precise measures to improve medicine taking behavior and compliance in elderly patients with chronic diseases.(2)This study used a self-developed questionnaire to investigate the demographic characteristics,economic and medical security,living environment,physical health status,and medication behavior and compliance status of elderly patients with chronic diseases aged 60 years and above in Shandong Province.Medication taking behaviors were measured and evaluated from five aspects:medication cognition,medication selection,medication purchase,medication reserve,and medication taking methods.Medication compliance was assessed with the Morisky Medication Adherence Scale.The influencing factors of medication taking behavior and medication compliance were found by univariate and multivariate analysis.Through structural equation model,the action path and intensity of relevant latent variables on medication taking behavior and compliance were quantitatively analyzed.These findings increase new understanding of medication taking behavior and compliance of elderly patients with chronic diseases and inspire new ideas for follow-up studies.Inadequacies and prospects:(1)In this research,only a cross-sectional survey is conducted in Shandong Province by means of sampling.As the medication taking behavior and compliance of patients with chronic diseases is dynamic and sensitive to the related effects and changes in policy and environmental conditions,the comparison and analysis of the longitudinal and chronological data is not available in the study.So the conclusion has certain spatiotemporal limitations.(2)The influencing factors of medication taking behavior are various.This study mainly investigated the demographic characteristics,socioeconomic status,living environment,information acquisition,and physical health status of patients with chronic diseases,and the status of medication taking behavior and medication compliance.Statistical analysis was performed to find the influencing factors.Follow-up studies can continue to collect indicators of health literacy,disease cognition,and self-efficacy in elderly patients with chronic diseases to enrich research conclusions.