LITHUANIAN UNIVERSITY OF HEALTH SCIENCES MEDICAL ACADEMY FACULTY OF PHARMACY DEPARTMENT OF DRUG TECHNOLOGY AND SOCIAL PHARMACY

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LITHUANIAN UNIVERSITY OF HEALTH SCIENCES MEDICAL ACADEMY

FACULTY OF PHARMACY

DEPARTMENT OF DRUG TECHNOLOGY AND SOCIAL PHARMACY

ESTER HAIMOV

KNOWLEDGE AND ATTITUDES TOWARDS SELF-MEDICATION AND HOME MEDICATION CABINET SAFETY AMONG PATIENTS ATTENDING PRIMARY HEALTH CARE SETTING IN ISRAEL

Master‘s Thesis

Thesis Supervisor: Ph.D. Jurgita Daukšiene

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LITHUANIAN UNIVERSITY OF HEALTH SCIENCES MEDICAL ACADEMY

FACULTY OF PHARMACY

DEPARTMENT OF DRUG TECHNOLOGY AND SOCIAL PHARMACY

APPROVED by

Dean of the faculty of Pharmacy Prof. Vitalis Briedis

KNOWLEDGE AND ATTITUDES TOWARDS

SELF-MEDICATION AND HOME SELF-MEDICATION CABINET SAFETY

AMONG PATIENTS ATTENDING PRIMARY HEALTH CARE

SETTING IN ISRAEL

Master Thesis

Thesis Supervisor Ph.D Jurgita Dauksiene

Reviewer The thesis performed by

Name, Surname, signature Ester Haimov

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SUMMARY

Home medicine cabinet is the place where people are keeping medication for personal use. It can be an indicator of medication use habits of the family and show the risks of irrational consumption and waste, including irresponsible self-medication, and they also increase the risk of both unintentional toxic exposure (particularly of small children) and intentional intoxication.

Self-medication is part of the larger frame of self-care and can be defined as obtaining and consuming drugs without the advice of a physician either for diagnosis, or treatment.

This study was aimed to assess knowledge and attitudes towards self-medication and home medication cabinet safety among patients attending primary health care setting in Israel.

Data were collected by cross-sectional survey. A method of the questionnaire was chosen. Only the new patients of the selected clinic were invited to participate in the study. The amount of 115 questionnaires were distributed during the July-August 2015 and during January 2016 at selected primary health care setting in located in Holon and 80 answers were collected. The questions about home medication cabinet, attitude towards medication, storage, and family health habits were included.

The results of our study have shown that most of the respondents (92.6%) had more than one place to store their medication. The majority of the drugs (43.8%) were kept in the bathroom. Most of the respondents (73.8%) have a designated compartment or box especially for storing medication. The most common method of disposal of unwanted medication was to throw them in the trash (81.3%) or in the toilet. (82.5%) of the respondents didn’t know that the best way to dispose of expired date medication is returning the medication back to the pharmacy. About 56.25% of them told that in their home medication cabinet OTC drugs are more prevalent. 38.3% of the respondents told that they will share prescribed medication. 38.75% felt that it’s unnecessary to consult with the doctor about using OTC drugs. 47.5% of the respondent will use the internet as a source of information and only 21.3% of them will consult the pharmacist about any information.

More than half of the respondents don’t know that the best way to dispose of expired date medication is returning the medication back to the pharmacy. This one example

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4 from the result that can indicate the problem of lack of knowledge. By the intervention of the pharmacist providing knowledge about the rational use of medication, safe storage, and proper disposal of expired or unneeded medication patient, many problems can be solved and prevent further problems.

The result of this study demonstrates the need for intervention in health education aiming rational use of medications.

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KEYWORDS

Home medication cabinet – the place where medication is kept, it can be a box containing an assortment of medicines.

Pharmacist- A pharmacist is a health care professional who cooperates with, consults with, and sometimes advises the licensed practitioner concerning drugs.

Self medication- Medication of oneself without professional supervision to treat an illness or condition, as by using an over-the-counter drug or preparation

Adherence- The extent to which a patient continues an agreed-upon mode of treatment under limited supervision when faced with conflicting demands.

Primary healthcare- a basic level of health care that includes programs directed at the promotion of health, early diagnosis of disease or disability, and prevention of disease. Primary health care is provided in an ambulatory facility to limited numbers of people, often those living in a particular geographic area. It includes continuing health care, as provided by a family nurse practitioner

Over the counter - Over-the-counter medicines are drugs that can be bought without a prescription. Some OTC medicines relieve aches, pains and itches. Some prevent or cure diseases, like tooth decay and athlete's foot. Others help manage recurring problems, like migraines.

Medication- A pharmaceutical drug called medicinal product can be defined as a chemical substance or product comprising such intended for use in the medical diagnosis cure treatment or prevention of disease.

Knowledge- Knowledge is a familiarity with someone or something, which can include facts, information, descriptions, or skills acquired through experience or education.

Medical prescription- A prescription is a health-care program implemented by a physician or other qualified health care practitioner in the form of instructions that govern the plan of care for an individual patient. The term refers to a health care provider's written authorization for a patient to purchase a prescription drug from a pharmacist.

PIL (patient information leaflet)- are leaflets containing specific information about medical conditions, doses, side effects that packed with medicines to give the user information about the product.

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6 Pharmacy- Pharmacy is the science and technique of preparing and dispensing drugs and medicines. It is a health profession that links the health sciences with the chemical sciences and aims to ensure the safe and effective use of pharmaceutical drugs.

Self-care - Self care is personal health maintenance. It is any activity of an individual, family or community, with the intention of improving or restoring health, or treating or preventing disease.

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ABREVATION

FIP- International Pharmaceutical Federation WHO- World Health Organization

SPSS- statistical Package for the Social Sciences USA -United States of America

OTC-over the counter

PIL- patient information leaflet IMA- Israel Medical Association

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INTRODUCTION

WHO defined self-medication as the autonomous decisions to use a medication without medical advice in order to treat self-diagnosed symptoms (1)

The consumption of medication has been increased in the last few years.

Saving time, limited knowledge about diseases and medication, and ineffective prescription medicines were some of the major reasons for self- medication (2)

This has led to increasing the consumption of over-the-counter medication and also for prescribed drug.

This increase in drugs at home can lead to irrational consumption and waste of products

Home medicine cabinet is the place where people are keeping medication for personal use. It can be a small cupboard with a door or simply drawer in the kitchen.

Eventually, the increasing self-medication care and home medication cabinet can bring to irrational self-medication for many reasons:

A place for keeping medications are reachable for children this problem can lead to intoxication in children.

Place for storage the medication is in poor condition as a result of exposure to light humidity, a drug can undergo conformational changes, and degradation leading to a formation of toxic compounds.

The content of home medication cabinet contains, expire date medications that are inappropriate for use, the drug is without his original package, a patient can’t be sure for which purpose this specific medication is indicated.

This research in aimed to assess knowledge and attitudes towards self-medication and home medication cabinet safety in order to find out if people in this area are aware of such risk because no previous study has examined what and how medication are stored in the center living of Israel.

The results of this research will demonstrate if there is a need for intervention in health education by the pharmacist or by the doctors in order to aim rational use of medications, proper storage, safe use, appropriate disposal and maintenance of drugs. .

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AIM AND TASKS

The aim:

To assess knowledge and attitudes towards self-medication and home medication cabinet safety among patients attending primary health care setting in Israel.

The research tasks:

1.To assess the content of home medication cabinet, their proper storage, safe use, and their disposal among patients attending primary health care setting in Israel.

2. To identify the problems associated with home medication cabinet among patients attending primary health care setting in Israel.

3. To determine the knowledge and adherence towards self -medication among patients attending primary health care setting in Israel.

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1. LITERATURE REVIEW

1.1 Responsible self-medication

Self-medication becomes more and more popular, people are dispensing themselves medication without a real need since, and the accessibility to medicine is easier than prescribed medication.

Many studies suggest that the storage medication at home and attitude towards it safe use can be a good indication of family’s medication use habits (2-7)(3),(4),(2),(5),(6),(7).

In practice self-care includes the actions people take to stay fit and maintain good physical and mental health; meet social and psychological needs; prevent illness or accidents; avoid unnecessary risks; care and self-medicate for minor ailments and long-term conditions (8)

Medicines for self-medication are often called ‘non-prescription’ or ‘over the counter’ (OTC) and are available without a doctor’s prescription through pharmacist and sold to costumers for use on their own initiation. In some countries, OTC products are also available in supermarkets and other outlets, like in Israel. In a Spanish study, 1 in 5 people engages in self-medication, using over-the-counter drugs for a different purpose, to alleviate an illness or condition, without professional supervision (6). The statistics show that in united states the OTC sales grow by 2.3%, and in England between 2003-2007 the OTC sales grow by 6.3%, in Israel for comparison July 2005, 2.8 million OTC drugs were sold (9). A Consumer Healthcare Products Association study in the United States revealed that every dollar spent on OTC medicines equates to a saving of $7 for the health care system (1).

Self-medication with OTC medicines is sometimes referred to as ‘responsible’ self-medication to distinguish this from the practice of purchasing and using a prescription medicine without a doctors’ prescription. This is irresponsible (and potentially even dangerous) ‘prescription’, and has no place in care or (responsible) self-medication (3). Responsible self-self-medication can be used to prevent and treat symptoms and diseases that don’t need medical consultation or oversight. Responsible self-medication reduces pressure on medical services, especially when these are

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11 limited. Any self-medication products should be safe for use; this implies the availability of appropriate consumer. Information and avoidance of any delay in diagnosis and treatment of disease not suitable for self-medication (8). In self-care treatment, patients must assess the severity of their illness and the result to be accepted from treatment with OTC medication (10). Most patients access information from sources that are convenient for them without considering if the quality of information they get is enough confident. Patients can get the information they need from different sources such; pharmacist, advertisements on media, physician, family, friends and at the point of sale information. Sometimes the information can be conflicting and it is very important to ensure the use of reliable sources of information.(11-14) (11)(12)(13)(14)

For summary we can because of the easy accessibility to OTC medication, patient tend to purchase them more, it can lead to increase in medication at home, which can lead to irresponsible self-medication.

Figure 1: Growth of OTC market 2000-2010 (15)

Figure 1 shows the growth of the OTC sales during the years of 2000-2010, during the years of 2000-2005 and 2007-2010 the sales were increased drastically, in contrast, a small decrease have been during 2005-2006.

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1.2 Home medication cabinet

Home medication cabinet is usually the place that people are keeping medication for personal use, in a case of an urgent medical problem like; bites, cuts, vomiting and headache, ears pain, treatment of flu, colds, sore throats, lowering fever, insomnia. Patients tend to have more medication in their homes; a study conducted in Saudi-Arabia found a mean of eight drugs per household, and up to 30% had at least 10, medication (16)

The place where medications are kept is usually at a kitchen, bathroom, fridge, or bedroom alone. In a data collection in Qatar, it was found that the majority of drugs (48.2%) were kept in bedrooms. (4)

The home medicine cabinet contents usually determined according to the needs of the family considering factors such as the number of people at home, the family's age, a presence of chronic diseases or sensitivities. Home medicine cabinet usually contains: aids and drugs, some prescription drugs and some were bought without a prescription (OTC), antibiotics, analgesics, thermometers, band-aids, ace bandage, medication to treat conditions such as bee stings, bruises, sprains and arthritis pain.

In Sudan, it was indicated that 22% of the home medication cabinet was antibiotics, and 11% was analgesic. (17)

The storage of drugs at home promotes self-medication, but storage of large quantities of medication in the house increases the risk of a wide range of potential drug-related problems, including errors in taking medication, doses too high or opposite, accidental poisoning, and adverse drug reaction and is also a waste of resources. (4) People usually don’t have knowledge about OTC drugs, they think if that medication can be given without prescription, its safe to use it as much as they want but in fact, they don’t think about any drug-drug interaction, adverse effect. So the drug that they bought can be taken for a minor illness that they have. Studies from America, Asian and European countries indicate that between 22% and 70% of parents have a misconception about the appropriate application and efficacy of antibiotics (17)(18) and often use them without a prescription (19)(20)(21). In Mongolia, 83% of respondents thought that antibiotics use for colds or flu, and 81% thought antibiotics use for a cough (22).

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13 Sometimes people are sharing their medication that they having in their cabinet, resulting in person that is taking medication that wasn’t prescribed or bought for his disease, can lead to many problems such allergy and adverse effect of the medicine or interaction with other medication that he might take. A study conducted in 2001 at Qatar found that 3%-12.7% of people had shared their medication to someone else (4). Large quantities of drug, may cause lose potency because of the poor storage due to exposure to heat, light, air and humidity places (bathrooms).

If the drug container is missing it’s difficult to say the expired day, that’s way it’s very important to save the drugs in their origin container. Expired drugs may lead to toxicity risk because it allows the active substance to undergo degradation leading to formation of toxic products.

Figure 2: Types of cabinet for storing medication

Figure 2 shows some example of an appropriate home medication cabinet •without exposure to the sun • can’t be reached to children hands • No exposure to humidity Unintentional poisoning of children may result due to inappropriate dosing of OTC or by keeping the home medication cabinet not away from children. In a community survey in New York, 22% of children had taken OTC medications in the preceding 2-day period. Studies in the United Kingdom also indicated high rates of OTC medication use among children, 28% during a 2-week period and 66% during a 4-week period (23). Since the use of OTC products has increased for all major therapeutic categories, education about proper use of OTC products is essential.

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14 As we can summarize that home medicine cabinet is the place there people are keeping medication for personal use, and we figure out that the most common place for keeping medication were kitchen, bathroom, ,and bedroom. Some problems can appear like: wrong place for storing medication, use of expired medication, children access to home medication cabinet, and here is where the role of the pharmacist should be put into practice.

1.2 Role of pharmacist

Pharmacists are one of the health care professionals that have a responsibility toward the public. For pharmacists, their greater involvement in self-care means greater responsibility toward their customers and an increased need for accountability. Pharmacists have always played an important role in recommending OTC products to help patients deal with their health issues. By asking their patients appropriate questions, pharmacists can learn when self-medication is appropriate.

One of the problems associated with drug treatment is patient noncompliance or partial response on his part to take drugs. Pharmacist involvement can greatly improve the situation (9)

The pharmacist can play a key role in helping a patient to make informed choices about self-care, and in providing and interpreting the information available. This requires a greater focus on illness management and health maintenance advising consumers on the selection and proper use of over-the-counter (OTC) medicines (24), rather than on products selling, indeed self-care doesn’t always require a use of a medicine. If, however, there is a need for self-medication in self-care then the role of the pharmacist must extend.

A pharmacist may also think about pharmaceutical care and instruct patients how to take the right dose of the right drug at the right time. The pharmacist can assist with sorting medications, identifying those that are no longer required or out of date, and then facilitating its correct disposal (25).When patients are taking multiple OTC products, pharmacists should recommend patients to look for the active ingredients of the products and to ensure that the ingredients are not found in other medications that they are taking in order to avoid over- dosages.

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15 Buy there is possible barriers to pharmacists’ provision of this service are that the pharmacists do not have time for it, patient sometimes take more than three drugs are not getting paid for it; perceive minimal consumer demand for it; are not confident in this area; and/or disagree with legislators on what level of care is needed for certain agents (26).

Due to the OTC market expanding pharmacists have, on one hand, greater scope to manage more conditions but, conversely, added responsibility to demonstrate they are competent healthcare professionals (27).

With increasing demands for evidence of effectiveness in all aspects of healthcare provision, pharmacists’ decisions and recommendations should be informed by valid and clinically relevant research. Traditionally, pharmacists and their staff perceived that patient feedback about OTC medicines was sufficient ‘evidence’ of its effectiveness.

Pharmacists should have the professional responsibility to develop their own knowledge and skills and to provide to the patient high-quality of care. This applies to all aspects of practice, and therefore they must have robust and up-to-date knowledge of the evidence for OTC medicines and be prepared to discuss information in an unbiased way to enable patients to make informed choices, the resulting interaction reflects the pharmacist’s role as information provider and enhances decision-making with a patient (27).

Many types of research were published about the role of the pharmacist and how the pharmacist involvement is improving the treatment of the patient, for example, In Israel, they found that approximately 2,500 of the patients their treatment was successfully (89%) due to prolonged consultation with pharmacists (9).

Seven Stars of Pharmacist is a term that expressed the World Health Organization (WHO), to describe the role of pharmacists in health care (1)

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16 Figure 3: World Health Organization concept of seven-star pharmacist (1)

1. Care-giver -pharmacist must be comfortable interacting with individuals and population. The pharmacist must view his practice as integrated and continuous with the health care system and another pharmacist.

2. Decision-maker- an appropriate, efficacious, and cost-effective should be at the foundation of the pharmacist work

3. A communicator-the pharmacist must provide a link between physicians and patient, and to other health care professionals.

4. Leader- the pharmacist also has a role as a leadership role in the healthcare system to make decisions, communicate, and manage effectively.

5. Manager-Pharmacists must have the ability to manage the natural and commercial resources which include physical and financial resources.

6. Life-long learner-It is impossible to acquire complete pharmacy education in an institute and professional experience needed to pursue a life-long career as a pharmacist.

7. Teacher- responsibilities are to assist with the education and training of future generations of pharmacists and the general public.

As we can summarize a pharmacist is a health care professional who consults with patients and sometimes advises the licensed practitioner concerning drugs. Pharmacist role is providing good knowledge and education toward home medication cabinet which can prevent the entire problem that was mentioned in home medication cabinet review.

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1.4 Health care and community pharmacy

Health care describes the act of taking preventative or necessary medical procedures to improve a person's well-being. A health care professional are those who proved to the patient the health care services.

Health care professional include: physicians, nurses, pharmacist.all of them have different mission but in common they have the responsibility to make the correct decision and give the most correct advice to the patient.

The Israel Medical Association reports that there is a disparity between the scopes of healthcare services available in the periphery compared to central Israel.(28)

One of the most complex problems with health services in the periphery is the difficulty in attracting medical and nursing manpower from central Israel )28(.

As pharmacists are available for consultation when other care providers are geographically inaccessible, pharmacist prescribing has great potential to immensely improve the health of Israelis. (29) Therefore, pharmacists can play a role in eliminating and addressing health disparities.

Entrusting pharmacists with more responsibilities is likely to reduce the load to other health care.

One way to improving patient access to medicines, making the best use of pharmacists’ clinical competencies is that the community pharmacist examines the patient and the therapy and then either refills the medication with a sufficient quantity to last until the next available appointment or consults the attending physician if there are problems with compliance or side effects .(30)

The disadvantage currently in Israel is that, only pharmacists who work in health funds pharmacies are able to access patient medical records, whilst pharmacists working in community chain and privately owned pharmacies, are unable to access these records. (29)

To summarize the situation of the pharmacist in Israel is in increase, pharmacist in center of Israel is more accessible, and patient can easily consult with the pharmacist about and drug therapy questions.

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2. MATERIAL AND METHODS

2.1 Research organization

The method of a questionnaire was chosen to assess knowledge and attitudes towards self-medication and home medication cabinet safety among patients attending primary health care setting in Israel.

Ethics approval was granted by Bioethics Research Committee of Lithuanian University of Health Sciences.

The prepared questionnaire composed of 30 different questions and needed to be translated into Hebrew for the Israelis patients.

2.2 Setting and Sample

This study was conducted during the year 2015 at selected primary health care setting located in Holon; part of the metropolitan Gush Dan area with a population of 188,834 thousand. The clinic has 6000 patients 4 physicians, 3 nurses, and 3 pharmacists. Every year approximately from 89 to 115 patient register as new ones. During the research, all new patients were asked to take part in a survey and fill the questionnaire. (The demographic characteristics of the sample are presented in Table 1.)

2.3 Data collection

Data were collected by cross-sectional survey. The questionnaires were distributed to the new patients of the clinic on working day in the morning (7:00am-13:00am). The questionnaires were distributed to each patient together with a written consent form with the explained aim of the survey and informed them about confidentiality. All participants were assured that their refuse not to participate in the research will not have any influence on the provision of health care services. The sight of on the consent form was accepted as an indicator that a patient wishes to participate in a

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19 research. It took from 15 to 30 minutes for every participant to fill up the questionnaire. All filled forms were collected by the researcher and returned to the leading investigator. Overall 111 questionnaires were distributed and 80 answers were collected. The return rate of the questionnaire was more than 70 %.

2.4 Study questionnaire

The questionnaire included 30 questions divided into 3 parts: the first set of the questions addressed demographic factors like age, family size, a level of education and occupation. The second set explores some of the attitudes towards location of the medication stored in the household, are the medication are stored in appropriate condition, knowledge whether the interviewee knew about the expiration date on the medication container, and about adherence to home medication cabinet, the third set consist of question about content of home medication cabinet, whether the store antibiotic medication, which of the group of medication is more prevalent in their home medication cabinet-OTC medication or prescribed medication.

Most of the questions were closed, with proposed choices of answers with “tick” box possibilities.

2.5 Data analysis

SPSS (version 22.0) was used for data analysis. Descriptive statistics such as frequencies, means and ranges were calculated to summarize the data. Z-score and chi-square were used to analyze the differences among groups. Results were considered significant when the p-value was less than 0.05.

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20 Table. 1. Socio-demographic characteristics of the respondents (n=80)

Demographics N (%) Gender Male 29 36.25 Female 51 63.75 Education level High school 30 37.5 Collage 24 30 University 26 32.5 Occupation Worker 64 80 Student 4 5 Housewife 7 8.75 Unemployed 5 6.25

Table 1 represents the demographic characteristics of the respondents.

Interviewed population was n=80, number of females contribute to 51 (63.75%) compared to males 29 (36.25%), mainly in the age group 21-62 years.

Most of the respondent were literate who could read and write, but only 26 (32.5%) were of high education, the rest of the sample 67.5% had received a formal education between high school and college.

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3. RESULTS

3.1 Home medication cabinet, safe use, and storage

Figure 4 shows that 45 (56.25%) of the respondent reported that their home medication cabinet contain OTC drugs, and the rest 43.75 % indicated that they have more prescribed medication.

Figure 4: The content of home medication cabinet.

Table 5 shows which kind of prescribed medication the respondent are keeping at their home medication cabinet.

17% of nervous system drug and 22% of cardiovascular drugs, 14% of the drugs are of the respiratory system and 8% were of alimentary tract drugs, 6% were of antiparasitic drugs. 5% were of vitamins, dermatology drugs, and antiinfective, 4% were of drugs for diabetes, and blood-forming drugs, 3% were of sensory organ and only hormonal preparation was 1%.

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22 Figure 5 : Prescribed drug at home medication cabinet

Table 2: Number of house member checking for expiry drugs

Number of respondent Percent

yes 47 58.8

sometimes ₁₂ _15.0

no ₂₁ _26.3

Table 2 shows that out of 80 respondents, only 47 respondents (58.8%) checked for expiry date before consuming any medication.

Table 3: Storage condition of the medication at home

Item %

The condition of medication storage -In the original package

-Without the original package

-some medication are with the original packet and some are without

73.8 7.5 18.8

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23 -Kitchen -living room -Bedroom -Bathroom 25 8.8 22.5 43.8

In which temperature the medicines are kept -At room temperature;

-In refrigeration;

-Each medicine is kept as it should be, some are at room temperature, and the others at refrigerator temperature;

-I don’t care about it

56.3 1.3 41.3

1.3 Do you keep the medicine away from light

-Yes; -No.

91.3 8.8

Do you keep the medicines away from children? -Yes;

-No.

91.3 8.8

Do you have only one place for storage for the medicine? Yes, only one place;

No, several places for storage of medicines.

92.5 7.5

Majority of the participants 59 (73.8%) indicated that their medication are stored with the original package

Most of the respondent indicated that they have only one place for storing medication, 35 of them (43.8%) reported that they store their medication at bathroom followed by kitchen (25%) and bedrooms (22.5%) and living room (8.8%)

92% of the respondent answered that they home medication cabinet is located away from children and the same number of respondents indicated that their medications are in place away from the sun exposure.

About 50 % of the respondent indicates that each medication is kept as it should be; some are at room temperature, and the others at refrigerator temperature.

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3.2 Problems associated with home medication cabinet

Figure 6: Home medication cabinet picture of several respondents

Figure 6 shows the picture of the respondent home medication cabinet. From all the three pictures we can see messy and unorganized cabinet. Some of the drugs are without the original box and some are without the patient leaflet.

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25 Figure 7: Reading the patient leaflet

About the question: do you read the patient leaflet before the use of the medication, announce that our respondents had different levels of adherence from “yes, I read the patient leaflet” to “sometimes I read the patient leaflet” to no, I’m not reading the patient leaflet” the results of this adherence question shown in figure 7.

Figure 8: The way of disposal of unwanted medication

The most common method of disposal of unwanted or expired medication was to throw them into the dumpster (78.75%) or to bring them to the pharmacy (17.5%) while some respondent (2.5%) indicate that they will throw them into the toilet or (1.25%) will use them it means that 82.5% of the respondents didn’t know that the

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26 best way to dispose of expired date medication is returning the medication back to the pharmacy, as shown in figure 8.

Figure 9: Sharing medication

More than 50 % of the respondent reported that they will use medication that wasn’t prescribed from than as shown in figure 9.

Table 4. The sociodemographic characteristics association with the use of other people medication.

The use of other people medication (n/N)% Statistical Reliability z-score , p-value Gender female (31/51) 60.78 z=2.2625 male (10/29) 34.48 p=0.02382 (p<0.05) * Education level High school (25/30) 83.3 z= 4.447 College or university (16/50) 32 p=0. (p < 0.05) * Age 20-44(young) (30/52) 57.69 p=1.571

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27 Employment status

Working (38/64)59.37 P= 2.9078

Unemployed/students/housewife (3/16)18.75 Z= 0.00362(p <0.05)*

Responsible for home medication cabinet

Yes (38/73) 52.05 P=0.4651

No (3/7) 42.86 Z= 0.63836 (p >0.05) ns

n- Number of positive cases in a group; N- Total number of cases; ns-not significant; * Significant difference

The results of statistical analysis for the association of use of other people’s medication with different visit and pharmacy characteristics are presented in Table 4. There was a higher risk of using medication that wasn’t intended to the patient associated with female gender (p<0.05), also respondent how has low level of education, and Employment status (p<0.05); No significant association was detected between age, responsibility toward home medication cabinet and use of medication.

3.3 Knowledge and adherence towards self-medication

Fig.10. Source of information about medication at home medicine cabinet.

Figure 10 shows the sources of information about medication which are already purchased and kept at home. For the information about the use of medication in home

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28 medication cabinet the main information sources are internet 38 (47.5%), followed by books and peers. 17 (21.30%) of the respondents indicated that they visit pharmacy, ask questions about the medication which are already at home and none of the respondents named that physician or a nurse would be an option for this case.

Figure 11: Evaluation of adherence

Figure 11, show that the interviews revealed a medium level of adherence because 25 (31.25%) indicated that they always follow the instruction of the medication, followed by 55(66.75%) they sometimes will follow the medication instruction.

Table 5: The socio-demographic characteristics association with medication adherence Medication adherence (n/N)% Statistical Reliability z-score , p-value Gender female (20/51) 39.21 z=2.034 male (5/29) 17.24 p=0.04136 (p<0.05) * Education level High school (15/30) 50 z= 2.8026 College or university (10/50) 20 p=0.00512 (p < 0.05) *

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29 Age

20-44(young) (18/52) 34.61 p=0.885

45-67 (middle age or elderly) (7/28) 25 z=0.37886 (p<0.05)ns

Employment status

Working (21/64) 32.81 P= 0.603

Unemployed/students/housewife (4/16)25 Z= 0.5485 (p <0.05)ns

Yes (23/73) 31.5 P=0.1601

No (2/7) 28.57 Z= 0.872 (p >0.05) ns

The results of statistical analysis for the adherence toward self-medication with different visit and pharmacy characteristics are presented in Table 5. There was a high risk of high level of adherence with female gender (p<0.05), also respondent how has low level of education, (p<0.05); No significant association was detected between age, employment status and responsibility toward home medication cabinet.

Figure 12: Consultation with the pharmacist about OTC medication

About the question of consulting with the pharmacist about OTC medication buying or consuming ,half of the respondent indicate that they will consult with the

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30 pharmacist about which medication to take from the OTC medication and the other half said that they will buy an OTC medication without consulting the pharmacist.

Table 6. The sociodemographic characteristics association consultation with the pharmacist about OTC medication

The cconsultation with the pharmacist about OTC medication (n/N)% Statistical Reliability z-score , p-value Gender female (33/51) 64.7 z=2.314 male (11/29) 37.93 p=0.0208 (p<0.05) * Education level High school (21/30) 70 z= 2.7713 College or university (19/50) 38 p=0.0056 (p < 0.05) * Age 20-44(young) (28/52) 53.84 p=0.9376

45-67 (middle age or elderly) (12/28) 42.85 z=0.34722 (p<0.05)ns

Employment status

Working (34/64) 53.12 P= 1.118

Unemployed/students/housewife (6/16) 37.5 Z= 0.2627(p <0.05)ns

Yes (37/73)50.68 P=0.957

No (3/7) 42.85 Z= 0.68916 (p >0.05) ns

The results of statistical analysis for cconsultation with the pharmacist about OTC medication with different visit and pharmacy characteristics are presented in Table 6. There was a higher risk of consultation about OTC medication with female gender (p<0.05), also respondent how has low level of education, (p<0.05); No significant

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31 association was detected between age, employment status and responsibility toward home medication cabinet.

Figure 13: Consultation with the doctor about OTC medication

49 participant over 80 said that they will not tell their doctor about any OTC medication or food supplement that they take while the doctor is prescribing them medication a sis shown in figure 13.

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32 more then 71 (85%) of the respondent indicated that they wont take their medication after the recommended time.

Figure 15: Will you take more the recommended dose for relieve the pain

65 (81.3 %) of the respondent indicated that they won’t take more doses as it was recommended by the doctor in order to relieve their pain however 15 (18.8%) answered that they will take more doses in order to relieve their pain.

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33

4. DISSUCION

In our study, we detected a number of home medication cabinet safety issues among patients attending primary health care setting in Israel. The main indicators of irrational self-medications were associated with sociodemographic characteristics: gender, education level, lack of knowledge and no intervention of health professional They were also detected in other studies: like in India (2), USA (7), Soudan (5), Kuwait (31), Spain (6)Saudi Arabia (32)

In our study women more often report themselves as responsible for home medication cabinet. It is also indicated in some other studies in Lithuania(33), Qatar (4)United Kingdom(34) and Estonia (10). Women are more responsible for the home medication cabinet has been indicated in this survey can be explained by the fact that women tend to be more at home and take care of many home and self-care options (7)

The most common medication in our study was OTC medication similar results were indicated in Brazil (3) and USA (7)

Most of the respondent 59 (73.8%) have a box especially for storing medication, in contrast, a survey conducted in Qatar (4) and in Saudi Arabia (35) most of the respondent did not have a designed compartment or box especially for storing medication. The important finding is that majority of the respondents (73%) keep the medication in their original package with patient information leaflets but only 31% always read it.

Keeping medication in the bathroom or in the kitchen could lead drugs to undergo physical or chemical changes due to exposure to heat, cold ‘humidity and sunlight, it was also indicated that keeping medication in a bathroom can be a risk factor for self-medication because it is placed with easy access and can be easily seen (3). More than 40% of respondent are keeping their medication at bathroom same result was reported in cook country(7), in opposition to Qatar and India- Karnataka 48 % and 84.62% were keeping their medication in bedroom respectively(4)(2) ; on another hand in Saudi Arabia respondent were reported that they are keeping their medication in fridge and in kitchen (35)

Appropriate storage condition was defined as storing medication away from children hands and away from light as shown in our study and in Sudan (5) In contrast, survey

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34 that was conducted in Brazil (3) shows that the home medication cabinet locations are easily accessed by children.

The most common method of disposal of unwanted medication was to throw them in the trash or in the toilet, the same problem was indicated in Qatar and in cook country and US (4),(7), (36), majority of the respondents (82.5%) didn’t know that the best way to dispose of expired date medication is returning the medication back to the pharmacy

More than half of the respondents checked the validity of their stored medicines immediately before administration. 26.3% respondents were illiterate about the importance of expiry dates. It repeats the results in Indian study at Noida (37)Karnataka Region, India (2) this lack of information about medicines shakes the basics of medication safety guidelines (2)

In our study for the information about the use of medication in home medication cabinet the main information sources are the internet (47.5%), followed by pharmacist and peers, and none of the respondents named that physician or a nurse would be an option for this case. This is differing than other studies: usually for the new medication: physician and pharmacist are the main sources of information (11), (12)]. Although in some studies are mentioned the growing impact of internet and responsibility of conflicting information [(12) (13)]. Majority of the respondent in this survey indicate that they are using the internet as the main source for drug information, in contrast , many surveys conducted abroad like in; Northern India ,Estonia , and in Qatar, reported that their main source of drug- related information were health-professionals [(38),(10),(4)] however in Karnataka, India 54.67% respondent look for information from their friends that were already used the medication (2), in contrast in Saudi Arabia the main source of information was the television (32). Half of the respondent indicates that they will consult with the doctor about which medication to take, same results shown in Sudan (5) 55.5% consumed medication that they already have without consulting the doctor.

More than 50 % of the respondent reported that they will use medication that wasn’t prescribed for them; similar results reported in Qatar and in Sudan more than 50% indicated that they will share medication with their family friends(4) (5) on another hand in survey performed in Kuwait only 16% reported that they will share medication (31).

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35 Only 16 respondent out of 50 respondent with high level of education reported that they will use medication that wasn’t intended for them versus 25 out of 50 respondent with low level of education reported that they will use medication that wasn’t prescribed for them, this result can be explained by Liability of self-medication increase with increasing educational level, this finding is according to the literature (6) people with higher education level have more knowledge about medication and correct use of them they can be assured that their way of using medication is correct and they don’t have to confirm of consult with their pharmacist compare to the less educate people.

Studies show that pharmacists could increase patient’s knowledge level and motivate them to avoid irrational use [(13), (39) (40)]. Patient has high expectations towards services at the pharmacy and pharmacist should encourage themselves to meet those high expectations of service quality (39). The pharmacist’s service can be very beneficial for the management and monitoring of acute coronary syndrome patients to improve their quality of life (40).

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36

5. CONCLUSION

1. The results of the survey of Holon city in Israel have shown that OTC medication takes the bigger part of home medication cabinet content. The respondents declared to keep their medication in one place and in drawer or cupboard but home medication cabinet was unorganized and untidy. The most popular storage places are bathroom kitchen and bedroom .Most of the respondent disposes of their medication using the dumpster or sink and not by returning them to the pharmacy.

2. Some problems like medication safety, use of expired medication, poisoning of the groundwater, use of another patients medications, keeping medication without original packet or without the patient's leaflet, are found in this survey.

3. The knowledge towards self medication of the selected sample in Israel has shown that the most popular source of information about medication at home medicine cabinet is the internet and peers. About half of the respondent read sometimes the patient leaflet and consult with the pharmacist about OTC medication. Interviews revealed medium level of adherence by indicating that they sometimes follow the instruction of the medication .More than half of them use another person’s medication.

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37

6. RECOMMENDATION

After the literature review and results of the patient’s survey we recommend: To patients:

• It’s recommended to take medication as directed; including a length of time and doses of medication should be taken as it’s prescribed by the doctor or recommended by the pharmacist.

• When the medication is too old –see expiration date to be sure, or when the medication is no longer needed, consult with the pharmacist about a close location of pharmacy where you can throw the medication there.

• Do not flush unused medications, this can lead to poisoning of the groundwater

• Keep your home medication in home temperature and not in the bathroom or kitchen, those places are humidly and warm this climate can lead to degradation of the medication, and change in structure of the medication To the Pharmacist:

• To look carefully to the prescription to avoid drug interaction.

• The pharmacist can prove education about proper administration of a drug, proper disposal, and maintenance of a drug.

• To explain for the patient why it’s important to follow the instruction and read the patient leaflet information before using a medication

To the Doctors

• To ask a patient if he is taking any OTC or food supplement before or while he is prescribing a medication to the patient. It can prevent further drug-drug interaction of drug-food supplement interaction.

• The doctor can clearly explain to the patient any further instruction about a medication to prevent patient confusion and prevent from the patient to look for information on the internet.

To Manager of “Clalit” clinic

• To make a course for the patient at this specific clinic, for improving their knowledge about all aspects concerning home medication cabinet.

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38 • to send all the health care professional of this clinic to an invigorating workshop to get better skills about offering and consulting patient about a safe use of medication.

• To dispense by pharmacist a simple brochure about a proper and safe use of medication.

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39

7. References:

1. World Health Organization. The role of the pharmacist in care and self-medication. World Heal Organ [Internet]. 1998;15. Available from:

http://scholar.google.com/scholarhl=en&btnG=Search&q=intitle:The+Role+of +the+Pharmacist+in+Self-Care+and+Self-Medication#0

2. Sharma A, Madaan A, Nagappa AN. Medication Storage and Self Medication Practice Among the Youth in Karnataka Region, India. 2012;3(8):2795–800. Available from: www.ijpsr.com

3. Tourinho FS V, Bucaretchi F, Stephan C, Cordeiro R. Home medicine chests and their relationship with self-medication in children and adolescents. J Pediatr (Rio J). 2008;84(5):416–22.

4. Kaissi1 NKMEHKWR, Yousif2 A. An exploratory study on medications in Qatar homes. Drug Healthc Patient Saf. 2017;3(2011):99–105.

5. Yousif MA. In-home drug storage and utilization habits: A Sudanese study. Vol. 8, Eastern Mediterranean Health Journal. 2002. p. 422–31.

6. P. Carrasco-Garrido PhD, MPH* RJ, ńez-GarcıáMD, Herna V, MD ńdez Barrera and A. Gil de Miguel. Predictive factors of self-medicated drug use among the Spanish adult population. Clin Neuropsychiatry. 2008;17(2):193– 199.

7. Wieczorkiewicz SM, Kassamali Z, Danziger LH. Behind closed doors: medication storage and disposal in the home. Ann Pharmacother [Internet]. 2013;47(4):482–9. Available from:

http://www.ncbi.nlm.nih.gov/pubmed/23535813

8. World Self-medication Industry. Responsible Self-Care and self-medication - A worldwide review of consumer surveys. Wsmi [Internet]. 2006;1–16. Available from: http://www.wsmi.org/pdf/wsmibro3.pdf

9. Nava herzberg. Medication without prescription. Available from: http://economy.gov.il/Research/Documents/X9120.pdf

10. Volmer D, Lilja J, Hamilton D. How well informed are pharmacy customers in Estonia about minor illnesses and over-the-counter medicines. Medicina (Kaunas) [Internet]. 2007;43(1):70–8. Available from:

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40 11. Närhi U, Helakorpi S. Sources of medicine information in Finland. Health

Policy (New York). 2007;84(1):51–7.

12. Holappa M, Ahonen R, Vainio K, Hämeen-Anttila K. Information sources used by parents to learn about medications they are giving their children. Res Soc Adm Pharm. 2012;8(6):579–84.

13. Pohjanoksa-Mäntylä M, Bell JS, Helakorpi S, Närhi U, Pelkonen A, Airaksinen MS. Is the Internet replacing health professionals? A population survey on sources of medicines information among people with mental disorders. Soc Psychiatry Psychiatr Epidemiol. 2011;46(5):373–9.

14. Carpenter DM, Elstad E a, Blalock SJ, DeVellis RF. Conflicting medication information: prevalence, sources, and relationship to medication adherence. J Health Commun [Internet]. 2014;19(1):67–81. Available from:

http://www.ncbi.nlm.nih.gov/pubmed/24015878

15. growth of OTC market during 2000-2010. Available from: http://www.imshealth.com/en

16. Abou-Auda HS. An economic assessment of the extent of medication use and wastage among families in Saudi Arabia and Arabian Gulf countries. Clin Ther. 2003;25(4):1276–92.

17. Belongia E a, Naimi TS, Gale CM, Besser RE. Antibiotic use and upper respiratory infections: a survey of knowledge, attitudes, and experience in Wisconsin and Minnesota. Prev Med (Baltim). 2002;34(3):346–52.

18. Huang SS, Rifas-Shiman SL, Kleinman K, Kotch J, Schiff N, Stille CJ, et al. Parental Knowledge About Antibiotic Use: Results of a Cluster-Randomized, Multicommunity Intervention. Pediatrics [Internet]. 2007;119(4):698–706. Available from:

http://www.ncbi.nlm.nih.gov/pubmed/17403840%5Cnhttp://pediatrics.aappubli cations.org/cgi/doi/10.1542/peds.2006-2600

19. Bi P, Tong S, Parton KA. Family self-medication and antibiotics abuse for children and juveniles in a Chinese city. Soc Sci Med. 2000;50(10):1445–50. 20. Larsson M, Kronvall G, Chuc NTK, Karlsson I, Lager F, Hanh HD, et al.

Antibiotic medication and bacterial resistance to antibiotics: A survey of children in a Vietnamese community. Trop Med Int Heal. 2000;5(10):711–21. 21. Okumura J, Wakai S, Umenai T. Drug utilisation and self-medication in rural

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41 22. Togoobaatar G, Ikeda N, Ali M, Sonomjamts M, Dashdemberel S, Mori R, et

al. A survey of non-prescribed use of antibiotics for children in an urban community in Mongolia. Bull World Health Organ. 2010;88(12):930–6. 23. Michael D, Pappas G. Over-the-counter Medication Use Among US

Preschool-age Children. 2015;(1):1–6.

24. McKee P, Hughes C, Hanna LA. Views of pharmacy graduates and pharmacist tutors on evidence-based practice in relation to over-the-counter consultations: A qualitative study. J Eval Clin Pract. 2015;21(6):1040–6.

25. Bj MK, Ms G, Gvs R, Svk S, Sowmya M, Kumaraswamy M. Home Medicine Cabinets: An Overview. Indian Journal Pharmacy Practice. 2012;5(2):7–10. 26. Taylor J, Landry E, Lalonde L, Tsuyuki RT. Results of a national survey on

over-the-counter medicines, Part 1: Pharmacist opinion on current scheduling status. Can Pharm J. 2012;145(1):40–44.e1.

27. Hanna LA, Hughes C, Watson M. Where’s the evidence? Over-the-counter medicines and pharmacy practice. Int J Pharm Pract. 2012;20(5):275–6. 28. inadequate healthcare and general inequity in the periphery. Isr Med Assoc

[Internet]. Available from:

http://www.ima.org.il/ENG/ViewCategory.aspx?CategoryId=6177

29. Yariv H. The case of pharmacist prescribing policy in Israel. Isr J Health Policy Res [Internet]. 2015;4:1–13. Available from: http://dx.doi.org/10.1186/s13584-015-0045-4

30. Courtenay M, Carey N, Stenner K. An overiew of non medical prescribing across one strategic health authority: a questionnaire survey. BMC Health Serv Res [Internet]. 2012;12(1):138. Available from:

http://www.biomedcentral.com/1472-6963/12/138%5Cnhttp://epubs.surrey.ac.uk/712190/1/An overview of non medical prescribing across one strategic health authority.docx

31. Abahussain EA, Ball DE, Matowe WC. Practice and opinion towards disposal of unused medication in Kuwait. Med Princ Pract. 2006;15(5):352–7.

32. Abahussain NA, Taha AZ. Knowledge and attitudes of female school students on medications in eastern Saudi Arabia. Saudi Med J. 2007;28(11):1723–7. 33. Dauksiene J, Radziūnas R. Nonadherence to medications among pharmacy

clients and their attitude toward medications kept a medicine cabinet at home. Medicina (Kaunas) [Internet]. 2009;45(12):1013–8. Available from:

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42 http://www.ncbi.nlm.nih.gov/pubmed/20173405

34. McNulty CAM, Boyle P, Nichols T, Clappison DP, Davey P. Antimicrobial drugs in the home, United Kingdom. Emerg Infect Dis. 2006;12(10):1523–6. 35. Al Ruwaili N, Al Balushi A, Alharf A, AlShaharani H, Eldali A. Do parents in

Saudi Arabia store medications safely? Int J Pediatr Adolesc Med [Internet]. 2014;1(1):21–5. Available from: http://dx.doi.org/10.1016/j.ijpam.2014.09.003 36. Law A V., Sakharkar P, Zargarzadeh A, Tai BWB, Hess K, Hata M, et al.

Taking stock of medication wastage: Unused medications in US households. Res Soc Adm Pharm [Internet]. 2015;11(4):571–8. Available from:

http://dx.doi.org/10.1016/j.sapharm.2014.10.003

37. Alam N, Gupta J, Bhardwaj A, Amin F. Prospective survey study on

assessment and education of home medicine cabinet in general population of community. Int J Pharm Sci Res. 2011;2(5):1237–43.

38. Joshi MC, Shalini, Agarwal S. A questionnaire based study of self-medication practices among young population. Res J Pharm Biol Chem Sci.

2011;2(4):761–6.

39. Tan CLH, Gan VBY. Pharmacy value added services: Early begininings, current implementation, and challenges from the Malaysian experience. Indian J Pharm Educ Res. 2016;50(3):335–43.

40. Mateti UV, Ummer J, Kodangala S. Impact of Clinical Pharmacist Counselling and Education on Quality of Life in Patients with Acute Coronary Syndrome. Indian J Pharm Educ Res [Internet]. 2016;50(3):360–7. Available from: http://www.ijper.org/article/458

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43 APPENDIX

Questionnaire

My name is Ester Haimov,4th year student in the Pharmacy faculty of LSMU University of Kaunas,Lithuania.

My master thesis will deal about the medicine cabinet.

The goal of this thesis is to assess the medicine cabinet safety, the problems that concerned

to the medicine cabinet.This research should provide additional knowledge about the

proper use of medicine, improve the awareness of proper storage of certain medicine.

Your answer has meaningful significance in this questionnaire, which is the one and only

way I can get information about habits of storage of medicine among population of the

state of Israel.

The answers will be used only for scientific research and statistical analysis. You can fill the answers as fits to you.

Thank you for participating in this questionnaire.

Please fill the answer as the following example :

➢ How many time are you doing physical activity? Please choose one suitable answer.

a.Once a week

b.Two times per week

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44 1.Who is the one that is responsible for the medicine cabinet in your

family?

Please choose one suitable answer.

a.Mother;

b.Father;

c.No one is responsible for the medicine cabinet. d.Other:____________________

2.Do you have only one place for storage for thr medicine? Please choose one suitable answer.

a.Yes,only one place;

b.No,we have several places for storage of medicines. 3.Please choose where do you store the medicines? Please choose one suitable answer.

a.Kitchen; b.living room; c.Bedroom; d.bathroom

e.Others:___________________

4.In which condition do you store the medicines? Please choose one suitable answer.

a.In the original medicine packet; b.Without the original packet;

c.All the medicines are storage in one big container:-in a box –in one small bag;

5.In which temperature the medicines are kept? Please choose one suitable answer.

a.At room temperature; b.In refrigeration;

c.Each medicine is kept as its should be,some are at room temperature,and the others at

refrigerator temperature; d.I don’t care about it.

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45 6.Do you keep the medicine away from light?

Please choose one suitable answer. a.Yes;

b.No.

7.Do you keep the medicines away from children? Please choose one suitable answer.

a.Yes; b.No.

8.How many times do you check your medicine cabinet medicine expire date?

Please choose one suitable answer. a.Every week;

b.Every month; c.Every six months; d.Once a year;

e.Im not checking my medicine cabinet.

9.Do you check the expiry date of the nedicine before using the medicine? Please choose one suitable answer.

a.Yes,always; b.Sometimes;

c.No,im not checking the expaire date of the medicine before using the medicine.

10.Did you know that if you have a medicine with expired date,you can bring them to the pharmacy?

Please choose one suitable answer. a.Yes,I knew and Im doing it always; b.No,I didn’t know about it.

11.If you have medicine with expiry date,what are you doing with them? Please choose one suitable answer.

a.Throwing them away;

b.Bring them to the pharmacy; c.Use them;

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46 12.If you marked in question number 11-A please choose one suitable answer,in which way you are getting rid of the medicine with expired date? a.Throwing them in the toilet;

b.Throwing them into the dumpster; c.Throwing them into sink;

13.Do you read the insert of the medicine before use for the first? Please choose one suitable answer.

a.Yes,always; b.Sometimes;

c.No,Im not reading the insert at all.

14.I you don’t have the insert, where you find information? Please choose one or more suitable answer.

a.On internet;

b.Ask my pharmacist; c.Looking at books;

d.Asking people that use the medication constantly;

15.Do you have in your family people who is suffering from chronic disease?

Please choose one suitable answer. a.Yes,I have;

b.No,I don’t have.

16.Do you know about medicines that you can buy,that are subsidized by the

government?

Please choose one suitable answer.

a.Yes,I knew and I consumed those medicines; b.Yes, I knew but I don’t need those medicines; c.NO,I didn’t know about such medicines.

17. Do you follow the instruction of the medicine? Please choose one suitable answer.

a.I always follow the instructions; b.Sometimes I follow the instruction; c.I dont follow the instruction.

18.Which of the medicine is more prevalent in your medicine cabinet? Please choose one suitable answer.

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47 b.Prescribed medicine;

19.How many time per week you are taking medicine for reliving the symptoms?

Please choose one suitable answer. a.At least once a week;

b.At least two times per week; c.More than three times per week;

20.Will you take more doses than its written in the leaflet to realiv the symptoms more quickly?

Please choose one suitable answer. a.Yes,I will take more than its written; b.No,I will take the dose as its written.

21.Before buying an OTC medicine,will you consult your pharmacist about its safe usage?

a.Yes I will consult with my pharmacist about adverse drug effect of the medicine;

b.No,I wont consul with my pharmacist about adverse drug effect of the medicine.

22.Will you use an prescribed medicine that your family is using,for your healthy problem?

a.I will use the same medicine without consulting a doctor; b.I will not use the medicine without consulting a doctor.

23.You got from you doctor medicine and he recommended you to take it only few days,will you take it after the recommended time?

Please choose one suitable answer. a.Yes I will insure that treatment;

b.No I will not take it over the recommended time.

24.Do you inform your doctor about the OTC medicine you are taking,when your doctor is prescribing you a medicine?

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48 b.No ,im not informing about OTC drugs that im taking.

25.What is the average monthly your family is spending on medicines? Please choose one suitable answer.

a.About 100 shekels per month; b.About 500 shekels per month; c.About 1000 shekels per month; d.Others:______________;

26.How much you will rate your medicine cabinet cart? Please choose one answer.

a.About 150 shekels;

b.Between 150-300 shekels; c.Between 400-750 shekels; d.More then 1000 shekels; e.Others:______________; 27.what is your monthly salary? Please choose one suitable answer. a.2500 shekels;

b.5000 shekels; c.7500 shekels;

d.others:______none_____;

28.please list your family members and their age: For exaple - women (30m.); Boy (10m.)

a. d. b. e. c. f.

29.What is your main occupation? Please choose one answer.

a.Student; b.Worker; c.Housewife; d.Unemployed;

30.what is your education?

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49 a.High school;

b.Collage;

c.Bachelor's degree; d.Master's degree ;

medication (ATC classification)

With r ec ep t W it hout re ce pt W it h lea fle t\ without lea fle t • E xp ire d d ate

• A02- A09 Alimentary tract drugs and metabolism products

• • • • • • • • • • • A10 – drugs for diabetes

• • • • • A11 – vitamins •

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50 • • • • • • • A12 – meneral ingredient

• • • • • • B – blood forming drugs

• • • • • • C – cardiovascular system drugs

• • • • • •

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51 • • • • • D – dermatology drugs • • • • • • • G – urogenital system ans sex hormone drugs

• • • • • • H – hormonal peparation • • • • • J – antiinfective drugs • •

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52 • • • • • L – antineoplastic drugs • • • • • • M – muscular and skeletal system drugs

• • • • • • • • • N – nervous system drugs

• • • • •

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53 • • • • • • P – antiparasitic drugs • • • • • • R – rsperatory system drugs

• • • • • • • • • • • S – sensory organ system drugs

•