PATIENT COUNSELLING: A WAY TO ENHANCE

PATIENT COMPLIANCE
Stuti Gupta1, Ravindra Pal Singh2, Rajendra k. Songara1, Sonia
Bisla1, Heema Naik1, Dolly Jain1
1
ijcrr School of Pharmaceutical Sciences, Jaipur National University, Jaipur,
rajasthan
Vol 03 issue 05 2
Gyan Vihar School of Pharmacy, Suresh Gyan Vihar University, Jaipur
Category: Review
Received on:11/03/11 E-mail of corresponding author: stutipharmabird@gmail.com
Revised on:01/04/11
Accepted on:07/04/11

ABSTRACT
Effective patient counseling makes the patient understand his/her illness, necessary lifestyle
modifications and pharmacotherapy in a better way and thus enhance patient compliance. The
pharmacist has immense responsibility in counseling the patients. The counseling pharmacist
should possess adequate knowledge and should be an effective communicator, making use of the
verbal and non-verbal communication skills.
________________________________________________________________________

Keywords: patient counseling, pharmacist in the manner intended because of a

perceived self-benefit and a positive
1. INTRODUCTION outcome (e.g. enhanced quality of life and
The availability of and rational use of well being).
medicines are critical for a successful Non- compliance can lead to various
therapeutic outcome. Though rapid consequences including underuse, overuse,
developments in science and technology misuse, abuse etc (Hussar DA, 2000). The
have led to easy understanding of etiology most common factors associated with
and pathophysiological basis of various noncompliance are the nature of the disease,
diseases and development of new molecules, multiple drug therapy, frequency of drug
many times clinicians fail to achieve the administration, duration of drug therapy,
desired therapeutic goals. One of the major adverse events, cost of medications,
reasons for this can be the patient administration technique, taste of
noncompliance or partial compliance medication etc (Ramesh, 1999). In the
towards the prescribed treatment (World present days, the term ―concordance‖ is used
Health Organization, 2003). Patient more often in place of ―compliance‖.
compliance is defined as the adherence of a
patient towards the prescriber‘s instructions. 2. PATIENT COUNSELING [17]
It implies an understanding of how the Patient counseling may be defined as
medicine is to be used, as well as a positive providing medication information orally or
behavior in which the patient is motivated in written form to the patients or their
sufficiently to use the prescribed treatment representative or providing proper directions
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Vol. 03 issue 05 May 2011
of use, advice on side effects, storage, diet conditions. Pharmacists who demonstrate a
and life style modifications. It involves a genuine interest in patient care are more
one-to-one interaction between a pharmacist likely to encourage dialogue. [20]
and a patient and/or a care giver. It is (2.) Communicate verbally- Pharmacists
interactive in nature. The effective can encourage dialogue by asking questions.
counseling should encompass all the They should assess what the patient already
parameters to make the patient/party knows about his or her chosen therapy and
understand his/her disease, medications and tailor the counseling to meet the needs of
life style modification required (Beardsley , each individual patient. Ask patients what
1997); ASHP, 1997). their physician has told them about the
In general, patient counseling has 3 main selected therapy and the condition for which
objectives: [18] they are being treated.
(1) Assessing the patient‘s understanding of (3.)Communicate Nonverbally- In addition
the therapy including proper use and adverse to verbal communication, it is essential for
effects of the medication. pharmacists to be aware of nonverbal
(2) Improving patient adherence. communication, such as maintaining eye
(3) Motivating the patient to take an active contact with the patient, to demonstrate
role in health management. [19] interest in the information the patient is
Studies have shown that patient counseling relaying. [21]Pharmacists also should be
can improve patient care in various ways cognizant of other nonverbal clues, such as
[19]: facial expressions and tone of voice, when
• Reducing medication errors. interacting with patients.
• Increasing patients understanding (4.) Listen- When counseling patients about
and management of their medical condition. medication therapy, listening to the
• Minimizing incidence of adverse concerns, questions, and needs of the patient
drug reactions and drug-drug interactions. is essential. Listening skills can be
• Improving patient outcomes and categorized into 4 classes: passive listening,
satisfaction with care. acknowledgment responses, encouragement,
Although every pharmacist implements and active listening. [22] Passive listening
individualized techniques to counsel occurs when the pharmacist enables the
patients, various skills are vital to successful patient to communicate without interruption.
pharmacist-patient interaction during patient An acknowledgment response such as
counseling sessions. nodding occurs during passive listening and
2.1 FEATURES OF EFFECTIVE alerts the patient that the pharmacist is
PATIENT COUNSELING: [18] indeed listening. Pharmacists also can use
(1.) Establish Trust- Pharmacists are encouragement strategies through the use of
among the most accessible and trusted words such as "yes" or "go on." Active
health care professionals. When initiating a listening involves 2- way interactions
patient counseling session, pharmacists between the patient and the pharmacist and
should introduce themselves with a brief, always should be implemented after passive
friendly greeting to make patients feel listening. [22]
comfortable enough to ask questions about (5.) Ask Questions- When posing questions
their medication therapies and health to the patient, pharmacists also should state
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Vol. 03 issue 05 May 2011
the reason for asking certain questions, so as (9.) Tailor Counseling to Meet Patient
not to offend the patient. [23,24]Asking Needs- The ability to tailor patient
open-ended questions enables pharmacists to counseling to meet individual needs is
gather more information that may lead to critical. Pharmacists should be aware of
other questions and/or provide valuable patients with disabilities and be prepared to
information to the pharmacist to further treat them with respect and understanding.
assess the patient. Techniques should be tailored to
(6.) Remain Clinically Objective- It is accommodate the needs of each patient via
important for pharmacists not to allow verbal counseling or the use of visual aids
personal belief‘s either ethical or religious‘ and demonstrations when warranted. When
to affect their ability to counsel a patient the medication therapy involves certain
effectively. Pharmacists should make every administration techniques, such as the use of
possible effort to be nonjudgmental and an inhaler, an injection, or a monitoring
impartial, to focus on patient care, and to device, pharmacists should demonstrate the
maintain a professional demeanor. proper technique to ensure that patients are
(7.) Show Empathy and Encouragement- adequately trained.
When a pharmacist displays empathy and (10.) Motivate Patients- Effective
encouragement, a patient may feel more counseling not only provides patients with
comfortable discussing his or her medical the pertinent information they need to use
condition and medication use, thus enabling their medication correctly, it also motivates
the pharmacist to obtain pertinent them to adhere to their medication regimens.
information on the patient‘s needs and Pharmacists can motivate patients by
concerns. Emphasizing to patients the discussing the benefits of medication
importance of adherence to medication adherence, offering support, and explaining
regimens can promote positive therapeutic the pros and cons of treatment. For example,
outcomes and motivate patients to take an when counseling a patient with diabetes, in
active role in the management of their addition to teaching the patient about
health. During counseling, pharmacists also medications, the pharmacist can stress the
should remind patients to call the pharmacy importance of maintaining tight glycemic
or their physician with any concerns about control to decrease or prevent the
their medications. complications associated with diabetes.
(8.) Provide Privacy and Confidentiality- Pharmacists also can make suggestions, such
Ensuring complete privacy and as the use of medication reminder
confidentiality helps enable patients to feel containers, to facilitate patient adherence.
comfortable discussing personal medical Information always should be relayed
issues. Today many pharmacies are positively, and pharmacists should look
equipped with special counseling areas to continually for ways to inspire patients to
address privacy issues. When counseling, learn more about their treatment plan.
pharmacists can reassure patients of privacy 2.2 WHY PHARMACISTS SHOULD
by monitoring voice levels and counseling COUNSEL PATIENTS? [25]
patients away from the dispensing area when Communicating with patients about their
possible. medications provides significant benefits to
both the patient and the pharmacist. The
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Vol. 03 issue 05 May 2011
patient will have a better understanding of 2.4 TECHNIQUES OF COUNSELING
the purpose for the prescribed therapy and [17]
the appropriate use of the medication. This Several techniques can be adopted for
leads to several potential benefits: effective counseling. Some of them include
• Improved therapeutic outcomes and providing written information to the patient
decreased adverse effects and the use of audiovisual materials. The use
• Improved patient adherence to the of various compliance aids include labeling,
treatment plan medication calendars, drug reminder chart
• Decreased medication errors and misuse and providing special medication containers
• Enhanced patient self-management by and caps can also be adopted. The United
involving the patient in designing the States Pharmacopoeia (USP) medication
therapeutic plan. counseling behavior guidelines divide
• Potential for decreased health care costs medication counseling into the following
due to appropriate use of medications and four stages (USP, 1997).
prevention of adverse events. Stage I: Medication information transfer,
2.3 NECESSITY OF PATIENT during which there is a monologue by the
COUNSELING [26] pharmacist providing basic, brief
Mock asserts that "the concept of effective information about the safe and proper use of
clinician-patient communication is a medicine.
necessity, not an option. Because Stage II: Medication information exchange,
commu¬nication is both a science and an art during which the pharmacist answers
that can be learned and mastered, there are questions and provides detailed information
many resulting benefits for those who work adapted to the patients‘ situation.
diligently to improve their technique, not the Stage III: Medication education, during
least of which is increased clinician which the pharmacist provides
satisfaction." A recent incident was reported comprehensive information regarding the
in New Brunswick where an incorrect proper use of medicines in a collaborative,
medication was dispensed on transfer. The interactive learning experience.
patient was not counseled and the error was Stage IV: Medication counseling, during
identified by the caregiver when the patient which the pharmacist and patient have a
was taking the medication later that night. detailed discussion intending to give the
Had the patient been shown the medication patient guidance that enhances problem-
in the counseling process, the incident could solving skills and assists with proper
have been immediately corrected. Much less management
harm is done by identifying medications
errors before they leave the pharmacy. 3. COUNSELING OF PATIENT AFTER
Therefore, health care profes¬sions FILLING PRESCRIPTION [28]
education, and specifically pharmacy After filling the prescription give some
education, should include specific training in advice to the patient about how to use drugs.
patient communication skills and an Some common advices are -
understanding of the psychological reactions (i) Removing of Drug from the Package-
to illness and treatment. To the unaware patient, the pharmacist must
demonstrate how the drug is to be removed
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Vol. 03 issue 05 May 2011
from the package. This seemingly simple bridge of the nose for about I min to prevent
task may be quite confusing to some drainage of solution from the eye.
patients. Handling of Dropainer eye Eye preparations should be discarded after
preparations, removal of dust cap from 1 month from the date of opening of the
suppositories, opening of safety containers container. Eye ointments are administered in
are some of the difficulties faced by the a similar manner; about l/4 to l/2 inch of the
untrained patient. ointment from a squeezable tube is placed
(ii) Administering the Drug- The inside the lower eyelid.
pharmacist should clearly mention to the (iv) Inhalations- The pharmacist must
patient, how and by which route the demonstrate the use of inhalers particularly
medicine has to be administered. The to the new users, children and elderly. The
importance of this lies in the fact that inhaler requires shaking before use. It
inadequate information may lead to faulty should be held between the index finger and
administration and consequently to the thumb so that the container is upside
diminution or exaggeration of the desired down. The patient is advised to hold the
effect. Consider the example of a tablet. breath for as long as possible to derive the
There are at least 9 different ways a tablet maximum benefit. The inhaler is removed
can be administered depending upon the from the mouth and exhalation is done
type of tablet and the drug it contains. These slowly through pressed lips. Likewise,
are (a) place on tongue and swallow with relevant instructions about the use of other
water, (b) chew and swallow (c) not to be dosage forms like suppositories, creams,
chewed (d) let it dissolve in mouth and suck lotions solutions etc. should be given to the
(e) sublingual, do not swallow (f) buccal, let patient.
it dissolve (g) dissolve in water and swallow (v) Timing of the dose- The pharmacist
(h) dissolve in water and use extremely (i) must use his knowledge of drugs when
moisten with water and insert vaginally or interpreting the directions of the physician
rectally. Inadequate instructions in such and give in¬structions to the patient to
cases will lead to wrong administration. ensure that the drug is maximally effective.
(iii) Ophthalmic preparations- For If the drug has the propensity to cause GI
instillation of an eye drop, the pa¬tient is upset, it is best taken with food or milk. If its
advised to tilt the head backward or if bioavailability is affected by the presence of
possible lie down looking up at the ceiling. food, the drug should be taken 1 hr before or
He should hold the dropper above affected 2 hr after meals. If steady state blood levels
eye and allow a drop of the medicine to fall are essential for the desired effect, the
in the space between the eyeball and the dosing schedule can be appropriately
inside the lower eye lid while looking up. adjusted.
The patient should be warned not to touch (vi) Duration of use- The duration of use of
the tip of the dropper to any surface or the medication is dependent on the nature of the
eye lid. The lower lid is released and the eye illness and the drug used. For chronic
kept open without blinking for at least 30 ailments, the length of drug intake is more.
sec. Thereafter, the patient is advised to The greater the duration of drug intake, the
apply gentle pressure with his fingers at the greater is the problem of compliance. The
patient is advised to take the medication
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Vol. 03 issue 05 May 2011
regularly and visit the physician frequently that all OTC drugs are safe. The pharmacist
to get the effectiveness of the therapeutic should dispel this notion and advise the
regimen assessed. patient accordingly.
(vii) Storage- Proper storage conditions are (x) Allergies- Careful documentation of the
necessary for safety and maintenance of the past medication history and ascer¬taining
efficacy of drugs. All medication should be any known allergy to any drug will
kept in a cabinet away from the reach of undoubtedly• reduce the incidence of drug-
children. External and internal use induced allergies. However, since many
preparation should be kept segregated. drugs are foreign to the body, they do have
Exposure• of drug to extremes of the capability to cause allergy. This fact
temperature and humidity should be should be carefully detailed to the patient.
avoided. The medication should not be used The patient should be advised that if he
after its date of expiration. experiences rashes, itching or burning of
(viii) Side Effects- No drug is without side skin, he should discontinue the drug and
effects and it is necessary that the consult the physician.
pharma¬cist makes some of the commonly
occurring side effects known to the patient. 4. COUNSELING OF SOME COMMON
However, the manner in which the DISEASE [29]
pharmacist tells this to the patient is (i) CORONARY HEART DISEASE [30]
important. The pharmacist should not drive As with other chronic diseases, the aim of
away the patient from using the medication treatment is to reduce the mortality,
or create a scare in him; rather the morbidity and associated impairment in the
informa¬tion should be presented in a quality of life. A pharmacist can play an
manner so as to encourage compliance. The active role in the management of this
pharmacist must also mention how to cope chronic illness in several ways.
with these side effects if it is possible, e.g. Non-pharmacological measures: It
headache with the use of metronidazole may includes education regarding diet, smoking,
be relieved by taking aspirin or paracetamol. and exercise and encouraging the patients to
For drugs which cause drowsiness, the maintain a diary on anginal attacks, pain
patient should be advised against driving symptoms etc.
during the period of drug intake. With some Pharmacological measures: Educating the
drugs like metronidazole, the use of alcohol patients on the use of nitrates in case of an
has to be avoided. The patient should be acute anginal attack is one of the important
specifically cautioned against it. With some roles of pharmacists. Some of the important
drugs the incidence of side effects decrease pharmacological measures are listed in
on continued use. (Table 1).
(ix) Drug Interaction- The patient should
be clearly mentioned of the possible (ii) ASTHMA [31]
interaction of his prescribed drug with Asthma is a chronic condition requiring
factors like food, tobacco smoking, alcohol lifelong drug therapy. Pharmacist can play
consumption, and with other. Non- an active role in counseling the patient
prescription drugs, that he may be taking. regarding self monitoring of drug therapy,
Unfortunately, there is a common notion, other life style modifications and usage of
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Vol. 03 issue 05 May 2011
specialized dosage forms such as metered monitoring and use of results, relationship
dose inhalers, dry powder inhalers, spacers between nutrition, exercise, medication, and
etc. blood glucose level.
Non-pharmacological measures: Safety Pharmacological measures: Studies
measures while traveling, prophylactic use suggest that the complications of diabetes
of drugs before exercise, avoidance of can be reduced by tight glycemic control
allergens, stopping cigarette smoking etc. (The diabetes control and complications trial
Pharmacological measures: Patient research group, 1993; UKPDS Group,
involvement in management of asthma is 1998.The drugs used in diabetes are also
very important. Specific counseling on drug known to possess certain peculiar features
therapy should concentrate on three areas; such as ―Taken half an hour before food‖ in
drugs to relieve symptoms, drugs used to case of Sulfonylureas; ―awareness of
prevent asthma attack and those drugs which hypoglycemia‖ during insulin therapy etc.
are given only as reserve treatment for (Table 3) lists some of the important
severe attacks (Gibbs and Small, 2003). pharmacological measures a pharmacist
Training regarding use of the metered dose should stress while counseling diabetic
inhaler is one of the important roles of the patients.
counseling pharmacist. Some of the
pharmacological measures to be included (iv) HYPERTENSION [32]
while counseling these patients are Though hypertension is not a disease, it is
summarized in (Table 2). known to be an important risk factor for
several complications resulting in end organ
(iii) DIABETES [32] damage (Thomas, 2003). If uncontrolled it
Diabetes is a chronic disease with altered can lead to a huge adverse impact on quality
carbohydrate, lipid and protein metabolism of life. The management of hypertension
(Kapur et al., 1998). The chronic requires non-pharmacological as well as
complications of diabetes are known to pharmacological methods (Chobanian et al.,
affect the quality of life of diabetic patients. 2003).
Various factors like understanding of the Non-pharmacological measures: In many
patients about their disease, dietary occasions nonpharmacological treatment
regulation, self-monitoring of blood glucose alone may suffice in the management of
are known to play a vital role in diabetes hypertension. A pharmacist can counsel the
management. Patient counseling and patients regarding weight loss and regular
education are known to improve the quality exercise, sodium and calorie restriction,
of life of these patients (Rasheed et al., restriction of saturated fats and increased
2002). Some of the non-pharmacological intake of dietary fibers, restriction of alcohol
and pharmacological measures intake, smoking cessation, caution while
are listed below. using cold remedies containing
Non-pharmacological approaches: The sympathomimetics, self-monitoring of blood
pharmacist can give an overview of pressure etc.
diabetes, stress and psycho-social Pharmacological measures: In a majority
adjustment, family involvement and social of patients, drug therapy is required. The
support, nutrition, exercise and activity, patients often underestimate hypertension as
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Vol. 03 issue 05 May 2011
by itself it usually does not exhibit any professional situation in India. Patient
major symptoms. Thus non-compliance counseling in USA is very well comparing
becomes very common. Added to this is the to India. USP medication counseling
fact that many of the antihypertensive drugs guidelines suggests four stages in counseling
causes side effects that are very serious such such as counseling introduction, content,
as Angiotension Converting Enzyme (ACE) process and counseling conclusion.USP has
inhibitors induced cough, beta blockers listed about 175 various counseling items
induced bradycardia etc. In some cases the that can be used during counseling. But in
dose modulation of the drugs is also very India condition to begin with, about 15 items
essential. Some of the pharmacological may be sufficient. As per the need and time,
measures that can be taken by the few or all these items can be used.
pharmacist during counseling are listed in Following are the counseling items which
(Table 4). are distributed into four stages such as
counseling introduction, counseling content,
5. STATUS OF PATIENT counseling process, and counseling
COUNSELING IN INDIA [32] conclusion.
Basic act of patient counseling will take
miles ahead of the present pharmacy

Table 1: Drug counseling points in coronary heart disease (USPDI, 1997; British
National Formulary, 2003; Sweetman, 2002).
DRUG CATEGORY PHARMACIST ROLE

Beta-blockers Monitor for hypotension, dizziness, headache, and bradycardia. Educate

the patient regarding possibility of nocturnal dreams and CNS problems.
Explain the need for dose tapering before stopping the drug.
Nitrates Sublingual administration, sublingual tablets should not be chewed or
crushed, use of transdermal patches, do not stand up immediately while
using this medication.Monitor for bluish colored lips, fingernails or
palms.
Aspirin Encourage the patient to take drug with food. Monitor for abdominal
pain, tarry stools, fever, spitting of blood. In case of enteric-coated
preparations, ask the patient not to crush or chew the tablets.

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Vol. 03 issue 05 May 2011
 Table 2: Drug counseling points in asthma (USPDI, 1997; British National Formulary,
2003; Sweetman, 2002)
DRUG CATEGORY PHARMACIST ROLE

Beta receptor agonists Short acting drugs belonging to this category should be used mainly
for symptom relief. Patients on long acting drugs should be told that
the medication may take some time period to show the action.
Theophyllines Patients on sustained release preparations should be told not to
crush/chew the tablets. Anticholinergics Monitor for dry throat,
nausea, headache, blurred vision, and painful urination.
Corticosteroids Medications should be administered regularly. They
should not be stopped abruptly.
Anticholinergics Monitor for dry throat, nausea, headache, blurred vision, and painful
urination. Corticosteroids Medications should be administered
regularly.
Mast cell stabilizers Patient should be told that this medication is used to prevent the
asthma attack and it does not relieve bronchospasm that has already
started.

Table 3: Drug counseling points in Diabetes (USPDI, 1997; British National Formulary,
2003; Sweetman, 2002)
DRUG CATEGORY PHARMACIST ROLE

Sulfonylurea‘s Explain the methods to prevent detect and manage hypoglycemia. Monitor
for symptoms of jaundice. Discuss the administration time in relation to
food and need for alcohol abstinence.
Insulin Explain the methods to prevent detect and manage hypoglycemia. Educate
the patient regarding newer insulin administration techniques, proper
storage conditions for insulin.
Metformin Advice the patient to take with/after food. Monitor for muscle pain,
unusual sleepiness, nausea, stomach pain, weight loss.

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Vol. 03 issue 05 May 2011
Table 4: Drug counseling points in hypertension (USPDI, 1997; British National Formulary,
2003; Sweetman, 2002)
DRUG CATEGORY PHARMACIST ROLE

Diuretics Monitor for muscle weakness, confusion, dizziness. Ensure patient

participation in dose modulation. Select appropriate dose timing to avoid
frequent urination in the night. Explain about the possibility of drug
interactions with ACE inhibitors.
Beta blockers Monitor for hypotension, dizziness, headache, and bradycardia. Educate
regarding possibility of nocturnal dreams, impotence and CNS problems.
ACE inhibitors Monitor for hypotension, dizziness, cough, taste disturbances and rash.
Calcium channel blockers Monitor for swollen gums, chest pain, swollen joints (with nifedipine),
constipation, dizziness, and light-headedness. Educate the patient to swallow
the extended release tablets as a whole. Explain to the patient how to monitor
his heart rate by measuring the pulse rate.
Alpha blockers Monitor for hypotension. Patients on Gastro Intestinal Therapeutic System
(GITS) preparation should be told not to crush/chew the tablets.

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47 International Journal of Current Research and Review www.ijcrr.com

Vol. 03 issue 05 May 2011