The main purpose of manufacturing digital pills is to improve patient adherence and improve patient care¹⁰. Evidence suggests that digital pill may improve medication adherence as it consists of sensor that is embedded in a tablet, which when swallowed transmits a signal to the patient’s mobile application as well as to the health care practitioner (HCP). Furthermore, the data can be shared with up to four people who are agreed by the patient¹¹. It was clearly stated that such digital pills “should not be used to track drug ingestion in real-time or during an emergency because detection may be delayed or may not occur”¹². However, the digital pill has not yet been proven to increase adherence, and more studies are required to collect data to confirm this relation¹⁰. Moreover, digital pills can improve patient care, as the physician will not depend on patient information about medication intake, instead the physician will know if the patient actually takes medication from the application; this will increase the health outcomes¹⁰. For instance, the physician can know from the application if the patient takes the medication in the right dose, right time or not, and in case the patient takes a wrong dose, and the physician can ask to investigate the reason¹⁰. On the contrary, many people argue that it is not a convenient way to be used because they feel that they are under supervision and observation of the healthcare provider, in addition they consider it as a compulsion in the treatment plan⁷. Hence, turning the traditional pills into a digital one that can gather, and share patients’ information has raised many ethical concerns. This paper outlines a new approach to investigate the medication intake behaviour and patients’ practice toward non-adherence especially for elderly people that find difficulties in using mobile phones. Moreover, to spot the light on the new type of innovative medication technology (Digital pill) from different perspectives including people acceptance, their ability to use it as well as ethical concerns which are challenging problems that have been raised. That is why we aimed to assess the readiness of patients to accept this new method especially if it gets generalized for other medication classes as well especially for chronic diseases individuals.

MATERIAL AND METHODS:

The current study was a descriptive cross-sectional survey study that was conducted among adolescents and adults in UAE from both genders. The study was done during a period of one month, from June 2018 until July 2018. The respondents were assessed through a hard copy and online electronic bilingual questionnaire. The study targeted 320 participants in the UAE. All respondents were willing to participate with no undue pressure. The study included participants from both genders aged 18 years and above and must be a resident of the United Arab Emirates (UAE). While the exclusion criteria included non-residents and participants outside UAE who were not enrolled in this study.

The questionnaire was initially developed in English language and translated into Arabic by native Arabic specialists, to enable Arabic speaking participants to give their feedback and to avoid any language barrier. The questionnaire was validated by several academics and researchers in Ajman University who commented on the questionnaire and its relevance and clarity which led to some required modifications according to their comments. A pilot study of 20 respondents was held prior to the study to assess the validity of the questionnaire.

The questionnaire consisted of several questions distributed in three sections: forgetfulness of taking medication, technology, and privacy. The research assured that anonymity would be maintained, and ethical principles would be followed. The confidentiality of participants was maintained all the time. Participants’ information obtained from the questionnaire was kept private.

In this study, the data were analysed using the Statistical Package for the Social Sciences (SPSS) version 20. Descriptive statistics were used to summarize the demographic characteristics data. Categorical variables (such as Age groups and nationality) were described by using frequency, percentages, and pie charts. A correlation was formed between the the informing behaviour and the gender of participants and the correlation was considered significant at ≤0.05

The illustration in (Figure 1) was done using one of the most well-known tools for assessing illustration which is Biorender website. Biorender is a web-based tool for designing illustrations for medical and research pursues.

RESULTS:

A total of 320 participants in the United Arab Emirates (UAE) were recruited in the current study. The respondents were aged 18 years and grouped as the following: 18-28 (86.9%), 29-39 (8.4%), 40-50 (3.1%), 51-61 (1.3%), 62-72 (0.3%), from both genders (Females=83.1% and Males=16.9%). The respondents were from different nationalities, but the majority (95.6%) were Arabs. All the participants were willing to participate and take part in the study. This study was conducted to assess four different parts including patients’ medication intake behaviour, non-adherence to medications and reminder techniques used the new technology of digital pills and its privacy issues.

The first part of the questionnaire aimed to investigate the medication intake behaviour and patients’ practice toward non-adherence. The majority respondents (61.9%) stated that they (sometimes) forget to take their medication, while less than quarter of them (24.4%) (Never or rarely) forget to take their medications. In terms of action taken by respondents when the medication is not taken, thirty-five per cent (35%) of respondents stated that they take medication anyway, thirty three per cent (33.4%) of respondents stated that they skip the dose of the medication. Few respondents (28.1%) mentioned that they ask the family member. All that leads us to the importance of finding a solution for forgetfulness of medication intake to increase patient safety and health benefits. (Table1)

Respectively, when the question was more specific whether they tell the doctor or not, half of the respondents (53.4%) reported that they do not tell the doctor if they forget to take their medication. When respondents were asked to mention which kind of reminders they used, the majority (44.7%) stated that they depend on family members to remind them, followed by those who said that the depend on themselves and also those who used a mobile phone reminder and those who used a pill box (40%, 28.4% and 20% respectively).It is also important to mention that two-thirds of the respondents (61.3%) said that they stopped taking their medication without telling the doctor because they felt the number of medications they were taking was too much. (Table2)

Our study designed a set of questions intended to investigate the acceptance of respondents toward the new technology medication “Digital Pill”. Approximately two-thirds of the participants (70.6%) said that they usually or always use their mobile phone. Moreover, nearly half of respondents (45.0%) found the use of new technologies (mobile applications) very easy. When respondents were asked about their opinion and impression if their mobile was able to confirm their medication intake using a special digital pill embedded in their tablets, the received response was really positive as the majority of respondents (78.8%) stated that it is a great thing and they are willing to use the digital pill tablets, while about (19.7%) were not sure about that and they stated that they somehow prefer the old reminder methods. (Table 3)

In terms of privacy, our study results assessed how the respondents would act towards certain health privacy issues. It was surprising to find that the majority of the respondents (56.9%) feel uncomfortable if the doctor finds out that they were not taking the medication (Figure 2). However, approximately more than half of the participants (55.9%) agreed that the doctor can access the drug application to confirm their medication intake (Figure 3).

Table 1: The results show that (61.9%) of respondents sometimes forget to take their medications followed by (24.4%, 13.8%) who never/rarely and usually/always forget to take their medications, respectively. We found that most of respondents (35.0%) take their medication anyway when they forget to take it, and (33.4%) they skip the dose of the medication. only few of the respondents (28.1%) mentioned that they ask the family member.

Table 2: majority of respondents (53.4%) do not tell the doctor if they forget to take their medication. Nearly half of respondents (44.7%) ask family members to remind them to take their medications, (40.0%) they remember to take their medications by themselves; followed by (28.4%, 20.0%) they remember to take their medication through mobile phone applications and pillbox, respectively. Approximately two-thirds of the respondents (61.3%) said that they stopped taking their medication without telling the doctor.

Table 1: Medication intake behaviour and patients’ practice toward non-adherence

Variable

Frequency (n=320)

(%)

Do you sometimes forget to take your medication?

Never/Rarely

Sometimes

Usually/Always

198

24.4

61.9

13.8

When you forget whether you have taken your medication or not, what do you do?

I take the medication anyway

I skip the dose of the medication

I ask a family member

Other

112

107

35.0

33.4

28.1

3.4

Table 2: Reporting behaviour of medication non-adherence and reminder techniques used

Variable

Frequency (n=320)

Percentage

(%)

Do you tell your doctor if you forgot to take your medications?

Yes

149

171

46.6

53.4

Which kind of reminder do you use to remember taking your medications?

Pillboxes

Phone (Reminder, application)

Write down notes

Ask family member to remind

I remember to take my drugs by myself

Other

143

128

28.4

8.4

44.7

2.2

Have you ever stopped taking your medication without telling your doctor, because you felt the number of medications you were taking was too much?

Yes

124

196

38.8

61.3

Table 3: Technology practice and usage and the willing to use digital pills by respondents

Variable

Frequency (n=320)

Percentage

(%)

How frequently do you use your mobile phone?

Never/ Rarely

Sometimes

Usually/ Always

226

9.1

20.3

70.6

How easy do you find it to deal with new technologies such as (Mobile Applications)?

Very difficult

Manageable

Very easy

240

2.2

22.8

What do you think if your phone was able to confirm and tell you that your medication (A Special Tablet) has reached your stomach and confirm that you had really taken your medication today?

I think it is great; I want to use such special tablet.

Maybe, but I prefer the old reminders (Pill box, notes, Family)

Others

Combine the technology with the body can be somehow dangerous I do not prefer that thing.

I can remember by myself it is more comfortable for me because I this way I think it has too many side effects.

I do not know. Is that healthy?

I do not need such a thing.

252

78.8

19.7

Table 3: we found that (70.6%) of respondents usually or always use their mobile phone. Nearly half of respondents (45.0%) describe the use of new technologies (digital pill) very easily. (78.8%) think that using a (A Special Tablet) is a great thing and they are willing to use It. on the other hand, (19.7%) were not sure about that and they stated that they somehow prefer the old reminder methods.

Table 4: The results show that male compared to females were more likely to inform their physician about their medication non-adherence but the correlation was found to be insignificant (OR: 1.190, CI: 0.899-1.576, p=0.249). The results show that male compared to females were less likely to feel uncomfortable, but the correlation was insignificant (OR:0.934, CI: 0.714 – 1.221, p=0.606)

Fig. 2: Respondents and healthcare professional awareness of medication non-adherence

Fig. 3: Health privacy disclosure to healthcare providers and granting permission for using technology to trace medication adherence.

DISCUSSION:

Several studies had discussed medication adherence from different angles, but it is rare to find studies which can relate that to technological techniques. To our knowledge this is the first study in the UAE discussing such relations, as well as the patients’ health and medication privacy. The current study is a unique study addressing people adherence and their opinions regarding different aspects of using this innovative pill. As it is already known, improving patients’ medication adherence will lead to improving the overall patient health and treatment outcomes that will be assured.

This study will focus on four different parts, including patients’ Medication intake behaviour, non-adherence to medications and reminder techniques used, digital pill technological part and digital pill privacy issues.

Regarding medication intake behaviour and patients’ practice toward non-adherence, our results showed that about (13.8%) of respondents always forget to take their medications, followed by (61.9%) who stated that they only forget (sometimes).

Consequently, we asked participants about the actions taken when they forget to take their medication and the majority of respondents (35%) stated that they take the medication anyway, followed by those who said that they skip the dose (33.4%). Both answers can affect the therapeutic plan especially in case of chronic diseases. By taking the medication anyway this can double the dose and leads to some side effects that negatively affects the patient, which also can be the reason for justifying why some of the participants answered by skipping the dose. However, we can interpret these results to many other reasons, but the most important thing, as healthcare providers is to take a step towards solving the core of the issue itself which can be attributed to forgetfulness as well as several chronic diseases and multiple drug therapy especially in elderly and come up with practical solutions in line with the current technological means.

Moreover, another study conducted in the USA found that patients skipped the dose due to different reasons such as to make medication last longer, they felt worse, they felt better or because they did not feel that the medication was helping¹³. From that we can say that it is important to have a true follow up system for the patients regardless of the traditional ways required to assure the proper medication adherence.

Generally, there is little known about this new type of pharmaceutical technology and up to our knowledge no study was done in UAE to assess the acceptance of people toward using digital pills and their concerns regarding privacy issues of using it, as it is new type of medication and most of the patients don’t have enough knowledge about it.

The current study indicated that most of respondents (78.8%) found that the new technological medication (Digital pill) is great, and they gave their positive impression as well as willingness to use this pill. The physician can be aware of patient health, which will positively influence the overall wellbeing of the patient. The current result is in agreement with other results that were obtained in the United Kingdom about ‘Direct Adherence Measurement Using an Ingestible Sensor Compared with Self-Reporting in High-Risk Cardiovascular Disease Patients’, they found that many of their participants agreed or strongly agreed to use the ingestible sensor¹⁴. All these findings confirm that using a digital pill in treatment plans is somehow accepted by the patients and can be used more in the future as it helps them to be more adherent to medications.

On the other hand, the current study shows that only one participant stated that “Combine the technology with the body can be somehow dangerous. I do not prefer that thing’’. This can be explained by the presence of technology with the pill may lead to some side effects. Comparison of this finding with other study that was held in the United Kingdom they found only one participant had a dermatitis side effect with the use of the patch of smart pill¹⁴. However, this finding does not affect the acceptance of people toward the use of the smart pills as only few cases can happen, but the overall advantages of this system is much more and by using it correctly this side effect can be avoided.

The last part to be discussed in this study is about the privacy toward digital pills. Privacy is the main concern, and it raises some challenging ethical issues. As patients’ medical information is very important and should be kept protected and secured. Additionally, this information can be shared with other health care providers only by having a previous consent permission from the patient.

Correspondingly, security methods must be introduced along with the digital medications, starting from collecting the information until reaching the last destination which here can be the sensor, application and the website⁷.

Consequently, the main obstacles of digital pills are patient ethical issues including “understanding for autonomy and informed consent, therapeutic misconceptions, data, external influences on decision-making, confidentiality and privacy, and device dependability”¹¹. Additionally, physicians can face some ethical challenges like; patient- doctor relationship and trust, therapeutic expectations and liability¹¹.

In the current study they found that more than half of participants about 56.9% (n=182) feel uncomfortable if the doctor finds out whether they took medications or not. Many individuals may feel that their privacy may not be protected completely if healthcare providers can be aware about their actual medication intake when they keep an eye on their treatment from mobile applications.

The results show that the majority of male participants (n=29) inform their physician about their medication non-adherence while the majority of females (n=146) tend not to inform the physician about the medication non-adherence. The correlation between the informing behaviour and the gender of participants showed that male compared to females were more likely to inform their physician about their medication non-adherence, but the correlation was found to be insignificant (OR: 1.190, CI: 0.899-1.576, p=0.249). The majority of males as well as the majority of females (n=29 and n=153 respectively) tend to feel un-comfortable if their physician finds out that their medication was not taken by them. The results show that male compared to females were less likely to feel uncomfortable, but the correlation was insignificant (OR:0.934, CI: 0.714 – 1.221, p=0.606) (Table 4).

In terms of privacy, the findings of an important study held in the USA concerned with the ethical side of using smart pills stated that when the patient registers their digital medicine application or device, they will be prompted to indicate agreement, but it is well known that user agreements which are written most of the time by lawyers which may include terms which can be changed upon any company’s preference at any time and these terms tend to be long documents that many people tend to skip. Another important point is that some applications cannot be active unless the agreement statement is agreed by the user which is not negotiable otherwise the app cannot be used¹⁵.

CONCLUSION:

In conclusion, the most obvious finding to emerge from this study is that a good percentage of respondents need to solve their problem in missing the dose of medication and a modern promising solution is the digital pills. Moreover, when the idea of digital pills was explained to the participants, many of them found it great and they are willing to use it. Although some concerns are raised with patient confidentiality, many people agree that the doctor can access the application that is connected to the digital pill and follow up with the patient. At the end, several questions remain to be answered as this would be a fruitful area for further work.

LIMITATIONS:

Certain limitations must be taken into consideration when interpreting the results. This study was conducted to a limited number of individuals and more focus on a large number of elderly individuals should be considered in future research.

CONFLICT OF INTEREST:

None to declare.

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Received on 18.08.2020 Modified on 21.11.2020

Research J. Pharm. and Tech. 2021; 14(9):4934-4940.

DOI: 10.52711/0974-360X.2021.00858

Variables	The medication non-adherence
	Informing the physician					Feeling un-comfortable if the doctor finds out
	Yes	No	OR	95%CI	P-value	Yes	No	OR	95%CI	P-value
Gender Male Female	29 120	25 146	1.190	0.899-1.576	0.249	29 153	25 113	0.934	0.714 – 1.221	0.606