Medication Counseling In Developing Countries

Counseling is an integral component of dispensing. It has a major role in patient compliance. However this component has been widely neglected by professionals in developing countries.  
In our current setting counseling means giving some verbal information about medicines to patients. Does this practice fulfils the objectives of counseling?  
  
Counseling is the process of telling people what you found, what it means, and what needs to be done, and doing so with tact and sensitivity. Jerger J. Effective Counseling in Audiology. Prentice-Hall;1994.   
  
Counseling is the process of giving and receiving information in a way that is meaningful, memorable and usable, changes behavior and facilitates a successful rehabilitative outcome. Yanz JL, Pociecha AL. Patient Counseling: Questioning, Retention & Social Style. Presentation at: American Academy of Audiology Annual Convention, Minneapolis; April 7, 2006.   
  
What do Patients Remember?  
  
    * Patients and family members remember unimportant details such as the color of the doctor\'s shirt or the kind of glasses he or she wore. They always vividly remember the date and can describe the trip to the hospital in explicit detail, but they usually fail to retain any of the important information. Luterman DM (2001). Counseling Persons with Communication Disorders and their Families. (4th ed.) Austin: Pro-Ed(p. 76-77)  

    * Overall studies indicate that about 50% of information provided by healthcare providers is retained. Shapiro DE, Boggs SR, Melamed BG, Graham-Pole J (1992). The effect of varied physician affect on recall, anziety, and perceptions in women at risk for breast cancer:an analogue study. Health Psychol 11:61-66.  

    * Depending on conditions, 40-80% can be forgotten immediately. Kessels RPC (2003). Patients\' memory for medical information. J Roy Soc Med 96:219-222  

    * Of the information that is recalled,  about half is remembered incorrectly.Anderson JL, Dodman S, Kopelman M, Fleming A (1979). Patient information recall in a rheumatology clinic. Rheumatol Rehabil 18:18-22  
      Kessels RPC (2003). Patients\' memory for medical information. J Roy Soc Med 96:219-222.
  
    * Physicians\' impressions of what patients would remember were not correlated with measures of patients\' actual recall. This finding reinforces the need to provide information in writing even for patients who appear to be absorbing everything.Anderson JL, Dodman S, Kopelman M, Fleming A (1979). Patient information recall in a rheumatology clinic. Rheumatol Rehabil 18:18-22.  

    * A study of recall of information presented during an informed consent process preceding elective surgery found that 25% of the information was correctly recalled. Godwin Y (2000). Do they listen? A review of information retained by patients following consent for reduction mammoplasty.  Br J Plast Surg 53:121-125  
  
Effective Counseling  
  
Thompson, Cunningham, & Hunt (2001) concluded from their study of information retention following an orthodontic consultation that verbal information  should not be given to patients unless supplemented by written and/or visual information (p. 169). Thomson AM, Cunningham SJ, Hunt NP (2001). A comparison of information retention at an initial orthodontic consultation. Eur J Orthod 23:169-178.  
  
Recommendations are more likely to be remembered and followed when they are specific rather than general.(Bradshaw et al., 1975; Ley, 1977, 1979)  
  
Robert H. Margolis suggests:  
   1. Advice should be given as concrete instructions. \"Use ear plugs when you use your power tools\" rather than \"Keep your noise exposure to a minimum\".   
   2.  Use easy to understand language. Short words and sentences are remembered better.  
   3. Don\'t present too much information  
   4. Supplement verbal information with written, graphical, and pictorial materials that the patient can take home.  
  
In 1992, the International Pharmaceutical Federation (FIP) developed standards for pharmacy under the heading \"Good pharmacy practice in community and hospital pharmacy settings\". The guideline includes:  
  
Instructions to the patients   
Step1: Instructions are verbal  
Step2: Instructions are verbal+ hand-written and affixed to the container  
Step3: Instructions are verbal+ printed/typed and affixed to the container  
Step4: In addition to step 3, verbal counseling is given to the patient  
Step5: In addition to step 4, supplementary written information is given  
Step6: GPP is observed  
  
Minimum requirement for label   
   1. Generic name & strength of medicine  
   2. Dose, frequency & duration of course, if applicable  
   3. Date of dispensing  
   4. Name of patient  
   5. Name/address of supplier  
   6. Child safety warning  
  
\"National Good Pharmacy Practice Guidelines\" drafted by Nepal Pharmacy Council, 2005 includes counseling methods under chapter of \"Patient Information\":  
    * Pharmacist should provide oral as well as written information  
    * All dispensed medicines should be provided with a label  
    * Dosage and usage information must be given verbally to the patients along with demonstrations and pictograms where ever required  
    * It must be ensured that information and advice given is correct  
  
These documents clearly highlight the importance of dispensing labels and their role in counseling. A dispensing label sample is show in figure.