Author : Melody Lam (MPH candidate 2022)
The global average life expectancy at birth is getting older, with Hong Kong reaching 85.16 years due to a reduction in fertility and improvement in survival.1 In 2019, there are approximately 9% of the global population aged 65 or above. It is projected that the proportion will rise to 16% by 2050, with a total number of 1.5 billion older people.2 To neutralize the increasing demand for healthcare, promotion of healthy behaviors is vital to prevent or minimize any illnesses or disability among the growing aging population. A study showed a positive correlation between drug adherence levels and age.3 Elderlies often have multiple comorbidities that requires multiple treatments and resulted in a problem of polypharmacy, hence they are more prone to have drug compliance problems and lower adherence level than younger adults.3
Two thirds of geriatric patients have been showed to have receive an inappropriate dosage of medication and approximately 30% of hospital admissions of geriatric patients is linked to the toxic effects of pharmaceutics. Some preventable problems such as depression, falls, confusion, constipations, and hip injuries are positively associated with the adverse effects of pharmaceutics.4,5 To reduce medication error happens in elderlies, Drug Icon has developed a set of drug pictogram to allow elderlies to easily understand the instructions on the drug bag. This strategic plan is to provide evidence-based suggestions to Drug Icon for the promotion of drug pictogram to the senior population.
Healthy ageing is widely promoted nowadays to encourage elderly to live actively and independently in community, rather than relying heavily on institutionalized care.6 To facilitate the concept of aging in place, technology is a potential resource that can contribute to community dwelling elderly to safely enjoy aging at home, while also improve the health-related quality of life.6 For instance, technologies are designed to provide support, monitor, or improve daily life activities and allow better information and communication.6
Although digital health technology is a new arising trend in enhancing ageing in place, not all elderlies or caregivers are familiar with it.7 It is observed that there is a generational gap in technology penetration and use between two age groups of elderlies. Population with age between 65 and 79 has a better device use and general digital awareness than population with age 80 or above.7 As the younger age group were already familiarized with the electronic gadgets when they were still in the workforce before retirement, while the older group did not.7 In view of the technology generation gap, promotion strategies must split into two directions, i.e. the younger elderly group will be targeted with digital health intervention, while the older elderly group will be targeted by the old fashioned way – educational intervention.
Digital health intervention
In Taiwan, they have widely used the Barcode scanning system throughout their medical procedures such as administration, prescription, transcription, and dispensation, and it showed that more than 50% of medical error have been reduced.8 They have also implemented a new labelling system making prescription drug and container information more accessible to the visually impaired patients, as well as for elderly with poor eyesight.9 The new labelling system consist of audible and large print formats, as well as QR codes.9 It aims to enhance drug safety by enabling consumers to understand their medications better. It has been proven that with QR code technology, it can increase drug safety for both older and younger population.10
In Hong Kong, currently there is no intervention on the information of drug label in the private sector. Basic medication information such as names and dosage are shown on the drug label, however the words are small and precise. To promote drug safety in HK, Drug Icon can adopt similar strategies as Taiwan to include QR code in the drug label. The QR code should consist of some basic information such as patient’s name, ID number, prescription issued date, dispensing date, days of medicine, name and ID number of medicine, dosing frequency, route to take the medicine and total amount of medicine.11 QR codes can also link to audio cues and videos about the usage of drugs and some general tips for using the medication.9 When elderly scan the QR code on the drug bag, they can get the audio or video version of drugs information, or a detail word format of drug information in the phone.
Collaboration can start with NGOs with community pharmacy settings, such as the Lok Sin Tong Benevolent Society Kowloon and the Health in Action. The QR code system can be set up by the Drug Icon and invite the NGOs to incorporate the QR code system into their dispensation flow. It can provide an efficient and inexpensive method to digitalize the prescription contents and can offer a better-quality pharmacy service to patients.11
To evaluate the effectiveness of the QR code system, a survey can be conducted by both the pharmacist and patients.11 (Appendix 1.) Feedback can be collected to improve the system and the information shown after scanning the QR code.11 After the trial, the system can be promoted to more NGOs to allow more patients and caregiver to benefit from it. If the feedback is positive, the QR code system can also advocate to the local hospitals and medical institutions.
For the older senior population, digital health technology might be too difficult for them to handle. Hence, conventional way of promotion of drug information should be conducted for this group of elderlies. Educational workshops can improve health behaviors of elderlies and caregivers to self-manage their chronic diseases, it may also indirectly improve medication compliance.12 Studies also highlighted that when the workshop allow elderly to interact, actively participate, and the educational activity is based on their interest and needs, it becomes more productive and effective to the elderly.12
The content of the educational workshops should include both the therapeutic and side effects of common drugs; adverse effects to the elderly when drug nonadherence; tips for managing pills with the help of diet; identification of the pictogram by Drug Icon; matching the pictogram to the corresponding drugs. The mode of the workshop can be conducted with some sharing of educational information by professionals, then discussion and games section to allow the elderlies and caregivers to know more drug icon through active participation, hence, leaving them a vivid impression of pictogram.
To evaluate the effectiveness of the educational workshops, pre and post survey can be carried out to see if they feel more confident towards self-management of disease and medication, hence improving medication adherence.13 (Appendix 2.) A de-briefing session can also be held to know more about the participants’ opinions about the content of workshops.13 Results from survey and participants’ opinions are vital for the improvement in the next workshops.
To advocate the importance of medical adherence to elderly and caregivers, QR code system on the drug bag and promoting pictogram to elderly through workshops are highly suggested to Drug Icon. It can improve drug safety and empower the elderlies to manage their chronic disease more independently.
Survey for QR code system11
Survey for pharmacist to test the effectiveness of QR code system in NGOs with community pharmacy setting.
- Length of time to key in a new patient’s personal identity data manually.
- Length of time to key in the essential items regarding medicines.
- Length of time to pick up the QR code contents.
- Rates of showing wrong medicine ID number and patient identity data.
- Overall satisfaction of the QR code system.
Survey for QR code users such as elderlies or caregivers14
- Demographics of user
- g. gender, age, who patient lived with, any previous adverse medication event, number of comorbidities, number of drugs, any plan used currently to prevent medication error, drug compliance
- Efficacy of the QR code (Scale of 1-5)
- Ease of use, degree of autonomy, reliability, audio cues or video instructions of drugs easily understood, overall satisfaction
- Self-evaluation (Before & after QR code) (Scale of 1-5)
- Knowledge of medication, drug compliance, confidence in self-managing drugs
Pre & Post Workshop Survey13
E.g. gender, age, who patient lived with, any previous adverse medication event, number of comorbidities, number of drugs, any plan used currently to prevent medication error, drug compliance
Knowledge (True/ False)
- Eating broccoli and spinach is highly recommended for patient who are taking warfarin.
- Dizziness and fatigue are the side effects of antihypertensive drugs.
- The following drug icon means: You have to take medication at noon.
Attitude (Yes/ No)
- Do you think it is important to follow medication regime set by doctors?
- Do you think it is good to take 1 more pill in the evening to compensate for the missed dose at noon?
- Do you think a drug icon can help you understand the instructions on drug label?
- Did you have confidence to manage medication by yourself?
Performance (Yes/No) (Post: 1 month review)
- Did you take medication based on the suggestion by doc?
- Have you ever skip medication?
- What do you expect about the workshop?
- Does the workshop makes you understand more about drug usage/ tips for medication/ Drug Icon?
- Rate the workshop (Scale of 1-5)
- eg. Content, activities, length, venue, speaker, logistic arrangements
- Self-evaluation (Before & after workshop) (Scale of 1-5)
- Knowledge of medication, knowledge of Drug Icon, confidence in managing drugs, drug compliance
- What is the important thing you have learnt in the workshop?
- Any suggestions to improve for the workshop?
- Hong Kong Life expectancy 1950-2022 [Internet]. Macrotrends. [cited 2022 Mar 10]. Available from: https://www.macrotrends.net/countries/HKG/hong-kong/life-expectancy
- United Nations. World population ageing 2019. United Nations Publications; 2020.
- Gomes D, Placido AI, Mó R, Simões JL, Amaral O, Fernandes I, Lima F, Morgado M, Figueiras A, Herdeiro MT, Roque F. Daily medication management and adherence in the polymedicated elderly: A cross-sectional study in Portugal. International Journal of Environmental Research and Public Health. 2020 Jan;17(1):200.
- Papaioannou A, Clarke JA, Campbell G, Bédard M. Assessment of adherence to renal dosing guidelines in long‐term care facilities. Journal of the American Geriatrics Society. 2000 Nov;48(11):1470-3.
- Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Archives of internal medicine. 2003 Dec 8;163(22):2716-24.
- Kim KI, Gollamudi SS, Steinhubl S. Digital technology to enable aging in place. Experimental gerontology. 2017 Feb 1;88:25-31.
- Ienca M, Schneble C, Kressig RW, Wangmo T. Digital health interventions for healthy ageing: a qualitative user evaluation and ethical assessment. BMC geriatrics. 2021 Dec;21(1):1-0.
- Chien SY. Estabilishment and application of medication barcode system in Taiwan. Changhua Christian Hospital. [cited 2022 Mar 20]. Available from: https://www.gs1.org/docs/healthcare/LevelBelowEach_profChien.pdf
- MOHW to trial accessible prescription labelling. Taiwan Today. 2015 Jul. Available from: https://taiwantoday.tw/news.php?unit=10&post=21576
- Svensk J, McIntyre SE. Using QR code technology to reduce self-administered medication errors. Journal of Pharmacy Practice. 2021 Aug;34(4):587-91.
- Lin CH, Tsai FY, Tsai WL, Wen HW, Hu ML. The feasibility of QR‐code prescription in Taiwan. Journal of Clinical Pharmacy and Therapeutics. 2012 Dec;37(6):643-6.
- Seabra CA, Xavier SP, Sampaio YP, Oliveira MF, Quirino GD, Machado MD. Health education as a strategy for the promotion of the health of the elderly: an integrative review. Revista brasileira de geriatria e gerontologia. 2019 Oct 24;22.
- Saarlas KN, Paluku KM, Roungou JB, Bryce JW, Naimoli JF, Benzerroug EH. Multiple Methods for Workshop Evaluation. International quarterly of community health education. 2007 Oct;27(3):245-64.
- Mira JJ, Guilabert M, Carrillo I, Fernandez C, Vicente MA, Orozco-Beltran D, Gil-Guillen VF. Use of QR and EAN-13 codes by older patients taking multiple medications for a safer use of medication. International journal of medical informatics. 2015 Jun 1;84(6):406-12.